Tumor Suppressor Gene Mutation in a Patient With a History of Hyperparathyroidism–Jaw Tumor Syndrome and Healed Generalized Osteitis Fibrosa Cystica: A Case Report and Genetic Pathophysiology Review

Abstract

Hyperparathyroidism–jaw tumor (HPT-JT) was first observed by Jackson in 1958 in a family who exhibited hyperparathyroidism and recurrent pancreatitis. The author noticed the presence of jaw tumors in the affected family and reported them as fibrous dysplasia. However, it was not until 1990 that a familial variety of hyperparathyroidism with fibro-osseous jaw tumors was recognized as HPT-JT syndrome and reported as a clinically and genetically distinct syndrome. Hyperparathyroidism generally arises from glandular hyperplasia or parathyroid adenomas, with only about 1% of cases resulting from parathyroid carcinoma.
However, parathyroid carcinoma develops in about 15% of HPT-JT patients. The true incidence of HPT-JT is unknown, although the prevalence of about 100 published cases suggests its rarity. Twenty percent of HPT-JT cases have renal hamartomas or tumors, and female patients with HPT-JT have been reported to have carcinoma of the uterus. This syndrome appears to arise from a variety of mutations that deactivate the tumor suppressor gene CDC73 (also known as HRPT2) and its production of the tumor suppressor protein parafibromin. Functional parafibromin has 531 amino acids, and mutations result in a short nonfunctional protein. CDC73 disorders exhibit dominant germline gene behavior, with varying degrees of penetration. In most cases an affected person has 1 parent with the condition, which raises the need for family investigation and genetic counseling. We report a case of HPT-JT syndrome in a male patient who presented to the local community hospital 6 years previously with a history of back pain. Investigations showed elevated serum parathyroid hormone and calcium levels, and a technetium 99m sestamibi parathyroid scan showed increased activity at the site of the lower left gland that proved to be a substernal parathyroid carcinoma. The patient’s parathyroid hormone level dropped from 126 to 97 pg/mL at 5 minutes andwas 65 pg/mL at 10 minutes after excision of the gland, and the calcium chemistry findings returned to normal. Parathyroid histologic analysis showed substantial cytologic atypia with nuclear pleomorphism and prominent nucleoli, but infrequent mitoses. Although the capsule was described as showing foci of vascular invasion by the carcinoma, there has been no evidence of recurrence. Six years later, the patient presented with bilateral mandibular cemento-ossifying fibromas, but no evidence of hyperparathyroidism.
The larger left tumor was excised and immediately reconstructed with an autogenous iliac crest bone graft,and the right lesion was enucleated. There has been no recurrence in 12 months. This case illustrates that
the hyperparathyroidism and the fibro-osseous tumors are independent features of the persistent germline tumor suppressor gene (CDC73) mutation. The syndromic fibro-osseous tumors are odontogenic cemento-ossifying fibromas, which only occur in the jaws.