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Bochicchio AM, Cammarota A, Storto G, Possidente L, Villonio A, Omer LC, Falco G, Laurino S, Russi S. Challenges in the diagnosis and management of tumor-induced osteomalacia: A case report. Heliyon 2024; 10:e31949. [PMID: 38882375 PMCID: PMC11177122 DOI: 10.1016/j.heliyon.2024.e31949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
The present case report is aimed to highlight the difficulty and the reason for the delayed diagnosis of phosphaturic mesenchymal tumors, emphasizing the need of standardized protocols for diagnosis, surgery and follow-up in high-volume hospitals. The clinical signs and symptoms, diagnostic and therapeutic procedures, immunohistological features were analyzed. Delayed diagnosis of phosphaturic mesenchymal tumor was primarily due to non-specific clinical symptoms such as fatigue, muscular and bone pain, and multiple fractures. This cryptic clinical picture made the diagnosis tricky that led to treatment of patient for non-specific pain and stress fractures before to consider the tumor-induced osteomalacia syndrome. Some well-documented studies were found in the literature in which the history of trauma is a critical trigger of glomus tumors. Extra-subungual tumors most frequently occur in the knee and ankle regions, particularly among young adults, and the diagnosis is typically made approximately 7.2 years after initial symptom onset. The difficult tumor localization represented an additional obstacle to the prompt treatment, leading to delayed curative surgery.
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Affiliation(s)
- Anna Maria Bochicchio
- Experimental Oncology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Aldo Cammarota
- Diagnostic and Imaging Department, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Giovanni Storto
- Nuclear Medicine Unit, IRCCS CROB Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Luciana Possidente
- Pathology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Antonio Villonio
- Diagnostic and Imaging Department, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Ludmila Carmen Omer
- Experimental Oncology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Geppino Falco
- Department of Biology, University of Naples Federico II, Naples, Italy
| | - Simona Laurino
- Laboratory of Preclinical and Translational Research, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Sabino Russi
- Laboratory of Preclinical and Translational Research, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
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2
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Álvarez-Rivas N, Lugo-Rodríguez G, Maneiro JR, Iñiguez-Ubiaga C, Melero-Gonzalez RB, Iglesias-Cabo T, Carmona L, García-Porrúa C, de Toro-Santos FJ. Tumor-induced osteomalacia: A systematic literature review. Bone Rep 2024; 21:101772. [PMID: 38774264 PMCID: PMC11107251 DOI: 10.1016/j.bonr.2024.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction Tumor-induced osteomalacia (TIO), is a rare acquired paraneoplastic syndrome characterized by defective bone mineralization, caused by the overproduction of fibroblast growth factor 23 (FGF23) by a tumor. Material and methods We conducted a systematic review to identify all case reports of TIO, focusing on those associated with mesenchymal tumors. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) consensus, and we included patients with a diagnosis of TIO and histological confirmation of phosphaturic mesenchymal tumors or resolution of the condition after treatment of the tumor. Bibliographical searches were carried out until December 2023 in the Cochrane Library, Medline and Embase, as well as congress abstracts online. Results We identified 769 articles with 1979 cases reported. Most patients were adults, with a higher incidence on men. Disease duration before diagnosis is a mean of 4.8 years. Most tumors were histologically classified as PMT. Lower limbs were the predominant location. Hypophosphatemia was present in 99.8 % of patients. The FGF23 was elevated at diagnosis in 95.5 %. Resection of the tumor was the treatment of choice in most of patients. After resection, there was a clinical improvement in 97.6 % of cases, and serum phosphorus and FGF23 levels returned to normal ranges in 91.5 % and 81.4 % of the patients, respectively. Conclusion TIO is usually misdiagnosed with rheumatological or musculoskeletal disorders. The diagnosis should be suspected in patients with hypophosphatemic osteomalacia, and the measurement of serum FGF23 can be useful for diagnosis and management.
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Affiliation(s)
- Noelia Álvarez-Rivas
- Rheumatology Department, Hospital Público da Mariña, Servizo Galego de Saúde (SERGAS), Burela, Spain
| | - Gloria Lugo-Rodríguez
- Endocrinology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Jose Ramón Maneiro
- Rheumatology Department, Complexo Hospitalario Universitario de Santiago (CHUS), Servizo Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Carlota Iñiguez-Ubiaga
- Rheumatology Department, Hospital Universitario del Bierzo, Servicio de Salud de Castilla y León (SACYL), Ponferrada, Spain
| | - Rafael Benito Melero-Gonzalez
- Rheumatology Department, Complexo Hospitalario Universitario de Ourense (CHUO), Servizo Galego de Saúde (SERGAS), Orense, Spain
| | - Tania Iglesias-Cabo
- Statistical Consulting Unit, Scientific and Technical Services, University of Oviedo, Oviedo, Spain
| | | | - Carlos García-Porrúa
- Rheumatology Department, Complexo Hospitalario Universitario de Lugo (CHULA), Servizo Galego de Saúde (SERGAS), Lugo, Spain
| | - Francisco Javier de Toro-Santos
- Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade de A Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
- Rheumatology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
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3
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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4
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Disorders of phosphate homeostasis in children, part 1: primer on mineral ion homeostasis and the roles of phosphate in skeletal biology. Pediatr Radiol 2022; 52:2278-2289. [PMID: 35536415 DOI: 10.1007/s00247-022-05374-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/22/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
Phosphate has extensive physiological roles including energy metabolism, genetic function, signal transduction and membrane integrity. Regarding the skeleton, not only do phosphate and calcium form the mineral component of the skeleton, but phosphate is also essential in regulating function of skeletal cells. Although our understanding of phosphate homeostasis has lagged behind and remains less than that for calcium, considerable advances have been made since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone that is a major regulator of phosphate homeostasis. In this two-part review of disorders of phosphate homeostasis in children, part 1 covers the basics of mineral ion homeostasis and the roles of phosphate in skeletal biology. Part 1 includes phosphate-related disorders of mineralization for which overall circulating mineral ion homeostasis remains normal. Part 2 covers hypophosphatemic and hyperphosphatemic disorders, emphasizing, but not limited to, those related to increased and decreased FGF23 signaling, respectively.
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Bosman A, Palermo A, Vanderhulst J, De Beur SMJ, Fukumoto S, Minisola S, Xia W, Body JJ, Zillikens MC. Tumor-Induced Osteomalacia: A Systematic Clinical Review of 895 Cases. Calcif Tissue Int 2022; 111:367-379. [PMID: 35857061 PMCID: PMC9474374 DOI: 10.1007/s00223-022-01005-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare and largely underdiagnosed paraneoplastic condition. Previous reviews often reported incomplete data on clinical aspects, diagnosis or prognosis. The aim of this study was to present a systematic clinical review of all published cases of TIO. A search was conducted in Pubmed, Embase, Web of Science from inception until April 23rd, 2020. We selected case reports and case series of patients diagnosed with TIO, with information on tumor localization and serum phosphate concentration. Two reviewers independently extracted data on biochemical and clinical characteristics including bone involvement, tumor localization and treatment. 468 articles with 895 unique TIO cases were included. Median age was 46 years (range 9 months-90 years) and 58.3% were males. Hypophosphatemia and inappropriately low or normal 1,25-dihydroxyvitamin D levels, characteristic for TIO, were present in 98% of cases. Median tumor size was 2.7 cm (range 0.5 to 25.0 cm). Serum fibroblast growth factor 23 was related to tumor size (r = 0.344, P < 0.001). In 32% of the cases the tumor was detected by physical examination. Data on bone phenotype confirmed skeletal involvement: 62% of cases with BMD data had a T-score of the lumbar spine ≤ - 2.5 (n = 61/99) and a fracture was reported in at least 39% of all cases (n = 346/895). Diagnostic delay was longer than 2 years in more than 80% of cases. 10% were reported to be malignant at histology. In conclusion, TIO is a debilitating disease characterized by a long diagnostic delay leading to metabolic disturbances and skeletal impairment. Increasing awareness of TIO should decrease its diagnostic delay and the clinical consequences.
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Affiliation(s)
- Ariadne Bosman
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Andrea Palermo
- Unit of Metabolic Bone and Thyroid Disorders, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Julien Vanderhulst
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiological and Cardiological Sciences, "Sapienza" Rome University, 00161, Rome, Italy
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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6
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Benson JC, Trejo-Lopez JA, Nassiri AM, Eschbacher K, Link MJ, Driscoll CL, Tiegs RD, Sfeir J, DeLone DR. Phosphaturic Mesenchymal Tumor. AJNR Am J Neuroradiol 2022; 43:817-822. [PMID: 35589138 DOI: 10.3174/ajnr.a7513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/17/2022] [Indexed: 11/07/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are neoplasms associated with tumor-induced osteomalacia. Patients typically present with pathologic fractures in the setting of chronic hypophosphatemic hyperphosphaturic osteomalacia, as well as gradual muscle weakness, bone pain, and difficulty walking. Because of their rarity and nonspecific symptomatology, phosphaturic mesenchymal tumors often go undiagnosed for years. Even when discovered on imaging, the tumors can be diagnostically challenging for radiologists. Phosphaturic mesenchymal tumors often tend to be small and can be located nearly anywhere in the body, and, therefore, can mimic many other tumors. This case highlights the imaging and pathologic markers of a phosphaturic mesenchymal tumor, often found in a patient with tumor-induced osteomalacia.
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Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., D.R.D.)
| | | | | | - K Eschbacher
- Laboratory Medicine and Pathology (J.A.T.-L., K.E.)
| | | | | | - R D Tiegs
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - J Sfeir
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - D R DeLone
- From the Departments of Radiology (J.C.B., D.R.D.)
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7
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Frank FA, Gerber L, Cornelius A, Baumhoer D, Krieg AH. FGF-23 transmitted tumor - induced hypophosphatemic osteomalacia: a rare case of a young woman with recurrent fractures and review of the literature. J Bone Oncol 2022; 33:100413. [PMID: 35169537 PMCID: PMC8829074 DOI: 10.1016/j.jbo.2022.100413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 12/31/2022] Open
Abstract
Tumor-transmitted osteomalacia is a rare FGF 23 transmitted phosphaturic disease. Delay of diagnosis is common due to small and clinically silent underlying tumors. The most sensitive imaging modality is 68Ga-DOTA-TOC-PET/CT-scan. Complete resection of the tumor mass cures this paraneoplastic disease.
We present a case of tumor-induced osteomalacia (TIO) in a young woman of 22 years. The fibroblast growth factor 23 transmitting tumor in her left foot remained undetected for several years. She suffered several fractures including insufficiency fractures of both femoral necks requiring bilateral proximal femoral nailing. After phosphaturia was diagnosed any known genetic etiology was excluded. Even advanced imaging modalities were unable to detect the clinically silent tumor until an 68Ga-DOTA-TOC-PET/CT-scan revealed a mass with paraneoplastic activity in the left foot. Complete resection of the tumor proved to cure her condition after 9 years of uncertainty and suffering. Serum phosphate levels returned to normal within days. After presentation of the case report, the current literature on published cases of TIO between 1956 and 2021 is summarized to emphasize the importance of an accurate and early diagnosis. Our case report aims to illustrate that a long latency period of diagnosis may be avoided utilizing the latest imaging techniques to spare affected patients from long treatment of symptoms instead of finding the underlying cause.
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8
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Sum M, Hoda ST, Rapp T, Zan E. Tumor-Induced Osteomalacia Localized and Excised After Pregnancy. AACE Clin Case Rep 2021; 7:363-366. [PMID: 34765732 PMCID: PMC8573288 DOI: 10.1016/j.aace.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Tumor-induced osteomalacia (TIO) is a rare osteomalacia characterized by paraneoplastic secretion of fibroblast growth factor 23. Concomitant occurrence of TIO during pregnancy is rarer still. Our objective was to report a young patient with debilitating fractures diagnosed with TIO who became pregnant and subsequently had her tumor localized by gallium-68 (Ga-68) DOTATATE positron emission tomography/magnetic resonance imaging (PET/MRI). Case Report A 28 year-old woman with a 2-year history of stress fractures was found to have the following: (1) alkaline phosphatase level, 220 (reference range, 30-95) U/L; (2) phosphorus level, 2.1 (2.5-5.0) mg/dL; (3) 1,25-dihydroxyvitamin D3 level, <8 (18-72) pg/mL; (4) 24-hour urine phosphorus level, 0.5 (0.3-1.3) g; and (5) fibroblast growth factor 23 levels, 1241 (reference range, <180) RU/mL. The patient became pregnant, and at term, a cesarean delivery was performed. Ga-68 DOTATATE PET/MRI showed a 9-mm intracortical mass in the right fibular head and right femoral and bilateral calcaneal stress fractures. The fibular lesion was resected; pathology showed a 1.5-cm lesion with positive fibroblast growth factor receptor 1 staining. Discussion This patient with TIO had an uneventful pregnancy and delivery. TIO is typically caused by benign mesenchymal tumors. Ga-68 DOTATATE PET/computed tomography has been used for localizing tumors causing TIO, yet MRI has superior contrast resolution over computed tomography. Therefore, it is not surprising that Ga-68 PET/MRI successfully localized this patient’s tumor to the intracortical space of the fibular head and distinguished it from insufficiency fractures. Conclusion To our knowledge, this is the first report of phosphate treatment in a pregnant patient with TIO and the first report of a tumor-inducing TIO being localized by Ga-68 DOTATATE PET/MRI.
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Key Words
- 1,25[OH]2D3, 1,25-dihydroxyvitamin D3
- ALP, alkaline phosphatase
- DOTATATE
- FGF23, fibroblast growth factor 23
- Ga-68, gallium-68
- MRI, magnetic resonance imaging
- PET, positron emission tomography
- PTH, parathyroid hormone
- SUV, standard uptake value
- TIO, tumor-induced osteomalacia
- TmP/GFR, tubular maximum reabsorption of phosphate per unit of glomerular filtration
- fibroblast growth factor 23
- hypophosphatemia
- iFGF23, intact fibroblast growth factor 23
- pregnancy
- renal phosphate wasting
- tumor-induced osteomalacia
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Affiliation(s)
- Melissa Sum
- Department of Medicine, NYU Langone Health, New York, New York
| | - Syed T Hoda
- Department of Pathology, NYU Langone Health, New York, New York
| | - Timothy Rapp
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Elcin Zan
- Department of Radiology, NYU Langone Health, New York, New York
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9
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Crotti C, Bartoli F, Coletto LA, Manara M, Marini E, Daolio PA, Parafioriti A, Armiraglio E, Zucchi F, Sinigaglia L, Caporali R, Varenna M. Tumor induced osteomalacia: A single center experience on 17 patients. Bone 2021; 152:116077. [PMID: 34175499 DOI: 10.1016/j.bone.2021.116077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 06/16/2021] [Indexed: 01/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome due to a phosphaturic tumor, which overproduces Fibroblast Growth Factor 23 (FGF-23), causing hyperphosphaturia, hypophosphatemia, low 1,25(OH)2D and osteomalacia. Tumor localization is critical, diagnostic delay ranges from 2.5 to 28 years and to date surgical removal is considered effective treatment. We retrospectively evaluated patients with definite diagnosis of TIO referred to a tertiary Rheumatology Center between September 2000 and May 2020, investigating clinical management and disease outcome. We included 17 patients: 10 (58.8%) were females, mean age at diagnosis was 55.3 ± 13.9 years (mean ± standard deviation), with a diagnostic delay from symptoms onset to tumor detection of 6.6 ± 6.25 years. Biochemical data were: serum phosphorus 1.3 ± 0.4 mg/dL (Reference Range: 2.5-4.6), serum 1,25(OH)2D 31.8 ± 22.9 ng/mL (RR: 25-86), intact FGF-23, 358.9 ± 677 pg/mL (RR: 25-45); 24 h-Urine Phosphorus was increased in only 2 patients, while tubular reabsorption of phosphate (TRP) was decreased in all patients confirming a renal phosphate wasting. In 2013 68Ga- DOTA-based PET/CT was introduced in routinely practice and diagnostic delay was consistently reduced (from 8.6 ± 7.9 to 4.3 ± 2.4 years). Thirteen patients underwent surgery, one patient underwent radiofrequency ablation; 3 patients, not eligible for surgery, were treated only with supplements of phosphorus and calcitriol. One was started on Burosumab after several unsuccessful surgical attempts. After surgery or ablation, 8 patients had complete remission, 3 TIO persistence, and 3 had overtime relapse. Relapses were observed only in patients who previously underwent closed biopsy. To our knowledge, this is the widest European cohort of TIO patients in the last two decades. We confirm a usual diagnostic delay and recommend a stepwise diagnostic approach. Tumor biopsy is not recommended due to the potential cell spilling. Surgery is generally considered a definitive treatment, even though other approaches have been successful in curing TIO. Active surveillance on possible recurrence is always needed. Burosumab appears a promising therapy.
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Affiliation(s)
- C Crotti
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - F Bartoli
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L A Coletto
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - M Manara
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - E Marini
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | - P A Daolio
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | | | - E Armiraglio
- UOC Pathology, Gaetano Pini Institute, Milan, Italy
| | - F Zucchi
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - R Caporali
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - M Varenna
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy.
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10
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Dahir K, Zanchetta MB, Stanciu I, Robinson C, Lee JY, Dhaliwal R, Charles J, Civitelli R, Roberts MS, Krolczyk S, Weber T. Diagnosis and Management of Tumor-induced Osteomalacia: Perspectives From Clinical Experience. J Endocr Soc 2021; 5:bvab099. [PMID: 34286168 PMCID: PMC8282217 DOI: 10.1210/jendso/bvab099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 01/12/2023] Open
Abstract
Purpose Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome of abnormal phosphate and vitamin D metabolism caused by typically small endocrine tumors that secrete fibroblast growth factor 23 (FGF23). TIO is characterized clinically by progressive musculoskeletal pain, fatigue, proximal muscle weakness, and multiple fractures, leading to long-term disability. Misdiagnosis and delayed diagnosis are common because of the nonspecific symptoms, and several years may elapse before patients receive an accurate diagnosis and appropriate treatment. Thus, it is vital that awareness of the appropriate recognition and management of TIO is increased among healthcare professionals who may encounter patients with suspected TIO. Methods A roundtable meeting was held on 10 January 2020 in Dallas, TX, USA, to gather perspectives on the diagnosis and treatment of TIO. The following topics were considered: clinical presentation, patient history, differential diagnosis, laboratory assessment, imaging, venous sampling, and treatment. Results This report provides a summary of our collective experiences in the management of TIO. Main conclusions Laboratory tests are mandatory to expedite TIO diagnosis and should include measurement of fasting serum phosphorus, renal phosphate reabsorption, serum 1,25-dihydroxyvitamin D, and serum FGF23 levels. Functional and anatomical imaging are essential to locate the FGF23-secreting tumor(s) causing TIO. Surgical resection is often a curative treatment when the tumor can be localized; however, better management of patients who cannot be operated on with targeted therapies is needed. Further efforts to increase awareness of TIO within the medical community, and education on recommended diagnostic and treatment pathways are required to improve the management of this debilitating disease.
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Affiliation(s)
- Kathryn Dahir
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Irinel Stanciu
- Panorama Orthopedics and Spine Center, Golden, CO 80401, USA
| | - Cemre Robinson
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Janet Y Lee
- University of California, San Francisco, CA 94143, USA
| | - Ruban Dhaliwal
- State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Julia Charles
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | | | - Stan Krolczyk
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, USA
| | - Thomas Weber
- Duke University School of Medicine, Durham, NC 27710, USA
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11
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Jiajue R, Ni X, Jin C, Huo L, Wu H, Liu Y, Jin J, Yu W, Lv W, Zhou L, Xia Y, Chi Y, Cui L, Pang Q, Li X, Jiang Y, Wang O, Li M, Xing X, Meng X, Xia W. Early Discrimination Between Tumor-Induced Rickets/Osteomalacia and X-Linked Hypophosphatemia in Chinese Children and Adolescents: A Retrospective Case-Control Study. J Bone Miner Res 2021; 36:1739-1748. [PMID: 33971042 DOI: 10.1002/jbmr.4331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/24/2021] [Accepted: 05/02/2021] [Indexed: 12/16/2022]
Abstract
In children and adolescents, distinguishing tumor-induced rickets/osteomalacia (TIR/O) from hereditary hypophosphatemic rickets/osteomalacia (HR/O) is a medical challenge. We retrospectively studied 10 Chinese children and adolescents with TIR/O who underwent surgery at a mean age of 17.4 ± 2.1 years and compared their characteristics to 24 age- and sex-matched patients with X-linked hypophosphatemia (XLH). Positive family history of HR/O and dental problems, such as enamel hypoplasia and dental abscess, were reported in 8 (33.3%) and 5 (20.8%) patients with XLX, respectively, but not in patients with TIR/O. In addition, in comparison with XLH patients, TIR/O patients had an older disease onset age (150 versus 24 months, p < 0.001), a higher height standard deviation score (SDS; -1.2 ± 1.8 versus -4.0 ± 1.4, p < 0.001), a lower Z-score of bone mineral density (BMD) at lumbar spine (LS) (-3.9 [6.0] versus +1.8 [7.0], p < 0.001), and a higher serum intact fibroblast growth factor 23 (FGF23) level (500.27 ± 87.20 versus 121.71 ± 70.94 pg/mL, p < 0.001), corresponding to a lower serum phosphate level (0.52 ± 0.07 versus 0.64 ± 0.11 mmol/L, p = 0.005) and a higher serum alkaline phosphatase (ALP) level (557 [631] versus 305 [249] U/L, p = 0.005). We generated receiver operating characteristic (ROC) curves and calculated the area under the ROC curve (AUC). The AUCs of onset age, FGF23, and LS Z-score were equal to 1, suggesting that these are excellent indices for the differential diagnosis between TIR/O and XLH. In summary, our study furthers our understanding of the spectrum of clinical, biochemical, and pathologic findings associated with TIR/O. For children and adolescent patients with HR/O, a comprehensive and careful clinical and laboratory evaluation is of great importance, and we recommend enquiry of the family history, onset age, and dental problems, as well as measurement of serum FGF23 and BMD. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Ruizhi Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xiaolin Ni
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Chenxi Jin
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jin Jin
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Lv
- Department of Ear, Nose, and Throat (ENT), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu Xia
- Department of Ultrasound Diagnosis, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yue Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Lijia Cui
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Qianqian Pang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xiang Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Xunwu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
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12
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Agrawal K, Padhy BM, Meher BR, Mohanty RR. Diagnostic utility of Ga-68 DOTA-SSTR and F-18 FDG PET/CT in the detection of culprit tumours causing osteomalacia: a systematic review and meta-analysis. Nucl Med Commun 2021; 42:646-655. [PMID: 33625187 DOI: 10.1097/mnm.0000000000001379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tumour-induced osteomalacia (TIO) or oncogenic osteomalacia is a rare variant of paraneoplastic syndrome secondary to a small benign phosphaturic mesenchymal tumour that secretes phosphaturic substances. Complete tumour excision is often curative. However, the localization of these offending tumours has always remained a challenge because of their small size, slow-growing nature, and presence in atypical locations. We performed a systemic review and meta-analysis on the sensitivity and specificity of F-18 FDG PET/CT and Ga-68 DOTA-SSTR PET/CT to detect tumours causing osteomalacia. METHODS Pub Med, SCOPUS, the Cochrane Library and Web of Science were searched for articles on F-18 FDG and Ga-68 DOTA-SSTR PET/CT in the detection of culprit tumours in TIO till September 2020. Both retrospective and prospective studies having three or more patients were included. The methodological quality of included studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies-2 checklist. A random-effect model was used for the statistical pooling of sensitivity and specificity. Pooled data were presented with 95% confidence intervals (95% CI) and displayed using Forest plots. Heterogeneity was expressed using the I2 statistic. RESULTS The pooled sensitivity of Ga-68 DOTA-SSTR PET/CT in detecting the culprit tumour derived from all included studies is 86% (95% CI: 79-91%). There is moderate statistical heterogeneity among the included studies (I2 = 72.7%). The pooled sensitivity of F-18 FDG PET/CT in detecting the offending tumour derived from all included studies is 73% (95% CI: 61-84%) with moderate statistical heterogeneity among the included studies (I2 = 45.4%). CONCLUSION In the detection of offending tumours in TIO, Ga-68 DOTA-SSTR PET/CT has better sensitivity than F-18 FDG PET/CT and should be used as first-line imaging modality due to very high sensitivity.
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Affiliation(s)
| | | | | | - Rashmi Ranjan Mohanty
- Department of General Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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13
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Turin CG, Wilson RJ, Mangone C, Rosenspire K, Berman J, Walker M, Amaravadi R, Al Mukaddam M. A Case of Tumor-Induced Osteomalacia: Finding the Culprit Acetabular Tumor and Successful Resection with a Novel Hip Joint-Preserving Surgery. J Orthop Case Rep 2021; 11:37-41. [PMID: 34239825 PMCID: PMC8241250 DOI: 10.13107/jocr.2021.v11.i03.2078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection of the tumor can be curative. However, these tumors are typically difficult to find anatomically due to small size and location. CASE REPORT We present the case of a patient who presented for evaluation of recurrent fractures and hypophosphatemia in the setting of elevated FGF23 suggestive of TIO. 68Gallium-DOTATATE revealed multiple somatostatin avid lesions in several ribs, left acetabulum, sacrum, right tibia, and feet, some of which appeared with fracture on computed tomography scan, initially concerning for metastatic disease. However, the lesion in acetabulum was considered the culprit tumor given its remarkably higher maximum standard uptake values. Complete surgical removal of the FGF23-secreting tumor led to cure of this disease. CONCLUSION This case report highlights the challenges with functional imaging differentiating fractures from the culprit lesion and reports on a novel surgical technique that allowed for surgical cure while preserving the hip joint.
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Affiliation(s)
- Christie G. Turin
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J. Wilson
- Department of Orthopaedic, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ciera Mangone
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Karen Rosenspire
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Berman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Michelle Walker
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Ravi Amaravadi
- Department of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mona Al Mukaddam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
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Florenzano P, Hartley IR, Jimenez M, Roszko K, Gafni RI, Collins MT. Tumor-Induced Osteomalacia. Calcif Tissue Int 2021; 108:128-142. [PMID: 32504138 DOI: 10.1007/s00223-020-00691-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral production of fibroblast growth factor 23 (FGF23). The hallmark biochemical features include hypophosphatemia due to renal phosphate wasting, inappropriately normal or frankly low 1,25-dihydroxy-vitamin D, and inappropriately normal or elevated FGF23. TIO is caused by typically small, slow growing, benign phosphaturic mesenchymal tumors (PMTs) that are located almost anywhere in the body from the skull to the feet, in soft tissue or bone. The recent identification of fusion genes in a significant subset of PMTs has provided important insights into PMT tumorigenesis. Although management of this disease may seem straightforward, considering that complete resection of the tumor leads to its cure, locating these often-tiny tumors is frequently a challenge. For this purpose, a stepwise, systematic approach is required. It starts with thorough medical history and physical examination, followed by functional imaging, and confirmation of identified lesions by anatomical imaging. If the tumor resection is not possible, medical therapy with phosphate and active vitamin D is indicated. Novel therapeutic approaches include image-guided tumor ablation and medical treatment with the anti-FGF23 antibody burosumab or the pan-FGFR tyrosine kinase inhibitor, BGJ398/infigratinib. Great progress has been made in the diagnosis and treatment of TIO, and more is likely to come, turning this challenging, debilitating disease into a gratifying cure for patients and their providers.
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Affiliation(s)
- Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
| | - Iris R Hartley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - Kelly Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Skeletal Disorders and Mineral Homeostasis Section, NIDCR, NIH, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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15
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Gupta N, Singh N. Occult tumour-induced osteomalacia causing lesion detected by FDG-PET/CT scan. World J Nucl Med 2020; 19:147-148. [PMID: 32939204 PMCID: PMC7478310 DOI: 10.4103/wjnm.wjnm_68_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 09/17/2019] [Indexed: 11/22/2022] Open
Abstract
Oncogenic osteomalacia is a rare condition, with overproduction of fibroblast growth factor 23, leading to hypophosphatemia, phosphaturia. If it is associated with benign mesenchymal tumor, then resection of tumor is curable. Thus, detection and localization of the lesion are of utmost importance. We report a case, where 18F-FDG PET/CT scan was useful in detection of such occult lesion.
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Affiliation(s)
- Nitin Gupta
- Department of Nuclear Medicine, Sir Gangaram Hospital, New Delhi, India
| | - Natasha Singh
- Department of Nuclear Medicine, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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16
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McKnight Q, Jenkins S, Li X, Nelson T, Marlier A, Cantley LG, Finberg KE, Fretz JA. IL-1β Drives Production of FGF-23 at the Onset of Chronic Kidney Disease in Mice. J Bone Miner Res 2020; 35:1352-1362. [PMID: 32154933 PMCID: PMC7363582 DOI: 10.1002/jbmr.4003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 02/14/2020] [Accepted: 03/04/2020] [Indexed: 12/27/2022]
Abstract
FGF-23 has arisen as an early biomarker of renal dysfunction, but at the onset of chronic kidney disease (CKD), data suggest that FGF-23 may be produced independently of the parathyroid hormone (PTH), 1,25(OH)2 -vitamin D3 signaling axis. Iron status is inversely correlated to the level of circulating FGF-23, and improvement in iron bioavailability within patients correlates with a decrease in FGF-23. Alternately, recent evidence also supports a regulatory role of inflammatory cytokines in the modulation of FGF-23 expression. To determine the identity of the signal from the kidney-inducing upregulation of osteocytic FGF-23 at the onset of CKD, we utilized a mouse model of congenital CKD that fails to properly mature the glomerular capillary tuft. We profiled the sequential presentation of indicators of renal dysfunction, phosphate imbalance, and iron bioavailability and transport to identify the events that initiate osteocytic production of FGF-23 during the onset of CKD. We report here that elevations in circulating intact-FGF-23 coincide with the earliest indicators of renal dysfunction (P14), and precede changes in serum phosphate or iron homeostasis. Serum PTH was also not changed within the first month. Instead, production of the inflammatory protein IL-1β from the kidney and systemic elevation of it in the circulation matched the induction of FGF-23. IL-1β's ability to induce FGF-23 was confirmed on bone chips in culture and within mice in vivo. Furthermore, neutralizing antibody to IL-1β blocked FGF-23 expression in both our congenital model of CKD and a second nephrotoxic serum-mediated model. We conclude that early CKD resembles a situation of primary FGF-23 excess mediated by inflammation. These findings do not preclude that altered mineral availability or anemia can later modulate FGF-23 levels but find that in early CKD they are not the driving stimulus for the initial upregulation of FGF-23. © 2020 American Society for Bone and Mineral Research.
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Affiliation(s)
- Quiana McKnight
- Department of Internal Medicine (Nephrology), Yale University School of Medicine, New Haven, CT, USA
| | - Sarah Jenkins
- Department of Internal Medicine (Nephrology), Yale University School of Medicine, New Haven, CT, USA
| | - Xiuqi Li
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Tracy Nelson
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Arnaud Marlier
- Department of Internal Medicine (Nephrology), Yale University School of Medicine, New Haven, CT, USA
| | - Lloyd G Cantley
- Department of Internal Medicine (Nephrology), Yale University School of Medicine, New Haven, CT, USA
| | - Karin E Finberg
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jackie A Fretz
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA.,Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
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17
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Chande S, Caballero D, Ho BB, Fetene J, Serna J, Pesta D, Nasiri A, Jurczak M, Chavkin NW, Hernando N, Giachelli CM, Wagner CA, Zeiss C, Shulman GI, Bergwitz C. Slc20a1/Pit1 and Slc20a2/Pit2 are essential for normal skeletal myofiber function and survival. Sci Rep 2020; 10:3069. [PMID: 32080237 PMCID: PMC7033257 DOI: 10.1038/s41598-020-59430-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/29/2020] [Indexed: 01/25/2023] Open
Abstract
Low blood phosphate (Pi) reduces muscle function in hypophosphatemic disorders. Which Pi transporters are required and whether hormonal changes due to hypophosphatemia contribute to muscle function is unknown. To address these questions we generated a series of conditional knockout mice lacking one or both house-keeping Pi transporters Pit1 and Pit2 in skeletal muscle (sm), using the postnatally expressed human skeletal actin-cre. Simultaneous conditional deletion of both transporters caused skeletal muscle atrophy, resulting in death by postnatal day P13. smPit1-/-, smPit2-/- and three allele mutants are fertile and have normal body weights, suggesting a high degree of redundance for the two transporters in skeletal muscle. However, these mice show a gene-dose dependent reduction in running activity also seen in another hypophosphatemic model (Hyp mice). In contrast to Hyp mice, grip strength is preserved. Further evaluation of the mechanism shows reduced ERK1/2 activation and stimulation of AMP kinase in skeletal muscle from smPit1-/-; smPit2-/- mice consistent with energy-stress. Similarly, C2C12 myoblasts show a reduced oxygen consumption rate mediated by Pi transport-dependent and ERK1/2-dependent metabolic Pi sensing pathways. In conclusion, we here show that Pit1 and Pit2 are essential for normal myofiber function and survival, insights which may improve management of hypophosphatemic myopathy.
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Affiliation(s)
- Sampada Chande
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel Caballero
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Bryan B Ho
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Fetene
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Juan Serna
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Dominik Pesta
- Department of Cellular&Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
- German Diabetes Center, Düsseldorf, Germany, University of Washington, Box 355061, Foege Hall Seattle, WA, 98195, USA
| | - Ali Nasiri
- Department of Cellular&Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Jurczak
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
- Department of Medicine, Division of Endocrinology, University of Pittsburgh, University of Washington, Box 355061, Foege Hall Seattle, WA, 98195, USA
| | - Nicholas W Chavkin
- Department of Bioengineering, University of Washington, Box 355061, Foege Hall Seattle, WA, 98195, USA
| | - Nati Hernando
- Institute of Physiology, University of Zürich, Switzerland and National Center of Competence in Research NCCR Kidney.CH, Zürich, Switzerland
| | - Cecilia M Giachelli
- Department of Bioengineering, University of Washington, Box 355061, Foege Hall Seattle, WA, 98195, USA
| | - Carsten A Wagner
- Institute of Physiology, University of Zürich, Switzerland and National Center of Competence in Research NCCR Kidney.CH, Zürich, Switzerland
| | - Caroline Zeiss
- Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Gerald I Shulman
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA
- Department of Cellular&Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
| | - Clemens Bergwitz
- Department of Internal Medicine, Section Endocrinology, Yale University School of Medicine, New Haven, CT, USA.
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18
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Abstract
Fibroblast growth factor 23 (FGF23), one of the endocrine fibroblast growth factors, is a principal regulator in the maintenance of serum phosphorus concentration. Binding to its cofactor αKlotho and a fibroblast growth factor receptor is essential for its activity. Its regulation and interaction with other factors in the bone-parathyroid-kidney axis is complex. FGF23 reduces serum phosphorus concentration through decreased reabsorption of phosphorus in the kidney and by decreasing 1,25 dihydroxyvitamin D (1,25(OH)2D) concentrations. Various FGF23-mediated disorders of renal phosphate wasting share similar clinical and biochemical features. The most common of these is X-linked hypophosphatemia (XLH). Additional disorders of FGF23 excess include autosomal dominant hypophosphatemic rickets, autosomal recessive hypophosphatemic rickets, fibrous dysplasia, and tumor-induced osteomalacia. Treatment is challenging, requiring careful monitoring and titration of dosages to optimize effectiveness and to balance side effects. Conventional therapy for XLH and other disorders of FGF23-mediated hypophosphatemia involves multiple daily doses of oral phosphate salts and active vitamin D analogs, such as calcitriol or alfacalcidol. Additional treatments may be used to help address side effects of conventional therapy such as thiazides to address hypercalciuria or nephrocalcinosis, and calcimimetics to manage hyperparathyroidism. The recent development and approval of an anti-FGF23 antibody, burosumab, for use in XLH provides a novel treatment option.
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Affiliation(s)
- Anisha Gohil
- Indiana University School of Medicine, Riley Hospital for Children, Fellow, Endocrinology and Diabetes, 705 Riley Hospital Drive, Room 5960, Indianapolis, IN 46202, USA, E-mail:
| | - Erik A Imel
- Indiana University School of Medicine, Riley Hospital for Children, Associate Professor of Medicine and Pediatrics, 1120 West Michigan Street, CL 459, Indianapolis, IN 46202, USA
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19
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Phosphaturic Mesenchymal Tumor of Soft Tissue of the Foot: Report of a Case With Review of the Literature. Adv Anat Pathol 2019; 26:320-328. [PMID: 31261249 DOI: 10.1097/pap.0000000000000240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm that ectopically secretes fibroblast growth factor 23, a bone cell-derived protein that regulates phosphate homeostasis. The overproduction of fibroblast growth factor 23 causes a paraneoplastic syndrome characterized by hyperphosphaturia, hypophosphatemia, hypovitaminosis D, and vitamin D refractory rickets/osteomalacia, effects that disappear with tumor removal. The PMT may occur in several anatomic regions, mainly in the limbs, usually involving both soft tissue and bone. Acral locations occur in 10% to 15% of the cases, mostly in the feet, with 95 cases reported in this anatomic region to date. We report a case of a PMT in a young adult male who presented in 2007 with the classic constellation of signs and symptoms. A small soft-tissue tumor was detected in his right heel, 3 years after exhaustively seeking for it by various imaging techniques performed at different institutions. Before the tumor was detected, attempts to manage this patient's osteomalacia with phosphate and vitamin D (both calcitriol and ergocalciferol) supplementation were unsuccessful. Following surgical resection, the patient experienced prompt correction of the phosphaturia and gradual reconstitution of his bone mineralization. The pathologic diagnosis was (benign) PMT, mixed connective tissue type. In 2019, 12 years after resection, the patient is asymptomatic, and his bone mineral homeostasis has been restored.
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20
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Imel EA, Biggin A, Schindeler A, Munns CF. FGF23, Hypophosphatemia, and Emerging Treatments. JBMR Plus 2019; 3:e10190. [PMID: 31485552 PMCID: PMC6715782 DOI: 10.1002/jbm4.10190] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/13/2019] [Accepted: 02/26/2019] [Indexed: 01/03/2023] Open
Abstract
FGF23 is an important hormonal regulator of phosphate homeostasis. Together with its co-receptor Klotho, it modulates phosphate reabsorption and both 1α-hydroxylation and 24-hydroxylation in the renal proximal tubules. The most common FGF23-mediated hypophosphatemia is X-linked hypophosphatemia (XLH), caused by mutations in the PHEX gene. FGF23-mediated forms of hypophosphatemia are characterized by phosphaturia and low or low-normal calcitriol concentrations, and unlike nutritional rickets, these cannot be cured with nutritional vitamin D supplementation. Autosomal dominant and autosomal recessive forms of FGF23-mediated hypophosphatemias show a similar pathophysiology, despite a variety of different underlying genetic causes. An excess of FGF23 activity has also been associated with a number of other conditions causing hypophosphatemia, including tumor-induced osteomalacia, fibrous dysplasia of the bone, and cutaneous skeletal hypophosphatemia syndrome. Historically phosphate supplementation and therapy using analogs of highly active vitamin D (eg, calcitriol, alfacalcidol, paricalcitol, eldecalcitol) have been used to manage conditions involving hypophosphatemia; however, recently a neutralizing antibody for FGF23 (burosumab) has emerged as a promising treatment agent for FGF23-mediated disorders. This review discusses the progression of clinical trials for burosumab for the treatment of XLH and its recent availability for clinical use. Burosumab may have potential for treating other conditions associated with FGF23 overactivity, but these are not yet supported by trial data. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Erik A Imel
- Division of EndocrinologyIndiana University School of Medicine, Indianapolis, INUSA
| | - Andrew Biggin
- The University of Sydney Children's Hospital Westmead Clinical School, University of SydneySydneyAustralia
- Department of EndocrinologyThe Children's Hospital at WestmeadWestmeadAustralia
| | - Aaron Schindeler
- The University of Sydney Children's Hospital Westmead Clinical School, University of SydneySydneyAustralia
- Orthopaedic Research Unit, The Children's Hospital at WestmeadWestmeadAustralia
| | - Craig F Munns
- The University of Sydney Children's Hospital Westmead Clinical School, University of SydneySydneyAustralia
- Department of EndocrinologyThe Children's Hospital at WestmeadWestmeadAustralia
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Yang M, Doshi KB, Roarke MC, Nguyen BD. Molecular Imaging in Diagnosis of Tumor-induced Osteomalacia. Curr Probl Diagn Radiol 2019; 48:379-386. [DOI: 10.1067/j.cpradiol.2018.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/31/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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Mishra T, Desouza MA, Patel K, Mazumdar GA. Phosphaturic Mesenchymal Tumors Involving Skull Bones: Report of Two Rare Cases. Asian J Neurosurg 2019; 14:253-255. [PMID: 30937047 PMCID: PMC6417335 DOI: 10.4103/ajns.ajns_176_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare tumor causing oncogenic osteomalacia (OO). Most such tumors occur in soft tissue and bones of extremities and appendicular skeleton. Intracranial location and involvement of temporal–occipital bone is extremely rare. We report two unusual cases: The first was intracranial, involving the temporal bone, while the other was a skull base tumor arising from the occipital–temporal bone. Both of them presented with paraneoplastic syndrome of OO, resembled a meningioma radiologically, and underwent gross total resection of tumor. Histologically, both of them were diagnosed as PMT, mixed connective tissue variant.
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Affiliation(s)
- Toshi Mishra
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Maria Alina Desouza
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Keyuri Patel
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Girish A Mazumdar
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Kurien R, Rupa V, Thomas M. Varied presentation of sinonasal phosphaturic mesenchymal tumour: report of a case series with follow-up. Eur Arch Otorhinolaryngol 2019; 276:1677-1684. [PMID: 30879192 DOI: 10.1007/s00405-019-05341-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/08/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Phosphaturic mesenchymal tumour (PMT) of the paranasal sinuses is a rare tumour that is associated with oncogenous osteomalacia causing predominant musculoskeletal symptoms. We present a series of eight patients diagnosed to have PMT of the paranasal sinuses with varied presentation and highlight the appropriate evaluation required to arrive at the diagnosis. METHODS Retrospective review of eight patients diagnosed to have PMT-causing tumour-induced osteomalacia with follow-up data. RESULTS Eight patients, 4 males and 4 females, aged 36-67 years (mean = 44 years) presented with vague musculoskeletal symptoms (6 patients) or epistaxis (3 patients). Six patients were found to have hypophosphatemia, phosphaturia and raised FGF-23 levels preoperatively. All eight patients were found to have a tumour in the nose and/ paranasal sinuses with one patient having intracranial extension. All patients were treated with endoscopic excision of these tumours which resulted in resolution of symptoms and normalisation of biochemical abnormalities. In addition, one patient required a craniofacial resection. Histopathological features were consistent with PMT mixed connective tissue variant. Two atypical patients were seen. The longest follow-up was for 5 years and there was no evidence of recurrence during the follow-up period in any patient. CONCLUSION Diagnosis of PMT of the paranasal sinuses causing oncogenous osteomalacia requires a high index of suspicion when there are no ENT symptoms. Appropriate biochemical tests and histopathology lead to the correct diagnosis. Total endoscopic surgical excision leads to a good outcome.
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Affiliation(s)
- Regi Kurien
- Department of ENT, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India.
| | - Vedantam Rupa
- Department of ENT, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India
| | - Meera Thomas
- Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Acharya RP, Won AM, Moon BS, Flint JH, Roubaud MS, Williams MD, Hessel AC, Murphy WA, Chambers MS, Gagel RF. Tumor-induced hypophosphatemic osteomalacia caused by a mesenchymal tumor of the mandible managed by a segmental mandibulectomy and microvascular reconstruction with a free fibula flap. Head Neck 2019; 41:E93-E98. [PMID: 30859653 DOI: 10.1002/hed.25657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Tumor-induced osteomalacia is a rare paraneoplastic syndrome in which patients develop hypophosphatemia and osteomalacia. METHODS AND RESULTS Here, we report a unique case of a 42-year-old man who presented to our institution with a 1-year history of pain in his ribs, hips, lower back, and feet. Radiologic examination revealed a decrease in bone density and multiple insufficiency fractures. Laboratory evaluation revealed hypophosphatemia, low serum 1,25 dihydroxy vitamin D3 , and elevated fibroblast growth factor 23 (FGF23). A positron emission tomography/CT scan showed increased uptake in the right mandibular third molar region. Panoramic radiography and CT scanning showed a lytic expansile bone lesion. A mandibular bone biopsy revealed a mixed connective tissue tumor. A right segmental mandibulectomy was performed, followed by microvascular reconstruction. The resection was confirmed by normalization of serum phosphate and FGF23. CONCLUSION Successful management of this condition was achieved, with complete surgical resection of the tumor and reconstructive surgery.
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Affiliation(s)
- Rishabh P Acharya
- Section of Oral Oncology and Maxillofacial Prosthodontics, Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander M Won
- Section of Oral Oncology and Maxillofacial Prosthodontics, Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan S Moon
- Department of Orthopaedic Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James H Flint
- Department of Orthopaedic Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Margaret S Roubaud
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michelle D Williams
- Department of Pathology, Division of Pathology/Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy C Hessel
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William A Murphy
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark S Chambers
- Section of Oral Oncology and Maxillofacial Prosthodontics, Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert F Gagel
- Department of Endocrine Neoplasia and Hormonal Disorders, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Tumour-induced osteomalacia: A case report of craniofacial localization. OTOLARYNGOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.xocr.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Our understanding of the regulation of phosphate balance has benefited tremendously from the molecular identification and characterization of genetic defects leading to a number of rare inherited or acquired disorders affecting phosphate homeostasis. The identification of the key phosphate-regulating hormone, fibroblast growth factor 23 (FGF23), as well as other molecules that control its production, such as the glycosyltransferase GALNT3, the endopeptidase PHEX, and the matrix protein DMP1, and molecules that function as downstream effectors of FGF23 such as the longevity factor Klotho and the phosphate transporters NPT2a and NPT2c, has permitted us to understand the complex interplay that exists between the kidneys, bone, parathyroid, and gut. Such insights from genetic disorders have allowed not only the design of potent targeted treatment of FGF23-dependent hypophosphatemic conditions, but also provide clinically relevant observations related to the dysregulation of mineral ion homeostasis in health and disease.
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Affiliation(s)
- Marta Christov
- Division of Nephrology, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Xiao X, Sun X, Ni P, Huang Y, Xie T. Phosphaturic mesenchymal tumor and related wound problem. Medicine (Baltimore) 2018; 97:e12507. [PMID: 30290606 PMCID: PMC6200523 DOI: 10.1097/md.0000000000012507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/29/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Phosphaturic mesenchymal tumor mixed connective tissue type (PMT/MCT) is the most common type (up to 90%) of phosphaturic mesenchymal tumor (PMT), a rare clinicopathologic entity. Besides overproduction of fibroblast growth factor 23 (FGF23), there is a big variation of immunohistochemical characteristic across types of PMT, which makes it difficult to obtain an early diagnosis of PMT/MCT. As a benign tumor, PMT/MCT usually happens in subcutaneous tissues and leads to nonhealing of wound. A complete excision of PMT/MCT facilitates wound healing. CONCLUSIONS Review of the existing evidence indicates that early diagnosis of PMT/MCT is critically important when treating PMT/MCT wound. Hence standardization of early diagnosis for PMT/MCT is mandated.
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Affiliation(s)
- Xian Xiao
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Xiaofang Sun
- Department of Dermatology, The Second Hospital Affiliated to Jiaxing University, Jiaxing, Zhejiang, China
| | - Pengwen Ni
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yao Huang
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Ting Xie
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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Misgar RA, Sahu D, Sehgal A, Malik SA, Mohsin M, Wani AI, Bashir MI, Masoodi SR. Tumor-Induced Osteomalacia due to Hitherto Undiagnosed Subcutaneous Phosphaturic Mesenchymal Tumor. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ahn SH, Park YK, Park IS, Kye J, Choi WY, Seo DH, Kim SH, Nam MS, Hong S. A Case of Tumor-Induced Osteomalacia Associated with an Organizing Hematoma. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171824.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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The Foot That Broke Both Hips: A Case Report and Literature Review of Tumor-Induced Osteomalacia. Case Rep Rheumatol 2017; 2017:3191673. [PMID: 29104808 PMCID: PMC5618748 DOI: 10.1155/2017/3191673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/20/2017] [Accepted: 07/04/2017] [Indexed: 12/11/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by hypophosphatemia and clinical symptoms of osteomalacia. Only discussed as case reports, there is still limited knowledge of this condition as a potentially curable cause of osteomalacia among clinicians and pathologists. In this article, we present a case of tumor-induced osteomalacia in a 59-year-old gentleman followed by an up-to-date review of the existing literature on TIO.
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Kawai S, Ariyasu H, Furukawa Y, Yamamoto R, Uraki S, Takeshima K, Warigaya K, Nakamoto Y, Akamizu T. Effective localization in tumor-induced osteomalacia using 68Ga-DOTATOC-PET/CT, venous sampling and 3T-MRI. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170005. [PMID: 28469928 PMCID: PMC5409940 DOI: 10.1530/edm-17-0005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/10/2017] [Indexed: 12/11/2022] Open
Abstract
Summary Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting leading to hypophosphatemia due to excessive actions of fibroblast growth factor 23 (FGF23) produced by the tumors. Although the best way of curing TIO is complete resection, it is usually difficult to detect the culprit tumors by general radiological modalities owing to the size and location of the tumors. We report a case of TIO in which the identification of the tumor by conventional imaging studies was difficult. Nonetheless, a diagnosis was made possible by effective use of multiple modalities. We initially suspected that the tumor existed in the right dorsal aspect of the scapula by 68Ga-DOTATOC positron emission tomography/computed tomography (68Ga-DOTATOC-PET/CT) and supported the result by systemic venous sampling (SVS). The tumor could also be visualized by 3T-magnetic resonance imaging (MRI), although it was not detected by 1.5T-MRI, and eventually be resected completely. In cases of TIO, a stepwise approach of 68Ga-DOTATOC-PET/CT, SVS and 3T-MRI can be effective for confirmation of diagnosis. Learning points:
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Affiliation(s)
| | | | | | | | | | | | - Kenji Warigaya
- Department of Human Pathology, Wakayama Medical University, WakayamaJapan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, KyotoJapan
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Abstract
Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia involving overproduction of fibroblast growth factor 23. TIO has been described largely in adults with small mesenchymal tumors. We report a case of TIO in a child who presented with knee pain and radiographic findings concerning for rickets, and was found to have maxillomandibular giant cell lesions. The patient was treated with oral phosphorus and calcitriol, surgical debulking, and intralesional corticosteroids, which resulted in tumor regression and normalization of serum fibroblast growth factor 23 and phosphorus. This case illustrates the occurrence of this rare paraneoplastic syndrome in children and adds to our knowledge about clinical manifestations and pathologic findings associated with pediatric TIO.
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Zhang Q, Doucet M, Tomlinson RE, Han X, Quarles LD, Collins MT, Clemens TL. The hypoxia-inducible factor-1α activates ectopic production of fibroblast growth factor 23 in tumor-induced osteomalacia. Bone Res 2016; 4:16011. [PMID: 27468359 PMCID: PMC4948305 DOI: 10.1038/boneres.2016.11] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 12/27/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome in which ectopic production of fibroblast growth factor 23 (FGF23) by non-malignant mesenchymal tumors causes phosphate wasting and bone fractures. Recent studies have implicated the hypoxia-inducible factor-1α (HIF-1α) in other phosphate wasting disorders caused by elevated FGF23, including X-linked hypophosphatemic rickets and autosomal dominant hypophosphatemia. Here we provide evidence that HIF-1α mediates aberrant FGF23 in TIO by transcriptionally activating its promoter. Immunohistochemical studies in phosphaturic mesenchymal tumors resected from patients with documented TIO showed that HIF-1α and FGF23 were co-localized in spindle-shaped cells adjacent to blood vessels. Cultured tumor tissue produced high levels of intact FGF23 and demonstrated increased expression of HIF-1α protein. Transfection of MC3T3-E1 and Saos-2 cells with a HIF-1α expression construct induced the activity of a FGF23 reporter construct. Prior treatment of tumor organ cultures with HIF-1α inhibitors decreased HIF-1α and FGF23 protein accumulation and inhibited HIF-1α-induced luciferase reporter activity in transfected cells. Chromatin immunoprecipitation assays confirmed binding to a HIF-1α consensus sequence within the proximal FGF23 promoter, which was eliminated by treatment with a HIF-1α inhibitor. These results show for the first time that HIF-1α is a direct transcriptional activator of FGF23 and suggest that upregulation of HIF-1α activity in TIO contributes to the aberrant FGF23 production in these patients.
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Affiliation(s)
- Qian Zhang
- Department of Orthopaedic Surgery, Johns Hopkins University , Baltimore, MD, USA
| | - Michele Doucet
- Department of Orthopaedic Surgery, Johns Hopkins University , Baltimore, MD, USA
| | - Ryan E Tomlinson
- Department of Orthopaedic Surgery, Johns Hopkins University , Baltimore, MD, USA
| | - Xiaobin Han
- Department of Medicine, University of Tennessee Health Science Center , Memphis, TN, USA
| | - L Darryl Quarles
- Department of Medicine, University of Tennessee Health Science Center , Memphis, TN, USA
| | - Michael T Collins
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institutes of Health , Bethesda, MD, USA
| | - Thomas L Clemens
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA; Baltimore Veterans Administration Medical Center, Baltimore, MD, USA
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Bone mineral density decline according to renal tubular dysfunction and phosphaturia in tenofovir-exposed HIV-infected patients. AIDS 2016; 30:1423-31. [PMID: 26919733 DOI: 10.1097/qad.0000000000001067] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The mechanisms underlying the effect of tenofovir disoproxil fumarate (TDF) on the decline of bone mineral density (BMD) have not been established, especially the effect of renal tubular dysfunction. METHODS Longitudinal study of 90 patients with two successive dual X-ray absorptiometry scans after evaluation of serum and urinary parameters (proteinuria, albuminuria, phosphaturia, uricosuria, glycosuria, β-2-microglobulin, and retinol-binding protein). RESULTS After a median of 38 months on TDF, osteopenia at spine and hip was observed in 49 and 48%, and osteoporosis in 9 and 2%, respectively. There was a lineal correlation between BMD at femoral neck and time on TDF (Spearman's rho = -0.27; P = 0.01). One or more tubular abnormalities were observed in 80% of cases (hyperphosphaturia, 50%). A lower BMD correlated with phosphaturia (r = -0.25; P = 0.03), even with phosphataemia within normal limits. In fact, patients with previous improvement in phosphaturia had better BMD at inclusion (Spearman's rho = -0.33; P < 0.01). A second dual X-ray absorptiometry, after a median of 40.8 months (33.8-45.1; 627.7 patients-year on TDF), showed additional BMD reduction at hip in 50% of cases (36% with bone loss >3%), a decline associated with phosphaturia (β, -0.31; P = 0.01) or number of tubular abnormalities (β, -0.41; P = 0.01), but also with use of boosted protease inhibitors (β, -0.47; P = 0.03) and BMD at inclusion (β, -0.33; P = 0.03). CONCLUSION Chronic abnormal phosphaturia explains, at least in part, progressive bone loss during TDF therapy. These data suggest that tubular dysfunction leads to an altered equilibrium between phosphataemia, phosphaturia, and bone as mechanism of progressive BMD decline.
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Goodwin CR, Clarke MJ, Gokaslan ZL, Fisher C, Laufer I, Weber MH, Sciubba DM. En Bloc Resection of Solitary Functional Secreting Spinal Metastasis. Global Spine J 2016; 6:277-83. [PMID: 27099819 PMCID: PMC4836935 DOI: 10.1055/s-0035-1558654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/22/2015] [Indexed: 12/26/2022] Open
Abstract
Study Design Literature review. Objective Functional secretory tumors metastatic to the spine can secrete hormones, growth factors, peptides, and/or molecules into the systemic circulation that cause distinct syndromes, clinically symptomatic effects, and/or additional morbidity and mortality. En bloc resection has a limited role in metastatic spine disease due to the current paradigm that systemic burden usually determines morbidity and mortality. Our objective is to review the literature for studies focused on en bloc resection of functionally active spinal metastasis as the primary indication. Methods A review of the PubMed literature was performed to identify studies focused on functional secreting metastatic tumors to the spinal column. We identified five cases of patients undergoing en bloc resection of spinal metastases from functional secreting tumors. Results The primary histologies of these spinal metastases were pheochromocytoma, carcinoid tumor, choriocarcinoma, and a fibroblast growth factor 23-secreting phosphaturic mesenchymal tumor. Although studies of en bloc resection for these rare tumor subtypes are confined to case reports, this surgical treatment option resulted in metabolic cures and decreased clinical symptoms postoperatively for patients diagnosed with solitary functional secretory spinal metastasis. Conclusion Although the ability to formulate comprehensive conclusions is limited, case reports demonstrate that en bloc resection may be considered as a potential surgical option for the treatment of patients diagnosed with solitary functional secretory spinal metastatic tumors. Future prospective investigations into clinical outcomes should be conducted comparing intralesional resection and en bloc resection for patients diagnosed with solitary functional secretory spinal metastasis.
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Affiliation(s)
- C. Rory Goodwin
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Michelle J. Clarke
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ziya L. Gokaslan
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Charles Fisher
- Department of Orthopaedics, Division of Spine, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Ilya Laufer
- Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States
| | - Michael H. Weber
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Daniel M. Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States,Address for correspondence Daniel M. Sciubba, MD Department of Neurosurgery, The Johns Hopkins University School of Medicine600 North Wolfe Street, Meyer 5-185, Baltimore, MD 21287United States
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Abstract
Tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome resulting in renal phosphate wasting and decreased bone mineralization. TIO is usually induced by small, slowly growing tumors of mesenchymal origin (phosphaturic mesenchymal tumor mixed connective tissue variant [PMTMCT]). Nonspecific symptoms including fatigue, bone pain, and musculoskeletal weakness make the diagnosis elusive and often lead to a delay in treatment. The prognosis of TIO is excellent following complete resection of the neoplasm, which leads to the rapid and complete reversal of all symptoms. If the tumor cannot be detected, treatment relies on supplementation with phosphate and active vitamin D compounds. Subsequent radiotherapy in case of incompletely resected tumors or definitive radiotherapy in unresectable tumors is an important treatment option to avoid recurrence or metastasis even though this occurs rarely. Due to the risk of recurrence or late metastases, long-term monitoring is required even in TIO patients diagnosed with a benign tumor.
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Comparison of 18F-FDG and 68Ga DOTATATE PET/CT in localization of tumor causing oncogenic osteomalacia. Clin Nucl Med 2015; 40:e6-e10. [PMID: 24999675 DOI: 10.1097/rlu.0000000000000460] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, usually caused by small benign mesenchymal tumors. The localization of these tumors is challenging, however, essential for the management. We compared the utility of F-FDG PET/CT and Ga DOTATATE PET/CT to detect the site of primary tumor in patients with suspicion of TIO. PATIENTS AND METHODS Retrospective analysis of 6 patients with hypophosphatemic osteomalacia and suspicion of TIO was performed. Ga DOTATATE PET/CT study was performed in all 6 patients to localize the tumor. F-FDG PET/CT was performed in 4 of 6 patients. F-FDG and Ga DOTATATE PET/CT studies were performed within 1 week of each other. Both studies were interpreted blindly without the knowledge of other imaging findings. RESULTS All patients had symptoms of osteomalacia and hypophosphatemia. All except 1 patient had increased level of fibroblast growth factor 23. The lag time (symptoms to PET diagnosis) ranged from 1.5 to 22 years. In 4 patients, where both studies were performed, F-FDG and Ga DOTATATE PET/CT were able to localize the tumor in 2 and 3 patients. Ga DOTATATE PET/CT detected tumor in 5 (83.3%) of 6 patients. CONCLUSIONS Ga DOTATATE PET/CT performed better than F-FDG PET/CT and is useful in the detection of tumors causing oncogenic osteomalacia. Therefore, in clinically suspected cases of hypophosphatemic osteomalacia, Ga DOTATATE PET/CT may be performed as first-line imaging investigation to avoid delay in the treatment of this devastating but curable disease. However, further studies with large patient population are warranted to validate our data.
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Sun ZJ, Jin J, Qiu GX, Gao P, Liu Y. Surgical treatment of tumor-induced osteomalacia: a retrospective review of 40 cases with extremity tumors. BMC Musculoskelet Disord 2015; 16:43. [PMID: 25879543 PMCID: PMC4349610 DOI: 10.1186/s12891-015-0496-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/11/2015] [Indexed: 01/29/2023] Open
Abstract
Background Tumor-induced osteomalacia (TIO) is a rare syndrome typically caused by mesenchymal tumors. It has been shown that complete tumor resection may be curative. However, to our knowledge, there has been no report of a large cohort to exam different surgical approaches. This study was aimed to assess outcomes of different surgical options of patients with tumor-induced osteomalacia at a single institution. Methods Patients with extremity tumors treated in our hospital from January, 2004 to July, 2012 were identified. The minimum follow-up period was 12 months. Patient’s demography, tumor location, preoperative preparation, type of surgeries were summarized, and clinical outcomes were recorded. Successful treatment was defined as significant symptom improvement, normal serum phosphorus and significant improvement or normalization of bone mineral density at the last follow-up. Differences between patients with soft tissue tumors and bone tumors were compared. Results There were 40 (24 male and 16 female) patients identified, with an average age of 44 years. The tumors were isolated in either soft tissue (25 patients) or bone (12 patients) and combined soft tissue and bone invasion was observed in 3 patients. For the primary surgery, tumor resection and tumor curettage were performed. After initial surgical treatment, six patients then received a second surgery. Four patients were found to have malignant tumors base on histopathology. With a minimum follow-up period of 12 months, 80% of patients (32/40) were treated successfully, including 50% of patients (2/4) with malignant tumors. Compared to patients with bone tumor, surgical results were better in patient with soft tissue tumor. Conclusions Surgical treatment was an effective way for TIO. Other than tumor curettage surgery, tumor resection is the preferred options for these tumors.
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Affiliation(s)
- Zhi-jian Sun
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District Shuaifuyuan No.1, Beijing, 100730, China.
| | - Jin Jin
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District Shuaifuyuan No.1, Beijing, 100730, China.
| | - Gui-xing Qiu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District Shuaifuyuan No.1, Beijing, 100730, China.
| | - Peng Gao
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District Shuaifuyuan No.1, Beijing, 100730, China.
| | - Yong Liu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District Shuaifuyuan No.1, Beijing, 100730, China.
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Tumor-Induced Osteomalacia: Increased Level of FGF-23 in a Patient with a Phosphaturic Mesenchymal Tumor at the Tibia Expressing Periostin. Case Rep Endocrinol 2014; 2014:729387. [PMID: 25221676 PMCID: PMC4158256 DOI: 10.1155/2014/729387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/11/2014] [Accepted: 08/12/2014] [Indexed: 01/12/2023] Open
Abstract
In our case, a 45-year-old male patient had multiple fractures accompanied by hypophosphatemia. FGF-23 levels were significantly increased, and total body magnetic resonance imaging (MRI) revealed a tumor mass located at the distal tibia leading to the diagnosis of tumor-induced osteomalacia (TIO). After resection of the tumor, hypophosphatemia and the increased levels of FGF-23 normalized within a few days. Subsequent microscopic examination and immunohistochemical analysis revealed a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT) showing a positive expression of somatostatin receptor 2A (SSTR2A), CD68, and Periostin. Electron microscopy demonstrated a poorly differentiated mesenchymal tumor with a multifocal giant cell component and evidence of neurosecretory-granules. However, the resected margins showed no tumor-free tissue, and therefore a subsequent postoperative radiotherapy was performed. The patient is still in complete remission after 34 months. Tumor resection of PMTMCTs is the therapy of choice. Subsequent radiotherapy in case of incompletely resected tumors can be an important option to avoid recurrence or metastasis even though this occurs rarely. The prognostic value of expression of Periostin has to be evaluated more precisely in a larger series of patients with TIO.
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Pithankuakul K, Ratanasuwan T, Thanakit V, Sukhantanak B, Kiatisevi P. Oncogenic osteomalacia caused by phosphaturic mesenchymal tumours in the proximal and shaft of the tibia: a case report. J Orthop Surg (Hong Kong) 2014; 22:257-62. [PMID: 25163969 DOI: 10.1177/230949901402200231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Oncogenic osteomalacia is caused by a small mesenchymal tumour characterised by phosphaturia, hypophosphatemia, decreased serum vitamin D3 level, and osteomalacia. Phosphaturic mesenchymal tumour of the mixed connective tissue type (PMTMCT) is the commonest subtype and usually involves a single site. We report a case of PMTMCT involving the left proximal and shaft of the tibia in a 42-year-old man.
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Affiliation(s)
- Kongkit Pithankuakul
- Orthopedic Oncology Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
| | - Tanaporn Ratanasuwan
- Endocrine Unit, Department of Internal Medicine, Lerdsin General Hospital, Bangkok, Thailand
| | - Voranuch Thanakit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bhasanan Sukhantanak
- Orthopedic Oncology Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
| | - Piya Kiatisevi
- Orthopedic Oncology Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
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Abstract
Teeth are mineralized organs composed of three unique hard tissues, enamel, dentin, and cementum, and supported by the surrounding alveolar bone. Although odontogenesis differs from osteogenesis in several respects, tooth mineralization is susceptible to similar developmental failures as bone. Here we discuss conditions fitting under the umbrella of rickets, which traditionally referred to skeletal disease associated with vitamin D deficiency but has been more recently expanded to include newly identified factors involved in endocrine regulation of vitamin D, phosphate, and calcium, including phosphate-regulating endopeptidase homolog, X-linked, fibroblast growth factor 23, and dentin matrix protein 1. Systemic mineral metabolism intersects with local regulation of mineralization, and factors including tissue nonspecific alkaline phosphatase are necessary for proper mineralization, where rickets can result from loss of activity of tissue nonspecific alkaline phosphatase. Individuals suffering from rickets often bear the additional burden of a defective dentition, and transgenic mouse models have aided in understanding the nature and mechanisms involved in tooth defects, which may or may not parallel rachitic bone defects. This report reviews dental effects of the range of rachitic disorders, including discussion of etiologies of hereditary forms of rickets, a survey of resulting bone and tooth mineralization disorders, and a discussion of mechanisms, known and hypothesized, involved in the observed dental pathologies. Descriptions of human pathology are augmented by analysis of transgenic mouse models, and new interpretations are brought to bear on questions of how teeth are affected under conditions of rickets. In short, the rachitic tooth will be revealed.
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Affiliation(s)
- Brian L Foster
- National Institute for Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland 20892
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Piemonte S, Romagnoli E, Cipriani C, De Lucia F, Pilotto R, Diacinti D, Pepe J, Minisola S. Six-year follow-up of a characteristic osteolytic lesion in a patient with tumor-induced osteomalacia. Eur J Endocrinol 2014; 170:K1-4. [PMID: 24144968 DOI: 10.1530/eje-13-0581] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia is a rare paraneoplastic syndrome characterized by hypophosphatemia and inappropriately normal or low 1,25-dihydroxyvitamin D. CLINICAL CASE Here, we report a 6-year postoperative follow-up of a patient with oncogenic osteomalacia with a distinctive skeletal manifestation. The latter was characterized by an almost linear lytic lesion of a few millimeters with irregular borders, mainly involving the trabecular compartment but extending into cortical shell, located in the middle third of the right fibula. Six years after tumor resection, a sclerotic repair with a complete recovery was observed. Furthermore, we monitored a striking increase in bone mineral density throughout the observation period, reaching a peak of 73% over basal values at lumbar spine after 2 years; at total femur and radius, the peak was 47.5 and 4.6% respectively, after 4 years from tumor resection. CONCLUSIONS We report for the first time that an osteolytic lesion may be part of the skeletal involvement in tumor-induced osteomalacia.
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Affiliation(s)
- Sara Piemonte
- Departments ofInternal Medicine and Medical Disciplines
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Sood A, Agarwal K, Shukla J, Goel R, Dhir V, Bhattacharya A, Rai Mittal B. Bone scintigraphic patterns in patients of tumor induced osteomalacia. Indian J Nucl Med 2013; 28:173-5. [PMID: 24250028 PMCID: PMC3822419 DOI: 10.4103/0972-3919.119541] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Tumor induced osteomalacia (TIO) or oncogenic osteomalacia is a rare condition associated with small tumor that secretes one of the phosphaturic hormones, i.e., fibroblast growth factor 23, resulting in abnormal phosphate metabolism. Patients may present with non-specific symptoms leading to delay in the diagnosis. Extensive skeletal involvement is frequently seen due to delay in the diagnosis and treatment. The small sized tumor and unexpected location make the identification of tumor difficult even after diagnosis of osteogenic osteomalacia. The bone scan done for the skeletal involvement may show the presence of metabolic features and the scan findings are a sensitive indicator of metabolic bone disorders. We present the bone scan findings in three patients diagnosed to have TIO.
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Affiliation(s)
- Ashwani Sood
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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44
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Thoracic phosphaturic mesenchymal tumors causing oncogenic osteomalacia. J Clin Neurosci 2013; 20:1057-61. [DOI: 10.1016/j.jocn.2012.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 09/15/2012] [Indexed: 11/22/2022]
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Cantalejo Moreira M, Veiga Cabello RM, Ruiz Giardín JM. Osteomalacia provocada por un tumor hiperfosfatúrico. ACTA ACUST UNITED AC 2013; 9:250-1. [DOI: 10.1016/j.reuma.2012.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 10/26/2022]
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Abstract
Oncogenic osteomalacia is a rare paraneoplastic syndrome of systemic bone demineralization secondary to a tumor-induced dysregulation of phosphorus metabolism. The tumor's low prevalence, small size, and variable location often result in years of muscular weakness and bone pain before diagnosis. With complete treatment, patient's symptoms swiftly dissipate. We report the case of a 63-year-old previously healthy man with a 20-month course of musculoskeletal symptoms before diagnosis and resection of a posterior tibial tumor. Postoperatively, the patient had returned to his previous lifestyle when an insufficiency fracture required prophylactic stabilization.
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Chong WH, Andreopoulou P, Chen CC, Reynolds J, Guthrie L, Kelly M, Gafni RI, Bhattacharyya N, Boyce AM, El-Maouche D, Crespo DO, Sherry R, Chang R, Wodajo FM, Kletter GB, Dwyer A, Collins MT. Tumor localization and biochemical response to cure in tumor-induced osteomalacia. J Bone Miner Res 2013; 28:1386-98. [PMID: 23362135 PMCID: PMC3900247 DOI: 10.1002/jbmr.1881] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/10/2013] [Accepted: 01/17/2013] [Indexed: 01/17/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare disorder of phosphate wasting due to fibroblast growth factor-23 (FGF23)-secreting tumors that are often difficult to locate. We present a systematic approach to tumor localization and postoperative biochemical changes in 31 subjects with TIO. All had failed either initial localization, or relocalization (in case of recurrence or metastases) at outside institutions. Functional imaging with ¹¹¹Indium-octreotide with single photon emission computed tomography (octreo-SPECT or SPECT/CT), and ¹⁸fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) were performed, followed by anatomic imaging (CT, MRI). Selective venous sampling (VS) was performed when multiple suspicious lesions were identified or high surgical risk was a concern. Tumors were localized in 20 of 31 subjects (64.5%). Nineteen of 20 subjects underwent octreo-SPECT imaging, and 16 of 20 FDG-PET/CT imaging. Eighteen of 19 (95%) were positive on octreo-SPECT, and 14 of 16 (88%) on FDG-PET/CT. Twelve of 20 subjects underwent VS; 10 of 12 (83%) were positive. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were as follows: sensitivity = 0.95, specificity = 0.64, PPV = 0.82, and NPV = 0.88 for octreo-SPECT; sensitivity = 0.88, specificity = 0.36, PPV = 0.62, and NPV = 0.50 for FDG-PET/CT. Fifteen subjects had their tumor resected at our institution, and were disease-free at last follow-up. Serum phosphorus returned to normal in all subjects within 1 to 5 days. In 10 subjects who were followed for at least 7 days postoperatively, intact FGF23 (iFGF23) decreased to near undetectable within hours and returned to the normal range within 5 days. C-terminal FGF23 (cFGF23) decreased immediately but remained elevated, yielding a markedly elevated cFGF23/iFGF23 ratio. Serum 1,25-dihydroxyvitamin D₃ (1,25D) rose and exceeded the normal range. In this systematic approach to tumor localization in TIO, octreo-SPECT was more sensitive and specific, but in many cases FDG-PET/CT was complementary. VS can discriminate between multiple suspicious lesions and increase certainty prior to surgery. Sustained elevations in cFGF23 and 1,25D were observed, suggesting novel regulation of FGF23 processing and 1,25D generation.
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Affiliation(s)
- William H Chong
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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Jamal SA, Dickson BC, Radziunas I. Tumour induced osteomalacia due to a sinonasal hemangiopericytoma: A case report. World J Clin Cases 2013; 1:59-63. [PMID: 24303466 PMCID: PMC3845926 DOI: 10.12998/wjcc.v1.i1.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/05/2013] [Accepted: 03/09/2013] [Indexed: 02/05/2023] Open
Abstract
Tumour induced osteomalacia (TIO) is a rare and often unrecognized cause of hypophosphatemia. We report on a case of TIO due to a hemangiopericytoma originating from the left nasal sinus. The patient was a 55-year-old male with a 3-year history of left hip pain and an undisplaced left hip fracture. Biochemical testing demonstrated low levels of serum phosphate and serum 1,25-dihydroxyvitamin D, and an elevated level of fibroblast growth factor 23. Octreotide scanning demonstrated uptake in the left nasal sinus area and a computed tomography scan revealed a left nasal sinus mass. The patient underwent surgical resection of the mass and histology was consistent with a sinonasal hemangiopericytoma. His serum phosphate levels normalized almost immediately after surgery and he had complete resolution of hip pain. Our case highlights the importance of considering TIO when assessing patients with low serum phosphate.
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Chiam P, Tan HC, Bee YM, Chandran M. Oncogenic osteomalacia -- hypophosphataemic spectrum from "benignancy" to "malignancy". Bone 2013; 53:182-7. [PMID: 23220596 DOI: 10.1016/j.bone.2012.11.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 11/27/2012] [Accepted: 11/29/2012] [Indexed: 12/24/2022]
Abstract
Though case reports and case series about oncogenic osteomalacia due to benign mesenchymal tumours and much more rarely, secondary to malignant ones exist in the literature, there has not been any series reported from a single department spanning the gamut of causes from benign to malignant. We present 3 patients who were seen at the department of endocrinology of our hospital between 2010 and 2012 with hypophosphataemia and severe skeletal complications. All of them were found to have oncogenic osteomalacia otherwise known as tumour induced osteomalacia (TIO) - a paraneoplastic syndrome characterised by renal phosphate wasting and severe hypophosphataemia. The implicating tumours in our patients ranged from a subcutaneous mesenchymal tumour in the heel to a mixed connective tissue variant within the nasal cavity to metastatic prostate cancer. All our patients had protracted periods before the diagnosis was made, during which time the burden of their metabolic and skeletal pathology had increased. A timely recognition of the clinical features and biochemical findings of this rare but potentially debilitating disease is critical. Physicians should be cognizant of the presence of the disease and its localising and treatment strategies.
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Affiliation(s)
- P Chiam
- Department of Endocrinology, Singapore General Hospital, Outram Road, Singapore
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Tumor-induced osteomalacia caused by primary fibroblast growth factor 23 secreting neoplasm in axial skeleton: a case report. Case Rep Endocrinol 2012; 2012:185454. [PMID: 23346426 PMCID: PMC3533608 DOI: 10.1155/2012/185454] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 11/26/2012] [Indexed: 01/19/2023] Open
Abstract
We report the case of a 66-year-old woman with tumor-induced osteomalacia (TIO) caused by fibroblast growth factor 23 (FGF-23) secreting mesenchymal tumor localized in a lumbar vertebra and review other cases localized to the axial skeleton. She presented with nontraumatic low back pain and spontaneous bilateral femur fractures. Laboratory testing was remarkable for low serum phosphorus, phosphaturia, and significantly elevated serum FGF-23 level. Magnetic resonance imaging (MRI) of the lumbar spine showed a focal lesion in the L-4 vertebra which was hypermetabolic on positron emission tomography (PET) scan. A computed tomography (CT) guided needle biopsy showed a low grade spindle cell neoplasm with positive FGF-23 mRNA expression by reverse transcriptase polymerase chain reaction (RT-PCR), confirming the diagnosis of a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT). The patient elected to have surgery involving anterior resection of L-4 vertebra with subsequent normalization of serum phosphorus. Including the present case, we identified 12 cases of neoplasms localized to spine causing TIO. To our knowledge, this paper represents the first documented case of lumbar vertebra PMT causing TIO. TIO is a rare metabolic bone disorder that carries a favorable prognosis. When a lesion is identifiable, surgical intervention is typically curative.
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