1
|
Sánchez Muñoz R, Sanmillan JL, Vidal Sarró N, Martín Quintero G, Martí Duce D, Gabarrós Canals A. Intracranial Phosphaturic Mesenchymal Tumors: A Systematic Literature Review of a Rare Entity. World Neurosurg 2024; 187:70-81. [PMID: 38561034 DOI: 10.1016/j.wneu.2024.03.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Phosphaturic Mesenchymal Tumors (PMTs) are rare mesenchymal neoplasms known for producing Tumor-induced Osteomalacia (TIO). TIO is an uncommon paraneoplastic syndrome characterized by radiographic evidence of inadequate bone mineralization and analytical abnormalites. METHODS We sought to present a case of TIO caused by skull base PMT with intracranial extension, manifesting with pain, progressive weakness, and multiple bone fractures. Furthermore, a systematic review was performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A search was conducted in PubMed database with title/abstract keywords "Phosphaturic mesenchymal tumor" and "Osteomalacia." Search results were reviewed looking for intracranial or skull base tumors. RESULTS Our systematic review included 29 reported cases of intracranial PMT. In the reviewed cases there was a significative female predominance with 22 cases (75,86%). Osteomalacia was presented in 25 cases (86,20%). Bone fractures were present in 10 cases (34,48%). The most common site of involvement was the anterior cranial fossa in 14 cases (48,27%). Surgery was performed in 27 cases (93,10%) with previous tumor embolization in 4 cases (13,79%). Total recovery of the presenting symptoms in the first year was achieved in 21 cases (72,41%). Recurrence of the disease was described in 6 cases (25%). CONCLUSIONS Skull base PMTs with intracranial extension are extremely rare tumors. Most patients are middle-aged adults with a PMT predominantly located in anterior cranial fossa. Surgery is the current treatment of choice with optimal outcome at 1-year follow-up, although recurrence could be present in almost 25% of the cases.
Collapse
Affiliation(s)
- Raúl Sánchez Muñoz
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Noemi Vidal Sarró
- Department of Pathology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Martín Quintero
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Daniel Martí Duce
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Andreu Gabarrós Canals
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| |
Collapse
|
2
|
Kojima D, Ohba S, Abe M, Suzuki A, Horibe S, Tateya I, Hasegawa M, Hirose Y. Intracranial phosphaturic mesenchymal tumors. A case report and review of literature. Neuropathology 2022; 42:453-458. [PMID: 35880350 DOI: 10.1111/neup.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
Most osteomalacia-inducing tumors (OITs) are phosphaturic mesenchymal tumors (PMTs) that secrete fibroblast growth factor 23 (FGF23). These tumors usually occur in the bone and soft tissues, and intracranial OITs are rare. Therefore, intracranial OIT is difficult to diagnose and treat. This paper presents a case of intracranial OIT and shows a review of previous cases. A 45-year-old man underwent nasal cavity biopsy and treatment with active vitamin D3 and neutral phosphate for hypophosphatemia. Amplification of FGF23 mRNA level within the tumor was detected. Subsequently, the surgical specimen was diagnosed with a PMT and was considered the cause of the patient's osteomalacia. The patient was referred to a neurosurgery department for the excision of the intracranial tumor extending to the nasal cavity. After tumor removal, the serum levels of FGF23 and phosphorus were normalized as compared to preoperative those. The patient remains disease-free, without additional treatment, approximately 10 years after surgery, with no tumor recurrence. As per the literature, intracranial OITs usually occur in patients aged 8-69 years. Bone and muscle pain are major complaints. Approximately 60% of the patients reported previously had symptoms because of intracranial tumors. In some cases, it took several years to diagnose OIT after the onset of the osteomalacia symptoms. Laboratory data in such cases show hypophosphatemia and elevated FGF23 levels. Because FGF23 levels are associated with the severity of osteomalacia symptoms, total tumor resection is recommended. PMT and hemangiopericytoma (HPC) are histologically similar, but on immunochemistry, PMT is negative for signal transducer and activator of transcription 6 (STAT6), whereas HPC is positive. FGF23 amplification is seen in PMTs but not in HPCs. Therefore, the analysis of FGF23 and STAT6 was helpful in distinguishing PMTs from HPCs. In cases of hypophosphatemia and osteomalacia without a history of metabolic, renal, or malabsorptive diseases, the possibility of oncogenic osteomalacia should be considered.
Collapse
Affiliation(s)
- Daijiro Kojima
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Shigeo Ohba
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Masato Abe
- Department of Pathology, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Seiji Horibe
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Ichiro Tateya
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | | | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| |
Collapse
|
3
|
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.
Collapse
|
4
|
Hadelsberg UP, Doviner V, Frankel M, Gonen L, Munter G, Margalit N. A rare brain tumor encountered: Phosphaturic mesenchymal tumor. Case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2018.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Wu H, Bui MM, Zhou L, Li D, Zhang H, Zhong D. Phosphaturic mesenchymal tumor with an admixture of epithelial and mesenchymal elements in the jaws: clinicopathological and immunohistochemical analysis of 22 cases with literature review. Mod Pathol 2019; 32:189-204. [PMID: 30206408 DOI: 10.1038/s41379-018-0100-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
Abstract
Information on the heterogeneity of phosphaturic mesenchymal tumor, a rare entity associated with tumor-induced osteomalacia, is limited. In this retrospective analysis of 222 phosphaturic mesenchymal tumors, 22 cases exhibited mixed mesenchymal and epithelial elements, which we propose to term "phosphaturic mesenchymal tumor, mixed epithelial, and connective tissue type." Phosphaturic mesenchymal tumor of the mixed epithelial and connective tissue type showed a distinctive and significant male predominance (male:female = 2.67:1), with most patients diagnosed at <40 years old. Moreover, all tumors were mainly located in the alveolar bone with focal invasion into surrounding soft tissue and oral mucosa, which could be detected preoperatively by oral examination. The mesenchymal component, composed of spindled cells resembling fibroblasts or myofibroblasts arranged in a storiform or fascicular pattern, exhibited a less prominent vasculature and lower cellularity than the typical phosphaturic mesenchymal tumor (mixed connective tissue type). The epithelial component was typically haphazardly and diffusely distributed throughout the tumor, forming small, irregular nests resembling odontogenic epithelial nests. All cases were immunoreactive for fibroblast growth factor-23, somatostatin receptor 2A, and NSE in both components. Mostly also demonstrated positive staining for CD99 (21/22, 96%), CD56 (16/22, 73%), Bcl-2 (21/22, 96%), and D2-40 (19/22, 86%) in one or both components. S100 was positive in both components in one of seven cases. Interestingly, immunoreactivity was typically stronger and more diffuse in the epithelial than in the paired mesenchymal components. The mesenchymal component was also diffusely positive for CD68 (17/17, 100%) and showed variable focal staining for SMA (15/22, 68%) and CD34 (9/19, 47 %). These results indicate that phosphaturic mesenchymal tumor of the mixed epithelial and connective tissue type has distinctive clinicopathological characteristics and a polyimmunophenotypic profile.
Collapse
Affiliation(s)
- Huanwen Wu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Marilyn M Bui
- Department of Anatomic Pathology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Dongmei Li
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Hui Zhang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Dingrong Zhong
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.
| |
Collapse
|
7
|
Shi Z, Deng Y, Li X, Li Y, Cao D, Coossa VS. CT and MR imaging features in phosphaturic mesenchymal tumor-mixed connective tissue: A case report. Oncol Lett 2018; 15:4970-4978. [PMID: 29552133 PMCID: PMC5840497 DOI: 10.3892/ol.2018.7945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/19/2017] [Indexed: 01/25/2023] Open
Abstract
Phosphaturic mesenchymal tumor-mixed connective tissue (PMT-MCT) is rare and usually benign and slow-growing. The majority of these tumors is associated with sporadic tumor-induced osteomalacia (TIO) or rickets, affect middle-aged individuals and are located in the extremities. Previous imaging studies often focused on seeking the causative tumors of TIO, not on the radiological features of these tumors, especially magnetic resonance imaging (MRI) features. PMT-MCT remains a largely misdiagnosed, ignored or unknown entity by most radiologists and clinicians. In the present case report, a review of the known literature of PMT-MCT was conducted and the CT and MRI findings from three patient cases were described for diagnosing the small subcutaneous tumor. Typical MRI appearances of PMT-MCT were isointense relative to the muscles on T1-weighted imaging, and markedly hyperintense on T2-weighted imaging containing variably flow voids, with markedly heterogeneous/homogenous enhancement on post contrast T1-weighted fat-suppression imaging. Short time inversion recovery was demonstrated to be the optimal sequence in localizing the tumor.
Collapse
Affiliation(s)
- Zhenshan Shi
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yiqiong Deng
- Department of Radiology, Fuzhou Children's Hospital, Fuzhou, Fujian 350005, P.R. China
| | - Xiumei Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yueming Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Dairong Cao
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | | |
Collapse
|
8
|
Ellis MB, Gridley D, Lal S, Nair GR, Feiz-Erfan I. Phosphaturic mesenchymal tumor of the brain without tumor-induced osteomalacia in an 8-year-old girl: case report. J Neurosurg Pediatr 2016; 17:573-7. [PMID: 26722864 DOI: 10.3171/2015.9.peds14617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Phosphaturic mesenchymal tumor (mixed connective tissue variant) (PMT-MCT) are tumors that may cause tumor-induced osteomalacia and rarely appear intracranially. The authors describe the case of an 8-year-old girl who was found to have PMT-MCT with involvement of the cerebellar hemisphere and a small tumor pedicle breaching the dura mater and involving the skull. This was removed surgically in gross-total fashion without further complication. Histologically the tumor was confirmed to be a PMT-MCT. There was no evidence of tumor-induced osteomalacia. At the 42-month follow-up, the patient is doing well, has no abnormalities, and is free of recurrence. PMT-MCTs are rare tumors that may involve the brain parenchyma. A gross-total resection may be effective to cure these lesions.
Collapse
Affiliation(s)
| | | | | | - Geetha R Nair
- Pathology, The University of Arizona College of Medicine-Phoenix, Maricopa Medical Center, Phoenix, Arizona
| | | |
Collapse
|
9
|
Fathalla H, Cusimano M, Di Ieva A, Karamchandani J, Fung R, Kovacs K. Osteomalacia-Inducing Tumors of the Brain: A Case Report, Review and a Hypothesis. World Neurosurg 2015; 84:189.e1-5. [DOI: 10.1016/j.wneu.2015.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 12/31/2022]
|
10
|
Deep NL, Cain RB, McCullough AE, Hoxworth JM, Lal D. Sinonasal phosphaturic mesenchymal tumor: Case report and systematic review. ALLERGY & RHINOLOGY 2015; 5:162-7. [PMID: 25565053 PMCID: PMC4275463 DOI: 10.2500/ar.2014.5.0100] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We report a case of sinonasal phosphaturic mesenchymal tumor (PMT) and conduct a systematic review of the literature to highlight a unique paraneoplastic syndrome associated with PMT. We used English language publications from Medline and Cochrane databases (1970-2013) as data sources. A systematic review of the literature was conducted. All reported cases of head and neck PMTs were included. The presence or absence of the associated paraneoplastic syndrome was noted. We found 33 cases of PMT in the head and neck reported in the literature, 17 of which occurred in the sinonasal area. Approximately 5% of all PMTs are located in the head and neck. Just greater than half are concentrated in the sinonasal area, and the remaining involve various bony and soft tissue structures of the head and neck. PMT is sometimes associated with a paraneoplastic syndrome of tumor-induced (oncogenic) osteomalacia (TIO) causing bone pain, muscle weakness, and pathologic fractures. We present the 18th reported case of sinonasal PMT. A smooth mucosa-covered midline intraseptal mass filling the posterior nasal cavity with destruction and erosion of the skull base was found in an adult male. The patient underwent successful endoscopic resection with wide negative margins and is without recurrence at 24-month follow-up. PMT is a benign, locally aggressive tumor with rare malignant transformation. Knowledge of the bony invasion and destruction caused by this tumor is essential in planning surgical resection with wide negative margins. Familiarity with the associated TIO is essential to investigate for and manage any associated bony morbidity.
Collapse
Affiliation(s)
- Nicholas L Deep
- Department of Otorhinolaryngology, Mayo Clinic, Phoenix, Arizona, USA
| | | | | | | | | |
Collapse
|
11
|
Tarasova VD, Trepp-Carrasco AG, Thompson R, Recker RR, Chong WH, Collins MT, Armas LAG. Successful treatment of tumor-induced osteomalacia due to an intracranial tumor by fractionated stereotactic radiotherapy. J Clin Endocrinol Metab 2013; 98:4267-72. [PMID: 24014621 PMCID: PMC5399525 DOI: 10.1210/jc.2013-2528] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CONTEXT Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, characterized by tumor secretion of fibroblast growth factor-23 (FGF23) causing hypophosphatemia due to renal phosphate wasting. TIO is usually caused by small, benign, difficult-to-localize, mesenchymal tumors. Although surgery with wide excision of tumor borders is considered the "gold standard" for definitive therapy, it can be associated with considerable morbidity depending on the location. To date, radiation therapy has not been considered as an effective treatment modality in TIO. OBJECTIVE A 67-year-old female presented with multiple nontraumatic fractures, progressive bone pain, and muscle weakness for 4 years. She was found to have biochemical evidence of urinary phosphate wasting with low serum phosphorus, low-normal serum calcium, normal 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, and high serum FGF23 levels. TIO was diagnosed. Selective venous sampling for FGF23 confirmed that a 1.7-cm left frontal mass, radiographically similar to a meningioma, was the causative tumor. She declined surgery due to fear of complications and instead underwent fractionated stereotactic radiotherapy for 6 weeks. RESULTS In less than 4 years after radiation therapy, she was successfully weaned off phosphorus and calcitriol, starting from 2 g of oral phosphorus daily and 1 μg of calcitriol daily. Her symptoms have resolved, and she has not had any new fractures. CONCLUSIONS Stereotactic radiotherapy was an effective treatment modality for TIO in our patient. Fractionated stereotactic radiation therapy represents an alternative to surgery for patients with TIO who are not surgical candidates or who decline surgery.
Collapse
|