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Kato H, Kimura S, Taguchi M, Sunouchi T, Hoshino Y, Hidaka N, Edvige Foligno N, Koga M, Manaka K, Tamiya H, Kawakami M, Kage H, Yasunaga Y, Nangaku M, Makita N, Ito N. FGF23-related hypophosphatemia in a patient with small cell lung cancer: a case report and literature review. Endocr J 2023; 70:1005-1013. [PMID: 37468265 DOI: 10.1507/endocrj.ej23-0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Although there are a few case reports of patients with small cell lung cancer developing hypophosphatemia, detailed information on this condition is scarce. A 52-year-old patient with advanced stage small cell lung cancer developed hypophosphatemia (1.1 mg/dL) during chemotherapy. A reduced level of the tubular reabsorption of phosphate concomitant with an inappropriately elevated level of fibroblast growth factor (FGF) 23 (48.4 pg/mL) was noted, leading to the diagnosis of FGF23-related hypophosphatemia. Laboratory data also showed hypercortisolemia with an elevated ACTH level and hyponatremia with an inappropriately unsuppressed level of antidiuretic hormone (ADH). These data suggested the overproduction of FGF23 in addition to ACTH and ADH. Because the octreotide loading test did not present a suppressive effect on ACTH or FGF23 levels, the patient was treated with phosphate supplementation, active vitamin D and metyrapone, which partially improved the serum phosphate and cortisol levels. Even after two subsequent courses of chemotherapy, the small cell lung cancer progressed, and the FGF23 level was further elevated (83.7 pg/mL). Although it is very rare, FGF23-related hypophosphatemia is one of the hormonal disturbances that could be observed in patients with small cell lung cancer. This article reviews similar clinical conditions and revealed that advanced states of malignancy seemed to be associated with the development of renal wasting hypophosphatemia, especially in lung cancer and prostate cancer. Therefore, the parameters related to hypophosphatemia should be monitored in patients with advanced small cell lung cancer to prevent the development of hypophosphatemic osteomalacia.
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Affiliation(s)
- Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Soichiro Kimura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Maho Taguchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Takashi Sunouchi
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Nadia Edvige Foligno
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Nephrology and Dialysis Unit, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Katsunori Manaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Hiroyuki Tamiya
- Department of Respiratory Medicine, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masanori Kawakami
- Department of Respiratory Medicine, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Hidenori Kage
- Department of Respiratory Medicine, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yoichi Yasunaga
- Department of Pathology, Graduate School of Medicine, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo 113-8655, Japan
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Abstract
X-linked hypophosphatemia (XLH) is caused by mutations in the PHEX gene which result in Fibroblast Growth Factor-23 (FG-F23) excess and phosphate wasting. Clinically, XLH children present with rickets, bone deformities and short stature. In adulthood, patients may still be symptomatic with bone and joint pain, osteomalacia-related fractures or pseudofractures, precocious osteoarthrosis, enthesopathy, muscle weakness and severe dental anomalies. Besides these musculoskeletal and dental manifestations, adult XLH patients are also prone to secondary and tertiary hyperparathyroidism, cardiovascular and metabolic disorders. Pathophysiology of hyperparathyroidism is only partially understood but FGF23 excess and deficient production of calcitriol likely contributes to its development. Similarly, the pathophysiological mechanisms of potential cardiovascular and metabolic involvements are not clear, but FGF-23 excess may play an essential role. Treatment should be considered in symptomatic patients, patients undergoing orthopedic or dental surgery and women during pregnancy and lactation. Treatment with oral phosphate salts and active vitamin D analogs has incomplete efficacy and potential risks. Burosumab, a recombinant human monoclonal antibody against FGF-23, has proven its efficacy in phase 2 and phase 3 clinical trials in adult patients with XLH, but currently its position as first line or second line treatment differ among the countries.
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Affiliation(s)
- Anne-Lise Lecoq
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, University Hospital of Florence, Florence, Italy
| | - Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- AP-HP, Department of Endocrinology and Reproductive Diseases, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, filière OSCAR, and Platform of Expertise for Rare Disorders, Bicêtre Paris Saclay Hospital, Le Kremlin-Bicêtre, France; Université Paris-Saclay, INSERM, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.
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