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Dehghani M, Dabbaghmanesh MH, Khalafi-Nezhad A, Riazmontazer N, Dehghanian A, Vojdani R, Sasani M. Glomus tumor as a cause of oncogenic osteomalacia. ACTA ACUST UNITED AC 2017; 14:359-362. [PMID: 29354168 DOI: 10.11138/ccmbm/2017.14.3.359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Many tumors that occasionally are benign in origin causes hypophosphatemic osteomalacia. Here we present a case of glomus tumor in a 59-year-old man with oncogenic osteomalacia. Diagnosis was made after observation of abnormal increase activity in octreotide scan. The magnetic resonance imaging showed a round lesion in left ankle joint. Surgical excision of tumor was curative and all symptoms and intractable hypophosphatemia improved after few weeks.
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Affiliation(s)
- Mehdi Dehghani
- Department of Hematology and Medical oncology, Shiraz University of Medical Sciences, Hematology Research Center, Shiraz, Iran
| | - Mohammad Hossien Dabbaghmanesh
- Shiraz Endocrinology and Metabolism Research Center, College of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abolfazele Khalafi-Nezhad
- Department of Hematology and Medical oncology, Shiraz University of Medical Sciences, Hematology Research Center, Shiraz, Iran
| | - Nader Riazmontazer
- Department of Pathology, Shiraz University of Medical Sciences, Trauma Research Center Shiraz, Iran
| | - Amireza Dehghanian
- Department of Pathology, Shiraz University of Medical Sciences, Trauma Research Center Shiraz, Iran
| | - Reza Vojdani
- Department of Hematology and Medical oncology, Shiraz University of Medical Sciences, Hematology Research Center, Shiraz, Iran
| | - Mohammadreza Sasani
- Medical Imaging Research Center, Department of Radiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
RATIONALE Tumor-induced osteomalacia (TIO) is a rare and often misdiagnosed syndrome. Surgical resection is currently the first line treatment for TIO. PATIENT CONCERNS Here we report the case of a 49-year-old woman presented with intermittent pain in the right chest and bilateral hip that had persisted for over two years. DIAGNOSES She was diagnosed of TIO caused by a phosphaturic mesenchymal tumor based on the following examinations. Laboratory tests revealed high serum alkaline phosphatase, high urinary phosphorus, hypophosphatemia and normal serum calcium levels. 18-FDG PET/CT indicated a systemic multi-site symmetrical pseudo fracture and a tumor in the 7th right rib. INTERVENTIONS Curettage of the tumor was performed, and pathological analysis also confirmed our diagnoses as a phosphaturic mesenchymal tumor. OUTCOMES At seven months post-surgery, the symptoms were relieved, proximal muscle strength was improved and serum levels of phosphorus and alkaline phosphatase normalized. The bilateral femoral neck and bilateral pubic bone fractures were blurred in the pelvic plain X-ray, suggesting that the fracture was healing. LESSONS This case report strengthened the importance of recognition of this rare disease to avoid delay of diagnosis and surgical removal of the causative tumor is recommended.
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Affiliation(s)
| | | | | | | | - Ningjun Li
- Department of Pathology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
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Zuo QY, Wang H, Li W, Niu XH, Huang YH, Chen J, You YH, Liu BY, Cui AM, Deng W. Treatment and outcomes of tumor-induced osteomalacia associated with phosphaturic mesenchymal tumors: retrospective review of 12 patients. BMC Musculoskelet Disord 2017; 18:403. [PMID: 28934935 PMCID: PMC5609032 DOI: 10.1186/s12891-017-1756-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 09/07/2017] [Indexed: 11/10/2022] Open
Abstract
Background Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by severe hypophosphatemia and osteomalacia. Nonspecific symptoms make the diagnosis elusive. In addition, locating the responsible tumor(s) is challenging. The aim of this study was to investigate the clinical management and outcomes of TIO. Methods The clinical features, diagnostic procedures, treatment, and outcomes of 12 patients were reviewed retrospectively. Results The cohort comprised six men and six women (mean age 45.5 ± 9.9 years, range 23–61 years). The mean duration of disease was 3.7 ± 2.6 years. All patients manifested progressive bone pain, muscle weakness, and/or difficulty walking. Serum phosphorus concentrations were low in all patients (mean 0.42 ± 0.12 mmol/L). Technetium-99m octreotide scintigraphy was performed in 11 patients and showed lesions in the right distal femur, left femoral head, and right tibial plateau, respectively, in three patients. Magnetic resonance imaging (MRI) was negative for lesions in one patient. Two patients underwent biopsies that showed negative histopathology. Two patients, at 2 years and 8 months, respectively, after having negative technetium-99m octreotide studies, underwent 18F–fluorodeoxyglucose positron emission tomography/computed tomography (CT), which revealed lesions in the sacrum and soft tissue of the left palm, respectively. One tumor was detected by CT and MRI. Overall, lesion sites were the head (two patients, 16.7%), thoracic and lumbar region (two, 16.7%), pelvis (three, 25%), lower limbs (four, 33.3%), and upper limbs (one, 8.3%). All patients underwent surgery, and histopathology showed phosphaturic mesenchymal tumors in each. Postoperatively, serum phosphorus concentrations normalized within 2–7 days in 11 patients. With follow-ups of 1–41 months, surgery was effective in 10 patients. One patient developed local recurrence and another had metastases. Conclusions Locating tumors responsible for tumor-induced osteomalacia is often challenging. Although complete tumor resection confers a good prognosis in most patients, surveillance for recurrence and metastasis is necessary. Before surgery or when surgery is not indicated, oral phosphate can alleviate symptoms and metabolic imbalance. Electronic supplementary material The online version of this article (10.1186/s12891-017-1756-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qing-Yao Zuo
- Department of Endocrinology, Beijing Jishuitan Hospital, Xicheng District, Xinjiekoudongjie No. 31, Beijing, 100035, China
| | - Hong Wang
- Department of Endocrinology, Beijing Jishuitan Hospital, Xicheng District, Xinjiekoudongjie No. 31, Beijing, 100035, China
| | - Wei Li
- Department of Endocrinology, Beijing Jishuitan Hospital, Xicheng District, Xinjiekoudongjie No. 31, Beijing, 100035, China
| | - Xiao-Hui Niu
- Department of Orthopaedic Oncology, Beijing Jishuitan Hospital, Beijing, China
| | - Yan-Hong Huang
- Department of Rheumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Jia Chen
- Department of Endocrinology, Beijing Jishuitan Hospital, Xicheng District, Xinjiekoudongjie No. 31, Beijing, 100035, China
| | - Yu-Hua You
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Bao-Yue Liu
- Department of Pathology, Beijing Jishuitan Hospital, Beijing, China
| | - Ai-Min Cui
- Department of General Surgery, Jishuitan Hospital, Beijing, China
| | - Wei Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Xicheng District, Xinjiekoudongjie No. 31, Beijing, 100035, China.
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Lee JY, Park HS, Han S, Lim JK, Hong N, Park SI, Rhee Y. Localization of Oncogenic Osteomalacia by Systemic Venous Sampling of Fibroblast Growth Factor 23. Yonsei Med J 2017; 58:981-987. [PMID: 28792142 PMCID: PMC5552653 DOI: 10.3349/ymj.2017.58.5.981] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/22/2017] [Accepted: 05/29/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Tumor-induced osteomalacia (TIO) is characterized by hypophosphatemia caused by a phosphaturic mesenchymal tumor. While surgical resection of the tumor leads to a cure, identification of the responsible tumor is challenging. Recently, several studies showed that systemic sampling of fibroblast growth factor 23 (FGF23) is helpful for localization of tumors. The present study aimed to evaluate the clinical utility of this method in Korean patients. MATERIALS AND METHODS Six patients compatible with TIO who were admitted to our hospital between 2006 and 2015 were analyzed. Systemic venous sampling of FGF23 was performed to detect blind lesions or to confirm a suspicious lesion identified in previous imaging studies. RESULTS Venous sampling helped confirming the tumor in five of the six patients. Three patients underwent surgery after sampling, and in two patients, the lesions were detected after 3 years by means of ⁶⁸Ga-DOTATOC positron emission tomography with computed tomography. In one patient, there was a local elevation of serum FGF23 without any related lesion on additional imaging. CONCLUSION Our data strengthened the value of venous sampling of FGF23 in predicting the location of tumors and suggested that it can be more effective in the presence of the relevant lesion in subsequent imaging analyses.
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Affiliation(s)
- Ji Yeon Lee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Park
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seunghee Han
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Feng J, Jiang Y, Wang O, Li M, Xing X, Huo L, Li F, Yu W, Zhong DR, Jin J, Liu Y, Qi F, Lv W, Zhou L, Meng XW, Xia WB. The diagnostic dilemma of tumor induced osteomalacia: a retrospective analysis of 144 cases. Endocr J 2017; 64:675-683. [PMID: 28450684 DOI: 10.1507/endocrj.ej16-0587] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diagnostic delay of tumor induced osteomalacia (TIO) is common in clinic practice. To investigate the diagnostic condition of TIO in China and raise clinicians' awareness of TIO, we retrospectively analyzed clinical manifestations, biochemical features, and specially evaluated missed diagnoses and misdiagnoses among 144 TIO patients from Peking Union Medical College Hospital during December 1982 to December 2014. Clinical presentations of TIO mainly included bone pain, difficulty in walking, pathological fractures, muscle weakness, and height loss. TIO patients demonstrated hypophosphatemia (0.48±0.13 mmol/L), elevated serum alkaline phosphatase (277.9±152.6 U/L), reduced tubular maximum for phosphorus/glomerular filtration rate (0.39±0.14) and markedly elevated serum fibroblast growth factor 23 (FGF23) (median level 302.9 pg/mL). The average time from onset to a correct diagnosis was 2.9±2.3 years while the mean duration from onset to tumor resection was 5.4±4.2 years. The initial misdiagnosis rate was 95.1% (137/144) and 240 case-times of misdiagnoses occurred among the 144 cases. The most frequent misdiagnoses were intervertebral disc herniation, spondyloarthritis (including ankylosing spondylitis) and osteoporosis. A total of 43.1% (62/144) cases with hypophosphatemia presented on their laboratory sheets were neglected and missed diagnosed. Our study showed that TIO was frequently misdiagnosed and missed diagnosed due to its rarity, insidious onset, nonspecific clinical manifestations and clinicians' poor recognition. It is necessary to test serum phosphorus in patients with musculoskeletal symptoms and difficulty in walking. The measurement of serum FGF23 is rather valuable. Once hypophosphatemia is discovered, TIO should be suspected and it is highly recommended to search for tumors and perform curative surgery.
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MESH Headings
- Beijing
- Biomarkers/blood
- Cohort Studies
- Diagnosis, Differential
- Diagnostic Errors
- Female
- Fibroblast Growth Factor-23
- Fibroblast Growth Factors/blood
- Hospitals, Teaching
- Humans
- Hypophosphatemia/blood
- Hypophosphatemia/etiology
- Hypophosphatemia/physiopathology
- Intervertebral Disc Displacement/blood
- Intervertebral Disc Displacement/diagnosis
- Intervertebral Disc Displacement/diagnostic imaging
- Intervertebral Disc Displacement/physiopathology
- Male
- Medical Records
- Neoplasms, Connective Tissue/blood
- Neoplasms, Connective Tissue/diagnosis
- Neoplasms, Connective Tissue/diagnostic imaging
- Neoplasms, Connective Tissue/physiopathology
- Osteomalacia/blood
- Osteomalacia/diagnosis
- Osteomalacia/diagnostic imaging
- Osteomalacia/physiopathology
- Osteoporosis/blood
- Osteoporosis/diagnosis
- Osteoporosis/diagnostic imaging
- Osteoporosis/physiopathology
- Paraneoplastic Syndromes
- Retrospective Studies
- Spondylitis, Ankylosing/blood
- Spondylitis, Ankylosing/diagnosis
- Spondylitis, Ankylosing/diagnostic imaging
- Spondylitis, Ankylosing/physiopathology
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Affiliation(s)
- Juan Feng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Li
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ding-Rong Zhong
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yong Liu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Qi
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Lv
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xun-Wu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei-Bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Minisola S, Peacock M, Fukumoto S, Cipriani C, Pepe J, Tella SH, Collins MT. Tumour-induced osteomalacia. Nat Rev Dis Primers 2017; 3:17044. [PMID: 28703220 DOI: 10.1038/nrdp.2017.44] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Tumour-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare paraneoplastic disorder caused by tumours that secrete fibroblast growth factor 23 (FGF23). Owing to the role of FGF23 in renal phosphate handling and vitamin D synthesis, TIO is characterized by decreased renal tubular reabsorption of phosphate, by hypophosphataemia and by low levels of active vitamin D. Chronic hypophosphataemia ultimately results in osteomalacia (that is, inadequate bone mineralization). The diagnosis of TIO is usually suspected when serum phosphate levels are chronically low in the setting of bone pain, fragility fractures and muscle weakness. Locating the offending tumour can be very difficult, as the tumour is often very small and can be anywhere in the body. Surgical removal of the tumour is the only definitive treatment. When the tumour cannot be located or when complete resection is not possible, medical treatment with phosphate salts or active vitamin D is necessary. One of the most promising emerging treatments for unresectable tumours that cause TIO is the anti-FGF23 monoclonal antibody KRN23. The recent identification of a fusion of fibronectin and fibroblast growth factor receptor 1 (FGFR1) as a molecular driver in some tumours not only sheds light on the pathophysiology of TIO but also opens the door to a better understanding of the transcription, translocation, post-translational modification and secretion of FGF23, as well as suggesting approaches to targeted therapy. Further study will reveal if the FGFR1 pathway is also involved in tumours that do not harbour the translocation.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Munro Peacock
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Seijii Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Sri Harsha Tella
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA.,Endocrinology and Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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58
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Kane SV, Kakkar A, Oza N, Sridhar E, Pai PS. Phosphaturic mesenchymal tumor of the nasal cavity and paranasal sinuses: A clinical curiosity presenting a diagnostic challenge. Auris Nasus Larynx 2017; 45:377-383. [PMID: 28579442 DOI: 10.1016/j.anl.2017.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 03/08/2017] [Accepted: 05/01/2017] [Indexed: 12/28/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare mesenchymal neoplasm associated with tumor-induced osteomalacia (TIO) and elevated serum FGF-23. Common in extremities, PMT rarely occurs in sinonasal region. We report a series of sinonasal PMT diagnosed at our institute over a 6-year period. Six cases of sinonasal PMT were identified during this period, of which five presented with features of TIO. Median age of patients was 45.5 years. All six tumors were composed of stellate to spindled cells, with prominent staghorn vasculature in four cases. Typical smudgy matrix was seen in all cases, but only focally; grungy calcification was absent. Accurate diagnosis of PMTs is imperative, as complete excision leads to dramatic resolution of TIO symptoms. Lack of knowledge of this entity prevents clinicians from ordering relevant investigations. Absence of specific morphological features, like grungy calcification, and presentation at atypical locations makes the diagnosis challenging. Awareness of this entity is essential in order to suspect PMT in patients presenting with a soft tissue mass and features of TIO, however unusual the location may be.
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Affiliation(s)
- Shubhada V Kane
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Aanchal Kakkar
- Department of Pathology, Tata Memorial Hospital, Mumbai, India.
| | - Nikita Oza
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Prathamesh S Pai
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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Zhu W, Ma Q, Bian Y, Zhuang Q, Xia Z, Jin J, Weng X. Total hip/knee arthroplasty in the treatment of tumor-induced osteomalacia patients: More than 1 year follow-up. PLoS One 2017; 12:e0177835. [PMID: 28545150 PMCID: PMC5435341 DOI: 10.1371/journal.pone.0177835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
Background Tumor-induced osteomalacia (TIO) may result in a better prognosis after complete resection of the causative neoplasm. However, tumors located proximal to the articular surface of the metaphysis remain largely uninvestigated. Methods A retrospective study of sixteen patients was undertaken to evaluate treatment of tumors with joint arthroplasty and tumor resection. The bone metabolism index, hip/knee joint function, arthroplasty complications and symptoms were followed up for at least 12 months in each patient. Results All patients presented with neoplasms situated in the articular surface of the metaphysis, with 13 cases undergoing hip arthroplasty and 3 undergoing knee arthroplasty. Treatment of the tumors with joint arthroplasty and tumor resection significantly and rapidly ameliorate bone metabolism indexes in patients with TIO (p<0.01), with no identified tumor recurrence. The joint function evaluation score was improved in 15 patients (93.75%). Complications in these patients included post-operative pain, joint squeaking and secondary hyperparathyroidism. Conclusions Joint arthroplasty that includes tumor-expanding resection appears to be a safe and appropriate method for the treatment of TIO patients with a neoplasm located in the metaphysis proximal to the articular surface. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Wei Zhu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qi Ma
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanyan Bian
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qianyu Zhuang
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zenan Xia
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- * E-mail: (JJ); (XW)
| | - Xisheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- * E-mail: (JJ); (XW)
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Qiu S, Cao LL, Qiu Y, Yan P, Li ZX, Du J, Sun LM, Zhang QF. Malignant phosphaturic mesenchymal tumor with pulmonary metastasis: A case report. Medicine (Baltimore) 2017; 96:e6750. [PMID: 28445300 PMCID: PMC5413265 DOI: 10.1097/md.0000000000006750] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE Phosphaturic mesenchymal tumor (PMT) is a new tumor entity of soft tissue and bone tumor recently accepted by the World Health Organization, which typically causes the paraneoplastic syndrome of tumor-induced osteomalacia (TIO). The majority of PMTs follow a benign clinical course and local recurrence occurs in < 10% of cases, malignant PMTs with distant organ metastasis are extremely uncommon. PATIENT CONCERNS We reported a 41-year-old woman who was diagnosed with PMT 10 years ago with a repeated recurrence and pulmonary metastasis. DIAGNOSES Based on clinical manifestations, MRI scan, serum biochemical indicators evaluation, followed by histopathological examination, the patient was diagnosed as malignant PMT with pulmonary metastasis. INTERVENTIONS The patient was treated with calcium, phosphorus, and vitamin D after surgical resection and measured the serum ion concentrations every 3 months. OUTCOMES The patient had a favorable outcome for 10 months without recurrence. LESSONS PMTs lack of characteristic histological morphology, some recurrence cases may appear benign morphologically; the malignant PMTs are easily overlooked. Patients with PMT should be carefully evaluated and monitored, in order to early identify its malignant potential.
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Affiliation(s)
- Shui Qiu
- Department of Orthopedic Surgery
| | | | - Yue Qiu
- Department of Ultrasonography, the First Affiliated Hospital of China Medical University, Shenyang
| | - Ping Yan
- Department of Pathology, Fushun Hospital of Traditional Chinese Medicine, Fushun
| | - Zi-xuan Li
- Department of Radiology and Key Laboratory of Diagnostic Imaging and Interventional Radiology, the First Affiliated Hospital of China Medical University
| | - Jiang Du
- Department of Pathology, the First Affiliated Hospital and College of Basic Medical Sciences of China Medical University, Shenyang, PR China
| | - Li-Mei Sun
- Department of Pathology, the First Affiliated Hospital and College of Basic Medical Sciences of China Medical University, Shenyang, PR China
| | - Qing-Fu Zhang
- Department of Pathology, the First Affiliated Hospital and College of Basic Medical Sciences of China Medical University, Shenyang, PR China
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Abstract
Fibroblast growth factor 23 (FGF23) is an important regulator of phosphate and vitamin D metabolism and its excessive or insufficient production leads to a wide variety of skeletal disorders. This article reviews the FGF23-α-Klotho signaling pathway, highlighting the latest developments in FGF23 regulation and action, and describes the disorders associated with FGF23 excess or deficiency.
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Affiliation(s)
- Anda R Gonciulea
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M Jan De Beur
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Arai R, Onodera T, Terkawi MA, Mitsuhashi T, Kondo E, Iwasaki N. A rare case of multiple phosphaturic mesenchymal tumors along a tendon sheath inducing osteomalacia. BMC Musculoskelet Disord 2017; 18:79. [PMID: 28193220 PMCID: PMC5307843 DOI: 10.1186/s12891-017-1446-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/07/2017] [Indexed: 01/07/2023] Open
Abstract
Background Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia, reduction of 1,25-dihydroxyl vitamin D, and bone calcification disorders. Tumors associated with TIO are typically phosphaturic mesenchymal tumors that are bone and soft tissue origin and often present as a solitary tumor. The high production of fibroblast growth factor 23 (FGF23) by the tumor is believed to be the causative factor responsible for the impaired renal tubular phosphate reabsorption, hypophosphatemia and osteomalacia. Complete removal of the tumors by surgery is the most effective procedure for treatment. Identification of the tumors by advanced imaging techniques is difficult because TIO is small and exist within bone and soft tissue. However, systemic venous sampling has been frequently reported to be useful for diagnosing TIO patients. Case presentation We experienced a case of 39-year-old male with diffuse bone pain and multiple fragility fractures caused by multiple FGF23-secreting tumors found in the hallux. Laboratory testing showed hypophosphatemia due to renal phosphate wasting and high levels of serum FGF23. Contrast-enhanced MRI showed three soft tissue tumors and an intraosseous tumor located in the right hallux. Systemic venous sampling of FGF23 revealed an elevation in the right common iliac vein and external iliac vein, which suggested that the tumors in the right hallux were responsible for overproduction of FGF23. Thereafter, these tumors were surgically removed and subjected to histopathological examinations. The three soft tissue tumors were diagnosed as phosphaturic mesenchymal tumors, which are known to be responsible for TIO. The fourth tumor had no tumor structure and was consisting of hyaline cartilage and bone tissue. Immediately after surgery, we noted a sharply decrease in serum level of FGF23, associated with an improved hypophosphatemia and a gradual relief of systematic pain that disappeared within two months of surgery. Conclusion The authors reported an unusual case of osteomalacia induced by multiple phosphaturic mesenchymal tumors located in the hallux. Definition of tumors localization by systemic venous sampling led to successful treatment and cure this patient. The presence of osteochondral tissues in the intraosseous tumor might be developed from undifferentiated mesenchymal cells due to high level of FGF23 produced by phosphaturic mesenchymal tumors.
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Affiliation(s)
- Ryuta Arai
- Departments of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Tomohiro Onodera
- Departments of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Mohamad Alaa Terkawi
- Departments of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Kita-14, Nish-5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Eiji Kondo
- Department of Advanced Therapeutic Research for Sports Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nish-7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Norimasa Iwasaki
- Departments of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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Chan J, James C, Darbandi K, Burch D, Bacaj P, Cheng J. Phosphaturic Mesenchymal Tumor: A Rare Cause of Severe Osteomalacia and Debilitation in A 44-YEAR-OLD Man. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161245.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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Maybody M, Grewal RK, Healey JH, Antonescu CR, Fanchon L, Hwang S, Carrasquillo JA, Kirov A, Farooki A. Ga-68 DOTATOC PET/CT-Guided Biopsy and Cryoablation with Autoradiography of Biopsy Specimen for Treatment of Tumor-Induced Osteomalacia. Cardiovasc Intervent Radiol 2016; 39:1352-7. [PMID: 27150801 DOI: 10.1007/s00270-016-1350-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/08/2016] [Indexed: 10/21/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by small benign tumors of mesenchymal origin also known as phosphaturic mesenchymal tumors mixed connective tissue variant. Excellent prognosis is expected with eradication of the culprit tumor. These small tumors are notoriously difficult to localize with conventional imaging studies; this often leads to an extensive work up and prolonged morbidity. We report a patient with clinical diagnosis of TIO whose culprit tumor was localized with Ga-68 DOTATOC PET/CT and MRI. Biopsy and cryoablation were performed under Ga-68 DOTATOC PET/CT guidance. Autoradiography of the biopsy specimen was performed and showed in situ correlation between Ga-68 DOTATOC uptake and histopathology with millimeter resolution.
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Affiliation(s)
- Majid Maybody
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M276C, New York, NY, 10065, USA.
| | - Ravinder K Grewal
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John H Healey
- Orthopedic Surgical Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cristina R Antonescu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Louise Fanchon
- Department of Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sinchun Hwang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jorge A Carrasquillo
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Assen Kirov
- Department of Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Azeez Farooki
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kuraganti G, Harper RJ, Pucar D, Homlar KC, Williams HT. VISUAL VIGNETTE. Endocr Pract 2016; 22:1361. [PMID: 27124690 DOI: 10.4158/ep161318.vv] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Higley M, Beckett B, Schmahmann S, Dacey E, Foss E. Locally aggressive and multifocal phosphaturic mesenchymal tumors: two unusual cases of tumor-induced osteomalacia. Skeletal Radiol 2015; 44:1825-31. [PMID: 26341245 DOI: 10.1007/s00256-015-2246-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/26/2015] [Accepted: 08/23/2015] [Indexed: 02/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) has long been recognized as a clinical paraneoplastic syndrome. The identification of a unique histopathologic entity, the phosphaturic mesenchymal tumor (PMT), as a distinct etiology for TIO has been a more recent discovery. The majority of published cases describe a solitary, non-aggressive appearing soft tissue or osseous lesions in patients with osteomalacia; aggressive appearing or multifocal lesions appear to be exceedingly rare. These tumors characteristically secrete fibroblast growth factor 23 (FGF23). Elevated serum levels of FGF23 result in phosphate wasting and osteomalacia. In the majority of cases, laboratory abnormalities and clinical signs and symptoms of osteomalacia precede identification of the causative lesion by years. Following diagnosis, complete resection with wide margins to prevent local recurrence is most often curative. Imaging characteristics of PMT are diverse and remain incompletely defined, as the majority of previous publications are outside of the radiologic literature. We present multiple imaging modalities in two cases of patients with debilitating osteomalacia and unusual appearing PMTs: one with a locally aggressive lesion leading to pathologic fracture, the second presenting with exceedingly rare multifocal PMT.
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Affiliation(s)
- Meghan Higley
- Department of Diagnostic Radiology L340, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | - Brooke Beckett
- Department of Diagnostic Radiology L340, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Sandra Schmahmann
- Department of Diagnostic Radiology L340, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Elizabeth Dacey
- Department of Diagnostic Radiology L340, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Erik Foss
- Department of Diagnostic Radiology L340, Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR, 97239, USA
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Abstract
Soft tissue lesions which mimic malignancy (pseudosarcomas), represent a significant diagnostic challenge for pathologists. Many features often associated with malignancy including rapid and infiltrative growth, increased cellularity and mitotic activity, and nuclear pleomorphism are present in benign and reactive conditions. This review highlights repair reactions including nodular fasciitis, proliferative fasciitis/myositis, intravascular papillary endothelial hyperplasia, and fat necrosis; lipoma and spindle cell/pleomorphic lipoma; fibroepithelial stromal (pseudosarcomatoid) polyp; phosphaturic mesenchymal tumor; and myxoma. While not inclusive of every pseudoneoplastic soft tissue lesion, this review emphasizes important diagnostic pitfalls and stresses the value of clinical, pathologic, and radiologic correlation.
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Affiliation(s)
- Jessica A Forcucci
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave MSC 908, Charleston, South Carolina 29425.
| | - Evelyn T Bruner
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave MSC 908, Charleston, South Carolina 29425
| | - Michael Timothy Smith
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, 171 Ashley Ave MSC 908, Charleston, South Carolina 29425
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