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Jijulal C, Sreedharan S, Naveen P. G, Surendran S, Patinharayil G, Fazil V.V. M, K.V. N, Sudhan S. R. PTH like substance secreting mesenchymal tumor causing oncogenic osteomalacia; unravelling the difficulties in localization - A report of 2 cases. J Orthop 2024; 58:123-127. [PMID: 39114427 PMCID: PMC11301177 DOI: 10.1016/j.jor.2024.06.034] [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: 06/02/2024] [Accepted: 06/23/2024] [Indexed: 08/10/2024] Open
Abstract
Background Oncogenic osteomalacia is a rare paraneoplastic association of Phosphaturic mesenchymal tumor (PMT) secreting excessive levels of a PTH like substance. They usually remain undiagnosed and patients suffer for years. The rarity of this tumor and its non-specific clinical presentations poses great challenge to the treating surgeons. Its management is poorly described in literature. We report two of such rare cases without much diagnostic delay. Case report We had 2 cases; A 53-year-old south east Asian male with 6 months of debilitating pain over multiple sites, and another 44-year-old male patient with complaints of low back ache, and pain over both lower and upper limbs for 1.5 years. Both had low serum phosphorus and elevated FGF-23 values, but all other parameters were normal. A PMT was suspected and confirmed on a Ga68- DOTATOC scan in both cases, and on complete excision, their symptoms and the altered blood parameters got normalized. Histology was consistent with PMT. Conclusion Accurate and timely diagnosis of a PMT with non-specific features are extremely challenging, but not without solutions. Even though a tumor of rarity, with the appropriate imaging modalities like Ga68- DOTATOC scan, and estimation of FGF-23 and serum phosphorus levels, they can be diagnosed. Once identified, complete removal is often curative within a few months.
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Affiliation(s)
- C.U. Jijulal
- Department of Orthopaedics, GMC Ortho Foundation Hospital and Research Centre, East Nadakkavu, Kozhikode, India
| | - Sreeja Sreedharan
- GMC Ortho Foundation Hospital and Research Centre, East Nadakkavu, Kozhikode, India
| | - Gopinath Naveen P.
- GMC Ortho Foundation Hospital and Research Centre, East Nadakkavu, Kozhikode, India
| | - Sibin Surendran
- Department of Orthopaedics, Govt Medical College Kozhikode, India
| | - Gopinathan Patinharayil
- Professor and Head of the Department of Orthopaedics, GMC Ortho Foundation Hospital and Research Centre, East Nadakkavu, Kozhikode, India
| | | | - Nikhil K.V.
- Department of Orthopaedics, Meitra Hospital, Kozhikode, India
| | - Ram Sudhan S.
- Department of Orthopaedics, IQRAA Hospital, Kozhikode, India
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Li B, Duan L, Li X, Shi J, Li H, Liu H, Cheng X, Wu X, Gao Y. Diagnostic accuracy of 99mTc-HYNIC-TOC SPECT/CT for detecting osteomalacia-associated tumors. Front Oncol 2023; 13:1228575. [PMID: 37554164 PMCID: PMC10405922 DOI: 10.3389/fonc.2023.1228575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/06/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES Tumor-induced osteomalacia (TIO) is a rare acquired paraneoplastic disorder characterized by hypophosphatemia resulting from tumor-secreted fibroblast growth factor-23 (FGF23). Surgical resection of the culprit TIO is the first choice of treatment. However, TIO is difficult to detect with conventional diagnostic tools due to its small size and variable location in the body. Somatostatin receptor scintigraphy (SSR) has recently emerged as a functional molecular imaging choice for TIO detection and localization. This research was undertaken to evaluate the efficacy of 99mTc-labeled hydrazinonicotinyl-Tyr3-octreotide (99mTc-HYNIC-TOC) SPECT/CT in detecting TIO. METHODS 99mTc-HYNIC-TOC SPECT/CT and the available clinical data of 25 patients with suspected TIO were analyzed retrospectively. The 99mTc-HYNIC-TOC SPECT/CT findings were compared with the post-surgical pathology diagnosis and clinical follow-up results. RESULTS Using 99mTc-HYNIC-TOC SPECT/CT, suspicious tumors were found in 18 of the 25 patients, and 15 of them underwent surgical resection. The post-operative pathology confirmed a TIO in those 13 patients whose symptoms and biochemical anomalies gradually resolved after the surgery. The remaining five patients were finally considered false positives. Moreover, the 99mTc-HYNIC-TOC SPECT/CT results were negative in seven patients, with six patients being true negative (4 patients were diagnosed with acquired Fanconi syndrome and 2 patients responded well to conservative therapy) and one being false negative. Therefore, the sensitivity and specificity values of 99mTc-HYNIC-TOC SPECT/CT in the evaluation of TIO were 92.9% (13/14) and 54.5% (6/11), respectively. The overall accuracy of 99mTc-HYNIC-TOC SPECT/CT for detecting TIO was 76.0% (19/25). CONCLUSIONS The 99mTc-HYNIC-TOC SPECT/CT is an accurate imaging modality for locating culprit tumors in TIO.
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Affiliation(s)
- Bo Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Lili Duan
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Xiali Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Jingqi Shi
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Huiqiang Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Huimin Liu
- Department of Oncology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xinyu Wu
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Yongju Gao
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
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Helgebostad R, Revheim ME, Johnsrud K, Amlie K, Alavi A, Connelly JP. Clinical Applications of Somatostatin Receptor (Agonist) PET Tracers beyond Neuroendocrine Tumors. Diagnostics (Basel) 2022; 12:diagnostics12020528. [PMID: 35204618 PMCID: PMC8870812 DOI: 10.3390/diagnostics12020528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
Somatostatin receptor (SSTR) agonist tracers used in nuclear medicine scans are classically used for neuroendocrine tumor diagnosis and staging. SSTR are however, expressed more widely in a variety of cells as seen in the distribution of physiological tracer uptake during whole body scans. This provides opportunities for using these tracers for applications other than NETs and meningiomas. In this qualitative systematic review, novel diagnostics in SSTR-PET imaging are reviewed. A total of 70 studies comprised of 543 patients were qualitatively reviewed. Sarcoidosis, atherosclerosis and phosphaturic mesenchymal tumors represent the most studied applications currently with promising results. Other applications remain in progress where there are many case reports but a relative dearth of cohort studies. [18F]FDG PET provides the main comparative method in many cases but represents a well-established general PET technique that may be difficult to replace, without prospective clinical studies.
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Affiliation(s)
- Rasmus Helgebostad
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kjersti Johnsrud
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Kristine Amlie
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA;
| | - James Patrick Connelly
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Correspondence:
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Hussein MAM, Cafarelli FP, Paparella MT, Rennie WJ, Guglielmi G. Phosphaturic mesenchymal tumors: radiological aspects and suggested imaging pathway. Radiol Med 2021; 126:1609-1618. [PMID: 34453276 PMCID: PMC8702419 DOI: 10.1007/s11547-021-01412-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review.
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Affiliation(s)
| | - Francesco Pio Cafarelli
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Maria Teresa Paparella
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Winston J Rennie
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy.
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Extended Whole-body Ga-68 DOTATATE PET-CT in evaluating Tumour-Induced Osteomalacia: Case report and review of literature. Nucl Med Mol Imaging 2021; 55:130-135. [PMID: 34109008 DOI: 10.1007/s13139-021-00695-6] [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: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
Tumour-induced osteomalacia is a rare paraneoplastic syndrome that manifests as chronic hypophosphataemia, non-specific bone pain and muscle weakness. It is generally caused by phosphaturic mesenchymal tumour (PMT), which is uncommonly associated with synchronous tumours. However, diagnosis is often delayed for several years due to the rarity, indolent growing nature and non-specific symptoms of the disease, often resulting in an overlook by clinicians during assessments. The patient initially presented with hypophosphataemia and generalised skeletal pain with multiple atraumatic fractures. Blood tests revealed serum calcium levels at the upper limit and extremely low inorganic phosphate levels. Herein, we report a case where two synchronous PMTs from two different sites were detected by 'extended' whole-body Ga-68 DOTATATE PET-CT, leading to remission of the disease after complete surgical removal. Early detection and diagnosis of PMT neoplasm is crucial, as complete surgical resection of this tumour is the only definitive treatment currently known. Upon excision, this curable disease will result in complete resolution of symptoms and blood parameters, leading to remission of the disease which significantly improves the patient's quality of life. PMT often over-expresses somatostatin receptors (SSTR), predominantly subtype 2A, and Ga-68 DOTATATE PET-CT is a selective SSTR imaging that targets this characteristic over-expression in these tumours. The high diagnostic accuracy of Ga-68 DOTATATE PET-CT should be the primary imaging modality for full evaluation of this disease.
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Kato A, Nakamoto Y, Ishimori T, Hayakawa N, Ueda M, Temma T, Sano K, Shimizu Y, Saga T, Togashi K. Diagnostic performance of 68Ga-DOTATOC PET/CT in tumor-induced osteomalacia. Ann Nucl Med 2021; 35:397-405. [PMID: 33582980 DOI: 10.1007/s12149-021-01575-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia (TIO) is caused by typically small tumors that secrete fibroblast growth factor 23 (FGF23). As tumor resection is the only effective treatment for TIO, it is important to detect the culprit tumor. We aimed to assess the utility of 68Gallium-DOTA-D-Phe(1)-Tyr(3)-octreotide (68Ga-DOTATOC) PET/CT in TIO and the correlation between biochemical parameters and the PET/CT results. METHODS Thirty-five patients with clinically suspected TIO who had undergone 68Ga-DOTATOC PET/CT were retrospectively analyzed. 68Ga-DOTATOC PET/CT results were compared with biochemical parameters and the final diagnosis, including histopathology. RESULTS 68Ga-DOTATOC PET/CT detected focal uptake consistent with TIO in 21/35 patients, one of which was considered false positive. In 16 patients, the cause of osteomalacia was confirmed histologically as phosphaturic mesenchymal tumor (n = 15) or fibrous dysplasia (n = 1). The other four patients were judged clinically as true positive by subsequent MRI and the clinical course. Overall, the detection rate of 68Ga-DOTATOC PET/CT was 57% (20/35). Median tumor maximum standardized uptake value (SUVmax) was 6.9 (range 1.5-37.7). There was no significant difference in serum intact FGF23 level between DOTATOC-positive and DOTATOC-negative cases, and no significant correlation was observed between intact FGF23 level and tumor SUVmax. CONCLUSIONS 68Ga-DOTATOC PET/CT was clinically useful in detecting culprit tumors and subsequent patient management in TIO.
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Affiliation(s)
- Ayako Kato
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takayoshi Ishimori
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Nobuyuki Hayakawa
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Diagnostic Imaging, Kyoto City Hospital, Kyoto, Japan
| | - Masashi Ueda
- Department of Biofunction Imaging Analysis, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Temma
- Department of Biofunctional Analysis, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Kohei Sano
- Laboratory of Biophysical Chemistry, Kobe Pharmaceutical University, Kobe, Japan
| | - Yoichi Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tsuneo Saga
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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He Q, Zhang B, Zhang L, Chen Z, Shi X, Yi C, Wang X, Zhang X. Diagnostic efficiency of 68Ga-DOTANOC PET/CT in patients with suspected tumour-induced osteomalacia. Eur Radiol 2020; 31:2414-2421. [PMID: 33021702 DOI: 10.1007/s00330-020-07342-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 09/23/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Currently, the main challenge in tumour-induced osteomalacia (TIO) is the difficulty in locating culprit tumours for definitive diagnosis and surgical therapy. Herein, we retrospectively evaluate the efficiency of 68Ga-DOTANOC PET/CT in the localisation and diagnosis of TIO, and compared with 18F-FDG. METHODS Twenty-four consecutive patients with hypophosphataemic osteomalacia (HO) and suspicion of TIO who were referred to our centre for 68Ga-DOTANOC PET/CT scanning were retrospectively reviewed. The images were evaluated qualitatively as well as semi-quantitatively, and imaging results were compared with the final diagnoses. RESULTS Among the total of 21 patients who were included in the final analyses, 17 were diagnosed with TIO, while four were proven to have other causes of HO. 68Ga-DOTANOC PET/CT produced positive results in 16 of the 17 patients with TIO, representing a sensitivity of 94.1%. Moreover, the 68Ga-DOTANOC PET/CT results were negative in 3 of the 4 patients without TIO, representing a specificity of 75.0%. The overall accuracy of 68Ga-DOTANOC PET/CT in locating the tumours responsible for TIO is 90.5%. In particular, 68Ga-DOTANOC PET/CT detected the culprit tumours in 4 out of 10 patients with negative results on previous 18F-FDG PET/CT and showed a significantly higher T/M ratio of tumours than 18F-FDG PET/CT in the same patients (n = 10; 4.76 ± 3.08 vs 1.95 ± 1.33, p < 0.05). CONCLUSIONS 68Ga-DOTANOC PET/CT is an accurate imaging modality in the localisation of tumours for TIO. It is superior to 18F-FDG PET/CT and may be useful in the differential diagnosis of HO. KEY POINTS • TIO should be considered a possible cause for patients diagnosed with HO, which usually needs to be differentiated from other aetiologies. • 68Ga-DOTANOC PET/CT is an accurate imaging modality in locating culprit tumours for TIO, superior to 18F-FDG PET/CT.
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Affiliation(s)
- Qiao He
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Bing Zhang
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Linqi Zhang
- Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, 510095, People's Republic of China.
| | - Zhifeng Chen
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Xinchong Shi
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Chang Yi
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Xiaoyan Wang
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Xiangsong Zhang
- Department of Nuclear Medicine, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China.
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Lessons learnt from delayed diagnosis of FGF-23-producing tumour-induced osteomalacia and post-operative hungry bone syndrome. Bone Rep 2020; 12:100276. [PMID: 32455150 PMCID: PMC7235936 DOI: 10.1016/j.bonr.2020.100276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/04/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022] Open
Abstract
Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by a fibroblast growth-factor-23 (FGF-23)-secreting phosphaturic mesenchymal tumour (PMT) and is characterised by hypophosphataemic osteomalacia. We present a 36-year-old man initially presenting with diffuse bone and joint pain who was inappropriately treated for presumed ankylosing spondylitis for 2 years. Whole-body bone scan suggested metabolic bone disease, prompting referral to our endocrine institution. He was subsequently diagnosed with persistent hypophosphataemia, inappropriately high renal tubular phosphate excretion, 1,25-dihydroxyvitamin D3 suppression, severe osteoporosis and severe osteomalacia. FGF-23 concentrations (140 ng/L) were raised 3-fold above the upper limit of normal. Initial Gallium-68 (68Ga) DOTATATE positron emission tomography (PET)/CT scan missed an active lesion in the left fibular head as the field only included the mid-brain to the proximal femora. Histopathology results from tumour resection confirmed a PMT over-expressing FGF-23. Serum phosphate and FGF-23 normalised immediately post-operatively. He developed severe hypocalcaemia 3-weeks post-operatively (1.77 mmol/L) which normalised after 1 month of high-dose caltrate and calcitriol therapy. Osteomalacia, osteoporosis and associated symptoms resolved during medium-term follow-up with >100% improvement in his bone mineral density. This case report and discussion highlights the pitfalls contributing to delayed diagnosis of TIO and alerts clinicians to the potential complication of hungry bone syndrome post-tumour resection.
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Kawthalkar AS, Janu AK, Deshpande MS, Gala KB, Gulia A, Puri A. Phosphaturic Mesenchymal Tumors from Head to Toe: Imaging Findings and Role of the Radiologist in Diagnosing Tumor-Induced Osteomalacia. Indian J Orthop 2020; 54:215-223. [PMID: 32257040 PMCID: PMC7096593 DOI: 10.1007/s43465-019-00005-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed at evaluating the imaging findings of phosphaturic mesenchymal tumors and tumor-induced osteomalacia and assess the clinical and biochemical profiles of patients with tumor-induced osteomalacia. MATERIALS AND METHODS Imaging findings in six patients with tumor-induced osteomalacia and histopathologically proven phosphaturic mesenchymal tumors were evaluated. Clinical and biochemical profiles of these patients were also assessed. RESULTS Along with having a characteristic biochemical profile, patients with phosphaturic mesenchymal tumors also have certain imaging findings which can aid in the diagnosis such as increased uptake on DOTA PET-CT and homogeneous post-contrast enhancement on CT and MRI. CONCLUSION Patients with tumor-induced osteomalacia have characteristic symptoms, imaging and biochemical profiles. For radiologists, raising the suspicion of a phosphaturic mesenchymal tumor in patients with refractory hypophosphatemic osteomalacia as well as localizing the tumor on imaging is crucial, as complete excision of the tumor leads to resolution of the osteomalacia and the patient's clinical symptoms.
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Affiliation(s)
- Ameya S. Kawthalkar
- grid.413283.f0000 0001 2152 2922Department of Radiology, Grant Medical College and Sir JJ Hospital, Mumbai, India
| | - Amit K. Janu
- grid.410871.b0000 0004 1769 5793Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mrunmayee S. Deshpande
- grid.413161.00000 0004 1766 9130Department of General Medicine, Topiwala Nair Medical College and BYL Nair Hospital, Mumbai, India
| | - Kunal B. Gala
- grid.410871.b0000 0004 1769 5793Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Ashish Gulia
- grid.410871.b0000 0004 1769 5793Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, India
| | - Ajay Puri
- grid.410871.b0000 0004 1769 5793Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, India
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Richardson AL, Richardson OK. Phosphaturic mesenchymal tumor: Case report. Radiol Case Rep 2019; 14:1518-1524. [PMID: 31681451 PMCID: PMC6818391 DOI: 10.1016/j.radcr.2019.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/22/2019] [Accepted: 09/22/2019] [Indexed: 01/01/2023] Open
Abstract
Phosphaturic mesenchymal tumors (PMT) are an extremely rare pathologic phenomenon that presents as paraneoplastic tumor-induced osteomalacia. Their diagnosis is often significantly delayed due to their rare occurrence in addition to the generalized and vague symptoms of their presentation including progressive bone pain, myopathies, arthralgias, fractures, and generalized weakness. This case report identifies a very characteristic presentation of a 37-year old African American male suffering from a PMT; with symptom onset presenting over 5-years prior to presentation with a consistent complaint of progressive and debilitating quadriparesis. The tumor was first identified by pelvic computerized tomography, although it was initially thought to be a noncontributory benign soft tissue mass. It was only after being hospitalized due to a severe and unresponsive hypophosphatemic state (less than 1 mg/dl) that the collective differential switched to one of a PMT with follow up nuclear 99mTc bone scintigraphy and magnetic resonance imaging being used to aid in the overall assessment of changes, extent, and general metabolic properties of the tumor. The confirmatory diagnosis of a PMT was later established through both serum fibroblast growth factor 23 testing and histopathologic review of the surgically removed specimen. By including this rare but curative disease into the differential of osteomalacia and thereby further examining patient serum phosphate levels, the previous 5-7 year delay in diagnosis will be dramatically reduced.
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Affiliation(s)
| | - Olivia K Richardson
- University of South Carolina School of Medicine, 6311 Garners Ferry Rd, Columbia, SC 29209, USA
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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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Broski SM, Folpe AL, Wenger DE. Imaging features of phosphaturic mesenchymal tumors. Skeletal Radiol 2019; 48:119-127. [PMID: 29987349 DOI: 10.1007/s00256-018-3014-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/11/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the CT and MR imaging features of phosphaturic mesenchymal tumors (PMTs). MATERIALS AND METHODS With IRB approval, our institutional radiology/pathology database was reviewed for pathologically-proven PMTs. CT and MRI examinations were reviewed in consensus noting several imaging features, and if available, comparative molecular imaging tests were analyzed. RESULTS We identified 39 patients (21 male, 18 females) with 40 PMTs [mean age, 52.9 ± 14.9 years (range, 14-78)], including 20 bone and 20 soft tissue lesions. Mean maximal lesion diameter was 3.4 ± 2.0 cm (range, 1.1-9.8). 12/18 primary bone lesions (66.6%) were osteolytic and 15/20 (75.0%) had a narrow zone of transition. Internal matrix was present in 18/32 (56.3%) lesions. PMTs were most commonly T1 isointense (31/37, 83.8%), T2 hyperintense (14/36, 38.9%), and solidly enhancing (21/30, 70.0%). The majority (32/36, 88.9%) contained areas of dark T2 signal. 8/9 PMTs were positive by 99mTc-sestamibi scintigraphy, 2/4 by 111In-pentetreotide scintigraphy, 2/2 by 68Ga-DOTATATE PET/CT and 11/13 by 18F-FDG PET/CT. On FDG PET/CT, the mean SUVmax was 4.1 ± 2.5 (range, 1.5-10.8). CONCLUSIONS Osseous PMTs are commonly osteolytic with a narrow zone of transition. Both bone and soft tissue PMTs often contain matrix and areas of dark T2 signal on MRI, independent of the presence of matrix. However, PMTs may mimic other bone and soft tissue neoplasms, including fibrous dysplasia, tenosynovial giant cell tumor, and even atypical lipomatous tumor. As such, clinical presentation and laboratory correlation are critical to PMT recognition and accurate diagnosis.
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Affiliation(s)
- Stephen M Broski
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Doris E Wenger
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Diagnostic performance and impact on patient management of 68Ga-DOTA-TOC PET/CT for detecting osteomalacia-associated tumours. Eur J Nucl Med Mol Imaging 2018. [PMID: 29532101 DOI: 10.1007/s00259-018-3971-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Oncogenic osteomalacia is an endocrine disorder induced by small benign tumours (TIO) producing excessive fibroblast growth factor-23 (FGF23). The only way of curing oncogenic osteomalacia is surgical resection of the culprit TIO, which is extremely difficult to detect using conventional imaging modalities due to its small size and variable location in the body. Since TIO frequently overexpress somatostatin receptors, a clinical utility of SPECT or PET with radiolabelled somatostatin analogues has been reported. Among them, 68Ga-DOTA-TOC has recently been granted a marketing authorization, facilitating its routine application. We report here the results of the first series evaluating the diagnostic performance of 68Ga-DOTA-TOC PET/CT in detecting TIO and its impact on patient management. METHODS 68Ga-DOTA-TOC PET/CT and clinical and imaging data from 15 patients with clinical and biochemical signs of oncogenic osteomalacia were retrospectively reviewed. The 68Ga-DOTA-TOC PET/CT findings were compared with the results of post-surgical pathology and clinical and biochemical follow-up. RESULTS 68Ga-DOTA-TOC PET/CT resulted in the detection of one focus suspicious for TIO in nine of 15 patients (60%), and a tumour was surgically removed in eight. Post-operative pathology confirmed a TIO in those eight patients whose symptoms diminished promptly and biochemical anomalies resolved. 68Ga-DOTA-TOC PET/CT sensitivity, specificity and accuracy were 73%, 67% and 71%, respectively. 68Ga-DOTA-TOC PET/CT findings affected patient management in 67% of cases. In particular, 68Ga-DOTA-TOC PET/CT was able to detect the TIO with a negative or a false-positive result of a previous 111In-pentetreotide SPECT/CT in 5/8 patients (63%) or a previous FDG PET/CT in 7/11 patients (64%). No close relationship was found between the positivity of 68Ga-DOTA-TOC PET/CT and the serum level of a biochemical marker. However, a true-positive result of 68Ga-DOTA-TOC PET/CT was obtained in only one patient with a non-elevated serum level of FGF23. CONCLUSION 68Ga-DOTA-TOC PET/CT is an accurate imaging modality in the detection of TIO; in particular, it is worthwhile after failure of somatostatin receptor SPECT(/CT) or FDG PET/CT.
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Singh D, Chopra A, Ravina M, Kongara S, Bhatia E, Kumar N, Gupta S, Yadav S, Dabadghao P, Yadav R, Dube V, Kumar U, Dixit M, Gambhir S. Oncogenic osteomalacia: role of Ga-68 DOTANOC PET/CT scan in identifying the culprit lesion and its management. Br J Radiol 2017; 90:20160811. [PMID: 28181822 DOI: 10.1259/bjr.20160811] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the role of 68Ga-DOTANOC positron emission tomography (PET)/CT scan in localization of culprit lesion for biopsy and required intervention [surgical excision/radiofrequency ablation (RFA)] in patients with long-standing oncogenic osteomalacia (OOM)/tumour-induced osteomalacia. METHODS 17 patients (8 males and 9 females) underwent 68Ga-DOTANOC PET/CT scan. The patients referred with clinical and biochemical evidence of hypophosphatemia and raised fibroblast growth factor-23. Qualitative and semi-quantitative parameters were used to identify culprit lesions. RESULTS 68Ga-DOTANOC PET/CT scan revealed 52 lesions in 17 patients, and 37/52 of these lesions were tracer avid. 26/37 lesions were non-specific focal tracer-avid skeletal lesions (fractures or degenerative changes). 11/37 tracer-avid skeletal lesions present in 9 patients (3 lesions in 1 patient and 1 each in rest of the 8 patients) were highly suspicious for culprit lesions in view of high maximum standardized uptake value (SUVmax) (range 1.5-15.4; mean 7.0 ± 4.6), lesion size (0.9-5.0 cm; mean 3.3 ± 1.5) and associated soft-tissue component. During subsequent imaging with CT/MRI, 7/9 patients showed concordant lesions which were excised or biopsied and histopathologically verified as phosphaturic mesenchymal tumours. Surgical excision was resorted to in most of the detected lesions, and RFA was performed in one patient. CONCLUSION There is some overlap in SUVmax between fracture-/bone-associated lesions and culprit lesions with a tendency of most non-culprit lesions to have lower SUVmax and no associated soft-tissue component. In such scenario, intensely tracer-avid, larger non-fracture lesions with soft-tissue component may lead to identification of culprit lesion among multiple lesions. Following detection of culprit lesion, surgical removal is the best treatment. RFA is alternative to surgery in cases where surgery is not possible owing to osteopenia/poor bone health. Advances in knowledge: The main challenge in patients of long-standing OOM is the presence of multiple skeletal lesions (both tumour- or tracer-avid fractures), and it is confusing to identify culprit lesion. This was noted in our study with 68Ga-DOTANOC and has not been mentioned in studies performed with 68Ga-DOTATATE/TOC PET/CT. In such scenario, 68Ga-DOTANOC PET/CT needs to be reviewed and read thoroughly to localize the culprit lesion out of the multiple tracer-avid lesions.
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Affiliation(s)
- Deepa Singh
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Aditi Chopra
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | | | - Srikant Kongara
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India.,3 Endolife Hospital, Guntur, Andhra Pradesh, India
| | - Eesh Bhatia
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | - Narvesh Kumar
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Sushil Gupta
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | - Subhash Yadav
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | | | | | - Veeresh Dube
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Utham Kumar
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Manish Dixit
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Sanjay Gambhir
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
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El-Maouche D, Sadowski SM, Papadakis GZ, Guthrie L, Cottle-Delisle C, Merkel R, Millo C, Chen CC, Kebebew E, Collins MT. 68Ga-DOTATATE for Tumor Localization in Tumor-Induced Osteomalacia. J Clin Endocrinol Metab 2016; 101:3575-3581. [PMID: 27533306 PMCID: PMC5052344 DOI: 10.1210/jc.2016-2052] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Phosphaturic mesenchymal tumors (PMTs) are small, typically difficult to localize, and express somatostatin receptors. Recent work suggests imaging studies using 68Gallium (68Ga)-conjugated somatostatin peptide analogues, such as 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)TATE, which enables somatostatin receptor imaging with positron emission tomography (PET), may be useful at identifying these tumors. OBJECTIVE Our objective was to evaluate the use of 68Ga-DOTATATE PET/computed tomography (CT) for tumor localization in tumor-induced osteomalacia (TIO). DESIGN This was a single-center prospective study of patients with TIO. SETTING The study was conducted at the National Institutes of Health Clinical Center between February 2014 and February 2015. SUBJECTS Eleven subjects (six females, five males) with TIO were included. INTERVENTION Subjects underwent 68Ga-DOTATATE PET/CT in addition to 111In-pentetreotide single-photon emission CT (Octreoscan- SPECT/CT) and fluorodeoxyglucose-PET/CT (18F FDG-PET/CT) scan. MAIN OUTCOME MEASURES Localization of PMTs on the previously described imaging modalities were determined. RESULTS The tumor was successfully localized in 6/11 (54.5%) subjects (one was metastatic). The tumor was identified by 68Ga-DOTATATE in all six cases. Both Octreoscan-SPECT/CT and 18F FDG-PET each identified the tumor in 4/6. In no cases was 68Ga-DOTATATE the only imaging study to identify the tumor. CONCLUSIONS In this first prospective study comparing 68Ga-DOTATATE PET/CT to Octreoscan-SPECT/CT and 18F FDG-PET in TIO localization, 68Ga-DOTATATE PET/CT demonstrated the greatest sensitivity and specificity, suggesting that it may be the best single study for localization of PMTs in TIO.
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Affiliation(s)
- Diala El-Maouche
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Samira M Sadowski
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Georgios Z Papadakis
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Lori Guthrie
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Candice Cottle-Delisle
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Roxanne Merkel
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Corina Millo
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Clara C Chen
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Electron Kebebew
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Michael T Collins
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
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