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Bochicchio AM, Cammarota A, Storto G, Possidente L, Villonio A, Omer LC, Falco G, Laurino S, Russi S. Challenges in the diagnosis and management of tumor-induced osteomalacia: A case report. Heliyon 2024; 10:e31949. [PMID: 38882375 PMCID: PMC11177122 DOI: 10.1016/j.heliyon.2024.e31949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
The present case report is aimed to highlight the difficulty and the reason for the delayed diagnosis of phosphaturic mesenchymal tumors, emphasizing the need of standardized protocols for diagnosis, surgery and follow-up in high-volume hospitals. The clinical signs and symptoms, diagnostic and therapeutic procedures, immunohistological features were analyzed. Delayed diagnosis of phosphaturic mesenchymal tumor was primarily due to non-specific clinical symptoms such as fatigue, muscular and bone pain, and multiple fractures. This cryptic clinical picture made the diagnosis tricky that led to treatment of patient for non-specific pain and stress fractures before to consider the tumor-induced osteomalacia syndrome. Some well-documented studies were found in the literature in which the history of trauma is a critical trigger of glomus tumors. Extra-subungual tumors most frequently occur in the knee and ankle regions, particularly among young adults, and the diagnosis is typically made approximately 7.2 years after initial symptom onset. The difficult tumor localization represented an additional obstacle to the prompt treatment, leading to delayed curative surgery.
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Affiliation(s)
- Anna Maria Bochicchio
- Experimental Oncology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Aldo Cammarota
- Diagnostic and Imaging Department, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Giovanni Storto
- Nuclear Medicine Unit, IRCCS CROB Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Luciana Possidente
- Pathology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Antonio Villonio
- Diagnostic and Imaging Department, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Ludmila Carmen Omer
- Experimental Oncology Unit, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Geppino Falco
- Department of Biology, University of Naples Federico II, Naples, Italy
| | - Simona Laurino
- Laboratory of Preclinical and Translational Research, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
| | - Sabino Russi
- Laboratory of Preclinical and Translational Research, IRCCS CROB Centro di Riferimento Oncologico Della Basilicata, Rionero in Vulture (PZ), Italy
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Salles Rosa Neto N, Pereira RMR, Yuki EFN, Souza FHCD, Takayama L, Carneiro MIDS, Lima LGCAD, Ishy A, Elias AJR. Healing of tumor-induced osteomalacia as assessed by high-resolution peripheral quantitative computed tomography is not similar across the skeleton in the first years following complete tumor excision. Bone Rep 2024; 21:101758. [PMID: 38584681 PMCID: PMC10997823 DOI: 10.1016/j.bonr.2024.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024] Open
Abstract
Tumor-induced osteomalacia is caused by excessive fibroblast growth factor 23 production mainly from phosphaturic mesenchymal tumors. Surgical excision or tumor ablation are the preferred treatment. Information on bone microarchitecture parameters assessed by high-resolution peripheral quantitative computed tomography is limited. We report a woman with hypophosphatemic osteomalacia with generalized pain, weakness and recurrent fractures, and a large thoracic vertebral mass extending to the posterior mediastinum. Detailed radiologic and histopathologic evaluation revealed a phosphaturic mesenchymal tumor. Two surgeries were necessary for complete removal of the mass. Clinical symptoms improved after attaining normophosphatemia. Four-year post-surgical HR-pQCT parameters, compared to baseline, showed in the left distal radius, stable trabecular and cortical volumetric bone mineral density although below reference range. There was stability of trabecular number and thickness. Both stiffness and failure load decreased. A shift in cortical parameters was noted in year 2. In the left distal tibia, trabecular volumetric bone mineral density decreased whereas cortical volumetric bone mineral density markedly increased, as did cortical area. There was stability in the trabecular number and thickness. Both stiffness and failure load improved. Findings from HR-pQCT measurements in this patient disclosed that the healing of osteomalacia is not similar across the peripheral skeletal sites in the first years following tumor removal. Results contrasted low but stable volumetric bone mineral density in the distal radius with increase in the distal tibia at the expense of cortical bone. Our report helps further delineate the pattern of bone healing after treatment of this rare bone disorder.
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Affiliation(s)
- Nilton Salles Rosa Neto
- Center for Rare and Immune Disorders, Hospital Nove de Julho, São Paulo, Brazil
- Universidade Santo Amaro, São Paulo, Brazil
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Álvarez-Rivas N, Lugo-Rodríguez G, Maneiro JR, Iñiguez-Ubiaga C, Melero-Gonzalez RB, Iglesias-Cabo T, Carmona L, García-Porrúa C, de Toro-Santos FJ. Tumor-induced osteomalacia: A systematic literature review. Bone Rep 2024; 21:101772. [PMID: 38774264 PMCID: PMC11107251 DOI: 10.1016/j.bonr.2024.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction Tumor-induced osteomalacia (TIO), is a rare acquired paraneoplastic syndrome characterized by defective bone mineralization, caused by the overproduction of fibroblast growth factor 23 (FGF23) by a tumor. Material and methods We conducted a systematic review to identify all case reports of TIO, focusing on those associated with mesenchymal tumors. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) consensus, and we included patients with a diagnosis of TIO and histological confirmation of phosphaturic mesenchymal tumors or resolution of the condition after treatment of the tumor. Bibliographical searches were carried out until December 2023 in the Cochrane Library, Medline and Embase, as well as congress abstracts online. Results We identified 769 articles with 1979 cases reported. Most patients were adults, with a higher incidence on men. Disease duration before diagnosis is a mean of 4.8 years. Most tumors were histologically classified as PMT. Lower limbs were the predominant location. Hypophosphatemia was present in 99.8 % of patients. The FGF23 was elevated at diagnosis in 95.5 %. Resection of the tumor was the treatment of choice in most of patients. After resection, there was a clinical improvement in 97.6 % of cases, and serum phosphorus and FGF23 levels returned to normal ranges in 91.5 % and 81.4 % of the patients, respectively. Conclusion TIO is usually misdiagnosed with rheumatological or musculoskeletal disorders. The diagnosis should be suspected in patients with hypophosphatemic osteomalacia, and the measurement of serum FGF23 can be useful for diagnosis and management.
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Affiliation(s)
- Noelia Álvarez-Rivas
- Rheumatology Department, Hospital Público da Mariña, Servizo Galego de Saúde (SERGAS), Burela, Spain
| | - Gloria Lugo-Rodríguez
- Endocrinology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Jose Ramón Maneiro
- Rheumatology Department, Complexo Hospitalario Universitario de Santiago (CHUS), Servizo Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Carlota Iñiguez-Ubiaga
- Rheumatology Department, Hospital Universitario del Bierzo, Servicio de Salud de Castilla y León (SACYL), Ponferrada, Spain
| | - Rafael Benito Melero-Gonzalez
- Rheumatology Department, Complexo Hospitalario Universitario de Ourense (CHUO), Servizo Galego de Saúde (SERGAS), Orense, Spain
| | - Tania Iglesias-Cabo
- Statistical Consulting Unit, Scientific and Technical Services, University of Oviedo, Oviedo, Spain
| | | | - Carlos García-Porrúa
- Rheumatology Department, Complexo Hospitalario Universitario de Lugo (CHULA), Servizo Galego de Saúde (SERGAS), Lugo, Spain
| | - Francisco Javier de Toro-Santos
- Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade de A Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
- Rheumatology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
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Zhang Y, Hu M, Guo C, Yang X, Xiang S, Xu H. Phosphaturic mesenchymal tumor-induced bilateral osteomalacia femoral neck fractures: a case report. Front Endocrinol (Lausanne) 2024; 15:1373794. [PMID: 38689735 PMCID: PMC11058989 DOI: 10.3389/fendo.2024.1373794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
Phosphaturic mesenchymal tumors (PMT) are rare and distinctive tumors that typically result in paraneoplastic syndrome known as tumor-induced osteomalacia (TIO). We report a case of bilateral osteoporotic femoral neck fracture caused by PMT. PMT was surgically resected, followed by sequential treatment of bilateral femoral neck fractures with total hip arthroplasty (THA). A 49-year-old perimenopausal woman experienced consistent bone pain with limb weakness persisting for over 2 years. Initially, she was diagnosed with early osteonecrosis of the femoral head and received nonsurgical treatment. However, from 2020 to 2022, her pain extended to the bilateral shoulders and knees with increased intensity. She had no positive family history or any other genetic diseases, and her menstrual cycles were regular. Physical examination revealed tenderness at the midpoints of the bilateral groin and restricted bilateral hip range of motion, with grade 3/5 muscle strength in both lower extremities. Laboratory findings revealed moderate anemia (hemoglobin 66 g/L), leukopenia (2.70 × 109/L), neutropenia (1.28 × 109/L), hypophosphatemia (0.36 mmol/L), high alkaline phosphatase activity (308.00 U/L), and normal serum calcium (2.22 mmol/L). After surgery, additional examinations were performed to explore the cause of hypophosphatemic osteomalacia. After definitive diagnosis, the patient underwent tumor resection via T11 laminectomy on August 6, 2022. Six months after the second THA, the patient regained normal gait with satisfactory hip movement function without recurrence of PMT-associated osteomalacia or prosthesis loosening. By providing detailed clinical data and a diagnostic and treatment approach, we aimed to improve the clinical understanding of femoral neck fractures caused by TIO.
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Affiliation(s)
- Yifan Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Mingwei Hu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Cuicui Guo
- Department of Sports Medicine, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Xue Yang
- Department of Operation Room, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Hao Xu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
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Chen D, Zhang L, Zhang J, Yin M, Gao X, Huang Q, Li L, Yang X. Treatment and Diagnose of Spinal Phosphaturic Mesenchymal Tumor: A Case Report and a Systematic Literature Review. World Neurosurg 2024; 184:65-73. [PMID: 38218444 DOI: 10.1016/j.wneu.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Spinal phosphaturic mesenchymal tumor (PMT) is a rare disorder but can be cured once the diagnosis is clear and a complete removal by surgery is performed. To the best of our knowledge, only 22 cases in the spine have been described, and we report a case with the largest number of spinal segments (T12-L5) affected among spine PMT cases. METHODS A comprehensive literature search was performed until May 23, 2023, following the Preferred Reporting Items for Systematic Reviews guidelines. Studies were chosen through relevant PubMed, Web of Science, and EMBASE searches to prioritize obtaining the largest studies. The Medical Subject Headings and Boolean operators employed for this search were ("PMT" or "TIO" or "Tumor-induced osteomalacia" or "phosphaturic mesenchymal tumor") and ("spine" or "spinal"). Two researchers (L.S.Z. and D.B.C) independently reviewed and evaluated the included articles. Any differing opinions were discussed until a consensus was reached. A total of 18 studies were included. A case report is also presented. RESULTS We report a case of spinal PMT. The full text of the relevant articles was construed. A total of 18 studies were reviewed and consolidated. These articles are roughly divided into the following 5 subcategories: 1) clinical features and baseline distribution, 2) laboratory and imaging findings, 3) pathological manifestations, and 4) surgical methods and treatment options. CONCLUSIONS Spinal PMT is very rare with a high rate of misdiagnosis and debilitating complications, so it is of significance to increase awareness of the disease among spine surgeons consulted by patients with spinal PMT. 68Ga-DOTATOC-PET/CT shows very high sensitivity to the spinal PMT but there is no way to exactly determine the location of the tumor. PMT has unique immunohistochemical characteristics and malignant PMT is rare. Once diagnosed, complete surgical excision is the recommended treatment. Burosumab is one of the available options, especially in cases that are recurrent and difficult to surgically resect.
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Affiliation(s)
- Dingbang Chen
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Luosheng Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Jie Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Mengchen Yin
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xin Gao
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Quan Huang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Lin Li
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xinghai Yang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China.
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Liu S, Zhou X, Liu Y, Zhang J, Xia W. Preoperative evaluation and orthopedic surgical strategies for tumor-induced osteomalacia. J Bone Oncol 2024; 45:100600. [PMID: 38577550 PMCID: PMC10990903 DOI: 10.1016/j.jbo.2024.100600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is very rare, with about 1000 reported cases globally. Removing most TIO culprit tumors requires the evaluation and intervention of orthopedic doctors. However, orthopedic doctors often have a poor understanding of the optical treatment of TIO due to its rarity. In addition, most TIO patients lack specific clinical manifestations. Also, the clinical localization and qualitative diagnosis of TIO are difficult and thus can easily be misdiagnosed and mistreated. Furthermore, the true incidence rate of TIO may be underestimated. Although many breakthroughs have been made in exploring the pathogenesis, clinical diagnosis, and treatment of TIO, rational and standardized orthopedic surgical treatment experience summary and sorting for TIO patients are lacking. In this article, the recent experience and progress in the field of orthopedic surgical treatment for TIO globally have been summarized, providing a theoretical basis and new clinical practice guidance for the rational treatment of TIO patients.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, National Health Commission Key Laboratory of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Schmidt FN, Delsmann J, Yazigi B, Beil FT, Amling M, Oheim R. Approaching virtual osteoid volume estimation and in-depth tissue characterization in patients with tumor-induced osteomalacia. J Bone Miner Res 2024; 39:116-129. [PMID: 38477742 PMCID: PMC11240151 DOI: 10.1093/jbmr/zjae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/08/2023] [Accepted: 01/12/2024] [Indexed: 03/14/2024]
Abstract
Tumor-induced osteomalacia (TIO) poses a significant diagnostic challenge, leading to increased disease duration and patient burden also by missing clinical suspicion. Today, diagnosis of osteomalacia relies on invasive iliac crest biopsy, if needed. Therefore, a noninvasive method would be beneficial for patients with severe osteomalacia, such as TIO, to inform their clinical management and address specific needs, like estimating the regeneration capacity at high osteoid volumes (OVs) or the potential of a hungry bone syndrome after tumor removal. Furthermore, given the lack of comprehensive histological characterization of TIO, there is a need for additional tissue characterization. Therefore, our assessment encompassed iliac crest biopsies that were examined using quantitative electron backscattered microscopy, Raman spectroscopy, micro-computed tomography, and histology to analyze the biopsy tissue. Our clinical assessment encompassed DXA and high-resolution peripheral quantitative computed tomography (HR-pQCT) alongside with biochemical analyses and clinical evaluations. Combining imaging and clinical data, we established a model to predict the OV. We compared 9 TIO patients with 10 osteoporosis (OPO) patients and 10 healthy controls. Histological analyses confirmed a pronounced OV in TIO patients (OPO: 1.20% ± 1.23% vs TIO: 23.55% ± 12.23%, P < .0005), and spectroscopy revealed lower phosphate levels in TIO biopsies. By combining HR-pQCT and laboratory diagnostics, we developed a linear regression model to noninvasively predict the OV revealing significantly higher modeled OV/BVmodel values of 24.46% ± 14.22% for TIO compared to the control group (5.952% ± 3.44%, P ≤ .001). By combining laboratory diagnostics, namely, ALP and Tt.BMDRadius measured by HR-pQCT, we achieved the calculation of the virtual osteoid volume to bone volume ratio (OV/BVmodel) with a significant correlation to histology as well as reliable identification of TIO patients compared to OPO and control. This novel approach is potentially helpful for predicting OV by noninvasive techniques in diagnostic procedures and improving the clinical management of TIO.
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Affiliation(s)
- Felix N Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Julian Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bashar Yazigi
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
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Wong MT, Azadbakht J, Fadare O, Smitaman EE. Test yourself answer: plantar soft tissue foot mass with insufficiency-type stress fractures. Skeletal Radiol 2024; 53:595-596. [PMID: 37798375 DOI: 10.1007/s00256-023-04470-w] [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] [Received: 07/10/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Mitchell T Wong
- School of Medicine, the University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | | | - Oluwole Fadare
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego, 9300 Campus Point Drive, Suite 1-200, La Jolla, CA, 92093, USA
| | - Edward Eddie Smitaman
- Department of Radiology, Division of Musculoskeletal Imaging, University of California San Diego, 408 Dickinson Street, Mail Code 8226, San Diego, CA, 92103, USA
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Jadhav SS, Shah R, Patil V. Tumor-induced osteomalacia: An overview. Best Pract Res Clin Endocrinol Metab 2024; 38:101834. [PMID: 37935612 DOI: 10.1016/j.beem.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Tumor-induced osteomalacia (TIO) is rare paraneoplastic syndrome of hypophosphatemic osteomalacia, caused by phosphaturic factors secreted by small mesenchymal origin tumors with distinct pathological features, called 'phosphaturic mesenchymal tumors'. FGF23 is the most well-characterized of the phosphaturic factors. Tumors are often small and located anywhere in the body from head to toe, which makes the localisation challenging. Functional imaging by somatostatin receptor-based PET imaging is the first line investigation, which should be followed with CT or MRI based anatomical imaging. Once localised, complete surgical excision is the treatment of choice, which brings dramatic resolution of symptoms. Medical management in the form of phosphate and active vitamin D supplements is given as a bridge to surgical management or in inoperable/non-localised patients. This review provides an overview of the epidemiology, pathophysiology, pathology, clinical features, diagnosis, and treatment of TIO, including the recent advances and directions for future research in this field.
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Affiliation(s)
| | - Ravikumar Shah
- Harikrushna Hormone Clinic, 304, 3rd Floor, Ashwamegh, Opposite Vyamshala, Anand, Gujarat, India.
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, India.
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May M, Oheim R, Bovy L, Doess A, Maessen D, Neukirch B, Norris R, Williams A, Abrahamsen B. Epidemiology of Tumor-Induced Osteomalacia in Germany Based on Real World Data. Calcif Tissue Int 2023; 113:630-639. [PMID: 37980279 PMCID: PMC10673975 DOI: 10.1007/s00223-023-01148-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/30/2023] [Indexed: 11/20/2023]
Abstract
Tumor-induced osteomalacia (TIO) is an ultra-rare disease caused mostly by benign tumors that secrete fibroblast growth factor-23. Because of nonspecific symptoms, the diagnostic delay is long, and therapy can be challenging. Moreover, epidemiological data on TIO are scarce owing to its rarity. Therefore, this study aimed to quantify TIO's incidence rates and prevalence in Germany. Retrospective longitudinal and cross-sectional analyses were conducted using anonymized German claims data from the statutory health insurance (SHI) database. This database, which comprises the data of approximately 5 million insurants, is a representative sample of the German population and supports national projections. As there is no unique International Statistical Classification of Diseases and Related Health Problems (ICD) code for TIO, operational categories based on different surrogates were defined to determine the prevalence and incidence rates of TIO among probable patients. This study showed that TIO has a prevalence of (documented code, advanced imaging, medication, or tumor removal) 0.187 per 100,000 persons and an incidence rate of ≤ 0.094 per 100,000 person years. This analysis provides the first epidemiological insight into German patients with TIO. Despite the general limitations associated with the analysis of SHI claims data of ultra-rare diseases, we believe that this analysis provides a sound basis for further analysis, particularly with regard to the care situation of patients with TIO.
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Affiliation(s)
- Melanie May
- Department of Payer Value & Patient Access, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany.
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Hospital Hamburg-Eppendorf (UKE), Lottestraße 59, 22529, Hamburg, Germany
| | - Leonore Bovy
- InGef - Institute for Applied Health Research Berlin GmbH, InGef, Otto-Ostrowski-Straße 5, 10249, Berlin, Germany
| | - Axel Doess
- Department of Payer Value & Patient Access, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany
| | - Dirk Maessen
- Department of Franchise Nephrology, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany
| | - Benno Neukirch
- Hochschule Niederrhein, University of Applied Sciences, Competence Center Routine Data, Reinarzstraße 49, 47805, Krefeld, Germany
| | - Raeleesha Norris
- InGef - Institute for Applied Health Research Berlin GmbH, InGef, Otto-Ostrowski-Straße 5, 10249, Berlin, Germany
| | - Angela Williams
- Department of HEOR, Kyowa Kirin International Ltd, 2 Globeside, Fieldhouse Lane, Marlow, SL7 1HZ, UK
| | - Bo Abrahamsen
- Department of Medicine 1, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
- Department of Clinical Research, University of Southern Denmark (SDU), Campusvej 55, 5230, Odense, Denmark
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Hacisahinogullari H, Tekin S, Tanrikulu S, Saribeyliler G, Yalin GY, Bilgic B, Isik EG, Salduz A, Tuncer S, Gul N, Uzum AK, Aral F, Tanakol R, Selcukbiricik OS. Diagnosis and management of tumor-induced osteomalacia: a single center experience. Endocrine 2023; 82:427-434. [PMID: 37480497 DOI: 10.1007/s12020-023-03450-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE The aim of this study is to review the clinical and laboratory characteristics, diagnostic and treatment modalities of tumor-induced osteomalacia (TIO) cases managed in a single center. MATERIAL METHODS Demographic and clinical features, biochemical findings, diagnostic procedures, treatment modalities, and outcomes of nine patients who had the diagnosis of TIO were reviewed retrospectively. RESULTS Mean age of the study group (F/M: 4/5) was 45.8 ± 10.8 years, and mean time from the onset of symptoms to diagnosis was 4.7 ± 2.8 years. The clinical manifestations were muscle weakness and difficulty in walking (8/9), hip pain (3/9), multiple fractures (2/9), stress fracture (2/9). Mean plasma phosphorus concentration was 1.28 ± 0.4 mg/dl at presentation. We performed radionuclide imaging modalities (18F-FDG PET/CT, Ga68-DOTATATE PET/CT, octreotide scintigraphy) in seven of nine patients, and tumor was detected in all. Lower extremity (n = 6; %67), head region (n = 2; %22) and thorax (n = 1; %11) were the tumor locations of our cases. Eight patients underwent surgery and remission was achieved postoperatively in all of the operated patients and plasma phosphorus level normalized in 4 ± 2 days. Pathological examination revealed mesenchymal tumors with different subtypes. Recurrence occurred in three patients at 13 ± 10.5 months after the first surgery. Two patients were reoperated and radiotherapy was also performed in one of them. CONCLUSION Hypophosphatemia necessitates careful evaluation for the etiology. TIO is one of the important causes of adult-onset hypophosphatemic osteomalacia. Diagnosis of TIO is essential because the laboratory and clinical findings resolve after appropriate treatment.
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Affiliation(s)
- Hulya Hacisahinogullari
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey.
| | - Sakin Tekin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Zonguldak Bulent Ecevit University, Faculty of Medicine, Zonguldak, Turkey
| | - Seher Tanrikulu
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Goktug Saribeyliler
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Gulsah Yenidunya Yalin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Bilge Bilgic
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Emine Goknur Isik
- Department of Nuclear Medicine, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ahmet Salduz
- Department of Orthopedics and Traumatology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Samuray Tuncer
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Nurdan Gul
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ayse Kubat Uzum
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ferihan Aral
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Refik Tanakol
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ozlem Soyluk Selcukbiricik
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
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12
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Montanari A, Pirini MG, Lotrecchiano L, Di Prinzio L, Zavatta G. Phosphaturic Mesenchymal Tumors with or without Phosphate Metabolism Derangements. Curr Oncol 2023; 30:7478-7488. [PMID: 37623022 PMCID: PMC10453447 DOI: 10.3390/curroncol30080541] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/26/2023] Open
Abstract
Phosphaturic mesenchymal tumors (PMT) are rare neoplasms, which can give rise to a multifaceted syndrome, otherwise called tumor-induced osteomalacia (TIO). Localizing these tumors is crucial to obtain a cure for the phosphate metabolism derangement, which is often the main cause leading the patient to seek medical help, because of invalidating physical and neuromuscular symptoms. A proportion of these tumors is completely silent and may grow unnoticed, unless they become large enough to produce pain or discomfort. FGF-23 can be produced by several benign or malignant PMTs. The phosphate metabolism, radiology and histology of these rare tumors must be collectively assessed by a multidisciplinary team aimed at curing the disease locally and improving patients' quality of life. This narrative review, authored by multiple specialists of a tertiary care hospital center, will describe endocrine, radiological and histological features of these tumors, as well as present surgical and interventional strategies to manage PMTs.
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Affiliation(s)
- Andrea Montanari
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Maria Giulia Pirini
- Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ludovica Lotrecchiano
- Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lorenzo Di Prinzio
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Guido Zavatta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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13
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Arboleya L, Braña I, Pardo E, Loredo M, Queiro R. Osteomalacia in Adults: A Practical Insight for Clinicians. J Clin Med 2023; 12:jcm12072714. [PMID: 37048797 PMCID: PMC10094844 DOI: 10.3390/jcm12072714] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/26/2023] [Accepted: 04/01/2023] [Indexed: 04/14/2023] Open
Abstract
The term osteomalacia (OM) refers to a series of processes characterized by altered mineralization of the skeleton, which can be caused by various disorders of mineral metabolism. OM can be genetically determined or occur due to acquired disorders, among which the nutritional origin is particularly relevant, due to its wide epidemiological extension and its nature as a preventable disease. Among the hereditary diseases associated with OM, the most relevant is X-linked hypophosphatemia (XLH), which manifests in childhood, although its consequences persist into adulthood where it can acquire specific clinical characteristics, and, although rare, there are XLH cases that reach the third or fourth decade of life without a diagnosis. Some forms of OM present very subtle initial manifestations which cause both considerable diagnosis and treatment delay. On occasions, the presence of osteopenia and fragility fractures leads to an erroneous diagnosis of osteoporosis, which may imply the prescription of antiresorptive drugs (i.e., bisphosphonates or denosumab) with catastrophic consequences for OM bone. On the other hand, some radiological features of OM can be confused with those of axial spondyloarthritis and lead to erroneous diagnoses. The current prevalence of OM is not known and is very likely that its incidence is much higher than previously thought. Moreover, OM explains part of the therapeutic failures that occur in patients diagnosed with other bone diseases. Therefore, it is essential that clinicians who treat adult skeletal diseases take into account the considerations provided in this practical review when focusing on the diagnosis and treatment of their patients with bone diseases.
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Affiliation(s)
- Luis Arboleya
- Rheumatology Division, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Ignacio Braña
- Rheumatology Division, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Estefanía Pardo
- Rheumatology Division, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Marta Loredo
- Rheumatology Division, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
| | - Rubén Queiro
- Rheumatology Division, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain
- ISPA Translational Immunology Division, Biohealth Research Institute of the Principality of Asturias (ISPA), 33011 Oviedo, Spain
- School of Medicine, Oviedo University, 33011 Oviedo, Spain
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14
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Tan K, Chen X, Gui S, Peng D. Minimally invasive approach for tumor-induced osteomalacia: A case report. Asian J Surg 2023:S1015-9584(23)00353-6. [PMID: 36958964 DOI: 10.1016/j.asjsur.2023.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/09/2023] [Indexed: 03/25/2023] Open
Affiliation(s)
- Kaiwen Tan
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, PR China
| | - Xia Chen
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, PR China
| | - Sijie Gui
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, PR China
| | - Dan Peng
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, PR China.
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15
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Jan de Beur SM, Minisola S, Xia WB, Abrahamsen B, Body JJ, Brandi ML, Clifton-Bligh R, Collins M, Florenzano P, Houillier P, Imanishi Y, Imel EA, Khan AA, Zillikens MC, Fukumoto S. Global guidance for the recognition, diagnosis, and management of tumor-induced osteomalacia. J Intern Med 2023; 293:309-328. [PMID: 36511653 PMCID: PMC10108006 DOI: 10.1111/joim.13593] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by mesenchymal tumors that secrete fibroblast growth factor 23 (FGF23). Patients present with progressive bone pain, muscle weakness, and fragility fractures. TIO is characterized by hypophosphatemia, excess renal phosphate excretion, and low/inappropriately normal 1,25-dihydroxyvitamin D (1,25(OH)2 D) levels. Rarity and enigmatic clinical presentation of TIO contribute to limited awareness among the medical community. Accordingly, appropriate diagnostic tests may not be requested, leading to delayed diagnosis and poorer patient outcomes. We have developed a global guidance document to improve the knowledge of TIO in the medical community, enabling the recognition of patients with TIO and appropriate referral. We provide recommendations aiding diagnosis, referral, and treatment, helping promote a global standard of patient management. We reviewed the literature and conducted a three-round Delphi survey of TIO experts. Statements were drafted based on published evidence and expert opinions (≥70% consensus required for final recommendations). Serum phosphate should be measured in patients presenting with chronic muscle pain or weakness, fragility fractures, or bone pain. Physical examination should establish features of myopathy and identify masses that could be causative tumors. Priority laboratory evaluations should include urine/serum phosphate and creatinine to assess renal tubular reabsorption of phosphate and TmP/GFR, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, 1,25(OH)2 D, and FGF23. Patients with the clinical/biochemical suspicion of TIO should be referred to a specialist for diagnosis confirmation, and functional imaging should be used to localize causative tumor(s). Recommended treatment is tumor resection or, with unresectable/unidentifiable tumors, phosphate salts plus active vitamin D, or burosumab.
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Affiliation(s)
- Suzanne M Jan de Beur
- Division of Endocrinology and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Wei-Bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bo Abrahamsen
- Open Patient data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark.,Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, University Hospital of Florence, Florence, Italy
| | - Roderick Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia.,Cancer Genetics Unit, Kolling Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Collins
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Pablo Florenzano
- Centro Traslacional de Endocrinología UC (CETREN-UC), Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Département des Maladies Rénales et Métaboliques, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Erik A Imel
- Division of Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, Calcium Disorders Clinic, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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16
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Kritmetapak K, Kumar R. Phosphatonins: From Discovery to Therapeutics. Endocr Pract 2023; 29:69-79. [PMID: 36210014 DOI: 10.1016/j.eprac.2022.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Phosphate is crucial for cell signaling, energy metabolism, nucleotide synthesis, and bone mineralization. The gut-bone-parathyroid-kidney axis is influenced by parathyroid hormone, 1,25-dihydroxyvitamin D, and phosphatonins, especially fibroblast growth factor 23 (FGF23). These hormones facilitate maintenance of phosphate homeostasis. This review summarizes current knowledge regarding the phosphate homeostasis, phosphatonin pathophysiology, and clinical implications of FGF23-related hypophosphatemic disorders, with specific focus on burosumab treatment. METHOD A focused literature search of PubMed was conducted. RESULTS Phosphatonins including FGF23, secreted frizzled-related protein 4, matrix extracellular phosphoglycoprotein, and fibroblast growth factor 7 play a pathogenic role in several hypophosphatemic disorders. Excess FGF23 inhibits sodium-dependent phosphate cotransporters (NaPi-2a and NaPi-2c), resulting in hyperphosphaturia and hypophosphatemia. Additionally, FGF23 suppresses 1,25-dihydroxyvitamin D synthesis in the proximal renal tubule, and thus, it indirectly inhibits intestinal phosphate absorption. Disorders of FGF23-related hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets, autosomal recessive hypophosphatemic rickets, fibrous dysplasia/McCune-Albright syndrome, and tumor-induced osteomalacia (TIO). Complications of conventional therapy with oral phosphate and vitamin D analogs comprise gastrointestinal distress, hypercalcemia, nephrocalcinosis, and secondary/tertiary hyperparathyroidism. In both children and adults with XLH and TIO, the anti-FGF23 antibody burosumab exhibits a favorable safety profile and is associated with healing of rickets in affected children and improvement of osteomalacia in both children and adults. CONCLUSION The treatment paradigm for XLH and TIO is changing based on data from recent clinical trials. Research suggest that burosumab is effective and safe for pediatric and adult patients with XLH or TIO.
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Affiliation(s)
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.
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17
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Osteomalacia Is Not a Single Disease. Int J Mol Sci 2022; 23:ijms232314896. [PMID: 36499221 PMCID: PMC9740398 DOI: 10.3390/ijms232314896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Among bone-material qualities, mineralization is pivotal in conferring stiffness and toughness to the bone. Osteomalacia, a disease ensuing from inadequate mineralization of the skeleton, is caused by different processes leading to decreased available mineral (calcium and/or phosphate) or enzymatic alterations. Vitamin D deficiency, which remains the major cause of altered mineralization leading to inadequate intestinal calcium and phosphate absorption, may be also associated with other conditions primarily responsible for abnormal mineralization. Given the reality of widespread vitamin D inadequacy, a full biochemical assessment of mineral metabolism is always necessary to rule out or confirm other conditions. Both too-high or too-low serum alkaline phosphatase (ALP) levels are important for diagnosis. Osteomalacic syndrome is reversible, at least in part, by specific treatment. Osteomalacia and bone mineralization themselves constitute largely unexplored fields of research. The true prevalence of the different forms of osteomalacia and the recovery after proper therapy have yet to be determined in the real world. Although non-invasive techniques to assess bone mineralization are not available in clinical practice, the systematic assessment of bone quality could help in refining the diagnosis and guiding the treatment. This review summarizes what is known of osteomalacia recent therapeutic developments and highlights the future issues of research in this field.
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18
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Kato H, Koga M, Kinoshita Y, Hidaka N, Hoshino Y, Takashi Y, Arai M, Kobayashi H, Katsura M, Nakamoto Y, Makise N, Ushiku T, Hoshi K, Nangaku M, Makita N, Fukumoto S, Ito N. Utility of Multimodality Approach Including Systemic FGF23 Venous Sampling in Localizing Phosphaturic Mesenchymal Tumors. J Endocr Soc 2022; 7:bvac181. [PMID: 36540156 PMCID: PMC9757682 DOI: 10.1210/jendso/bvac181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Indexed: 11/27/2022] Open
Abstract
Context Tumor-induced osteomalacia (TIO) is one of the most common forms of acquired fibroblast growth factor 23 (FGF23)-related hypophosphatemia and is usually caused by phosphaturic mesenchymal tumors (PMTs). Although the complete resection of PMTs can cure TIO, preoperative localization of tumors by standard imaging modalities is often challenging. In addition to 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (FDG-PET) and 111In-pentetreotide scintigraphy (SRS), systemic FGF23 venous sampling (FGF23VS) has been used to help localize PMTs in specialized institutions. Objective This study aimed to evaluate the diagnostic performance of each imaging test and their combinations in localizing PMTs. Methods In an observational retrospective study of patients with adult-onset FGF23-related osteomalacia who underwent all 3 imaging studies (FDG-PET, SRS, and FGF23VS), the rate of successful preoperative localization of the tumors was evaluated only in the patients with pathological diagnoses of PMTs, considering the possibility that pathogenesis of patients without identified tumors might be due to other causes such as late-onset hereditary FGF23-related hypophosphatemia. Results A total of 30 Japanese patients with TIO (median age, 60 years [range, 28-87 years]; 10 women [33.3%]) were included in the study. The success rate of preoperative localization for each test and combinations of 2 or 3 tests among 18 patients with PMTs was as follows: 72% (FDG-PET), 72% (SRS), 94% (FGF23VS), 89% (FDG-PET, SRS), 100% (FDG-PET, FGF23VS), 94% (SRS, FGF23VS), and 100% (FDG-PET, SRS, and FGF23VS). Conclusion We observed the highest localization rate of PMTs in patients with identified PMTs with the combination of FDG-PET and FGF23VS.
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Affiliation(s)
| | | | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, 814-0180, Japan
| | - Makoto Arai
- Division of Molecular Physiology and Metabolism, Faculty of Medicine, Tohoku University, Miyagi, 980-8575, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masaki Katsura
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, Kyoto, 606-8507, Japan
| | - Naohiro Makise
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan,Division of Surgical Pathology, Chiba Cancer Center, Chiba, 260-8717, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Kazuto Hoshi
- Department of Oral-maxillofacial Surgery, Dentistry and Orthodontics, and Division of Tissue Engineering, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, 770-8503, Japan
| | - Nobuaki Ito
- Correspondence: Nobuaki Ito, MD, PhD, Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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19
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Wang R, Zhou J, Yu Y, Deng J, Wu Z, Ou C, Wu Y, Yang K, Wang J. Phosphaturic mesenchymal tumor in right thigh: 2 cases report and literature review. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2022; 15:2632010X221129588. [PMID: 36313588 PMCID: PMC9597019 DOI: 10.1177/2632010x221129588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/12/2022] [Indexed: 11/15/2022]
Abstract
Background Phosphaturic mesenchymal tumor (PMT) is a very rare tumor of bone and soft tissue that has no specific clinical manifestations. Here we present 2 cases of PMT in the right thigh, including comparatively adequate immunohistochemistry. Case Presentation We described 2 cases of PMT in the right thigh with manifestations of hypophosphatemia. PET-CT examination showed that both patients had lesions with increased expression of somatostatin receptors in the right thigh. Bland cells and dirty calcified stroma were exhibited under the microscope. And immunohistochemical detection of FGF-23 was positive. Conclusions PMT is a very uncommon tumor for which diagnosis and treatment are often delayed. Considering the importance of surgery for the treatment of this disease, a full understanding of its clinicopathological features will facilitate the diagnosis of this disease.
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Affiliation(s)
- Ruifeng Wang
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China
| | - Jiayu Zhou
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China
| | - Yupei Yu
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China
| | - Junqi Deng
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China
| | - Ze Wu
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China
| | - Chunlin Ou
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China,National Clinical Research Center for Geriatric
Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yanhao Wu
- Department of Respiratory Medicine, National Key
Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya
Hospital, Central South University, Changsha, Hunan, China
| | - Keda Yang
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China,Keda Yang, Department of Pathology, Xiangya Hospital,
Central South University, 87 Xiangya Road, Kaifu District, Changsha 410008, China.
| | - Junpu Wang
- Department of Pathology, Xiang-ya Hospital,
Central South University, Changsha City, Hunan Province, China,Department of Pathology, School of Basic
Medicine, Central South University, Changsha City, Hunan Province, China,National Clinical Research Center for Geriatric
Disorders, Xiangya Hospital, Central South University, Changsha, China,Key Laboratory of Hunan Province in
Neurodegenerative Disorders, Xiangya Hospital, Central South University, Changsha, Hunan,
China,Ultrapathology (Biomedical electron microscopy)
Center, Department of Pathology, Xiang-ya Hospital, Central South University, Changsha City,
Hunan Province, China,Junpu Wang, Department of Pathology, Xiangya Hospital,
Central South University, 87 Xiangya Road, Kaifu District, Changsha 410008, China.
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Minisola S, Barlassina A, Vincent SA, Wood S, Williams A. A literature review to understand the burden of disease in people living with tumour-induced osteomalacia. Osteoporos Int 2022; 33:1845-1857. [PMID: 35643939 PMCID: PMC9463218 DOI: 10.1007/s00198-022-06432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED This study reviews publications to describe the signs, symptoms and impact of tumour-induced osteomalacia (TIO) on patients' burden of disease. TIO is associated with a spectrum of signs and symptoms imposing a significant clinical burden, but the psychosocial impact of this rare disease has been poorly researched so far. INTRODUCTION To describe the signs, symptoms and impacts of tumour-induced osteomalacia (TIO) and summarise the state of research on the burden of disease of this ultra-rare condition. METHODS A targeted literature review was conducted in PubMed using pre-defined search terms. Relevant articles published between 1980 and 2021 were screened for inclusion. Seventy records were selected for analysis. Data were extracted and grouped into categories and sub-categories to identify recurrent signs, symptoms and impacts of TIO and describe the burden on patients. Chord diagrams were created to analyse the relationships between different TIO outcomes and characterise the presentation of TIO. RESULTS Although the number of articles on TIO published have been increasing over the past 20 years, most studies were case reports and case series (n = 65/70) and only few were studies with higher quality of evidence (n = 5/70). Most articles were based on data reported by clinicians (n = 67/70). Patients with TIO experienced a combination of outcomes including chronic pain, weakness, skeletal-related manifestations and limitations in mobility. Only a few studies (n = 2/70) analysed the burden of TIO on the emotional wellbeing and on the work life of the patient. CONCLUSION Patients with TIO present with a spectrum of signs and symptoms that impose a significant burden. The impact on the psychosocial wellbeing of patients should be further investigated, as this has been poorly researched so far. Studies with high quality of evidence should be designed to further the understanding of the burden of disease of TIO from the patient's perspective.
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Affiliation(s)
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, United Kingdom
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21
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Hidaka N, Koga M, Kimura S, Hoshino Y, Kato H, Kinoshita Y, Makita N, Nangaku M, Horiguchi K, Furukawa Y, Ohnaka K, Inagaki K, Nakagawa A, Suzuki A, Takeuchi Y, Fukumoto S, Nakatani F, Ito N. Clinical Challenges in Diagnosis, Tumor Localization and Treatment of Tumor-Induced Osteomalacia: Outcome of a Retrospective Surveillance. J Bone Miner Res 2022; 37:1479-1488. [PMID: 35690913 DOI: 10.1002/jbmr.4620] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/27/2022] [Accepted: 06/04/2022] [Indexed: 01/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is an acquired fibroblast growth factor 23 (FGF23)-related hypophosphatemic osteomalacia caused by phosphaturic mesenchymal tumors (PMTs) developed in the bone or soft tissue. Diagnostic delay should be addressed, and ideal techniques to localize PMTs and efficient treatment options should be explored to improve the outcomes of this rare disease. To clarify the detailed clinical course and outcomes of TIO patients, retrospective questionnaire surveys were conducted among physicians from the Japanese Society for Bone and Mineral Research (JSBMR) and the Japan Endocrine Society (JES). The primary survey collected the number of TIO patients between January 2007 and December 2018. The secondary survey aimed to obtain the detailed characteristics, laboratory data, and outcomes. Eighty-eight patients (52 males, mean: 52 years old) were included, and 24 patients were clinically diagnosed with TIO without localized PMTs. The median duration from the onset to detection of high FGF23 levels was 3.4 years, with 77 patients being initially misdiagnosed. Among the methods used to detect small, localized PMTs (≤10 mm), fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography and somatostatin receptor scintigraphy were less sensitive than somatostatin receptor positron emission tomography/computed tomography (SRPET/CT). Systemic venous sampling (SVS) of FGF23 was performed in 53 patients; among them, SVS was considered useful for detecting localized PMTs in 45 patients with diverse tumor sizes. Finally, 45 patients achieved biochemical remission by surgery, 39 patients continued pharmaceutical treatment, including burosumab (11 patients), and four patients died. These results encouraged us to further increase the awareness of TIO and to improve the accessibility of SRPET/CT and SVS. Further evidence about the efficacy of new pharmaceutical treatments is awaited. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Minae Koga
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Soichiro Kimura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Toranomon Hospital Endocrine Center, Toranomon Hospital, Tokyo, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Horiguchi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yasushi Furukawa
- First Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Keizo Ohnaka
- Department of Geriatric Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Inagaki
- Endocrine Center, Okayama University Hospital, Okayama, Japan
| | - Atsushi Nakagawa
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Kahoku, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yasuhiro Takeuchi
- Toranomon Hospital Endocrine Center, Toranomon Hospital, Tokyo, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Fumihiko Nakatani
- Department of Musculoskeletal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
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22
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Collins MT, Marcucci G, Anders HJ, Beltrami G, Cauley JA, Ebeling PR, Kumar R, Linglart A, Sangiorgi L, Towler DA, Weston R, Whyte MP, Brandi ML, Clarke B, Thakker RV. Skeletal and extraskeletal disorders of biomineralization. Nat Rev Endocrinol 2022; 18:473-489. [PMID: 35578027 DOI: 10.1038/s41574-022-00682-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 12/15/2022]
Abstract
The physiological process of biomineralization is complex and deviation from it leads to a variety of diseases. Progress in the past 10 years has enhanced understanding of the genetic, molecular and cellular pathophysiology underlying these disorders; sometimes, this knowledge has both facilitated restoration of health and clarified the very nature of biomineralization as it occurs in humans. In this Review, we consider the principal regulators of mineralization and crystallization, and how dysregulation of these processes can lead to human disease. The knowledge acquired to date and gaps still to be filled are highlighted. The disorders of mineralization discussed comprise a broad spectrum of conditions that encompass bone disorders associated with alterations of mineral quantity and quality, as well as disorders of extraskeletal mineralization (hyperphosphataemic familial tumoural calcinosis). Included are disorders of alkaline phosphatase (hypophosphatasia) and phosphate homeostasis (X-linked hypophosphataemic rickets, fluorosis, rickets and osteomalacia). Furthermore, crystallopathies are covered as well as arterial and renal calcification. This Review discusses the current knowledge of biomineralization derived from basic and clinical research and points to future studies that will lead to new therapeutic approaches for biomineralization disorders.
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Affiliation(s)
- Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA.
| | - Gemma Marcucci
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Hans-Joachim Anders
- Department of Medicine IV, Hospital of the University of Munich, Ludwig-Maximilians University, Munich, Germany
| | - Giovanni Beltrami
- Department Paediatric Orthopedic Oncology, Careggi and Meyer Children Hospital, Florence, Italy
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Rajiv Kumar
- Departments of Medicine, Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Agnès Linglart
- APHP, Endocrinologie et diabète de l'enfant, Paris, France
| | - Luca Sangiorgi
- Medical Genetics and Skeletal Rare Diseases, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Dwight A Towler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ria Weston
- Cardiovascular Research Group, Manchester Metropolitan University, Manchester, UK
| | - Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St Louis, MO, USA
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA
| | | | - Bart Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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23
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Rendina D, Abate V, Cacace G, D'Elia L, De Filippo G, Del Vecchio S, Galletti F, Cuocolo A, Strazzullo P. Tumor-induced Osteomalacia: A Systematic Review and Individual Patient's Data Analysis. J Clin Endocrinol Metab 2022; 107:e3428-e3436. [PMID: 35468192 DOI: 10.1210/clinem/dgac253] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Indexed: 01/10/2023]
Abstract
CONTEXT Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, usually caused by small, benign, and slow-growing phosphaturic mesenchymal tumors. Clinically, TIO is characterized by renal phosphate leak, causing hypophosphatemia and osteomalacia. This review was performed to assess the clinical characteristics of TIO patients described worldwide so far. EVIDENCE ACQUISITION On June 26, 2021, a systematic search was performed in Medline, Google Scholar, Google book, and Cochrane Library using the terms: "tumor induced osteomalacia," "oncogenic osteomalacia," "hypophosphatemia." There were no language restrictions. This review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. EVIDENCE RESULTS Overall, 1725 TIO cases were collected. TIO was more frequent in adult men, who showed a higher incidence of fractures compared with TIO women. The TIO-causing neoplasms were identified in 1493 patients. The somatostatin receptor-based imaging modalities have the highest sensitivity for the identification of TIO-causing neoplasms. TIO-causing neoplasms were equally located in bone and soft tissues; the latter showed a higher prevalence of fractures and deformities. The surgery is the preferred TIO definitive treatment (successful in > 90% of patients). Promising nonsurgical therapies are treatments with burosumab in TIO patients with elevated fibroblast growth factor-23 levels, and with radiolabeled somatostatin analogs in patients with TIO-causing neoplasm identified by somatostatin receptor-based imaging techniques. CONCLUSION TIO occurs preferentially in adult men. The TIO clinical expressiveness is more severe in men as well as in patients with TIO-causing neoplasms located in soft tissues. Treatments with burosumab and with radiolabeled somatostatin analogs are the most promising nonsurgical therapies.
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Affiliation(s)
- Domenico Rendina
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Veronica Abate
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Giuseppe Cacace
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Lanfranco D'Elia
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Gianpaolo De Filippo
- Assistance Publique - Hôpitaux de Paris, Hôpital Robert Debré, Service d'Endocrinologie et DiabétologiePédiatrique, Paris 75015, France
| | - Silvana Del Vecchio
- Department of Advanced Biomedical Sciences, Federico II University, Naples 80131, Italy
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, Federico II University, Naples 80131, Italy
| | - Pasquale Strazzullo
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
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24
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Benson JC, Trejo-Lopez JA, Nassiri AM, Eschbacher K, Link MJ, Driscoll CL, Tiegs RD, Sfeir J, DeLone DR. Phosphaturic Mesenchymal Tumor. AJNR Am J Neuroradiol 2022; 43:817-822. [PMID: 35589138 DOI: 10.3174/ajnr.a7513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/17/2022] [Indexed: 11/07/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are neoplasms associated with tumor-induced osteomalacia. Patients typically present with pathologic fractures in the setting of chronic hypophosphatemic hyperphosphaturic osteomalacia, as well as gradual muscle weakness, bone pain, and difficulty walking. Because of their rarity and nonspecific symptomatology, phosphaturic mesenchymal tumors often go undiagnosed for years. Even when discovered on imaging, the tumors can be diagnostically challenging for radiologists. Phosphaturic mesenchymal tumors often tend to be small and can be located nearly anywhere in the body, and, therefore, can mimic many other tumors. This case highlights the imaging and pathologic markers of a phosphaturic mesenchymal tumor, often found in a patient with tumor-induced osteomalacia.
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Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., D.R.D.)
| | | | | | - K Eschbacher
- Laboratory Medicine and Pathology (J.A.T.-L., K.E.)
| | | | | | - R D Tiegs
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - J Sfeir
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - D R DeLone
- From the Departments of Radiology (J.C.B., D.R.D.)
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25
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Tumor induced osteomalacia - A long way toward correct diagnosis and management. Bone Rep 2022; 16:101180. [PMID: 35281212 PMCID: PMC8914328 DOI: 10.1016/j.bonr.2022.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 11/20/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is an uncommon type of osteomalacia associated with phosphaturic mesenchymal tumors (PMTs). Due to nonspecific symptoms, the diagnosis and appropriate management of the disease is often delayed for many years. Involvement of spine with TIO associated tumors is exceedingly rare. We present a 53-year-old woman with a 10-year history of bone pain, muscle weakness and multiple bone fractures that markedly impaired her quality of life. Biochemical evaluation revealed hypophosphatemia due to renal phosphate wasting and elevated plasma fibroblast growth factor 23 (FGF-23) concentration indicating PMT. It was found using 68Ga DOTA TOC PET/CT scan in the vertebral body L2. The patient underwent surgical resection of the tumor. Postoperatively, there was a significant decrease in phosphaturia, normalization of serum phosphate, 1.25 dihydroxyvitamin D and plasma FGF23 concentration. Thereafter the patient's condition markedly improved concerning her motility and basic daily activities. This case report demonstrates the first known case of TIO in the Slovakia and points to a long way from onset of symptoms toward correct diagnosis and successful surgical management. Phosphaturic mesenchymal tumor (PMT) as a cause of TIO Due to nonspecific symptoms, the diagnosis of TIO is often delayed for many years. Hypophosphatemia, hyperphosphaturia, elevated FGF23 are leading laboratory markers. Successful identification of PMT is a key to appropriate management of the patient. We report case of female patient with TIO caused by PMT of the vertebral body L2.
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26
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Beil FT, Stürznickel J, Rolvien T, Amling M, Oheim R. [Tumor localization and treatment of tumor-induced osteomalacia]. Z Rheumatol 2022; 81:182-188. [PMID: 35103802 DOI: 10.1007/s00393-022-01160-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/29/2022]
Abstract
Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia (OOM) is a rare paraneoplastic renal phosphate wasting syndrome. The disease is mostly triggered by small, benign mesenchymal tumors that express somatostatin receptors (SSTR) and produce excessive levels of fibroblast growth factor 23 (FGF 23) or other phosphatonins. These reduce the phosphate back resorption in the proximal tubules of the kidneys, thereby causing hypophosphatemia and lead to an absolute or relatively low calcitriol serum concentration. The main symptoms include muscle weakness, bone pain and recurrent insufficiency fractures secondary to sometimes pronounced osteomalacia. The suspected diagnosis can only be confirmed by determination of the phosphate level. It can often take years before the tumor is successfully localized. The necessary tumor localization is often the most difficult step in the treatment before the OOM can be curatively treated by open surgical resection of the tumor. In recent years new approaches for faster tumor localization and treatment of the tumor have been developed. Positron emission tomography (PET) in co-registration with computed tomography (68Ga-DOTA-TATE PET/CT) is currently the most sensitive imaging methodology for tumor detection. The application of the monoclonal FGF 23 antibody burosumab represents a promising new option in the treatment of inoperable adult OOM.
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Affiliation(s)
- Frank Timo Beil
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julian Stürznickel
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.,Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Tim Rolvien
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Michael Amling
- Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ralf Oheim
- Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,National Bone Board am Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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27
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Zavatta G, Altieri P, Vandi G, Vicennati V, Pagotto U, Vescini F. Phosphate Metabolism and Pathophysiology in Parathyroid Disorders and Endocrine Tumors. Int J Mol Sci 2021; 22:ijms222312975. [PMID: 34884774 PMCID: PMC8657508 DOI: 10.3390/ijms222312975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/27/2022] Open
Abstract
The advent of new insights into phosphate metabolism must urge the endocrinologist to rethink the pathophysiology of widespread disorders, such as primary hyperparathyroidism, and also of rarer endocrine metabolic bone diseases, such as hypoparathyroidism and tumor-induced hypophosphatemia. These rare diseases of mineral metabolism have been and will be a precious source of new information about phosphate and other minerals in the coming years. The parathyroid glands, the kidneys, and the intestine are the main organs affecting phosphate levels in the blood and urine. Parathyroid disorders, renal tubule defects, or phosphatonin-producing tumors might be unveiled from alterations of such a simple and inexpensive mineral as serum phosphate. This review will present all these disorders from a ‘phosphate perspective’.
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Affiliation(s)
- Guido Zavatta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Paola Altieri
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Giulia Vandi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University Hospital Udine, 33100 Udine, Italy
- Correspondence:
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