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Zhang Z, Li J, Zhang Z, Shao Z. Tumor-induced Osteomalacia: A Case Report and Etiological Analysis with Literature Review. Orthop Surg 2023; 15:3342-3352. [PMID: 37933469 PMCID: PMC10694022 DOI: 10.1111/os.13901] [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: 04/25/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) belongs to a rare disease of the paraneoplastic syndrome. Phosphate uric mesenchymal tumor (PMT) is the most common cause of TIO, while the possibility of other tumors cannot be excluded. CASE PRESENTATION We present a case of a 36-year-old female patient with systemic skeletal abnormalities. The woman complained of low back pain with mild motor dysfunction for 2 years. Laboratory examination showed abnormalities in markers of bone metabolism, parathyroid hormone (PTH), vitamin D and serum phosphorus. Pooled imaging examination indicated extension abnormalities in the skeletal system and a single lesion in the right femoral head. The lesion of the right femoral was imaging with somatostatin receptor-positive, which was highly suggestive of a single neuroendocrine tumor. CT guided right femoral tumorectomy and bone grafting were performed when medical treatment failed. Postoperative pathological diagnosis was phosphate urinary mesenchymal tumor secreting fibroblast growth factor 23 (FGF23), which accorded with pre-operative expectations. The postoperative symptoms were effectively relieved, and indicators returned to normal. CONCLUSION The tumors causing TIO exhibited significant heterogeneity in terms of tissue origin, pathological characteristics and biological behavior, but the unique common characteristic is the secretion of FGF23. With significant progress in diagnosis and treatment, the clinical follow-up of most TIO patients shows a good prognosis, but the prognosis of those with malignant tumors is relatively poor.
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Affiliation(s)
- Zhenhao Zhang
- Department of Orthopaedics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Jiaxin Li
- Department of Orthopaedics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Zhicai Zhang
- Department of Orthopaedics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Zengwu Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Гронская СА, Белая ЖЕ, Рожинская ЛЯ, Мельниченко ГА, Дубовицкая ТА, Мамедова ЕО, Родионова СС, Буклемишев ЮВ, Пигарова ЕА, Дегтярев МВ, Бабаева ДМ, Владимирова ВП, Тарбаева НВ, Серженко СС, Григорьев АЮ, Дзеранова ЛК, Карпенко ВЮ, Карасев АЛ, Федотов РН, Ульянова ИН, Торопцова НВ, Лесняк ОМ, Мокрышева НГ, Дедов ИИ. [Clinical features, diagnostics and treatment of FGF23 secreting tumors: series of 40 clinical cases]. PROBLEMY ENDOKRINOLOGII 2023; 69:25-38. [PMID: 37968949 PMCID: PMC10680540 DOI: 10.14341/probl13221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Tumor-induced osteomalacia is an acquired rare disease manifested by hypophosphatemic osteomalacia due to excessive secretion of fibroblast growth factor 23 (FGF23). FGF 23 is a non-classical hormone secreted by bone tissue (osteocytes) and regulates phosphorus metabolism.The aim of this work is to present clinical experience in the diagnosis, treatment and rehabilitation of patients with tumor-induced osteomalacia. MATERIALS AND METHODS 40 patients with clinically-confirmed tumor-induced osteomalacia were included in the study, 34 of whom had the tumor localized, 27 underwent surgical treatment and 21 achieved stable remission. RESULTS The median age was 48 [41; 63] years, 43% were men, the time left from the the onset of the disease was 8 [4; 10] years. Biochemical findings were hypophosphatemia 0.47 [0.4; 0.53] mmol/l, a decrease in the tubular reabsorption phosphate 62 [52; 67]%, and an increase in alkaline phosphatase of 183 [112; 294] units/l. At the time of diagnosis, 100% had multiple pathological fractures, only 10% could move independently, and 77.5% classified the pain as unbearable (8-10 points according to the 10-point pain syndrome scale ). Among the methods used to detect tumors, the most sensitive were scintigraphy with tectrotide with SPECT/CT 71.4% (20/28) and MRI 90% (18/20). In 35% of cases, the tumor was localized in soft tissues and in 65% in bone tissue; The tumor was most often detected in the lower extremities, followed by the head in frequency of localization. 18 patients currently have no remission and they receive conservative treatment (phosphorus and alfacalcidol n=15 and burosumab n=3). In case of achieving remission (n=21), regression of clinical symptoms and restoration of bone and muscle mass was observed. Extensive excision of the tumor without prior biopsy resulted in the best percentage of remission - 87%. CONCLUSION Tumor-induced osteomalacia is characterized by severe damage to bone and muscle tissue with the development of multiple fractures, muscle weakness and severe pain syndrome. In laboratory diagnostics, attention should be paid to hypophosphatemia, a decrease in the tubular reabsorption phosphate index and increased alkaline phosphatase. The use of functional diagnostic methods with a labeled somatostatin analogue to the subtype 2 receptor and MRI with contrast enhancement are the most accurate methods of topical diagnostics. In case of localization of the tumor, a wide excision without a preliminary biopsy is recommended.
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Affiliation(s)
- С. А. Гронская
- Национальный медицинский исследовательский центр эндокринологии
| | - Ж. Е. Белая
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | | | | | - Е. О. Мамедова
- Национальный медицинский исследовательский центр эндокринологии
| | - С. С. Родионова
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Ю. В. Буклемишев
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | - М. В. Дегтярев
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. М. Бабаева
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Н. В. Тарбаева
- Национальный медицинский исследовательский центр эндокринологии
| | - С. С. Серженко
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Ю. Григорьев
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. К. Дзеранова
- Национальный медицинский исследовательский центр эндокринологии
| | - В. Ю. Карпенко
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - А. Л. Карасев
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Р. Н. Федотов
- Московский государственный медико-стоматологический университет им. А.И. Евдокимова
| | - И. Н. Ульянова
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Торопцова
- Научно-исследовательский институт ревматологии им. В.А. Насоновой
| | - О. М. Лесняк
- Северо-Западный государственный медицинский университет им. И.И. Мечникова
| | - Н. Г. Мокрышева
- Национальный медицинский исследовательский центр эндокринологии
| | - И. И. Дедов
- Национальный медицинский исследовательский центр эндокринологии
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Bouraima F, Sapin V, Kahouadji S, Pickering ME, Pereira B, Bouvier D, Oris C. Tumor-Induced Osteomalacia in Patients With Malignancy: A Meta-analysis and Systematic Review of Case Reports. J Clin Endocrinol Metab 2023; 108:3031-3040. [PMID: 37235783 DOI: 10.1210/clinem/dgad297] [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: 03/17/2023] [Revised: 05/08/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023]
Abstract
CONTEXT Tumor-induced osteomalacia (TIO) due to fibroblast growth factor 23 (FGF23) overexpression is becoming recognized in patients with malignancy. The condition may be underdiagnosed, with a scarce medical literature. OBJECTIVE To perform a meta-analysis of case reports to allow a better understanding of malignant TIO and its clinical implications. METHODS Full texts were selected according to strict inclusion criteria. All case reports were included where patients had hypophosphatemia, malignant TIO, and FGF23 blood levels. Thirty-two of 275 eligible studies (n = 34 patients) met inclusion criteria. A list of desired data was extracted and graded for methodological quality. RESULTS Prostate adenocarcinoma (n = 9) were the most tumors reported. Twenty-five of 34 patients had a metastatic disease and a poor clinical outcome was reported for 15 of 28 patients. The median levels of blood phosphate and C-terminal FGF23 (cFGF23) were 0.40 mmol/L and 788.5 RU/mL, respectively. For most of patients, blood PTH was elevated or within range, and calcitriol levels were inappropriately low or normal. Alkaline phosphatase concentrations were increased for 20 of 22 patients. The cFGF23 values were significantly higher for patients with a poor clinical outcome when compared to other patients (1685 vs 357.5 RU/mL). In case of prostate cancer, cFGF23 levels were significantly lower (429.4 RU/mL) than for other malignancies (1007.5 RU/mL). CONCLUSION We report for the first time a detailed description of the clinical and biological characteristics of malignant TIO. In this context, FGF23 blood measurement would be of value for the diagnostic workup, prognostication, and follow-up of patients.
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Affiliation(s)
- Farouk Bouraima
- Biochemistry and Molecular Genetics Department, University Hospital, 63000 Clermont-Ferrand, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, University Hospital, 63000 Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, 63000 Clermont-Ferrand, France
| | - Samy Kahouadji
- Biochemistry and Molecular Genetics Department, University Hospital, 63000 Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, 63000 Clermont-Ferrand, France
| | - Marie-Eva Pickering
- Rheumatology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics unit (DRCI) Department, University Hospital, 63000 Clermont-Ferrand, France
| | - Damien Bouvier
- Biochemistry and Molecular Genetics Department, University Hospital, 63000 Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, 63000 Clermont-Ferrand, France
| | - Charlotte Oris
- Biochemistry and Molecular Genetics Department, University Hospital, 63000 Clermont-Ferrand, France
- Clermont Auvergne University, CNRS, INSERM, iGReD, 63000 Clermont-Ferrand, France
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Hervier E, Gorican K, Boudabbous S, Biver E, Ferrari S, Saiji E, Garibotto V, Mainta I. Unusual phosphaturic mesenchymal tumor mimicking osteoid osteoma. Radiol Case Rep 2023; 18:2738-2743. [PMID: 37304318 PMCID: PMC10250829 DOI: 10.1016/j.radcr.2023.05.008] [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: 03/23/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Phosphaturic mesenchymal tumor is a rare tumor characterized by paraneoplastic osteomalacia. The diagnosis is often delayed because of nonspecific symptoms and difficulty to localize the tumor. In this study we report a case of PMT of the left femur detected by Ga-68-DOTATATE PET-CT with radiological features mimicking osteoid osteoma. We report a 31-year-old female patient who presented to our hospital for evaluation due to progressive bone pain and muscle weakness. Her laboratory data showed hypophosphatemia and increased fibroblast growth factor 23 (FGF-23) together with reduced bone mineral density on bone densitometry. The diagnosis of PMT was suspected and the tumor was identified on Ga-68-DOTATATE PET-CT as a focal uptake in a lucent lesion of the left femoral head with a central sclerotic dot mimicking a nidus as seen in osteoid osteoma. The lesion was treated with percutaneous radiofrequency ablation. Laboratory tests and bone densitometry rapidly improved post-treatment. The present case emphasizes the difficulty to diagnose PMT due to its nonspecific biochemical and clinical presentation and the relevance of functional imaging for locating these tumors despite different radiological presentation.
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Affiliation(s)
- Elsa Hervier
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
| | - Karel Gorican
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Sana Boudabbous
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Emmanuel Biver
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Serge Ferrari
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Essia Saiji
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Valentina Garibotto
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ismini Mainta
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
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Zhang Y, Wang P, Jing H. Lung Nodule as Culprit Lesion Causing Recurrent Tumor-Induced Osteomalacia Revealed by 68Ga-DOTATATE PET/CT. Clin Nucl Med 2023:00003072-990000000-00643. [PMID: 37486706 DOI: 10.1097/rlu.0000000000004771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
ABSTRACT Neoplasms that cause tumor-induced osteomalacia are very rarely located in the lung. A 27-year-old man underwent a surgery in the right femoral head to remove the tumor that induced osteomalacia 8 years ago with complete symptomatic relief. However, his bone pain occurred again recently, which lead to suspicion of a recurrent tumor-induced osteomalacia. 68Ga-DOTATATE PET/CT images showed a pulmonary nodule with mildly increased uptake along with increased activity in the left foot. The pulmonary nodule was subsequently resected and was pathologically confirmed as a phosphaturic mesenchymal tumor. The symptoms were completely relieved postsurgery.
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Affiliation(s)
- Yuwei Zhang
- From the Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, BeijingKey Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
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Strydom A, Greeff W, Ferrao PNF, Saragas NP. Tumor induced osteomalacia from a peripheral mesenchymal tumour of the foot. Foot (Edinb) 2023; 55:101979. [PMID: 36871520 DOI: 10.1016/j.foot.2023.101979] [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: 07/22/2020] [Accepted: 02/15/2023] [Indexed: 03/07/2023]
Abstract
Tumour induced osteomalacia (TIO) is a rare condition caused by peripheral mesenchymal tumours (PMT) which produce fibroblast-growth factor 23 (FGF23). FGF23 inhibits renal phosphate reabsorption leading to vitamin D resistant osteomalacia. The rarity of the condition and difficulty with isolating the PMT make diagnosis difficult, with delayed treatment leading to significant patient morbidity. We present a case of PMT of the foot with TIO, with a discussion on diagnosis and treatment.
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Affiliation(s)
- Andrew Strydom
- Consultant Foot and Ankle Surgeon, Suite 3A, -2 Level, Westwing, Netcare Sunninghill Hospital, Cnr Nanyuki & Witkoppen Road, Sunninghill, 2157, South Africa.
| | - Wessel Greeff
- Orthopaedic Surgeon, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), University of the Witwatersrand, Division of Orthopaedic Surgery, South Africa.
| | - Paulo N F Ferrao
- Orthopaedic Surgeon, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), University of the Witwatersrand, Division of Orthopaedic Surgery, South Africa; Consultant Foot and Ankle Surgeon, The Orthopaedic Foot and Ankle Unit, Suite 303 Netcare Linksfield Park Clinic, 24 12th Avenue, Orange Grove, 2192, South Africa.
| | - Nikiforos P Saragas
- Adjunct Professor, University of the Witwatersrand, Division of Orthopaedic Surgery, South Africa; Consultant Foot and Ankle Surgeon, The Orthopaedic Foot and Ankle Unit, Suite 303 Netcare Linksfield Park Clinic, 24 12th Avenue, Orange Grove, 2192, South Africa.
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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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Ewendt F, Feger M, Föller M. Role of Fibroblast Growth Factor 23 (FGF23) and αKlotho in Cancer. Front Cell Dev Biol 2021; 8:601006. [PMID: 33520985 PMCID: PMC7841205 DOI: 10.3389/fcell.2020.601006] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022] Open
Abstract
Together with fibroblast growth factors (FGFs) 19 and 21, FGF23 is an endocrine member of the family of FGFs. Mainly secreted by bone cells, FGF23 acts as a hormone on the kidney, stimulating phosphate excretion and suppressing formation of 1,25(OH)2D3, active vitamin D. These effects are dependent on transmembrane protein αKlotho, which enhances the binding affinity of FGF23 for FGF receptors (FGFR). Locally produced FGF23 in other tissues including liver or heart exerts further paracrine effects without involvement of αKlotho. Soluble Klotho (sKL) is an endocrine factor that is cleaved off of transmembrane Klotho or generated by alternative splicing and regulates membrane channels, transporters, and intracellular signaling including insulin growth factor 1 (IGF-1) and Wnt pathways, signaling cascades highly relevant for tumor progression. In mice, lack of FGF23 or αKlotho results in derangement of phosphate metabolism and a syndrome of rapid aging with abnormalities affecting most organs and a very short life span. Conversely, overexpression of anti-aging factor αKlotho results in a profound elongation of life span. Accumulating evidence suggests a major role of αKlotho as a tumor suppressor, at least in part by inhibiting IGF-1 and Wnt/β-catenin signaling. Hence, in many malignancies, higher αKlotho expression or activity is associated with a more favorable outcome. Moreover, also FGF23 and phosphate have been revealed to be factors relevant in cancer. FGF23 is particularly significant for those forms of cancer primarily affecting bone (e.g., multiple myeloma) or characterized by bone metastasis. This review summarizes the current knowledge of the significance of FGF23 and αKlotho for tumor cell signaling, biology, and clinically relevant parameters in different forms of cancer.
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Affiliation(s)
- Franz Ewendt
- Department of Nutritional Physiology, Institute of Agricultural and Nutritional Sciences, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Martina Feger
- Department of Physiology, University of Hohenheim, Stuttgart, Germany
| | - Michael Föller
- Department of Physiology, University of Hohenheim, Stuttgart, Germany
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Florenzano P, Hartley IR, Jimenez M, Roszko K, Gafni RI, Collins MT. Tumor-Induced Osteomalacia. Calcif Tissue Int 2021; 108:128-142. [PMID: 32504138 DOI: 10.1007/s00223-020-00691-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral production of fibroblast growth factor 23 (FGF23). The hallmark biochemical features include hypophosphatemia due to renal phosphate wasting, inappropriately normal or frankly low 1,25-dihydroxy-vitamin D, and inappropriately normal or elevated FGF23. TIO is caused by typically small, slow growing, benign phosphaturic mesenchymal tumors (PMTs) that are located almost anywhere in the body from the skull to the feet, in soft tissue or bone. The recent identification of fusion genes in a significant subset of PMTs has provided important insights into PMT tumorigenesis. Although management of this disease may seem straightforward, considering that complete resection of the tumor leads to its cure, locating these often-tiny tumors is frequently a challenge. For this purpose, a stepwise, systematic approach is required. It starts with thorough medical history and physical examination, followed by functional imaging, and confirmation of identified lesions by anatomical imaging. If the tumor resection is not possible, medical therapy with phosphate and active vitamin D is indicated. Novel therapeutic approaches include image-guided tumor ablation and medical treatment with the anti-FGF23 antibody burosumab or the pan-FGFR tyrosine kinase inhibitor, BGJ398/infigratinib. Great progress has been made in the diagnosis and treatment of TIO, and more is likely to come, turning this challenging, debilitating disease into a gratifying cure for patients and their providers.
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Affiliation(s)
- Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
| | - Iris R Hartley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - Kelly Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Skeletal Disorders and Mineral Homeostasis Section, NIDCR, NIH, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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Abe I, Lam AKY. Anaplastic thyroid carcinoma: Updates on WHO classification, clinicopathological features and staging. Histol Histopathol 2020; 36:239-248. [PMID: 33170501 DOI: 10.14670/hh-18-277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Anaplastic thyroid carcinoma is an uncommon carcinoma representing 1 to 4% of all thyroid cancers. The carcinoma is most common in females of the eight decades. It is a locally advanced cancer with frequent infiltration of surrounding organs, blood vessels and skin of neck. Paraneoplastic manifestations could occur. Approximately half of the patients with anaplastic thyroid carcinoma had distant metastasis with lung and brain as the most frequent sites of metastasis. The median survival of patients with anaplastic thyroid carcinoma reported was from 1 to 6 months. The terminology of the cancer in World Health Organization is "anaplastic thyroid carcinoma" rather than "undifferentiated thyroid carcinoma". In the latest American Joint Committee on Cancer (AJCC) TNM staging system for anaplastic thyroid carcinoma, there are updates on T and N categories. To conclude, updated knowledge of clinicopathological features, classification, pathological staging will improve our understanding of the cancer and will help in the management of the patients with this aggressive cancer.
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Affiliation(s)
- Ichiro Abe
- Cancer Molecular Pathology, School of Medicine and Destistry, Gold Coast campus, Griffith University, gold Coast, Australia.,Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Alfred King-Yin Lam
- Cancer Molecular Pathology, School of Medicine and Destistry, Gold Coast campus, Griffith University, Gold Coast, Australia.
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11
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Li B, Dong Y, Liu D, Yao Q, Guo S, Xin H, Wang H, Liu L, Zhang Y. Left maxillary sinus tumour-induced hypophosphataemic osteomalacia and combined with thyroid papillary carcinoma: a case report and literature review. Intern Med J 2020; 50:755-761. [PMID: 32537923 DOI: 10.1111/imj.14864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 11/27/2022]
Abstract
Tumour-induced osteomalacia (TIO) is a rare disease characterised by hypophosphataemia and clinical symptoms of osteomalacia. Herein we report the case of a 29-year-old man who was admitted to hospital with progressive bone pain and was diagnosed with TIO caused by maxillary sinus tumours. In the preoperative evaluation, it was found that the patient had thyroid malignant tumours at the same time. Two operations were performed separately on the left maxillary sinus tumour and thyroid tumour after complete examination. After tumour resections, the symptoms of bone pain were relieved and the level of blood phosphorus was restored, long-term replacement therapy was needed for thyroid. When a patient is diagnosed with TIO, it is necessary to screen for the presence of other malignant tumours and explore the treatment options in order to benefit patients preferably.
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Affiliation(s)
- Baoxin Li
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Yuehua Dong
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Dandan Liu
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Qi Yao
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Shuqin Guo
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Huanhuan Xin
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - He Wang
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Lifang Liu
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
| | - Yunliang Zhang
- Department of Endocrinology, Baoding NO.1 Central Hospital, Baoding, China
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12
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Layman AAK, Joshi S, Shah S. Metastatic prostate cancer presenting as tumour-induced osteomalacia. BMJ Case Rep 2019; 12:e229434. [PMID: 31315844 PMCID: PMC6663299 DOI: 10.1136/bcr-2019-229434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2019] [Indexed: 11/04/2022] Open
Abstract
Tumour-induced osteomalacia (TIO), or oncogenic osteomalacia, is a paraneoplastic syndrome marked by hypophosphataemia, renal phosphate wasting, bone pain, weakness, and fractures. The syndrome has been reported with both benign and malignant tumours including parotid gland basal cell tumours, thyroid carcinomas, colon adenocarcinomas, and prostate cancer. Often, the syndrome is marked by an insidious course during which patients present with generalised bony pain and weakness, which do not resolve until the underlying tumour is identified and treated. We present a case of a patient with Parkinson's disease whose subacute weakness, lower extremity paresis, and renal phosphate wasting led to the synchronous diagnosis of metastatic prostate adenocarcinoma and TIO.
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Affiliation(s)
- Awo Akosua K Layman
- Perelman School of Medicine, Medical Scientist Training Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shivam Joshi
- Internal Medicine, New York University, New York, New York, USA
| | - Sanjeev Shah
- Renal, Electrolyte, and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Medicine, Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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13
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14
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Oncogenic osteomalacia and metastatic breast cancer: a case report and review of the literature. J Diabetes Metab Disord 2019; 18:267-272. [PMID: 31275898 DOI: 10.1007/s40200-019-00398-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/14/2019] [Indexed: 12/16/2022]
Abstract
Objectives Oncogenic osteomalacia is a rare paraneoplastic metabolic syndrome that is characterised by severe hypophosphataemia, hyperphosphaturia and osteomalacia secondary to renal loss of phosphate. It is commonly caused by overproduction of fibroblast growth factor-23 (FGF23) from benign tumours of mesenchymal origin. Currently, there is no clear evidence on the management of oncogenic osteomalacia in patients with metastatic solid tumours. Methods We report a case of breast cancer-induced oncogenic osteomalacia and discuss its diagnosis and management. Results A 71-year-old woman with advanced breast cancer developed symptomatic oncogenic osteomalacia with raised FGF23, severe hypophosphataemia and hypocalcaemia. The electrolytic disturbances were exacerbated after the administration of bisphosphonates in the context of her oncological treatment. Systemic chemotherapy and maintenance endocrine treatment along with phosphate and calcium supplementation reduced the activity of oncogenic osteomalacia and resolved the electrolytic imbalances. Conclusions To our knowledge, this is the first reported case of oncogenic osteomalacia in a patient with breast cancer. Oncogenic osteomalacia constitutes a diagnostic and therapeutic challenge. Pre-clinical and clinical evidence suggest that a possible underlying mechanism is the presence of molecular alterations in the FGF/FGFR signalling pathway leading to overexpression of FGF23. In metastatic setting, anticancer treatment can potentially lead to the normalisation of the electrolytic disturbances and reduction of the activity of oncogenic osteomalacia. The use of antiresorptive therapy in patients with bone metastases can potentially trigger FGF23 overexpression. Its use should be guided by the patients' risk of skeletal-related events and electrolytic disturbances as well as the degree of activity of oncogenic osteomalacia.
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15
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16
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Ectopic expression of Klotho in fibroblast growth factor 23 (FGF23)-producing tumors that cause tumor-induced rickets/osteomalacia (TIO). Bone Rep 2018; 10:100192. [PMID: 30627598 PMCID: PMC6321977 DOI: 10.1016/j.bonr.2018.100192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/28/2018] [Accepted: 12/27/2018] [Indexed: 02/03/2023] Open
Abstract
Tumor-induced rickets/osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumors that ectopically express fibroblast growth factor 23 (FGF23). FGF23 is a bone-derived hormone that regulates serum phosphate concentrations. Patients with TIO develop hypophosphatemic rickets/osteomalacia due to FGF23 excess and suffer from symptoms such as leg deformities, bone pain, skeletal muscle myopathy, and multiple fractures/pseudofractures. Usually, successful surgical removal of the causative tumors normalizes serum FGF23 and phosphate concentrations in patients with TIO. Most FGF23-producing tumors associated with TIO are histologically called phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). The precise mechanism by which these tumors ectopically overproduce FGF23 outside of bone is yet to be clarified. Therefore, we performed an RNA sequencing analysis of a PMTMCT that was found in the left parotid gland of a patient with TIO. Among the upregulated genes, we focused on Klotho, the protein product of which is a single pass transmembrane protein that works along with an FGF receptor 1c as a receptor complex for FGF23. Subsequent histological analysis confirmed the ectopic expression of Klotho in other PMTMCTs. From these results, we assume that the ectopic expression of Klotho in PTMMCTs enables a positive feedback loop in FGF23 production via the activation of FGF receptor 1c and exacerbates disease manifestations in TIO. Klotho is ectopically expressed in the FGF23-producing mesenchymal tumors. Klotho enables the activation of the FGFR signaling pathway in PMTMCTs. Klotho enables the autocrine/paracrine effects of FGF23 in PMTMCTs.
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17
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Boland JM, Tebben PJ, Folpe AL. Phosphaturic mesenchymal tumors: what an endocrinologist should know. J Endocrinol Invest 2018; 41:1173-1184. [PMID: 29446010 DOI: 10.1007/s40618-018-0849-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/15/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as "oncogenic osteomalacia", is a rare cause of osteomalacia. TIO often has an insidious onset characterized clinically by progressive muscle weakness and bone pain with fractures. The hallmark biochemical finding is a persistent low serum phosphorus concentration due to renal phosphate wasting. The vast majority of cases of TIO result from production of the phosphaturic hormone fibroblast growth factor 23 (FGF23) by a histologically distinctive mesenchymal tumor, termed "phosphaturic mesenchymal tumor" (PMT). Circulating FGF23 induces internalization of renal sodium/phosphate co-transporters resulting in reduced proximal tubular phosphate reabsorption. FGF23 also inhibits production of 1α,25-dihydroxyvitamin D which is inappropriately low or normal in the context of hypophosphatemia. Diagnosis is often delayed owing to the rarity of the condition and an underappreciation for the role of phosphorus as a cause for the constellation of symptoms. Primary treatment for TIO is identification of the offending tumor and surgical removal. However, these tumors are notoriously difficult to find, precluding the opportunity for a curative surgery in many. In such cases, phosphate and calcitriol therapy is used to improve symptoms and heal the osteomalacia. Recently, molecular genetic studies have shown recurrent genetic events in PMT, including the novel fusions FN1-FGFR1 and less commonly FN1-FGF1. These fusion events are hypothesized to result in autocrine/paracrine signaling loops within the tumor, spurring tumorigenesis. This review will cover the clinical features, imaging characteristics, pathologic features, molecular genetic aspects, and therapy of PMT, with a brief discussion of other neoplasms that may cause TIO.
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Affiliation(s)
- J M Boland
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - P J Tebben
- Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - A L Folpe
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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18
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Reinert RB, Bixby D, Koenig RJ. Fibroblast Growth Factor 23-Induced Hypophosphatemia in Acute Leukemia. J Endocr Soc 2018; 2:437-443. [PMID: 29696242 PMCID: PMC5912090 DOI: 10.1210/js.2018-00010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/03/2018] [Indexed: 11/19/2022] Open
Abstract
Fibroblast growth factor 23 (FGF23)-induced hypophosphatemia is a rare paraneoplastic syndrome of phosphate wasting that, if unrecognized, may cause tumor-induced osteomalacia. It is classically associated with benign mesenchymal tumors but occasionally has been found in patients with other malignancies. Hypophosphatemia has been associated with acute leukemia but has not previously been reported to be due to inappropriate FGF23 secretion. Here, we describe FGF23-induced severe hypophosphatemia and renal phosphate wasting associated with a mixed-phenotype Philadelphia chromosome-like acute leukemia in a previously healthy 22-year-old man. He was found to have low serum 1,25-dihydroxyvitamin D and extremely high FGF23 levels, as well as inappropriate urinary phosphorus excretion. The hypophosphatemia improved with calcitriol and oral phosphate treatment but normalized only during chemotherapy-induced ablation of the blasts. FGF23 levels declined with a reduction in peripheral blast counts. Using real-time reverse transcription polymerase chain reaction, we found that the leukemia cells were the source of FGF23. To our knowledge, this is the first description of FGF23-induced hypophosphatemia associated with acute leukemia. We recommend that the FGF23 paraneoplastic syndrome be considered as a possible etiology of hypophosphatemia in patients with acute leukemia.
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Affiliation(s)
- Rachel B Reinert
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Dale Bixby
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ronald J Koenig
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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The Findings on Bone Scintigraphy in Patients With Suspected Tumor-Induced Osteomalacia Should Not Be Overlooked. Clin Nucl Med 2018; 43:239-245. [PMID: 29504962 DOI: 10.1097/rlu.0000000000002012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a chronic, devastating disease. The causative tumor is usually a small benign one that is very difficult to localize. Because the presenting symptoms include diffuse bone pain, a bone scintigraphy is commonly performed to determine the cause of the pain before TIO is suspected. In this retrospective investigation, we tried to assess whether bone scintigraphy acquired will be helpful in the eventual identification of the culprit tumor. METHODS The images of bone scan and clinical charts of total 91 patients with confirmed TIO were retrospectively reviewed. The image findings were compared with the results of other imaging studies, surgical notes, histopathologic examinations and clinical follow-ups. RESULTS In 76.9% (70 of 91) of the patients, the findings of bone scintigraphy did not correspond to the sites of the causative tumors, which were subsequently located. However, in 23.1% of the patients (21 of 91), the sites of the causative tumors corresponded to one of the abnormal technetium 99m-methyl diphosphonate activity on bone scintigraphy. More importantly, 6 tumors corresponded to the dominant activity on bone scintigraphy. CONCLUSIONS Although findings of whole-body scintigraphy are nonspecific in patients with TIO, careful evaluation of bone scintigraphy results can be helpful in guiding further evaluation in some patients.
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