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Biswal B, Aradhana A, Mohanty MD, Choudhury J, Behera BK, Beura S. Tumor-Induced Osteomalacia- Like Syndrome with Rickets and Infantile Hepatic Hemangioendothelioma. Indian J Pediatr 2024; 91:842-844. [PMID: 37248381 DOI: 10.1007/s12098-023-04612-x] [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: 01/19/2023] [Accepted: 04/06/2023] [Indexed: 05/31/2023]
Abstract
Tumor-induced osteomalacia (TIO), a rare paraneoplastic syndrome is seen in association with the overproduction of fibroblast growth factor-23 (FGF-23) by certain mesenchymal tumors in adults. In children, these phosphaturic mesenchymal tumors produce features of rickets similar to TIO. This condition is characterized by elevated blood levels of FGF-23, low phosphate, low or normal active vitamin D, and high alkaline phosphatase. Though the removal of the tumor is curative; in cases where surgical resection is not possible, medical treatment is successful with phosphate and active vitamin D in the improvement of symptoms. The case of a child with features of rickets is presented here to illustrate the importance of identifying this rare condition and instituting appropriate intervention.
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Affiliation(s)
- Basudev Biswal
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India
| | - Aparna Aradhana
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India
| | - Mamata Devi Mohanty
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India
| | - Jasashree Choudhury
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India
| | - Braja Kishore Behera
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India
| | - Subhasree Beura
- Department of Pediatrics, IMS & SUM Hospital, Bhubaneswar, 751003, Odisha, India.
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Vollmer S, Olsson K. Tumour-induced osteomalacia: the long road to diagnosis and recovery. BMJ Case Rep 2024; 17:e258858. [PMID: 38697682 PMCID: PMC11085914 DOI: 10.1136/bcr-2023-258858] [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] [Indexed: 05/05/2024] Open
Abstract
Tumour-induced osteomalacia is caused by tumorous production of fibroblast growth factor 23 (FGF23) leading to urinary phosphate wasting, hypophosphataemia and decreased vitamin D activation. The resulting osteomalacia presents with muscle weakness and bone pain but progresses to multiple pathological fractures. Patients often remain undiagnosed for years with severe physical, psychological and economic ramifications. A young woman presented with multiple spontaneous fractures including bilateral femoral fractures. Laboratory tests revealed severe hypophosphataemia, elevated bone turnover markers and low to normal calcium and 25-hydroxy-vitamin D levels. Treatment with phosphate, alfalcalcidol, calcium and magnesium was initiated. 68Gallium-DOTATOC positron emission tomography imaging revealed a mass in the right foot and venous sampling of FGF23 from all extremities confirmed this tumour as the culprit. Biopsy and histology were consistent with a phosphaturic mesenchymal tumour, which was surgically resected. Phosphate levels quickly normalised postoperatively but a long convalescence with hungry bone syndrome, fracture healing and physical therapy followed.
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Affiliation(s)
- Shobitha Vollmer
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Karin Olsson
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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3
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Oris C, Lautrette A, Dougé A, Bouraima F, Kahouadji S, Pickering ME, Garrouste C, Gagnière J, Guièze R, D'Ostrevy N, Futier E, Grobost V, Buisson A, Batisse M, Bouillon-Minois JB, Pereira B, Durif J, Sapin V, Bouvier D. Prevalence of FGF23 elevation in patients with hypophosphatemia. Clin Chim Acta 2024; 554:117782. [PMID: 38224930 DOI: 10.1016/j.cca.2024.117782] [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: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND AND AIMS To investigate the contribution of FGF23 in explaining the cases of hypophosphatemia observed in clinical practice, we aimed to determine for the first time the prevalence of FGF23 elevation in patients with hypophosphatemia and to describe the different mechanisms of FGF23-related hypophosphatemic disorders. MATERIALS AND METHODS We performed a prospective, observational, multicenter, cohort study of 260 patients with hypophosphatemia. Blood measurements (PTH, 1,25-dihydroxyvitamin D, bone alkaline phosphatase, 25-hydroxyvitamin D, and FGF23) were performed on a Liaison XL® (DiaSorin) analyzer. RESULTS Primary elevation of FGF23 (>95.4 pg/mL) was reported in 10.4% (95CI: 7.0-14.7) of patients (n = 27) with hypophosphatemia, suggesting that at least 1 in 10 cases of hypophosphatemia was erroneously attributed to an etiology other than FGF23 elevation. Patients with elevated blood FGF23 were grouped according to the etiology of the FGF23 elevation. Thus, 10 patients had a renal pathology, chronic kidney disease or post-renal transplantation condition. The remaining patients (n = 17) had the following etiologies: malignancies (n = 9), benign pancreatic tumor (n = 1), post-cardiac surgery (n = 4), cirrhosis (n = 2), and chronic obstructive pulmonary disease (n = 1). CONCLUSION In order to improve patient management, it seems essential to better integrate plasma FGF23 measurement into the routine evaluation of hypophosphatemia.
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Affiliation(s)
- Charlotte Oris
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Department of Intensive Care Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Aurore Dougé
- Department of Oncology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Farouk Bouraima
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Samy Kahouadji
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Marie-Eva Pickering
- Rheumatology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Romain Guièze
- Department of Clinical Hematology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Nicolas D'Ostrevy
- Department of Cardiac Surgery, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, Anesthesia & Critical Care, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Vincent Grobost
- Department of Internal Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Anthony Buisson
- Department of Hepato-Gastroenterology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Marie Batisse
- Department of Oncology, Centre Jean Perrin, 63000 Clermont-Ferrand, France
| | | | - Bruno Pereira
- Biostatistics Unit (DRCI) Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Julie Durif
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Damien Bouvier
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France.
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Yang Y, Jin P, Zhang S, Chen K, He H, Mo Z, Yuan J. A case of hyperparathyroidism secondary to tumor-induced osteomalacia. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:1937-1944. [PMID: 38448388 PMCID: PMC10930739 DOI: 10.11817/j.issn.1672-7347.2023.220547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Indexed: 03/08/2024]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome in which tumor-induced osteochondrosis is a metabolic bone disease caused by increased renal excretion of phosphorus due to excessive secretion of fibroblast growth factor 23 (FGF23) by tumor tissue. We report here a rare case of TIO in which the tumor was found in the hyoid body and the patient had tertiary hyperparathyroidism. The patient's symptoms did not improve after removal of the tumor from the hyoid body, and the patient's hypophosphatemia was gradually improved after subsequent removal of the left parathyroid gland. TIO derived from the tongue tumor is very rare, and also subsequent tertiary hyperparathyroidism is even rarer. This report helps to improve the understanding of TIO and provides reference in the diagnosis and treatment of TIO.
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Affiliation(s)
- Youbo Yang
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013.
| | - Ping Jin
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Shuting Zhang
- Department of Clinical Laboratory, Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Ke Chen
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Honghui He
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Zhaohui Mo
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Jingjing Yuan
- Department of Endocrinology, Third Xiangya Hospital, Central South University, Changsha 410013.
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Jha SS, Srivastava A, Kambhampati SBS, Elhence A. Introduction to Osteoporosis, Osteomalacia, and Fragility Fractures. Indian J Orthop 2023; 57:25-32. [PMID: 38107821 PMCID: PMC10721584 DOI: 10.1007/s43465-023-01015-0] [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: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 12/19/2023]
Abstract
Background Osteoporosis is a disease of the bones leading to decreased bone mineral density, leading to fragility fractures. This article is an overview of osteoporosis, osteomalacia and fragility fractures and serves as an introductory article for this special issue on osteoporosis. Methods This is a short, comprehensive account of the given conditions with concepts and a review from the recent literature. The authors provide relevant references from the literature in the bibliography. The sections herein have also been deliberated in the meetings of experts of osteoporosis. Results An overview of osteoporosis, osteomalacia and fragility fractures is provided, including definitions and summaries of aetiology, pathophysiology, diagnosis, prevention, and management. A detailed account of some of these topics will be provided in subsequent chapters. Conclusion Osteoporosis is a silent disease with the potential to cause significant morbidity and mortality if not detected early. It is important to differentiate from and diagnose associated osteomalacia to provide accurate therapy. It is also important to identify the type of fragility fractures and initiate treatment for bone strengthening to prevent subsequent fractures.
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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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Sun X, Ni P, Xie T, Wu S. Phosphaturic Mesenchymal Tumor Along the Hallux side Inducing a Chronic non-Healing Wound: A Case Report with Literature Review. INT J LOW EXTR WOUND 2023; 22:779-787. [PMID: 35043721 DOI: 10.1177/15347346221074163] [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] [Indexed: 11/17/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia, and bone calcification disorders. Complete surgical resection of the tumor is believed to be the most effective treatment measure. However, the diagnosis of PMT is very difficult because of its insidious and small size, especially, when it appears in subcutaneous tissue with a chronic non-healing wound. We report a rare case of a 38-year-old man with a chronic non-healing wound on the left hallux for approximately eight months. Plain radiographic images and magnetic resonance imaging (MRI) revealed a cystic radiolucent shadow in the left distal phalanx. Bone scan observations also showed increased uptake in the same location. Histologically, this tumor was composed of numerous spindle cells with clusters of giant cells. The serum FGF23 level was significantly higher before surgery, with higher FGF23 levels closer to the tumor. Reverse transcription polymerase chain reaction and immunohistochemistry further confirmed the high expression of FGF23 in tumors. These data suggest that FGF23 may be a potential causative factor of PMT. The serum FGF23 levels might be useful for the diagnosis of PMT and localization of the tumor. The tumor was CD56- and D2 to 40-positive and CD31-negative. The non-healing wound caused by PMT might be attributed to the invasive growth of the tumor, destruction of intercellular junctions, and decrease in the number of endothelial cells.
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Affiliation(s)
- Xiaofang Sun
- The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Pengwen Ni
- Shanghai ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Xie
- Shanghai ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shaohan Wu
- The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
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8
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Thi HN, Manh CP, Tuan LT, Le Thi LA, Thanh NN, Vilaiyuk S. Tumor-induced Osteomalacia in a Boy with Maxillary Ossifying Fibroma. J Clin Res Pediatr Endocrinol 2023; 15:421-425. [PMID: 35135186 PMCID: PMC10683546 DOI: 10.4274/jcrpe.galenos.2022.2021-8-14] [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: 08/20/2021] [Accepted: 01/12/2022] [Indexed: 12/01/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare, paraneoplastic disorder of hypophosphatemia associated with elevated tumor-produced fibroblast growth factor 23 (FGF23). Maxillofacial tumors are rarely involved in TIO, especially maxillary TIO in children. We present a 14-year-old boy with osteomalacia and high serum levels of FGF23, a hormone associated with decreased phosphate resorption, due to a maxillary tumor. The patient was treated with oral phosphorus and calcitriol, and surgical removal of the tumor was performed. After 21 months follow-up, he was pain free and had returned to full activity. We review the reported pediatric cases of TIO in the maxillofacial and oral region and discuss the management of these patients considering the published evidence.
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Affiliation(s)
- Ha Nguyen Thi
- Hanoi Medical University, Bach Mai Hospital, Clinic of Pediatrics, Hanoi, Vietnam
| | - Cuong Pham Manh
- Bach Mai Hospital, Diagnostic Imaging Central, Hanoi, Vietnam
| | - Linh To Tuan
- Viet Duc Hospital, Maxillofacial, Department of Plastic and Aesthetic Surgery, Hanoi, Vietnam
| | - Lan Anh Le Thi
- Hanoi Medical University, Bach Mai Hospital, Clinic of Pediatrics, Hanoi, Vietnam
| | | | - Soamarat Vilaiyuk
- Mahidol University Faculty of Medicine; Ramathibodi Hospital, Department of Pediatrics, Division of Rheumatology, Bangkok, Thailand
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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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Chinoy A, Padidela R. Commentary on Severe Hypophosphatemia: The Hidden Truth. Clin Chem 2023; 69:453-454. [PMID: 37115577 DOI: 10.1093/clinchem/hvad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Amish Chinoy
- Paediatric Endocrinology and Metabolic Bone Disorders, Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Raja Padidela
- Paediatric Endocrinology and Metabolic Bone Disorders, Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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11
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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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12
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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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13
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Ramos P, Larson B, Ashrafzadeh-Kian S, Ito N, Kato H, Bornhorst JA, Algeciras-Schimnich A. Intact Fibroblast Growth Factor 23 Concentrations in Hypophosphatemic Disorders. Endocr Pract 2023; 29:193-198. [PMID: 36627024 DOI: 10.1016/j.eprac.2023.01.003] [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: 10/26/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Evaluation of circulating fibroblast growth factor 23 (FGF23) concentrations plays a key role in the differential diagnosis of patients presenting with hypophosphatemia. FGF23 concentrations obtained by different immunoassays are not comparable and subsequently, differences in the clinical performance of the assays might arise. In this study, we evaluated the clinical performance of the Medfrontier FGF23 Intact immunoassay (MedFrontier, Minaris Medical Co, Ltd, Tokyo, Japan) in clinically relevant hypophosphatemic conditions. METHODS Intact FGF23 (iFGF23) was measured in serum samples from 61 patients with FGF23-dependent hypophosphatemia (42-tumor induced osteomalacia [TIO] and 19-X-linked hypophosphatemia [XLH]); 8 patients with FGF23-independent hypophosphatemia (6-Fanconi Syndrome and 2-Vitamin D dependent rickets); 10 normophosphatemic patients; 15 chronic kidney disease (CKD) stage-2/3 and 20 CKD stage-4/5 patients; and a healthy control population. Disease-specific differences in measured iFGF23 concentrations and FGF23 concentration association with phosphate concentrations were reported. RESULTS iFGF23 concentrations were significantly elevated in 90% and 84% of TIO and XLH hypophosphatemia patients as compared to healthy controls (both TIO and XLH, P = .0001). There was no significant correlation between iFGF23 and phosphate concentrations (P = .74 and P = .86) for TIO and XLH, respectively. Patients with CKD showed a significant increase in serum iFGF23 as the estimated glomerular filtration rate decreased (ρ = -0.79, P ≤ 0.0001). CONCLUSIONS This study evaluated the clinical performance of the MedFrontier iFGF23 assay in a large cohort of XLH and TIO Caucasian and Asian patients. The clinical sensitivity of this iFGF23 assay is appropriate for clinical use.
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Affiliation(s)
- Paola Ramos
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Bethany Larson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Nobuaki Ito
- 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
| | - Joshua A Bornhorst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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14
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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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15
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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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16
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Rosa J. Osteomalacia. VNITRNI LEKARSTVI 2023; 69:254-260. [PMID: 37468295 DOI: 10.36290/vnl.2023.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Osteomalacia with characteristic histomorphometric, radiographic, laboratory and clinical features is a prominent syndrome of disturbed bone mineralisation in adulthood. From an etiological point of view, osteomalacia is usually caused by substrate (calcium, phosphate) deficiency, presence of excess mineralization inhibitors or deficiency or ineffectivness of mineralization facilitator (vitamin D). In proportion to the high number of congenital and acquired causes of osteomalacia, its clinical and laboratory picture is heterogeneous and rarely fully expressed. The treatment of a particular case is determined by the cause of osteomalacia and may (but does not necessarily) include correction of the underlying disease, administration of calcium and various forms of vitamin D, as well as orthopaedic interventions. For some of the hereditary forms, biological or replacement therapy is prospectively available. The article attempts to cover the whole range of osteomalacia variants, mentioning a fact discussed only in recent years - the occurrence of oligosymptomatic, incompletely expressed forms.
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17
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Abstract
Hypophosphatemic rickets typically presents in infancy or early childhood with skeletal deformities and growth plate abnormalities. The most common causes are genetic (such as X-linked hypophosphatemia), and these typically will result in lifelong hypophosphatemia and osteomalacia. Knowledge of phosphate metabolism, including the effects of fibroblast growth factor 23 (FGF23) (an osteocyte produced hormone that downregulates renal phosphate reabsorption and 1,25-dihydroxyvitamin-D (1,25(OH)2D) production), is critical to determining the underlying genetic or acquired causes of hypophosphatemia and to facilitate appropriate treatment. Serum phosphorus should be measured in any child or adult with musculoskeletal complaints suggesting rickets or osteomalacia. Clinical evaluation incudes thorough history, physical examination, laboratory investigations, genetic analysis (especially in the absence of a guiding family history), and imaging to establish etiology and to monitor severity and treatment course. The treatment depends on the underlying cause, but often includes active forms of vitamin D combined with phosphate salts, or anti-FGF23 antibody treatment (burosumab) for X-linked hypophosphatemia. The purpose of this article is to explore the approach to evaluating hypophosphatemic rickets and its treatment options.
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Affiliation(s)
- Sarah A Ackah
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Erik A Imel
- Department of Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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18
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Cipriani C, Minisola S, Colangelo L, DE Martino V, Ferrone F, Biamonte F, Danese V, Sonato C, Santori R, Occhiuto M, Pepe J. FGF23 functions and disease. Minerva Endocrinol (Torino) 2022; 47:437-448. [PMID: 33792238 DOI: 10.23736/s2724-6507.21.03378-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The main function of fibroblast growth factor 23 (FGF23) is the regulation of phosphate metabolism through its action on the sodium-dependent phosphate cotransporters in the proximal renal tubules. Additionally, FGF23 interacts with vitamin D and parathyroid hormone in a complex metabolic pathway whose detailed mechanisms are still not clear in human physiology and disease. More recently, research has also focused on the understanding of mechanisms of FGF23 action on organs and system other than the kidneys and bone, as well as on its interaction with other metabolic pathways. Collectively, the new evidence are successfully used for the clinical evaluation and management of FGF23-related disorders, for which new therapies with many potential applications are now available.
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Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy -
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Luciano Colangelo
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Viviana DE Martino
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Federica Ferrone
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Federica Biamonte
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Vittoria Danese
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Chiara Sonato
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Rachele Santori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Marco Occhiuto
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
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19
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Marques JVO, Moreira CA, Borba VZC. New treatments for rare bone diseases: hypophosphatemic rickets/osteomalacia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:658-665. [PMID: 36382755 PMCID: PMC10118827 DOI: 10.20945/2359-3997000000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Phosphorus is one of the most abundant minerals in the human body; it is required to maintain bone integrity and mineralization, in addition to other biological processes. Phosphorus is regulated by parathyroid hormone, 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], and fibroblast growth factor 23 (FGF-23) in a complex set of processes that occur in the gut, skeleton, and kidneys. Different molecular mechanisms - overproduction of FGF-23 by tumors responsible for oncogenic osteomalacia, generation of an FGF-23 mutant that is resistant to cleavage by enzymes, and impaired FGF-23 degradation due to a reduction in or loss of the PHEX gene - can lead to FGF-23-stimulating activity and the consequent waste of urinary phosphate and low levels of 1,25(OH)2D3. Conventional treatment consists of multiple daily doses of oral phosphate salts and vitamin D analogs, which may improve radiographic rickets but do not normalize growth. Complications of the conventional long-term treatment consist of hypercalcemia, hypercalciuria, nephrolithiasis, nephrocalcinosis, impaired renal function, and potentially chronic kidney disease. Recently, burosumab, an antibody against FGF-23, was approved as a novel therapy for children and adults with X-linked hypophosphatemia and patients with tumor-induced osteomalacia. Burosumab showed good performance in different trials in children and adults. It increased and sustained the serum phosphorus levels, decreased the rickets severity and pain scores, and improved mineralization. It offers a new perspective on the treatment of chronic and disabling diseases.
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20
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-z] [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: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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21
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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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22
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Liu SH, Xiao Z, Mishra SK, Mitchell JC, Smith JC, Quarles LD, Petridis L. Identification of Small-Molecule Inhibitors of Fibroblast Growth Factor 23 Signaling via In Silico Hot Spot Prediction and Molecular Docking to α-Klotho. J Chem Inf Model 2022; 62:3627-3637. [PMID: 35868851 PMCID: PMC10018682 DOI: 10.1021/acs.jcim.2c00633] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is a therapeutic target for treating hereditary and acquired hypophosphatemic disorders, such as X-linked hypophosphatemic (XLH) rickets and tumor-induced osteomalacia (TIO), respectively. FGF23-induced hypophosphatemia is mediated by signaling through a ternary complex formed by FGF23, the FGF receptor (FGFR), and α-Klotho. Currently, disorders of excess FGF23 are treated with an FGF23-blocking antibody, burosumab. Small-molecule drugs that disrupt protein/protein interactions necessary for the ternary complex formation offer an alternative to disrupting FGF23 signaling. In this study, the FGF23:α-Klotho interface was targeted to identify small-molecule protein/protein interaction inhibitors since it was computationally predicted to have a large fraction of hot spots and two druggable residues on α-Klotho. We further identified Tyr433 on the KL1 domain of α-Klotho as a promising hot spot and α-Klotho as an appropriate drug-binding target at this interface. Subsequently, we performed in silico docking of ∼5.5 million compounds from the ZINC database to the interface region of α-Klotho from the ternary crystal structure. Following docking, 24 and 20 compounds were in the final list based on the lowest binding free energies to α-Klotho and the largest number of contacts with Tyr433, respectively. Five compounds were assessed experimentally by their FGF23-mediated extracellular signal-regulated kinase (ERK) activities in vitro, and two of these reduced activities significantly. Both these compounds were predicted to have favorable binding affinities to α-Klotho but not have a large number of contacts with the hot spot Tyr433. ZINC12409120 was found experimentally to disrupt FGF23:α-Klotho interaction to reduce FGF23-mediated ERK activities by 70% and have a half maximal inhibitory concentration (IC50) of 5.0 ± 0.23 μM. Molecular dynamics (MD) simulations of the ZINC12409120:α-Klotho complex starting from in silico docking poses reveal that the ligand exhibits contacts with residues on the KL1 domain, the KL1-KL2 linker, and the KL2 domain of α-Klotho simultaneously, thereby possibly disrupting the regular function of α-Klotho and impeding FGF23:α-Klotho interaction. ZINC12409120 is a candidate for lead optimization.
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Affiliation(s)
- Shih-Hsien Liu
- UT/ORNL Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee37831, United States
- Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee37996, United States
| | - Zhousheng Xiao
- Department of Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee38163, United States
| | - Sambit K Mishra
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee37831, United States
| | - Julie C Mitchell
- Biosciences Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee37831, United States
| | - Jeremy C Smith
- UT/ORNL Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee37831, United States
- Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee37996, United States
| | - L Darryl Quarles
- Department of Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee38163, United States
| | - Loukas Petridis
- UT/ORNL Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee37831, United States
- Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee37996, United States
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23
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Kojima D, Ohba S, Abe M, Suzuki A, Horibe S, Tateya I, Hasegawa M, Hirose Y. Intracranial phosphaturic mesenchymal tumors. A case report and review of literature. Neuropathology 2022; 42:453-458. [PMID: 35880350 DOI: 10.1111/neup.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
Most osteomalacia-inducing tumors (OITs) are phosphaturic mesenchymal tumors (PMTs) that secrete fibroblast growth factor 23 (FGF23). These tumors usually occur in the bone and soft tissues, and intracranial OITs are rare. Therefore, intracranial OIT is difficult to diagnose and treat. This paper presents a case of intracranial OIT and shows a review of previous cases. A 45-year-old man underwent nasal cavity biopsy and treatment with active vitamin D3 and neutral phosphate for hypophosphatemia. Amplification of FGF23 mRNA level within the tumor was detected. Subsequently, the surgical specimen was diagnosed with a PMT and was considered the cause of the patient's osteomalacia. The patient was referred to a neurosurgery department for the excision of the intracranial tumor extending to the nasal cavity. After tumor removal, the serum levels of FGF23 and phosphorus were normalized as compared to preoperative those. The patient remains disease-free, without additional treatment, approximately 10 years after surgery, with no tumor recurrence. As per the literature, intracranial OITs usually occur in patients aged 8-69 years. Bone and muscle pain are major complaints. Approximately 60% of the patients reported previously had symptoms because of intracranial tumors. In some cases, it took several years to diagnose OIT after the onset of the osteomalacia symptoms. Laboratory data in such cases show hypophosphatemia and elevated FGF23 levels. Because FGF23 levels are associated with the severity of osteomalacia symptoms, total tumor resection is recommended. PMT and hemangiopericytoma (HPC) are histologically similar, but on immunochemistry, PMT is negative for signal transducer and activator of transcription 6 (STAT6), whereas HPC is positive. FGF23 amplification is seen in PMTs but not in HPCs. Therefore, the analysis of FGF23 and STAT6 was helpful in distinguishing PMTs from HPCs. In cases of hypophosphatemia and osteomalacia without a history of metabolic, renal, or malabsorptive diseases, the possibility of oncogenic osteomalacia should be considered.
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Affiliation(s)
- Daijiro Kojima
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Shigeo Ohba
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Masato Abe
- Department of Pathology, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Seiji Horibe
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Ichiro Tateya
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | | | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
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Cianferotti L, Delli Poggi C, Bertoldo F, Caffarelli C, Crotti C, Gatti D, Giannini S, Gonnelli S, Mazzantini M, Ombretta V, Sella S, Setti A, Varenna M, Zucchi F, Brandi ML. Persistence and recurrence in tumor-induced osteomalacia: A systematic review of the literature and results from a national survey/case series. Endocrine 2022; 76:709-721. [PMID: 35381903 PMCID: PMC9156492 DOI: 10.1007/s12020-022-03039-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Tumor induced osteomalacia (TIO) is a rare disease of mineral metabolism, whose clinical picture is dominated by hypophosphatemia usually due to an excess of circulating FGF23 produced by small mesenchymal tumors. Data on the real prevalence of the disease are lacking, with the knowledge of the disease mainly relying on case reports and small case series. No estimate is available on the prevalence of uncured TIO. METHODS National multi-center, cross-sectional and retrospective study on persistent or recurrent cases of TIO followed in referral centers for bone diseases; systematic review of the published persistent and recurrent cases of TIO. Data from patients consecutively evaluated in referral Italian centers for bone diseases were collected; a PubMed search on persistent, recurrent and unoperable cases of TIO was carried out. RESULTS Sixteen patients (mean age at diagnosis 52.5 ± 10.6 years) with persistent (n = 6, 37,5%), recurrent (n = 7, 43.7%) or not operable (n = 3, 18.8%) TIO were described. Delay in diagnosis (2.5 ± 1.3 years) was demonstrated. All patients experienced fragility fractures or pseudofractures and disabling bone and muscle pain. BMD was significantly reduced (mean T-score -2.7 ± 1.7 and -2.7 ± 0.9 at lumbar spine and femoral neck, respectively). Fourteen patients were maintained under therapy with phosphate salts and calcitriol, while in 2 patients therapy with burosumab, an anti-FGF23 antibody, was commenced. CONCLUSION A significant number of patients with TIO remain either undiagnosed for tumor localization or tumor recur or persist after surgery. These patients with active disease represent possible candidates for burosumab treatment.
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Affiliation(s)
- Luisella Cianferotti
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Bone Metabolic Diseases Unit, University Hospital of Florence, largo Palagi 1, 50139, Florence, Italy
| | - Chiara Delli Poggi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Bone Metabolic Diseases Unit, University Hospital of Florence, largo Palagi 1, 50139, Florence, Italy
| | - Francesco Bertoldo
- Department of Medicine, University of Verona, Piazzale LA Scuro 10, Policlinico GB Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Carla Caffarelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Chiara Crotti
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
| | - Davide Gatti
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, Policlinico G.B. Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Sandro Giannini
- Department of Medicine (DIMED), Clinica Medica Uno, University of Padua, via Nicolò Giustiniani, 2, 35128, Padua, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Maurizio Mazzantini
- Rheumatology Unit, and Fracture Liaison Service, University Hospital of Pisa, via Roma 67, 56126, Pisa, Italy
| | - Viapiana Ombretta
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, Policlinico G.B. Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Stefania Sella
- Department of Medicine (DIMED), Clinica Medica Uno, University of Padua, via Nicolò Giustiniani, 2, 35128, Padua, Italy
| | - Angela Setti
- Department of Medicine, University of Verona, Piazzale LA Scuro 10, Policlinico GB Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Massimo Varenna
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
| | - Francesca Zucchi
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
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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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Ovejero D, Hartley IR, de Castro Diaz LF, Theng E, Li X, Gafni RI, Collins MT. PTH and FGF23 Exert Interdependent Effects on Renal Phosphate Handling: Evidence From Patients With Hypoparathyroidism and Hyperphosphatemic Familial Tumoral Calcinosis Treated With Synthetic Human PTH 1-34. J Bone Miner Res 2022; 37:179-184. [PMID: 34464000 DOI: 10.1002/jbmr.4429] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 12/27/2022]
Abstract
Parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) both influence blood phosphate levels by regulating urinary phosphate reabsorption. Clinical data suggest that adequate renal phosphate handling requires the presence of both FGF23 and PTH, but robust evidence is lacking. To investigate whether the phosphaturic effects of PTH and FGF23 are interdependent, 11 patients with hypoparathyroidism, which features high blood phosphate in spite of concomitant FGF23 elevation, and 1 patient with hyperphosphatemic familial tumoral calcinosis (HFTC), characterized by deficient intact FGF23 action and resulting hyperphosphatemia, were treated with synthetic human PTH 1-34 (hPTH 1-34). Biochemical parameters, including blood phosphate, calcium, intact FGF23 (iFGF23), nephrogenic cAMP, 1,25(OH)2 vitamin D (1,25D), and tubular reabsorption of phosphate (TRP), were measured at baseline and after hPTH 1-34 treatment. In patients with hypoparathyroidism, administration of hPTH 1-34 increased nephrogenic cAMP, which resulted in serum phosphate normalization followed by a significant decrease in iFGF23. TRP initially decreased and returned to baseline. In the patient with HFTC, hPTH 1-34 administration also increased nephrogenic cAMP, but this did not produce changes in phosphate or TRP. No changes in calcium were observed in any of the studied patients, although prolonged hPTH 1-34 treatment did induce supraphysiologic 1,25D levels in the patient with HFTC. Our results indicate that PTH and FGF23 effects on phosphate regulation are interdependent and both are required to adequately regulate renal phosphate handling. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Diana Ovejero
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Musculoskeletal Research Unit, Hospital del Mar Medical Research Institute, Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain
| | - Iris R Hartley
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Luis Fernandez de Castro Diaz
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth Theng
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Xiaobai Li
- Biostatistics and Clinical Epidemiology Services (XL), National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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Vitamin D and Phosphate Interactions in Health and Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:37-46. [DOI: 10.1007/978-3-030-91623-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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High bone turnover and hyperparathyroidism after surgery for tumor-induced osteomalacia: A case series. Bone Rep 2021; 15:101142. [PMID: 34901333 PMCID: PMC8640873 DOI: 10.1016/j.bonr.2021.101142] [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: 07/28/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 11/23/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is an ultrarare disorder that is caused by renal phosphate wasting due to uncontrolled tumoral production of fibroblast growth factor 23 (FGF23) from phosphaturic mesenchymal tumors. Surgical removal of the tumor is curative. There is limited information on the biochemical changes in mineral metabolism and bone remodeling activity after surgery, but it is reported that surgery is followed by a hungry bone syndrome (HBS) with hypocalcemia and secondary hyperparathyroidism. We report the biochemical response to surgery in two patients, who presented with severe TIO, as manifested by proximal myopathy, multiple stress fractures, high FGF23, low serum phosphate, low maximum renal phosphate reabsorption threshold (TmP/GFR), and low 1,25-dihydroxy-vitamin D (1,25(OH)2D). Prior to surgery, both patients developed secondary hyperparathyroidism and one case had progressed to tertiary hyperparathyroidism. After surgery there was normalization of FGF23, TmP/GFR, and phosphate. High 1,25(OH)2D was recorded. One patient had hypocalcaemia and worsening secondary hyperparathyroidism consistent with HBS; the other patient did not have hypocalcemia but had worsening tertiary hyperparathyroidism that only resolved with cinacalcet. There was a marked increase in bone remodeling markers, both resorption and formation, consistent with a high bone turnover state. There was a different pattern of change in bone specific alkaline phosphatase, reflecting healing of osteomalacia. Biochemical monitoring in the post-surgical management of TIO is warranted for guiding adjustments in medical intervention, both short-term and long-term. Future use of burosumab prior to surgery for TIO may ameliorate the immediate post-surgery effects.
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Oe Y, Kameda H, Nomoto H, Sakamoto K, Soyama T, Cho KY, Nakamura A, Iwasaki K, Abo D, Kudo K, Miyoshi H, Atsumi T. Favorable effects of burosumab on tumor-induced osteomalacia caused by an undetectable tumor: A case report. Medicine (Baltimore) 2021; 100:e27895. [PMID: 34797338 PMCID: PMC8601343 DOI: 10.1097/md.0000000000027895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Tumor-induced osteomalacia (TIO) is curable by tumor resection, but detection of the tumor can be challenging. Overproduction of fibroblast growth factor 23 (FGF23) by the tumor causes hypophosphatemia and consequently induces inappropriate bone turnover. Conventionally oral phosphate supplementation was the only treatment for TIO, but had risks of hypercalciuria and nephrocalcinosis. Burosumab, a human monoclonal anti-FGF23 antibody, was recently post-marketed in Japan against for FGF23-related hypophosphatemia. Herein, we present a case of TIO with undetectable tumor that was successfully treated with burosumab. PATIENT CONCERNS A 47-year-old woman was forced to use a wheelchair because of pain in both feet. DIAGNOSIS Laboratory findings showed hypophosphatemia, elevated bone markers, and high serum FGF23 without renal tubular defects. Imaging studies revealed bone atrophy in the feet, decreased bone density, and multiple pseudofractures in the talar, sacral, and L5 vertebral regions. After excluding drug-induced and hereditary osteomalacia, we diagnosed her as TIO. INTERVENTIONS Comprehensive imaging studies and stepwise venous sampling failed to localize the tumor, and we started to administer subcutaneous burosumab. OUTCOMES After administration of burosumab, her serum phosphate was normalized without phosphate supplementation within 2 months. Improvement of pseudofractures, relief of pain evaluated by a visual analog scale, and normalization of bone biomarkers were observed. The patient was able to stand by herself after 6 months administration of burosumab. LESSONS This is the first report in clinical practice to demonstrate favorable effects of burosumab, including not only normalization of serum phosphate but also improvements of pseudofractures and subjective pain, in a patient with TIO and undetectable tumor.
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Affiliation(s)
- Yuki Oe
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Keita Sakamoto
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Koji Iwasaki
- Department of Orthopedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideaki Miyoshi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Division of Diabetes and Obesity, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Moreno Romero M, Pérez Muñoz I, González Lizán F, Gallego Rivera J, Valdivielso Cañas L. The phosphaturic mesenchymal tumor as a cause of oncogenic osteomalacia. Three cases and review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Crotti C, Bartoli F, Coletto LA, Manara M, Marini E, Daolio PA, Parafioriti A, Armiraglio E, Zucchi F, Sinigaglia L, Caporali R, Varenna M. Tumor induced osteomalacia: A single center experience on 17 patients. Bone 2021; 152:116077. [PMID: 34175499 DOI: 10.1016/j.bone.2021.116077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/21/2021] [Accepted: 06/16/2021] [Indexed: 01/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome due to a phosphaturic tumor, which overproduces Fibroblast Growth Factor 23 (FGF-23), causing hyperphosphaturia, hypophosphatemia, low 1,25(OH)2D and osteomalacia. Tumor localization is critical, diagnostic delay ranges from 2.5 to 28 years and to date surgical removal is considered effective treatment. We retrospectively evaluated patients with definite diagnosis of TIO referred to a tertiary Rheumatology Center between September 2000 and May 2020, investigating clinical management and disease outcome. We included 17 patients: 10 (58.8%) were females, mean age at diagnosis was 55.3 ± 13.9 years (mean ± standard deviation), with a diagnostic delay from symptoms onset to tumor detection of 6.6 ± 6.25 years. Biochemical data were: serum phosphorus 1.3 ± 0.4 mg/dL (Reference Range: 2.5-4.6), serum 1,25(OH)2D 31.8 ± 22.9 ng/mL (RR: 25-86), intact FGF-23, 358.9 ± 677 pg/mL (RR: 25-45); 24 h-Urine Phosphorus was increased in only 2 patients, while tubular reabsorption of phosphate (TRP) was decreased in all patients confirming a renal phosphate wasting. In 2013 68Ga- DOTA-based PET/CT was introduced in routinely practice and diagnostic delay was consistently reduced (from 8.6 ± 7.9 to 4.3 ± 2.4 years). Thirteen patients underwent surgery, one patient underwent radiofrequency ablation; 3 patients, not eligible for surgery, were treated only with supplements of phosphorus and calcitriol. One was started on Burosumab after several unsuccessful surgical attempts. After surgery or ablation, 8 patients had complete remission, 3 TIO persistence, and 3 had overtime relapse. Relapses were observed only in patients who previously underwent closed biopsy. To our knowledge, this is the widest European cohort of TIO patients in the last two decades. We confirm a usual diagnostic delay and recommend a stepwise diagnostic approach. Tumor biopsy is not recommended due to the potential cell spilling. Surgery is generally considered a definitive treatment, even though other approaches have been successful in curing TIO. Active surveillance on possible recurrence is always needed. Burosumab appears a promising therapy.
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Affiliation(s)
- C Crotti
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - F Bartoli
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L A Coletto
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - M Manara
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - E Marini
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | - P A Daolio
- Oncologic Orthopedic Surgery, Gaetano Pini Institute, Milan, Italy
| | | | - E Armiraglio
- UOC Pathology, Gaetano Pini Institute, Milan, Italy
| | - F Zucchi
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - L Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - R Caporali
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - M Varenna
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy.
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Brandi ML, Clunie GPR, Houillier P, Jan de Beur SM, Minisola S, Oheim R, Seefried L. Challenges in the management of tumor-induced osteomalacia (TIO). Bone 2021; 152:116064. [PMID: 34147708 DOI: 10.1016/j.bone.2021.116064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare acquired paraneoplastic disease, which is challenging to diagnose and treat. TIO is characterized by hypophosphatemia resulting from excess levels of tumor-secreted fibroblast growth factor 23 (FGF23), one of the key physiological regulators of phosphate metabolism. Elevated FGF23 results in renal phosphate wasting and compromised vitamin D activation, ultimately resulting in osteomalacia. Patients typically present with progressive and non-specific symptoms, including bone pain, multiple pathological fractures, and progressive muscle weakness. Diagnosis is often delayed or missed due to the non-specific nature of complaints and lack of disease awareness. Additionally, the disease-causing tumour is often difficult to detect and localize because they are often small, lack localizing symptoms and signs, and dwell in widely variable anatomical locations. Measuring serum/urine phosphate should be an inherent diagnostic component when assessing otherwise unexplained osteomalacia, fractures and weakness. In cases of hypophosphatemia with inappropriate (sustained) phosphaturia and inappropriately normal or frankly low 1,25-dihydroxy vitamin D, differentiation of the potential causes of renal phosphate wasting should include measurement of FGF23, and TIO should be considered. While patients experience severe disability without treatment, complete excision of the tumour is typically curative and results in a dramatic reversal of symptoms. Two additional key current unmet needs in optimizing TIO management are: (1 and 2) the considerable delay in diagnosis and consequent delay between the onset of symptoms and surgical resection; and (2) alternative management. These may be addressed by raising awareness of TIO, and taking into consideration the accessibility and variability of different healthcare infrastructures. By recognizing the challenges associated with the diagnosis and treatment of TIO and by applying a stepwise approach with clear clinical practice guidelines, patient care and outcomes will be improved in the future.
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Affiliation(s)
- Maria Luisa Brandi
- FirmoLab, FIRMO Foundation, Stabilimento Chimici Farmaceutico Militare di Firenze, Via Reginaldo Giuliani 201, 50141 Florence, Italy.
| | - Gavin P R Clunie
- Cambridge University Hospitals, Box 204, Hills Road, Cambridge CB2 0QQ, UK.
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Suzanne M Jan de Beur
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA.
| | | | - Ralf Oheim
- University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Lothar Seefried
- Julius-Maximilians University, Brettreichstr. 11, 97074 Würzburg, Germany.
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Mendes DAB, Coelho MCA, Gehrke B, de Pinho LKJ, Cardoso Lima LF, Paranhos-Neto F, de Mendonça LMC, Farias MLF, Madeira M. Microarchitectural parameters and bone mineral density in patients with tumour-induced osteomalacia by HR-pQCT and DXA. Clin Endocrinol (Oxf) 2021; 95:587-594. [PMID: 34043830 DOI: 10.1111/cen.14533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Tumour-induced osteomalacia (TIO) is a rare paraneoplastic condition characterised by decreased tubular phosphate reabsorption. The purpose of this study is to evaluate bone mineral density (BMD) and microarchitecture in six TIO patients, compared with 18 healthy controls. METHODS Volumetric BMD and microarchitecture were evaluated by high-resolution peripheral quantitative computed tomography (HR-pQCT), and areal BMD by dual-energy X-ray absorptiometry (DXA). Differences between groups were significant for p < .05. RESULTS All TIO subjects were healthy until the development of diffuse bone pain and multiple skeletal fractures and deformities. At baseline, sPi and TmPi/GFR were low and patients were on vitamin D and phosphate replacement at the study. Compared with controls, TIO patients had lower aBMD at lumbar spine and hip, and lower vBMD at trabecular, cortical and entire bone, at distal radius (R) and distal tibia (T): trabecular vBMD (R = 118.3 × 177.1; T = 72.3 × 161.3 gHA/cm3 ); cortical vBMD (R = 782.3 × 866.5; T = 789.1 × 900.9 gHA/cm3 ); total region vBMD (R = 234.5 × 317; T = 167.1 × 295.8 gHA/cm3 ). Bone microarchitecture was very heterogeneous among patients and significantly different from controls: lower cortical thickness (R = 0.59 × 0.80; T = 0.90 × 1.31 mm), bone volume-to-total volume ratio (R = 0.09 × 0.14; T = 0.06 × 0.13) and Tb.N (R = 1.46 × 2.10; T = 0.93 × 1.96 mm-1 ) and also higher Tb.Sp (R = 0.70 × 0.41; T = 1.28 × 0.45 mm) and Tb.1/N.SD (R = 0.42 × 0.18; T = 0.87 × 0.20 mm). CONCLUSION In this original study of TIO patients, DXA and HR-pQCT evaluation identified lower areal and volumetric BMD and severely impaired microarchitecture at cortical and trabecular bones, which probably contribute to bone fragility and fractures.
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Affiliation(s)
- Danielle A B Mendes
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria C A Coelho
- Endocrinology Division, Faculty of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bárbara Gehrke
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrinology Division, Faculty of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Postgraduate Program in Clinical and Experimental Pathophysiology (FISCLINEX), Faculty of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro K J de Pinho
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luis F Cardoso Lima
- Nuclear Engineering Program, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Francisco Paranhos-Neto
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Laura M C de Mendonça
- Rheumatology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - M L Fleiuss Farias
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Miguel Madeira
- Endocrinology Division, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Zanchetta MB, Jerkovich F, Nuñez S, Mocarbel Y, Pignatta A, Elías N, Díaz AG, Roganovich JM, Vigovich C, Balonga MC, Cohen AC, Mumbach G, Gonzalez S, Plantalech L, Fradinger E, Zanchetta JR. Impaired bone microarchitecture and strength in patients with tumor-induced osteomalacia. J Bone Miner Res 2021; 36:1502-1509. [PMID: 33950560 DOI: 10.1002/jbmr.4325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 12/29/2022]
Abstract
Some studies based on bone biopsy have demonstrated that in patients with tumor-induced osteomalacia (TIO) the mineralization process of the bone matrix is profoundly disturbed. However, the interrelationship between clinical and biochemical features and bone microarchitecture in this disease needs further analysis. With this purpose in mind, we set out three objectives: (i) to determine bone microarchitecture and estimated bone strength in a group of patients with tumor-induced osteomalacia using high-resolution peripheral quantitative computed tomography (HR-pQCT) and finite element analysis (FEA), (ii) to investigate correlations between duration of disease, biochemical features, bone density, HR-pQCT and FEA parameters, and (iii) to compare HR-pQCT and FEA parameters with a healthy control group. Ten patients with TIO were included. All patients had non-resolved disease. At the distal radius, all bone microarchitecture parameters were significantly affected in patients with TIO in comparison with healthy controls. At the distal tibia, all parameters were significantly impaired, except for trabecular thickness. All the parameters were more affected in the distal tibia than in the distal radius. Women with TIO (n = 7) had significantly lower bone strength parameters than healthy controls. In men (n = 3), bone strength parameters were significantly lower than in the control group at the distal tibia. Alkaline phosphatase levels exhibited a negative correlation with microarchitecture parameters, failure load, and stiffness. Higher levels of parathyroid hormone correlated with poorer microarchitecture parameters. We believe that in TIO, hormonal disturbances and the lack of mechanical stimulus specially converge to generate an extremely harmful combination for bone health. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- María Belén Zanchetta
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - Fernando Jerkovich
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina.,División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Selva Nuñez
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - Yamile Mocarbel
- División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Analía Pignatta
- Servicio de Endocrinología, Hospital Interzonal San Juan Bautista, San Fernando del Valle de Catamarca, Argentina
| | - Natalia Elías
- Servicio de Endocrinología, Metabolismo, Nutrición y Diabetes, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Adriana Graciela Díaz
- División Endocrinología, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | | | - María Celeste Balonga
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | | | | | | | - Luisa Plantalech
- Servicio de Endocrinología y Medicina Nuclear, Sector Osteopatías, Hospital Italiano, Buenos Aires, Buenos Aires, Argentina
| | - Erich Fradinger
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
| | - José Rubén Zanchetta
- IDIM, Instituto de Diagnóstico e Investigaciones Metabólicas, Universidad del Salvador, LIBERTAD 836 1 PISO, BUENOS AIRES, Argentina, C1012AAR, Argentina
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Muniz CR, Bezerra GAM, da Silva VC, Aguiar PMF, Gerson G, D'Alva CB, Nunes AAA. Ethmoid glomangioma and oncogenic osteomalacia: a case report. J Med Case Rep 2021; 15:348. [PMID: 34271987 PMCID: PMC8285823 DOI: 10.1186/s13256-021-02916-0] [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: 03/16/2020] [Accepted: 05/18/2021] [Indexed: 12/05/2022] Open
Abstract
Background Glomangioma is a benign tumor of mesenchymal origin, derived from the glomus body. It is responsible for the thermal regulation of the dermis. The occurrence of oncogenic osteomalacia related to glomangioma is rare. Only two cases have been reported thus far. Case presentation A 32-year-old female, Brazilian, presented diffuse pain, during pregnancy, that developed progressively, limiting her mobility. Imaging showed a femoral neck fracture, and rheumatological laboratory examination showed hypophosphatemia. Also, the patient reported episodes of epistaxis during childhood and recurrence along with progressively right nasal obstruction. Endoscopic resection of the tumor was performed, and immunohistochemistry was conclusive for glomangioma. This case report describes the third case in which endonasal endoscopic surgery resulted in a favorable outcome. Conclusion This case of glomangioma-induced oncogenic osteomalacia suggests that surgeons and clinicians should consider sinonasal tumors as a differential diagnosis of osteomalacia, and endonasal endoscopic surgery should be a possible curative resection.
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Affiliation(s)
- Camila R Muniz
- Department of Otorhinolaryngology, Walter Cantídio University Hospital of Ceará Federal University, Capitão Francisco Pedro Street, 1290, Ilha 6, Rodolfo Teófilo, Fortaleza, CE, CEP: 60430-370, Brazil.
| | - Gabriela A M Bezerra
- Department of Otorhinolaryngology, Walter Cantídio University Hospital of Ceará Federal University, Capitão Francisco Pedro Street, 1290, Ilha 6, Rodolfo Teófilo, Fortaleza, CE, CEP: 60430-370, Brazil
| | - Viviane C da Silva
- Department of Otorhinolaryngology, Walter Cantídio University Hospital of Ceará Federal University, Capitão Francisco Pedro Street, 1290, Ilha 6, Rodolfo Teófilo, Fortaleza, CE, CEP: 60430-370, Brazil
| | - Priscilla M F Aguiar
- Department of Pathology, Walter Cantídio University Hospital of Ceará Federal University, Fortaleza, Brazil
| | - Gunter Gerson
- Department of Pathology, Walter Cantídio University Hospital of Ceará Federal University, Fortaleza, Brazil
| | - Catarina B D'Alva
- Department of Endocrinology, Walter Cantídio University Hospital of Ceará Federal University, Fortaleza, Brazil
| | - André A A Nunes
- Department of Otorhinolaryngology, Walter Cantídio University Hospital of Ceará Federal University, Capitão Francisco Pedro Street, 1290, Ilha 6, Rodolfo Teófilo, Fortaleza, CE, CEP: 60430-370, Brazil
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Raj R, Hasanzadeh S, Dashtizadeh M, Kalantarhormozi M, Vahdat K, Dabbaghmanesh MH, Nabipour I, Ravanbod M, Assadi M, Hashemi B, Asadipooya K. Oncogenic osteomalacia secondary to glomus tumor. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200202. [PMID: 34196273 PMCID: PMC8284959 DOI: 10.1530/edm-20-0202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Oncogenic osteomalacia secondary to glomus tumor is extremely rare. Localization of causative tumors is critical as surgical resection can lead to a complete biochemical and clinical cure. We present a case of oncogenic osteomalacia treated with resection of glomus tumor. A 39-year-old woman with a history of chronic sinusitis presented with chronic body ache and muscle weakness. Biochemical evaluation revealed elevated alkaline phosphatase hypophosphatemia, increased urinary phosphate excretion, low calcitriol, and FGF23 was unsuppressed suggestive of oncogenic osteomalacia. Diagnostic studies showed increase uptake in multiple bones. Localization with MRI of paranasal sinuses revealed a sinonasal mass with concurrent uptake in the same area on the octreotide scan. Surgical resection of the sinonasal mass was consistent with the glomus tumor. The patient improved both clinically and biochemically postoperatively. Along with the case of oncogenic osteomalacia secondary to a glomus tumor, we have also discussed in detail the recent development in the diagnosis and management of oncogenic osteomalacia. LEARNING POINTS Tumor-induced osteomalacia is a rare cause of osteomalacia caused by the secretion of FGF23 from mesenchymal tumors. Mesenchymal tumors causing TIO are often difficult to localize and treat. Resection of the tumor can result in complete resolution of biochemical and clinical manifestations in a very short span of time. Glomus tumor can lead to tumor induced osteomalacia and should be surgically treated.
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Affiliation(s)
- Rishi Raj
- Pikeville Medical Center, Pikeville, Kentucky, USA
| | | | | | | | | | | | - Iraj Nabipour
- Bushehr University of Medical Sciences, Bushehr, Iran
| | | | - Majid Assadi
- Bushehr University of Medical Sciences, Bushehr, Iran
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Extended Whole-body Ga-68 DOTATATE PET-CT in evaluating Tumour-Induced Osteomalacia: Case report and review of literature. Nucl Med Mol Imaging 2021; 55:130-135. [PMID: 34109008 DOI: 10.1007/s13139-021-00695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
Tumour-induced osteomalacia is a rare paraneoplastic syndrome that manifests as chronic hypophosphataemia, non-specific bone pain and muscle weakness. It is generally caused by phosphaturic mesenchymal tumour (PMT), which is uncommonly associated with synchronous tumours. However, diagnosis is often delayed for several years due to the rarity, indolent growing nature and non-specific symptoms of the disease, often resulting in an overlook by clinicians during assessments. The patient initially presented with hypophosphataemia and generalised skeletal pain with multiple atraumatic fractures. Blood tests revealed serum calcium levels at the upper limit and extremely low inorganic phosphate levels. Herein, we report a case where two synchronous PMTs from two different sites were detected by 'extended' whole-body Ga-68 DOTATATE PET-CT, leading to remission of the disease after complete surgical removal. Early detection and diagnosis of PMT neoplasm is crucial, as complete surgical resection of this tumour is the only definitive treatment currently known. Upon excision, this curable disease will result in complete resolution of symptoms and blood parameters, leading to remission of the disease which significantly improves the patient's quality of life. PMT often over-expresses somatostatin receptors (SSTR), predominantly subtype 2A, and Ga-68 DOTATATE PET-CT is a selective SSTR imaging that targets this characteristic over-expression in these tumours. The high diagnostic accuracy of Ga-68 DOTATATE PET-CT should be the primary imaging modality for full evaluation of this disease.
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Amaratunga EA, Ernst EB, Kamau J, Kotala R, Snyder R. Renal Phosphate Wasting Due to Tumor-Induced (Oncogenic) Osteomalacia. Cureus 2021; 13:e15507. [PMID: 34268038 PMCID: PMC8263127 DOI: 10.7759/cureus.15507] [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] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
Osteomalacia is a widely prevalent bone disorder that is caused by an imbalance in body calcium and phosphate. Tumor-induced osteomalacia (TIO) is a rare form of osteomalacia that is associated with mesenchymal tumors. It is caused by overproduction of fibroblast growth factor 23 (FGF-23), a hormone involved in phosphate regulation. A 59-year-old male with a history of factor V Leiden mutation, pulmonary embolism, and deep vein thrombosis was diagnosed with oncogenic osteomalacia in 2008 following laboratory findings significant for low phosphorus and elevated FGF-23 levels. He underwent a resection of a right suprascapular notch mass with the biopsy confirming a phosphaturic mesenchymal tumor. He was maintained on oral phosphorus and calcitriol replacements with a regular follow-up with oncology and nephrology. Eight years later, the patient’s phosphorus levels started declining despite replacement. A repeat test showed FGF-23 levels once again elevated. A whole-body magnetic resonance imaging (MRI) scan showed no significant findings. The patient was continued on oral replacement therapy with a close follow-up. Two years later, urine phosphorus excretion was elevated at 2494 mg per 24 hours with low plasma phosphorus (1.2 mg/dL) and an elevated FGF-23 level of 1005 relative units (RU)/mL. A repeat MRI of the right shoulder revealed a mass in the supraspinatus muscle and another in the spinal glenoid notch. The masses were resected and the biopsy was consistent with a recurrence of the phosphaturic mesenchymal tumor. Follow-up serum phosphate levels remained in the normal range. FGF-23 plays a critical role in bone mineralization through the regulation of phosphate levels. Overproduction, as seen in mesenchymal tumors, results in hyperphosphaturia, hypophosphatemia, and low calcitriol levels. While the definitive treatment of TIO involves the resection of the mesenchymal tumor, localization of the tumor is often challenging given its small size and slow growth. This leads to delayed diagnosis and treatment. For individuals whose tumor cannot be resected or detected, burosumab is the preferred form of therapy. Interestingly, FGF-23 is shown to have a potential cardiovascular (CV) morbidity and mortality through various mechanisms like activation of myocardial FGF-23 receptors, endothelial dysfunction, inflammation, and altered phosphorus and vitamin D metabolisms. While studies have shown possible FGF-23 effects on CV outcomes in patients with chronic kidney disease, this has not been proven in cases of TIO.
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Affiliation(s)
| | - Emily B Ernst
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - James Kamau
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Ragarupa Kotala
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Richard Snyder
- Internal Medicine, St. Luke's University Health Network, Easton, USA
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Xiao Z, Liu J, Liu SH, Petridis L, Cai C, Cao L, Wang G, Chin AL, Cleveland JW, Ikedionwu MO, Carrick JD, Smith JC, Quarles LD. Novel Small Molecule Fibroblast Growth Factor 23 Inhibitors Increase Serum Phosphate and Improve Skeletal Abnormalities in Hyp Mice. Mol Pharmacol 2021; 101:408-421. [PMID: 35339985 PMCID: PMC11033927 DOI: 10.1124/molpharm.121.000471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/20/2022] [Indexed: 11/22/2022] Open
Abstract
Excess fibroblast growth factor (FGF) 23 causes hereditary hypophosphatemic rickets, such as X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO). A small molecule that specifically binds to FGF23 to prevent activation of the fibroblast growth factor receptor/α-Klotho complex has potential advantages over the currently approved systemically administered FGF23 blocking antibody. Using structure-based drug design, we previously identified ZINC13407541 (N-[[2-(2-phenylethenyl)cyclopenten-1-yl]methylidene]hydroxylamine) as a small molecule antagonist for FGF23. Additional structure-activity studies developed a series of ZINC13407541 analogs with enhanced drug-like properties. In this study, we tested in a preclinical Hyp mouse homolog of XLH a direct connect analog [(E)-2-(4-(tert-butyl)phenyl)cyclopent-1-ene-1-carbaldehyde oxime] (8n), which exhibited the greatest stability in microsomal assays, and [(E)-2-((E)-4-methylstyryl)benzaldehyde oxime] (13a), which exhibited increased in vitro potency. Using cryo-electron microscopy structure and computational docking, we identified a key binding residue (Q156) of the FGF23 antagonists, ZINC13407541, and its analogs (8n and 13a) in the N-terminal domain of FGF23 protein. Site-directed mutagenesis and bimolecular fluorescence complementation-fluorescence resonance energy transfer assay confirmed the binding site of these three antagonists. We found that pharmacological inhibition of FGF23 with either of these compounds blocked FGF23 signaling and increased serum phosphate and 1,25-dihydroxyvitamin D [1,25(OH)2D] concentrations in Hyp mice. Long-term parenteral treatment with 8n or 13a also enhanced linear bone growth, increased mineralization of bone, and narrowed the growth plate in Hyp mice. The more potent 13a compound had greater therapeutic effects in Hyp mice. Further optimization of these FGF23 inhibitors may lead to versatile drugs to treat excess FGF23-mediated disorders. SIGNIFICANCE STATEMENT: This study used structure-based drug design and medicinal chemistry approaches to identify and optimize small molecules with different stability and potency, which antagonize excessive actions of fibroblast growth factor 23 (FGF23) in hereditary hypophosphatemic rickets. The findings confirmed that these antagonists bind to the N-terminus of FGF23 to inhibit its binding to and activation of the fibroblast growth factor receptors/α-Klotho signaling complex. Administration of these lead compounds improved phosphate homeostasis and abnormal skeletal phenotypes in a preclinical Hyp mouse model.
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Affiliation(s)
- Zhousheng Xiao
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jiawang Liu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Shih-Hsien Liu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Loukas Petridis
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Chun Cai
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Li Cao
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Guangwei Wang
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Ai Lin Chin
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jacob W Cleveland
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Munachi O Ikedionwu
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jesse D Carrick
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Jeremy C Smith
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
| | - Leigh Darryl Quarles
- Department of Medicine, College of Medicine (Z.X., C.C., L.C., G.W.W., L.D.Q.) and Department of Pharmaceutical Sciences, College of Pharmacy (J.L.), University of Tennessee Health Science Center, Memphis, Tennessee; University of Tennessee (UT)/Oak Ridge National Laboratory (ORNL) Center for Molecular Biophysics, Oak Ridge National Laboratory, Oak Ridge, Tennessee (S.H.L., L.P., J.C.S.); Department of Biochemistry and Cellular and Molecular Biology, University of Tennessee, Knoxville, Tennessee (L.P., J.C.S.); and Department of Chemistry, Tennessee Technological University, Cookeville, Tennessee (A.L.C., J.W.C., M.O.I., J.D.C.)
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Moreno Romero M, Pérez Muñoz I, González Lizán F, Gallego Rivera JI, Valdivielso Cañas L. The phosphaturic mesenchymal tumor as a cause of oncogenic osteomalacia. Three cases and review of the literature. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 65:S1888-4415(21)00050-3. [PMID: 33903024 DOI: 10.1016/j.recot.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/13/2020] [Accepted: 12/22/2020] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION The phosphaturic mesenchymal tumour (PMT) is a very uncommon cause of oncogenic osteomalacia (OO), which is a paraneoplastic syndrome with severe clinical osteomalacia. The PMT is a neoplasia that produces the fibroblast growth factor FGF23, resulting in reduced proximal tubular phosphate reabsorption leading to hyperphosphaturia and hypophosphatemia. Our aim is to present our experience and complications in diagnosis and treatment of PMT in three patients. MATERIAL AND METHODS We propose an observational, descriptive and retrospective study of three cases of OO secondary to PMT found in our database of bone and soft tissue tumours. The inclusion criteria were: symptoms related with OO, presence of hyperphosphaturic hypophosphatemia, elevated levels of FGF23 in blood and pathological diagnosis of PMT. RESULTS In all cases, the disease showed asthenia, non-specific bone pain, progressive functional weakness, and pathological fractures. The average delay time in diagnosis was 7 years. All presented with hyperphosphaturic hypophosphatemia, elevated levels of alkaline phosphatase as well as FGF23. The use of Octreoscan and PET-CT were essential to find the producing tumour and its subsequent biopsy. Treatment was surgery in two cases and one case was treated by CT-guided cryotherapy with neurophysiological control. Once the surgery was performed, the blood parameters normalized. There is no recurrence. CONCLUSIONS Phosphaturic mesenchymal tumor is a very rare entity as part of bone and soft tissue tumors, it may occur in both tissues. The phosphate-calcium homeostasis is altered due to high serum levels of FGF23 because of PMT. Delay in diagnosis is usual, leading to renal and skeletal comorbidities. To avoid this, knowledge of this entity together with high diagnostic suspicion are critical. Surgical treatment leads to normalization of serum levels and systemic symptoms.
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Affiliation(s)
- M Moreno Romero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Ramón y Cajal, Madrid, España.
| | - I Pérez Muñoz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Ramón y Cajal, Madrid, España
| | - F González Lizán
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Ramón y Cajal, Madrid, España
| | | | - L Valdivielso Cañas
- Servicio de Endocrinología y Nutrición, Hospital Ramón y Cajal, Madrid, España
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Leow MKS, Dogra S, Ge X, Chuah KL, Liew H, Loke KSH, McFarlane C. Paraneoplastic Secretion of Multiple Phosphatonins From a Deep Fibrous Histiocytoma Causing Oncogenic Osteomalacia. J Clin Endocrinol Metab 2021; 106:e2299-e2308. [PMID: 33462615 PMCID: PMC8063243 DOI: 10.1210/clinem/dgaa964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 12/27/2022]
Abstract
CONTEXT Literature suggests that oncogenic osteomalacia is usually caused by a benign mesenchymal tumor secreting fibroblast growth factor subtype-23 (FGF-23), but the involvement of other phosphatonins has only been scarcely reported. We have previously published a seemingly typical case of oncogenic osteomalacia. Following curative neoplasm resection, we now report unique molecular characteristics and biology of this tumor. CASE DESCRIPTION A 25-year-old man had been diagnosed with severe oncogenic osteomalacia that gradually crippled him over 6 years. 68Ga-DOTA-TATE positron emission tomography/computed tomography scan localized the culprit tumor to his left sole, which on resection revealed a deep fibrous histiocytoma displaying a proliferation of spindle cells with storiform pattern associated with multinucleated giant cells resembling osteoclasts. Circulating FGF-23, which was elevated more than 2-fold, declined to undetectable levels 24 h after surgery. Microarray analysis revealed increased tumor gene expression of the phosphatonins FGF-23, matrix extracellular phosphoglycoprotein (MEPE) and secreted frizzled-related protein subtype 4, with elevated levels of all 3 proteins confirmed through immunoblot analysis. Differential expression of genes involved in bone formation and bone mineralization were further identified. The patient made an astonishing recovery from being wheelchair bound to fully self-ambulant 2 months postoperatively. CONCLUSION This report describes oncogenic osteomalacia due to a deep fibrous histiocytoma, which coincidentally has been found to induce profound muscle weakness via the overexpression of 3 phosphatonins, which resolved fully upon radical resection of the tumor. Additionally, genes involved in bone formation and bone remodeling contribute to the molecular signature of oncogenic osteomalacia.
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Affiliation(s)
- Melvin Khee Shing Leow
- Singapore Institute for Clinical Sciences (A*STAR), Brenner Centre for Molecular Medicine, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, Singapore
| | - Shaillay Dogra
- Singapore Institute for Clinical Sciences (A*STAR), Brenner Centre for Molecular Medicine, Singapore
| | - Xiaojia Ge
- Singapore Institute for Clinical Sciences (A*STAR), Brenner Centre for Molecular Medicine, Singapore
| | | | - Huiling Liew
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore
| | - Kelvin Siu Hoong Loke
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Craig McFarlane
- Singapore Institute for Clinical Sciences (A*STAR), Brenner Centre for Molecular Medicine, Singapore
- Department of Molecular & Cell Biology, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville QLD, Australia
- Correspondence and Reprint Requests: Dr. Craig McFarlane, Department of Molecular and Cell Biology, College of Public Health, Medical and Veterinary Sciences, 1 James Cook Drive, Townsville, QLD 4811, Australia.
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Yuce G, Aytekin N, Eren S, Genç B, Ateş ÖF, Canyiğit M. Is radiofrequency ablation safe and effective in treating osteoid osteomas? A prospective single-center study with atypical cases. J Orthop Surg (Hong Kong) 2021; 28:2309499020960555. [PMID: 33021151 DOI: 10.1177/2309499020960555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Osteoid osteomas are benign and nonprogressive lesions. The clinical presentation of osteoid osteoma is typical with night pain responsive to nonsteroidal anti-inflammatory agents. The typical radiological appearance is lucent nidus and adjacent reactive sclerosis. The most traditional management of osteoid osteoma is surgical removal which is associated with significant morbidity. This article aims to demonstrate our single-center experience of 55 patients with osteoid osteoma treated with percutaneous radiofrequency ablation (RFA). METHODS Fifty-five symptomatic patients who were seen at our orthopedics outpatient clinics, diagnosed with osteoid osteoma, and referred to interventional radiology department between May 2015 and April 2019 were enrolled. The nidus size, pain numeric rating scale score, and intramedullary edema diameter before and after RFA were compared. Clinical and technical success, intervention-related complications, and need for subsequent ablation were recorded. RESULTS Of the 55 patients, including 12 pediatric cases, 6 had atypical locations such as metatarsal, vertebra, and scapula, while 1 case had osteoid osteoma with multiple nidus. The mean age was 18.5 ± 9.6 years. Preintervention maximum nidus diameter, pain score, and edema diameter were significantly lower in postintervention measurements (p < 0.001). Technical success rate was 98.1%, and clinical success was 96.36%. Severe complication occurred in one patient with soft tissue burn and osteomyelitis. CONCLUSION This is one of the largest series of osteoid osteoma treated with RFA done in a single center with atypical cases. In conclusion, RFA is safe and effective in both pediatric and adult patients with rare complications even in challenging cases with atypical locations.
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Affiliation(s)
- Gokhan Yuce
- Interventional Radiology Department, 536164Ankara City Hospital, Ankara, Turkey
| | - Nedim Aytekin
- Orthopedics and Traumatology Clinics, 536164Ankara City Hospital, Ankara, Turkey
| | - Serhan Eren
- Interventional Radiology Department, 536164Ankara City Hospital, Ankara, Turkey
| | - Birgul Genç
- Endocrinology Department, 536164Ankara City Hospital, Ankara, Turkey
| | - Ömer Faruk Ateş
- Interventional Radiology Department, Sakarya Training and Research Hospital, Ankara, Turkey
| | - Murat Canyiğit
- Interventional Radiology Department, 536164Ankara City Hospital, Ankara, Turkey
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Xian MF, Pan KM, Zhang JC, Cheng MQ, Huang H, Chen LD, Zhao ZX, Wang W. Application of ultrasound-guided biopsy and percutaneous radiofrequency ablation in 2 cases with phosphaturic mesenchymal tumor and literature review. Clin Hemorheol Microcirc 2021; 77:61-69. [PMID: 32924995 DOI: 10.3233/ch-200921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a vanishingly rare paraneoplastic syndrome which is usually caused by phosphaturic mesenchymal tumors (PMTs). The conventional treatment for PMTs is total resection, and ultrasound-guided radiofrequency ablation (RFA) can also be used for the treatment of PMTs patients, especially for patients in whom complete resection may lead to serious complications. We report two cases with PMT who presented syndrome with progressive musculoskeletal complaints and performed ultrasound-guided biopsy and RFA. Ultrasound-guided RFA, which is a safe and effective minimally invasive treatment option, appears to be a valuable alternative to surgery for patients presenting with PMT. We are the first reported case of RFA guided by ultrasonography in the treatment of PMT.
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Affiliation(s)
- Meng-Fei Xian
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kang-Ming Pan
- Department of Hepatobiliary Surgery, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian-Chao Zhang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mei-Qing Cheng
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Huang
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Da Chen
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhen-Xian Zhao
- Department of Hepatobiliary Surgery, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Paramba F, Silas M, Masoodi N, Benjamin S, Palaki JA. Hypophosphatemic Osteomalacia in a Young Adult. Cureus 2021; 13:e13697. [PMID: 33833917 PMCID: PMC8019330 DOI: 10.7759/cureus.13697] [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] [Indexed: 11/09/2022] Open
Abstract
Tumor-induced osteomalacia (TIO), otherwise known as oncogenic osteomalacia, is a rare paraneoplastic syndrome, characterized by hypophosphatemia due to decreased tubular reabsorption and low or inappropriately normal level of active vitamin D. The syndrome, first recognized by Robert McCance in 1947, is well described in the medical literature. However, the diagnosis can be delayed due to the nonspecific nature of its presentation. The tumor responsible for TIO produces fibroblast growth factor 23 (FGF-23) which plays a role in regulating renal handling of phosphate and 25-hydroxyvitamin D 1α-hydroxylase activity. Chronic hypophosphatemia eventually leads to inadequate bone mineralization and osteomalacia. The diagnosis should be considered when a patient presents with low phosphate and osteomalacia or rickets and should be differentiated from other disorders of phosphate metabolism such as X-linked, autosomal dominant and recessive hypophosphatemic rickets, and acquired cause like vitamin D deficiency. The localization of the tumor is rather difficult as the tumor can be too small and be anywhere in the body. A combination of thorough physical examination, laboratory tests, and proper imaging is needed for the diagnosis. Surgical removal of the tumor often leads to complete resolution of the syndrome. If the tumor is undetectable or unresectable, then phosphate and vitamin D supplements should be considered.
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Affiliation(s)
| | - Manju Silas
- Family Medicine, Al Wakra Primary Health Centre, Doha, QAT
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Wang P, Zhang S, Huo L, Jing H, Li F. Prognostic Value of Positive Presurgical FDG PET/CT in the Evaluation of Tumor-Induced Osteomalacia. Clin Nucl Med 2021; 46:214-219. [PMID: 33351512 DOI: 10.1097/rlu.0000000000003463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
METHODS Seventy-six patients who had surgically removed tumors that caused osteomalacia were included in this retrospective investigation. All patients underwent both 18F-FDG and 68Ga-DOTATATE PET/CT prior to surgery. The prognostic value of presurgical FDG PET/CT study was determined with 5-year follow-up. RESULTS In the presurgical evaluation, 68Ga-DOTATATE detected lesions in all 76 patients. However, FDG PET/CT was positive in only 25 among all 76 patients. Following surgical removal of the causative tumor, all 76 patients had symptomatic relief and normalization of the serum phosphate level initially. However, 15 of 76 cases (19.7%) had recurrent hypophosphatemia and became symptomatic again during the follow-up. Among these 15 patients with recurrence, 11 (73.3%) had recurrent lesions at the original location of the resected causative tumors, whereas 4 were in other locations due to malignant nature of the primary tumor. Interestingly, 14 of these 15 patients with recurrent disease had positive presurgical FDG PET/CT findings with an incident ratio of 56.0% (14 of 25). In contrast, only 1 patient with recurrent disease had negative presurgical FDG PET/CT scan with an incident ratio of 1.9% (1 of 51), significantly less than the positive presurgical FDG PET/CT group (P < 0.05). CONCLUSIONS A positive presurgical FDG PET/CT suggests increased likelihood for possible recurrence of TIO after surgical resection. In contrast, when a causative tumor detected by 68Ga-DOTATATE PET/CT does not have elevated activity on FDG PET/CT, the chance of recurrence is very small.
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Affiliation(s)
| | - Shu Zhang
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Imanishi Y, Ito N, Rhee Y, Takeuchi Y, Shin CS, Takahashi Y, Onuma H, Kojima M, Kanematsu M, Kanda H, Seino Y, Fukumoto S. Interim Analysis of a Phase 2 Open-Label Trial Assessing Burosumab Efficacy and Safety in Patients With Tumor-Induced Osteomalacia. J Bone Miner Res 2021; 36:262-270. [PMID: 32967046 PMCID: PMC7988547 DOI: 10.1002/jbmr.4184] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/20/2022]
Abstract
Patients with tumor-induced osteomalacia (TIO), an acquired paraneoplastic condition characterized by osteomalacia due to hypophosphatemia, exhibit a similar clinical picture to those with X-linked hypophosphatemic rickets/osteomalacia (XLH). The human monoclonal anti-fibroblast growth factor 23 (FGF23) antibody burosumab (KRN23) increases serum phosphate and improves bone turnover, fracture healing, pain, and physical function in XLH patients by inhibiting circulating FGF23; thus, burosumab is expected to be an effective treatment for TIO. We report here an interim analysis of a multicenter, open-label, intraindividual dose-adjustment study of burosumab (0.3 to 2.0 mg/kg every 4 weeks) in Japanese and Korean TIO patients. The primary endpoint was the fasting serum phosphate level at each visit. Key secondary endpoints were changes over time in bone biomarkers, pharmacodynamic markers, bone histomorphometric parameters, motor function, and patient-reported outcomes. Safety was assessed based on treatment-emergent adverse events (TEAEs). Thirteen patients received burosumab treatment, of whom 4 underwent bone biopsy. The mean dose after week 112 was approximately 1.0 mg/kg. After the first burosumab administration, mean serum phosphate levels increased and remained above the lower limit of normal and in the normal range from weeks 14 to 112. Bone biomarkers initially increased, reaching maximum values at week 16 or 24, and then gradually decreased. After burosumab treatment, patients were able to walk further (evaluated by the 6-minute walk test), reported decreased pain levels, and showed a tendency toward healing of baseline fractures and pseudofractures. Two patients discontinued, one each due to disease progression and consent withdrawal. Burosumab was generally well tolerated, with no treatment-related TEAEs of grade ≥3 and no treatment-related serious AEs. In conclusion, the interim results of this first study of burosumab to treat TIO patients indicate that this drug has the potential to provide clinical benefit for patients with unresectable tumors. The full study results are eagerly anticipated. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)..
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Affiliation(s)
- Yasuo Imanishi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yasuhiro Takeuchi
- Endocrine Center, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | | | | | | | | | - Yoshiki Seino
- Department of Pediatrics, Osaka Hospital, Japan Community Healthcare Organization (JCHO), Osaka, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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Nandam N, Ejaz S, Ahrens W, Styner M. A Normal FGF23 Does Not Preclude Tumor-Induced Osteomalacia. JBMR Plus 2021; 5:e10438. [PMID: 33615107 PMCID: PMC7872335 DOI: 10.1002/jbm4.10438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/05/2020] [Accepted: 11/15/2020] [Indexed: 01/11/2023] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare cause of impaired bone mineralization mediated by the osteocyte-derived, phosphaturic hormone: fibroblast growth factor 23 (FGF23). The case is presented of a previously healthy 45-year-old man who developed fragility fractures at multiple sites (initially metatarsals, eventually ribs, hips, spine, scapula, and sacrum) resulting in rapid functional deterioration, weakness, and the inability to bear weight and ambulate without a walker. Workup for secondary causes of bone loss was negative except for mild hypogonadotropic hypogonadism with normal pituitary MRI and hypophosphatemia that persisted despite aggressive supplementation. Testosterone was initiated but discontinued 6 months later because of deep vein thrombosis and pulmonary embolism, likely provoked by his new sedentary state, in addition to smoking history and possibly testosterone usage. Serum FGF23 was nonelevated at 138 mRU/mL (44-215). A genetic panel for OI variants was negative for a causal mutation. At the age of 48, 3 years after his initial fracture, he was referred to our academic endocrine clinic. We ruled out additional mutations that lead to hypophosphatemic rickets, including phosphate-regulating endopeptidase homolog, X-linked. PET/CT looking for a potential TIO locus revealed uptake in the left suprapatellar recess. Biopsy was consistent with a phosphaturic mesenchymal tumor. FGF23 was repeated for a preoperative baseline and now found to be elevated at 289 mRU/mL. In retrospect, it is likely that the initial level was inappropriately elevated for the degree of hypophosphatemia. After resection, he experienced marked improvement in physical function, decreased pain, and resolution of renal phosphate wasting. The principals of establishing a robust clinical diagnosis of TIO should be emphasized, excluding other entities and avoiding pitfalls in the interpretation of laboratory testing. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Neeharika Nandam
- Department of Medicine, Division of Endocrinology and MetabolismUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Sadia Ejaz
- Department of Medicine, Division of Endocrinology and MetabolismUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - William Ahrens
- Department of PathologyCarolinas Medical CenterCharlotteNCUSA
| | - Maya Styner
- Department of Medicine, Division of Endocrinology and MetabolismUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Gökyer A, Sayın S, Küçükarda A, Çelik M, Güldiken S, Çiçin İ. Nasal hemangiopericytoma presenting with oncogenic osteomalasia: A case report and literature review. Curr Probl Cancer 2021; 45:100704. [PMID: 33446319 DOI: 10.1016/j.currproblcancer.2020.100704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/05/2020] [Accepted: 12/04/2020] [Indexed: 12/01/2022]
Abstract
Sinonasal type hemangiopericytoma is a rare soft tissue tumor. Oncogenic osteomalacia (tumor-induced osteomalacia) is a rare syndrome that develops especially due to benign mesenchymal tumors. Nonspecific general bone pain and weakness delay the diagnosis and treatment of oncogenic osteomalacia, and it is difficult to determine the localization of the primary tumor causing oncogenic osteomalacia. A 43-year-old male patient with nasal hemangiopericytoma with symptoms of oncogenic osteomalacia is presented. The patient had musculoskeletal complaints at first and was diagnosed with lumbar disc herniation and surgery was performed. When his complaints recurred 1 year later, he was re-evaluated and diagnosed with hypophosphatemic osteomalacia. Despite the various treatments he received, his complaints did not decrease but increased, so a detailed examination was decided. When the positive PHEX mutation and very high fibroblast growth factor 23 level were detected, PET-CT imaging was performed with a pre-diagnosis of possible oncogenic osteomalacia, but no finding was found. Then he was evaluated with Ga-68 DOTATATE, and the soft tissue mass filling the right ethmoidal sinus was detected. Due to the relation of the mass with surrounding structures, it was considered unsuitable for total excision and incomplete surgical excision was performed. Pathologic evaluation revealed sinonasal type hemangiopericytoma (glomangiopericytoma). A significant remission in the patient's complaints was observed after the operation. Young patients with osteomalacia with unknown causes should be evaluated for malignancy, and screening and further examinations should be performed.
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Affiliation(s)
- Ali Gökyer
- Trakya University School of Medicine, Department of Internal Medicine, Division of Medical Oncology, Edirne, Turkey.
| | - Sezin Sayın
- Trakya University School of Medicine, Edirne, Turkey
| | - Ahmet Küçükarda
- Trakya University School of Medicine, Department of Internal Medicine, Division of Medical Oncology, Edirne, Turkey
| | - Mehmet Çelik
- Trakya University School of Medicine, Department of Internal Medicine, Division of Endocrinology, Edirne, Turkey
| | - Sibel Güldiken
- Trakya University School of Medicine, Department of Internal Medicine, Division of Endocrinology, Edirne, Turkey
| | - İrfan Çiçin
- Trakya University School of Medicine, Department of Internal Medicine, Division of Medical Oncology, Edirne, Turkey
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Performance of 68Ga-DOTA-SST PET/CT, octreoscan SPECT/CT and 18F-FDG PET/CT in the detection of culprit tumors causing osteomalacia: a meta-analysis. Nucl Med Commun 2021; 41:370-376. [PMID: 32000173 PMCID: PMC7077972 DOI: 10.1097/mnm.0000000000001163] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objectives The objective of this study was to assess and compare the performance of 68Ga-DOTA-conjugated-somatostatin-receptor-targeting-peptides (68Ga-DOTA-SST) PET/CT, octreoscan-SPECT/CT and 18F-FDG-PET/CT in the detection of tumor-induced osteomalacia (TIO). Methods Relevant studies reporting the performance 68Ga-DOTA-SST PET/CT, octreoscan-SPECT/CT and 18F-FDG-PET/CT in TIO were identified by searching PubMed, EMBASE, and Web of Science (last updated June 2019). Two authors independently extracted the numbers of true and false positives, and true and false negatives. The pooled estimates on a per-patient basis were calculated with 95% confidence interval (CI) obtained using a random-effects model. Results Fourteen studies comprising 346 patients were included in this meta-analysis. The meta-analysis provided the following results on a per-patient analysis. The pooled sensitivities of both 68Ga-DOTA-SST PET/CT (90%, 95% CI 82–95%) and octreoscan-SPECT/CT (83%, 95% CI 75–89%) were found to be significantly higher (P < 0.005) than that of 18F-FDG PET/CT (67%, 95% CI 53–80%). There was no statistically significant difference between the sensitivity of 68Ga-DOTA-SST PET/CT and octreoscan-SPECT/CT (P = 0.161). Owing to the low number of articles with true negative findings, the pooled specificities were not calculated. A total of 287 tumors were identified in 287 patients according to the data the included studies offered. The majority of the tumors were located in the lower extremities (59.6%, 171/287), followed by craniofacial regions (24.0%, 69/287), torso (9.4%%, 27/287), and upper extremities (6.9%, 20/287). Conclusion This meta-analysis demonstrates that somatostatin receptor-based imaging modalities outperformed 18F-FDG PET/CT in the detection of TIO, with 68Ga-DOTA-SST PET/CT performing slightly better than octreoscan-SPECT/CT.
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Ryhänen EM, Schalin-Jäntti C, Matikainen N. Prolonged Hypophosphatemia and Intensive Care After Curative Surgery of Tumor Induced Osteomalacia: A Case Report. Front Endocrinol (Lausanne) 2021; 12:686135. [PMID: 34149623 PMCID: PMC8209372 DOI: 10.3389/fendo.2021.686135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/19/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Rare FGF23-producing mesenchymal tumors lead to paraneoplastic tumor-induced osteomalacia (TIO) presenting with phosphate wasting, hypophosphatemia, chronic hypomineralization of the bone, fragility fractures and muscle weakness. Diagnosis of TIO requires exclusion of other etiologies and careful search for a mesenchymal tumor that often is very small and can appear anywhere in the body. Surgical removal of the tumor is the only definitive treatment of TIO. Surgical complications due to chronic hypophosphatemia are not well recognized. CASE DESCRIPTION The current case describes severe fragility fractures in a 58-year-old woman, who lost her ability to walk and was bedridden for two years. First, the initial diagnostic laboratory work-up did not include serum phosphorus measurements, second, the suspicion of adverse effects of pioglitazone as an underlying cause delayed correct diagnosis for at least two years. After biochemical discovery of hyperphosphaturic hypophosphatemia at a tertiary referral centre, a FGF23-producing tumor of the mandible was discovered on physical examination, and then surgically removed. Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for ventilation support, intensive care and phosphate supplementation. After two years of rehabilitation, the patient was able to walk short distances. The tumor has not recurred, and serum phosphate concentration has remained within normal limits during 3.5 years of follow-up. CONCLUSIONS The case report illustrates knowledge gaps in the diagnostic work-up of rare causes of low bone mass and fragility fractures. Compared to other low phosphate conditions, surgical recovery from TIO-induced hypophosphatemia warrants special attention. Increased alkaline phosphatase concentration may indicate impaired postsurgical recovery due to prolonged hypophosphatemia, underlining the need for proactive perioperative correction of hypophosphatemia.
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