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Álvarez-Rivas N, Lugo-Rodríguez G, Maneiro JR, Iñiguez-Ubiaga C, Melero-Gonzalez RB, Iglesias-Cabo T, Carmona L, García-Porrúa C, de Toro-Santos FJ. Tumor-induced osteomalacia: A systematic literature review. Bone Rep 2024; 21:101772. [PMID: 38774264 PMCID: PMC11107251 DOI: 10.1016/j.bonr.2024.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction Tumor-induced osteomalacia (TIO), is a rare acquired paraneoplastic syndrome characterized by defective bone mineralization, caused by the overproduction of fibroblast growth factor 23 (FGF23) by a tumor. Material and methods We conducted a systematic review to identify all case reports of TIO, focusing on those associated with mesenchymal tumors. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) consensus, and we included patients with a diagnosis of TIO and histological confirmation of phosphaturic mesenchymal tumors or resolution of the condition after treatment of the tumor. Bibliographical searches were carried out until December 2023 in the Cochrane Library, Medline and Embase, as well as congress abstracts online. Results We identified 769 articles with 1979 cases reported. Most patients were adults, with a higher incidence on men. Disease duration before diagnosis is a mean of 4.8 years. Most tumors were histologically classified as PMT. Lower limbs were the predominant location. Hypophosphatemia was present in 99.8 % of patients. The FGF23 was elevated at diagnosis in 95.5 %. Resection of the tumor was the treatment of choice in most of patients. After resection, there was a clinical improvement in 97.6 % of cases, and serum phosphorus and FGF23 levels returned to normal ranges in 91.5 % and 81.4 % of the patients, respectively. Conclusion TIO is usually misdiagnosed with rheumatological or musculoskeletal disorders. The diagnosis should be suspected in patients with hypophosphatemic osteomalacia, and the measurement of serum FGF23 can be useful for diagnosis and management.
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Affiliation(s)
- Noelia Álvarez-Rivas
- Rheumatology Department, Hospital Público da Mariña, Servizo Galego de Saúde (SERGAS), Burela, Spain
| | - Gloria Lugo-Rodríguez
- Endocrinology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Jose Ramón Maneiro
- Rheumatology Department, Complexo Hospitalario Universitario de Santiago (CHUS), Servizo Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Carlota Iñiguez-Ubiaga
- Rheumatology Department, Hospital Universitario del Bierzo, Servicio de Salud de Castilla y León (SACYL), Ponferrada, Spain
| | - Rafael Benito Melero-Gonzalez
- Rheumatology Department, Complexo Hospitalario Universitario de Ourense (CHUO), Servizo Galego de Saúde (SERGAS), Orense, Spain
| | - Tania Iglesias-Cabo
- Statistical Consulting Unit, Scientific and Technical Services, University of Oviedo, Oviedo, Spain
| | | | - Carlos García-Porrúa
- Rheumatology Department, Complexo Hospitalario Universitario de Lugo (CHULA), Servizo Galego de Saúde (SERGAS), Lugo, Spain
| | - Francisco Javier de Toro-Santos
- Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidade de A Coruña, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
- Rheumatology Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
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Jadhav SS, Shah R, Patil V. Tumor-induced osteomalacia: An overview. Best Pract Res Clin Endocrinol Metab 2024; 38:101834. [PMID: 37935612 DOI: 10.1016/j.beem.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Tumor-induced osteomalacia (TIO) is rare paraneoplastic syndrome of hypophosphatemic osteomalacia, caused by phosphaturic factors secreted by small mesenchymal origin tumors with distinct pathological features, called 'phosphaturic mesenchymal tumors'. FGF23 is the most well-characterized of the phosphaturic factors. Tumors are often small and located anywhere in the body from head to toe, which makes the localisation challenging. Functional imaging by somatostatin receptor-based PET imaging is the first line investigation, which should be followed with CT or MRI based anatomical imaging. Once localised, complete surgical excision is the treatment of choice, which brings dramatic resolution of symptoms. Medical management in the form of phosphate and active vitamin D supplements is given as a bridge to surgical management or in inoperable/non-localised patients. This review provides an overview of the epidemiology, pathophysiology, pathology, clinical features, diagnosis, and treatment of TIO, including the recent advances and directions for future research in this field.
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Affiliation(s)
| | - Ravikumar Shah
- Harikrushna Hormone Clinic, 304, 3rd Floor, Ashwamegh, Opposite Vyamshala, Anand, Gujarat, India.
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, India.
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Colangelo L, Sonato C, Cipriani C, Pepe J, Farinacci G, Palmisano B, Occhiuto M, Riminucci M, Corsi A, Minisola S. Occipital bone and tumor-induced osteomalacia: a rare tumor site for an uncommon paraneoplastic syndrome. Arch Osteoporos 2023; 18:94. [PMID: 37436671 PMCID: PMC10338621 DOI: 10.1007/s11657-023-01305-y] [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: 02/28/2023] [Accepted: 07/03/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome due to the overproduction of fibroblast growth factor 23 (FGF23). It is predominantly caused by mesenchymal tumors and cured upon their complete removal. Non-surgical treatment is an alternative option but limited to specific clinical conditions. METHODS We report a challenging case of TIO caused by a tumor involving the occipital bone. We also performed a literature review of TIO caused by tumors localized at this site, focusing on clinical findings, treatment, and outcomes. RESULTS The patient, a 62-year-old male, presented with a long-lasting history of progressive weakness. Biochemical evaluation revealed severe hypophosphatemia due to low renal tubular reabsorption of phosphate with raised intact FGF23 values. A 68 Ga-DOTATATE PET/TC imaging showed a suspicious lesion located in the left occipital bone that MRI and selective venous catheterization confirmed to be the cause of TIO. Stereotactic gamma knife radiosurgery was carried out, but unfortunately, the patient died of acute respiratory failure. To date, only seven additional cases of TIO have been associated to tumors located in the occipital bone. Furthermore, the tumor involved the left side of the occipital bone in all these patients. CONCLUSION The occipital region is a difficult area to access so a multidisciplinary approach for their treatment is required. If anatomical differences could be the basis for the predilection of the left side of the occipital bone, it remains to be clarified.
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Affiliation(s)
- Luciano Colangelo
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Chiara Sonato
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | | | - Biagio Palmisano
- Department of Molecular Medicine, Sapienza University, Rome, Italy
| | - Marco Occhiuto
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mara Riminucci
- Department of Molecular Medicine, Sapienza University, Rome, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine, Sapienza University, Rome, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Cancarevic I, Ilyas U, Nassar M. Hypophosphatemia in Patients With Multiple Myeloma. Cureus 2023; 15:e40487. [PMID: 37342302 PMCID: PMC10279409 DOI: 10.7759/cureus.40487] [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] [Accepted: 06/15/2023] [Indexed: 06/22/2023] Open
Abstract
Hypophosphatemia is among the most common electrolyte abnormalities, especially among patients with underlying malignancies, and is frequently associated with adverse prognoses. Phosphorus levels are regulated through a number of mechanisms, including parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23), vitamin D, and other electrolyte levels themselves. Clinically, the findings are nonspecific, and the diagnosis is frequently delayed. This article is a narrative literature review. The PubMed database was searched for relevant articles pertaining to hypophosphatemia causes and consequences in patients suffering from multiple myeloma. We found a variety of causes of hypophosphatemia in patients with multiple myeloma. Tumor-induced osteopenia, although more common among patients with small squamous cell carcinomas, can occur with multiple myeloma as well. Additionally, both light chains themselves and medications can trigger Fanconi syndrome, which leads to phosphorus wasting by the kidney. Bisphosphonates, in addition to being a possible cause of Fanconi syndrome, lead to a decrease in calcium levels, which then stimulates parathyroid hormone (PTH) release, predisposing the patient to significant hypophosphatemia. Additionally, many of the more modern medications used to manage multiple myeloma have been associated with hypophosphatemia. A better understanding of those mechanisms may give clinicians a clearer idea of which patients may need more frequent screening as well as what the potential triggers in the individual patient may be.
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Affiliation(s)
- Ivan Cancarevic
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Usman Ilyas
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York, USA
| | - Mahmoud Nassar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, NYC Health + Hospitals/Queens, New York, USA
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Gupta A, Kandasamy D, Sharma R, Damle N, Goyal A, Goyal A, Agarwal S, Dharmashaktu Y. Imaging characteristics of phosphaturic mesenchymal tumors. Acta Radiol 2023; 64:2061-2073. [PMID: 36915965 DOI: 10.1177/02841851231160086] [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: 03/16/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome associated with phosphaturic mesenchymal tumors (PMTs). Localization of the causative tumor in these cases is an arduous task since the culprit lesions are usually small, slow-growing, and can be located almost anywhere from head to toe. PURPOSE To describe the morphological characteristics of histologically proven PMTs on various radiological modalities. MATERIAL AND METHODS After institutional ethical approval, this retrospective study analyzed 20 cases with a histopathological evidence of PMT. Various imaging characteristics of the tumors on available computed tomography (CT) and magnetic resonance imaging (MRI) scans were evaluated. Descriptive statistical analyses were conducted. RESULTS The tumors were located in diverse locations: lower extremities (n = 10); head and neck (n = 5); vertebral column (n = 3); pelvis (n = 1); and upper extremities (n = 1). Bone lesions seen on CT had variable morphology: sclerotic (n = 3/8, 37.5%); lytic (n = 3/8, 37.5%), and both lytic and sclerotic (n = 2/8, 25%) with presence of narrow zone of transition in all cases (n = 8/8) and amorphous internal matrix calcifications in 25% of cases (n = 2/8). Of the tumors, 68.4% (n = 13/19) were hypointense on T1 and all of them showed hyperintense signal on T2-weighted and STIR images (n = 19/19) and contrast enhancement (n = 16/16). Of the tumors, 66.7% (n = 6/9) showed restricted diffusion. DOTANOC PET/CT showed tumor uptake in all cases (n = 8/8). CONCLUSION PMTs may have variable and non-specific tumor appearances on various imaging modalities. However, in an appropriate clinical scenario and a background of suggestive biochemical work-up, the radiologist should keep a high index of suspicion.
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Affiliation(s)
- Amit Gupta
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Nishikant Damle
- Department of Nuclear Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiodiagnosis and Interventional Radiology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Alpesh Goyal
- Department of Endocrinology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Department of Pathology, 28730All India Institute of Medical Sciences, New Delhi, India
| | - Yamini Dharmashaktu
- Department of Nuclear Medicine, 28730All India Institute of Medical Sciences, New Delhi, India
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Paraneoplastic musculoskeletal disorders: review and update for radiologists. Skeletal Radiol 2023; 52:421-433. [PMID: 35604445 DOI: 10.1007/s00256-022-04074-w] [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: 03/30/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/02/2023]
Abstract
Rheumatic paraneoplastic syndromes are rare syndromes that occur at distant sites from the underlying tumor and may involve the bones, joints, fasciae, muscles, or vessels. In the absence of a known tumor, early recognition of a rheumatic syndrome as paraneoplastic permits dedicated work-up for, and potentially early treatment of an occult malignancy. Although there is a continuously growing list of paraneoplastic rheumatic disorders, not all of these disorders have a well-established association with a neoplastic process. The goals of this article are to review the clinical characteristics, diagnostic work-up, and imaging findings of well-documented rheumatic paraneoplastic disorders.
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Barai R, Tsang T, Cespedes L. Tumour-induced osteomalacia due to residual benign glomangioma. BMJ Case Rep 2022; 15:e250237. [PMID: 36357106 PMCID: PMC9660516 DOI: 10.1136/bcr-2022-250237] [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: 11/11/2022] Open
Abstract
Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome. The constellation of findings of unprovoked fractures, hypophosphataemia, urinary phosphate wasting and a negative genetic evaluation suggest a TIO diagnosis. Tumours leading to TIO are often small and difficult to localise using standard imaging studies. The 68Ga-DOTATATE CT/positron emission tomography, a somatostatin receptor imaging modality, is the radiographical study of choice for localisation. It is highly sensitive and specific since tumours that cause oncogenic osteomalacia have been shown to express somatostatin receptors. Complete surgical resection is the treatment of choice; however, it may not always be feasible. Burosumab, a human anti-fibroblast growth factor-23 monoclonal antibody, is a therapeutic option in cases of unresectable TIO to normalise phosphorus levels and improve fracture healing. Our patient was initiated on burosumab, which led to healing of his fractures and profound symptomatic improvement of his pain. TIO is often undiagnosed for many years, leading to significant patient morbidity.
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Affiliation(s)
- Rakhee Barai
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Tiffany Tsang
- Department of Endocrinology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lissette Cespedes
- Department of Endocrinology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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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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Hou G, Zhang Y, Liu Y, Wang P, Xia W, Xing X, Huo L, Li F, Jing H. Head-to-Head Comparison of 68Ga-DOTA-TATE and 68Ga-DOTA-JR11 PET/CT in Patients With Tumor-Induced Osteomalacia: A Prospective Study. Front Oncol 2022; 12:811209. [PMID: 35280786 PMCID: PMC8913035 DOI: 10.3389/fonc.2022.811209] [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: 11/08/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background The purpose of this study is to compare the sensitivity of 68Ga-DOTA-JR11 and 68Ga-DOTA-TATE PET/CT for detecting the responsible tumor of tumor-induced osteomalacia (TIO) and investigate if 68Ga-DOTA-JR11 PET/CT can identify the culprit tumor of TIO in multiple suspicious lesions in 68Ga-DOTA-TATE PET/CT. Methods A total of 19 patients with suspected TIO were prospectively recruited in this study. Each patient underwent whole-body PET/CT scan 40–60 min postinjection using 68Ga-DOTA-TATE and 68Ga-DOTA-JR11 on the same PET/CT, respectively in sequence, and on consecutive days. The diagnosis of TIO was confirmed by the combination of the postsurgical pathological results of the tumor and clinical information. Results Among the 19 patients with TIO who were included in this study, culprit tumors from all patients were confirmed pathologically. 68Ga-DOTA-TATE PET/CT positively identified the causative tumor in 18/19 patients, whereas 68Ga-DOTA-JR11 PET/CT was positive in 11/19 patients (94.7% vs. 57.9%, respectively; p < 0.05). 68Ga-DOTA-TATE PET/CT demonstrated more than one increased focal activity in 7 patients for a total of 16 lesions (3 lesions each in 2 patients and 2 lesions each in the rest 5 patients). However, seven of these 16 lesions showed concordant results on 68Ga-DOTA-JR11 PET/CT by demonstrating increased activity (one lesion in each of the 7 patients). The surgical specimens of the lesions in these 7 patients confirmed the phosphaturic mesenchymal tumor. A total of 11 culprit tumors were positive in both 68Ga-DOTA-TATE and 68Ga-DOTA-JR11 PET/CT. The SUVmax of 11 culprit tumors was significantly higher on 68Ga-DOTA-TATE PET/CT compared with that on 68Ga-DOTA-JR11 PET/CT (17.8 ± 12.5 vs. 6.8 ± 6.2; p < 0.05). Conclusions 68Ga-DOTA-TATE PET/CT is more sensitive to 68Ga-DOTA-JR11 PET/CT in the detection of the culprit tumor of TIO. However, 68Ga-DOTA-JR11 PET/CT might be helpful to identify the tumor in multiple suspicious lesions in 68Ga-DOTA-TATE PET/CT. Clinical Trial Registration clinicaltrials.gov, identifier NCT 04689893.
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Affiliation(s)
- Guozhu Hou
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Yuwei Zhang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Yu Liu
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Peipei Wang
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Huo
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Fang Li
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Hongli Jing
- Department of Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
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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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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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12
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Sum M, Hoda ST, Rapp T, Zan E. Tumor-Induced Osteomalacia Localized and Excised After Pregnancy. AACE Clin Case Rep 2021; 7:363-366. [PMID: 34765732 PMCID: PMC8573288 DOI: 10.1016/j.aace.2021.06.008] [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: 11/03/2020] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Tumor-induced osteomalacia (TIO) is a rare osteomalacia characterized by paraneoplastic secretion of fibroblast growth factor 23. Concomitant occurrence of TIO during pregnancy is rarer still. Our objective was to report a young patient with debilitating fractures diagnosed with TIO who became pregnant and subsequently had her tumor localized by gallium-68 (Ga-68) DOTATATE positron emission tomography/magnetic resonance imaging (PET/MRI). Case Report A 28 year-old woman with a 2-year history of stress fractures was found to have the following: (1) alkaline phosphatase level, 220 (reference range, 30-95) U/L; (2) phosphorus level, 2.1 (2.5-5.0) mg/dL; (3) 1,25-dihydroxyvitamin D3 level, <8 (18-72) pg/mL; (4) 24-hour urine phosphorus level, 0.5 (0.3-1.3) g; and (5) fibroblast growth factor 23 levels, 1241 (reference range, <180) RU/mL. The patient became pregnant, and at term, a cesarean delivery was performed. Ga-68 DOTATATE PET/MRI showed a 9-mm intracortical mass in the right fibular head and right femoral and bilateral calcaneal stress fractures. The fibular lesion was resected; pathology showed a 1.5-cm lesion with positive fibroblast growth factor receptor 1 staining. Discussion This patient with TIO had an uneventful pregnancy and delivery. TIO is typically caused by benign mesenchymal tumors. Ga-68 DOTATATE PET/computed tomography has been used for localizing tumors causing TIO, yet MRI has superior contrast resolution over computed tomography. Therefore, it is not surprising that Ga-68 PET/MRI successfully localized this patient’s tumor to the intracortical space of the fibular head and distinguished it from insufficiency fractures. Conclusion To our knowledge, this is the first report of phosphate treatment in a pregnant patient with TIO and the first report of a tumor-inducing TIO being localized by Ga-68 DOTATATE PET/MRI.
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Key Words
- 1,25[OH]2D3, 1,25-dihydroxyvitamin D3
- ALP, alkaline phosphatase
- DOTATATE
- FGF23, fibroblast growth factor 23
- Ga-68, gallium-68
- MRI, magnetic resonance imaging
- PET, positron emission tomography
- PTH, parathyroid hormone
- SUV, standard uptake value
- TIO, tumor-induced osteomalacia
- TmP/GFR, tubular maximum reabsorption of phosphate per unit of glomerular filtration
- fibroblast growth factor 23
- hypophosphatemia
- iFGF23, intact fibroblast growth factor 23
- pregnancy
- renal phosphate wasting
- tumor-induced osteomalacia
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Affiliation(s)
- Melissa Sum
- Department of Medicine, NYU Langone Health, New York, New York
| | - Syed T Hoda
- Department of Pathology, NYU Langone Health, New York, New York
| | - Timothy Rapp
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Elcin Zan
- Department of Radiology, NYU Langone Health, New York, New York
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13
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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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14
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Abrahamsen B, Smith CD, Minisola S. Epidemiology of Tumor-Induced Osteomalacia in Denmark. Calcif Tissue Int 2021; 109:147-156. [PMID: 33818653 PMCID: PMC8273058 DOI: 10.1007/s00223-021-00843-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare, acquired condition of phosphate wasting due to phosphaturic mesenchymal tumors. Because the incidence and prevalence of TIO is unknown, we conducted an observational cohort study using national Danish health registers for the period 2008 to 2018 to obtain such information. The study also aimed to describe the demographics of the TIO population and the prognosis. The operational definition was based on hypophosphatemia or adult osteomalacia diagnoses, combined with prescriptions used in the initial management and procedures consistent with advanced imaging used for locating tumors. The incidence of TIO in Denmark was found to be below 0.13 per 100,000 person years for the total population of the country and 0.10 per 100,000 in adult-onset disease. The prevalence of TIO was estimated to be no more than 0.70 per 100,000 persons for the total population and 0.43 per 100,000 in adults. In 2018, there were a maximum of nine new cases of TIO in Danish adults. Mortality was low but few patients fulfilled the protocol cure criterion during the observation period. TIO has no ICD-10 code and limitations to the study include lack of information on serum biochemistry and on the use of phosphate supplements. Strengths include the use of long-term longitudinal, national hospital and prescription data from a country with universal healthcare. Given the very small patient population with TIO and the known delay to diagnosis and cure, management of patients with suspected TIO should be centralized.
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Affiliation(s)
- Bo Abrahamsen
- Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, 5000, Odense C, Denmark.
- Department of Medicine, Holbæk Hospital, 4300, Holbæk, Denmark.
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX2 6NN, UK.
| | - Christopher D Smith
- Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, 5000, Odense C, Denmark
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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15
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Zheng G, Kanduri SR, Canterbury JP, Nguyen T, Velez JCQ. A Case of Hypophosphatemia due to Oncogenic Osteomalacia in a Patient with Natural Killer T-Cell Lymphoma. Kidney Blood Press Res 2021; 46:647-651. [PMID: 34293749 DOI: 10.1159/000516390] [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: 02/08/2021] [Accepted: 04/03/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Oncogenic osteomalacia (Onc-Ost) is a paraneoplastic phenomenon characterized by hypophosphatemia due to elevated fibroblast growth factor-23 (FGF-23). Onc-Ost has been previously reported in patients with germ line mesenchymal tumors and solid organ malignancies. This is the first report of aggressive natural killer (NK) T-cell lymphoma presenting as Onc-Ost. CASE DESCRIPTION A 33-year-old Vietnamese female with active hepatitis B and Mycobacterium avium complex, on ongoing therapy with tenofovir disoproxil, azithromycin, and ethambutol, presented with persistent fevers and developed refractory hypophosphatemia. Workup confirmed severe renal phosphate wasting. Tenofovir disoproxil was initially suspected; however, presence of isolated phosphaturia without Fanconi syndrome and persistence of hypophosphatemia despite discontinuation of medication led to clinical suspicion of Onc-Ost. Elevated FGF-23 warranted further workup, leading to a definitive diagnosis of clinically subtle NK T-cell lymphoma. Chemotherapy was initiated; however, patient continued to deteriorate clinically and expired. CONCLUSION Along with commonly reported germ line mesenchymal tumors and solid malignancies, NK T-cell lymphoma can also present as Onc-Ost. Timely detection of associated tumors and subsequent antitumor therapy would likely reverse hypophosphatemia and improve clinical outcomes.
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Affiliation(s)
- Guoliang Zheng
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia
| | - Swetha Rani Kanduri
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - John P Canterbury
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Thuy Nguyen
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia
| | - Juan Carlos Q Velez
- Ochsner Clinical School/The University of Queensland, Brisbane, Queensland, Australia.,Department of Nephrology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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Turin CG, Wilson RJ, Mangone C, Rosenspire K, Berman J, Walker M, Amaravadi R, Al Mukaddam M. A Case of Tumor-Induced Osteomalacia: Finding the Culprit Acetabular Tumor and Successful Resection with a Novel Hip Joint-Preserving Surgery. J Orthop Case Rep 2021; 11:37-41. [PMID: 34239825 PMCID: PMC8241250 DOI: 10.13107/jocr.2021.v11.i03.2078] [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: 12/01/2022] Open
Abstract
INTRODUCTION Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection of the tumor can be curative. However, these tumors are typically difficult to find anatomically due to small size and location. CASE REPORT We present the case of a patient who presented for evaluation of recurrent fractures and hypophosphatemia in the setting of elevated FGF23 suggestive of TIO. 68Gallium-DOTATATE revealed multiple somatostatin avid lesions in several ribs, left acetabulum, sacrum, right tibia, and feet, some of which appeared with fracture on computed tomography scan, initially concerning for metastatic disease. However, the lesion in acetabulum was considered the culprit tumor given its remarkably higher maximum standard uptake values. Complete surgical removal of the FGF23-secreting tumor led to cure of this disease. CONCLUSION This case report highlights the challenges with functional imaging differentiating fractures from the culprit lesion and reports on a novel surgical technique that allowed for surgical cure while preserving the hip joint.
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Affiliation(s)
- Christie G. Turin
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J. Wilson
- Department of Orthopaedic, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ciera Mangone
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Karen Rosenspire
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Berman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Michelle Walker
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Ravi Amaravadi
- Department of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mona Al Mukaddam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
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17
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Usefulness of 68Ga-DOTATOC PET/CT to localize the culprit tumor inducing osteomalacia. Sci Rep 2021; 11:1819. [PMID: 33469091 PMCID: PMC7815743 DOI: 10.1038/s41598-021-81491-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/21/2020] [Indexed: 12/26/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome presenting with sustained hypophosphatemia. Treatment of choice is removal of the tumor causing the TIO, but identification of the culprit tumor by routine imaging is challenging. This study aimed to assess the usefulness of somatostatin receptor imaging, called 68Ga-DOTATOC PET/CT, in the management of patients with TIO. Twelve patients who were suspected of having TIO underwent 68Ga-DOTATOC PET/CT. Lesion detectability and maximum standardized uptake value (SUVmax) were determined and retrospectively compared with the clinical/imaging surveillance and histopathologic diagnosis. The median duration of suspected TIO with hypophosphatemia was 7.8 years (range 2.1–21.0). Conventional radiologic and/or nuclear medicine images failed to identify the culprit tumors. However, 68Ga-DOTATOC PET/CT scans showed that 8 of the 12 patients had positive lesions, suggesting the presence of focal culprit tumors. The SUVmax of positive tumors was 1.9–45.7 (median: 11.5). Six skeletal lesions and two extra-skeletal lesions were identified. Seven of the lesions were pathologically confirmed as potential culprits of TIO. Hypophosphatemia was resolved in five patients who underwent lesion excision. The 68Ga-DOTATOC PET/CT is a useful whole-body imaging modality for the detection of causative tumors in patients with suspected TIO.
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18
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Athonvarangkul D, Insogna KL. New Therapies for Hypophosphatemia-Related to FGF23 Excess. Calcif Tissue Int 2021; 108:143-157. [PMID: 32504139 DOI: 10.1007/s00223-020-00705-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
FGF23 is a hormone produced by osteocytes in response to an elevation in the concentration of extracellular phosphate. Excess production of FGF23 by bone cells, or rarely by tumors, is the hormonal basis for several musculoskeletal syndromes characterized by hypophosphatemia due to renal phosphate wasting. FGF23-dependent chronic hypophosphatemia causes rickets and osteomalacia, as well as other skeletal complications. Genetic disorders of FGF23-mediated hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets (ADHR), autosomal recessive hypophosphatemic rickets (ARHR), fibrous dysplasia of bone, McCune-Albright syndrome, and epidermal nevus syndrome (ENS), also known as cutaneous skeletal hypophosphatemia syndrome (CSHS). The principle acquired form of FGF23-mediated hypophosphatemia is tumor-induced osteomalacia (TIO). This review summarizes current knowledge about the pathophysiology and clinical presentation of the most common FGF23-mediated conditions, with a focus on new treatment modalities. For many decades, calcitriol and phosphate supplements were the mainstay of therapy. Recently, burosumab, a monoclonal blocking antibody to FGF23, has been approved for treatment of XLH in children and adults, and an active comparator trial in children has shown good efficacy and safety for this drug. The remainder of FGF23-mediated hypophosphatemic disorders continue to be treated with phosphate and calcitriol, although ongoing trials with burosumab for treatment of tumor-induced osteomalacia show early promise. Burosumab may be an effective treatment for the remainder of FGF23-mediated disorders, but clinical trials to support that possibility are at present not available.
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Affiliation(s)
- Diana Athonvarangkul
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA.
| | - Karl L Insogna
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA
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19
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Indirli R, Guabello G, Longhi M, Niada S, Maruca K, Mora S, Maggioni M, Corbetta S. FGF23-related hypophosphatemia in patients with low bone mineral density and fragility fractures: challenges in diagnosis and management. J Endocrinol Invest 2020; 43:787-798. [PMID: 31863362 DOI: 10.1007/s40618-019-01165-9] [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: 07/16/2019] [Accepted: 12/13/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE Hypophosphatemia (HP) can be observed in patients evaluated for skeletal fragility. We investigated prevalence of HP among outpatients referred for low bone density or fragility fractures, HP-associated clinical and biochemical features and outcomes of recommended diagnostic algorithm in our cohort. METHODS Chronic HP (phosphate ≤ 2.7 mg/dL over 6 months or longer) was retrospectively investigated among 2319 patients. In renal wasting-related HP, intact FGF23 was assessed; non-suppressed FGF23 prompted the performance of 68Ga-DOTATOC PET/CT in the suspicion of tumor-induced steomalacia (TIO). RESULTS Renal wasting-related HP (median 2.2, range 1.6-2.6 mg/dL) was observed in 19 patients (0.82%). FGF23 levels were suppressed in two patients diagnosed with renal tubular disease, increased in one and within normal range in most patients. X-linked hypophosphatemic rickets was diagnosed in one woman. In the remaining 16 patients, highly prevalent fragility fractures (50%) and severely reduced bone mineral density were detected, though diagnostic criteria for osteomalacia were not fulfilled. 68Ga-PET was performed in nine patients and was positive in four. While intact FGF23 levels alone failed to differentiate PET's outcomes (positive: FGF23 median 70.5 pg/mL; negative: 52 pg/mL, P = 0.462), the coexistence of multiple biochemical and radiologic alterations performed better in prediction of PET's positivity. CONCLUSION Mild, apparently unexplained HP is observed in 0.82% of patients with low bone density or fragility fractures. In asymptomatic patients with isolated mild hypophosphatemia, the probability of finding an underlying tumor disease is very low, and utility of extensive and expensive diagnostic workup should be carefully considered in this setting.
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Affiliation(s)
- R Indirli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Guabello
- Rheumatology Unit, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - M Longhi
- Rheumatology Unit, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - S Niada
- Laboratory of Biotechnological Applications, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - K Maruca
- Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Institute, Milan, Italy
| | - S Mora
- Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Institute, Milan, Italy
- Pediatric Bone Densitometry Service, IRCCS San Raffaele Institute, Milan, Italy
| | - M Maggioni
- Division of Pathology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Corbetta
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Via R.Galeazzi 4, 20161, Milan, Italy.
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Lessons learnt from delayed diagnosis of FGF-23-producing tumour-induced osteomalacia and post-operative hungry bone syndrome. Bone Rep 2020; 12:100276. [PMID: 32455150 PMCID: PMC7235936 DOI: 10.1016/j.bonr.2020.100276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/04/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022] Open
Abstract
Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by a fibroblast growth-factor-23 (FGF-23)-secreting phosphaturic mesenchymal tumour (PMT) and is characterised by hypophosphataemic osteomalacia. We present a 36-year-old man initially presenting with diffuse bone and joint pain who was inappropriately treated for presumed ankylosing spondylitis for 2 years. Whole-body bone scan suggested metabolic bone disease, prompting referral to our endocrine institution. He was subsequently diagnosed with persistent hypophosphataemia, inappropriately high renal tubular phosphate excretion, 1,25-dihydroxyvitamin D3 suppression, severe osteoporosis and severe osteomalacia. FGF-23 concentrations (140 ng/L) were raised 3-fold above the upper limit of normal. Initial Gallium-68 (68Ga) DOTATATE positron emission tomography (PET)/CT scan missed an active lesion in the left fibular head as the field only included the mid-brain to the proximal femora. Histopathology results from tumour resection confirmed a PMT over-expressing FGF-23. Serum phosphate and FGF-23 normalised immediately post-operatively. He developed severe hypocalcaemia 3-weeks post-operatively (1.77 mmol/L) which normalised after 1 month of high-dose caltrate and calcitriol therapy. Osteomalacia, osteoporosis and associated symptoms resolved during medium-term follow-up with >100% improvement in his bone mineral density. This case report and discussion highlights the pitfalls contributing to delayed diagnosis of TIO and alerts clinicians to the potential complication of hungry bone syndrome post-tumour resection.
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21
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Then C, Asbach E, Bartsch H, Thon N, Betz C, Reincke M, Schmidmaier R. Fibroblast Growth Factor 23-Producing Phosphaturic Mesenchymal Tumor with Extraordinary Morphology Causing Oncogenic Osteomalacia. ACTA ACUST UNITED AC 2020; 56:medicina56010034. [PMID: 31963334 PMCID: PMC7023375 DOI: 10.3390/medicina56010034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 11/16/2022]
Abstract
A possible cause of hypophosphatemia is paraneoplastic secretion of fibroblast growth factor 23 (FGF-23). Tumors secreting FGF-23 are rare, mostly of mesenchymal origin, usually benign, and may be located anywhere in the body, including hands and feet, which are often not represented in conventional imaging. A 50-year-old woman presented with diffuse musculoskeletal pain and several fractures. Secondary causes of osteoporosis were excluded. Laboratory analysis revealed hypophosphatemia and elevated alkaline phosphatase, parathyroid hormone, and FGF-23. Thus, oncogenic osteomalacia due to neoplastic FGF-23 secretion was suspected. FDG-PET-CT and DOTATATE-PET-CT imaging demonstrated no tumor. Cranial MRI revealed a tumorous mass in the left cellulae ethmoidales. The tumor was resected and histopathological examination showed a cell-rich tumor with round to ovoid nuclei, sparse cytoplasm, and sparse matrix, resembling an olfactory neuroblastoma. Immunohistochemical analysis first led to diagnosis of olfactory neuroblastoma, which was later revised to phosphaturic mesenchymal tumor. Following the resection, FGF-23 and phosphate levels normalized. In conclusion, we here describe a patient with an FGF-23-secreting phosphaturic mesenchymal tumor with an unusual morphology. Furthermore, we emphasize diagnostic pitfalls when dealing with FGF-23-induced hypophosphatemia.
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Affiliation(s)
- Cornelia Then
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336 Munich, Germany
- Correspondence: ; Tel.: +49-89-4400-52111; Fax: +49-89-4400-54428
| | - Evelyn Asbach
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Harald Bartsch
- Institute of Pathology, Klinikum der Universität München, Ludwig-Maximilians-University, 80337 Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, Klinikum Universität München, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Christian Betz
- Department of Otorhinolaryngology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, 80336 Munich, Germany
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Detection Rate of Culprit Tumors Causing Osteomalacia Using Somatostatin Receptor PET/CT: Systematic Review and Meta-Analysis. Diagnostics (Basel) 2019; 10:diagnostics10010002. [PMID: 31861469 PMCID: PMC7169446 DOI: 10.3390/diagnostics10010002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Tumor-induced or oncogenic osteomalacia (TIO) is a rare paraneoplastic syndrome in which osteomalacia is a consequence of fibroblast growth factor 23 (FGF23) secretion by a mesenchymal tumor. The localization of the culprit lesion in patients with TIO is often challenging. Several studies have evaluated the detection rate (DR) of these tumors using somatostatin receptor positron emission tomography (SSTR-PET/CT). We aimed to summarize literature findings on this topic providing pooled estimates of DR. Methods: A comprehensive literature search by screening PubMed, Embase and Cochrane library electronic databases through August 2019 was performed. The pooled DR of culprit tumors using SSTR-PET/CT in patients with TIO was calculated using a random-effects statistical model. Results: Fourteen studies on the use of SSTR-PET/CT in detecting the culprit tumor in patients with TIO were included in the qualitative analysis. The pooled DR of SSTR-PET/CT on a per-patient-based analysis calculated using eleven studies (166 patients) was 87.6% (95% confidence interval (95% CI) 80.2–95.1%). Statistical heterogeneity among studies was detected (I-square = 63%), likely due to the use of different radiolabeled somatostatin analogues, as demonstrated by a subgroup analysis. Conclusions: Despite limited literature data due to the rarity of the disease, SSTR-PET/CT demonstrated a very high DR of culprit tumors in patients with TIO and it could be used as first-line imaging method for this indication.
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