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Puente N, Solis P, Riancho JA. Genetic causes of hypophosphatemia. Minerva Med 2024; 115:320-336. [PMID: 38727708 DOI: 10.23736/s0026-4806.24.09198-5] [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: 06/21/2024]
Abstract
Phosphate is a key component of mineralized tissues and is also part of many organic compounds. Phosphorus homeostasis depends especially upon intestinal absorption, and renal excretion, which are regulated by various hormones, such as PTH, 1,25-dihydroxyvitamin D, and fibroblast growth factor 23. In this review we provide an update of several genetic disorders that affect phosphate transporters through cell membranes or the phosphate-regulating hormones, and, consequently, result in hypophosphatemia.
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Affiliation(s)
- Nuria Puente
- Service of Internal Medicine, Hospital U. M. Valdecilla, University of Cantabria, Santander, Spain
- Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain
- Valdecilla Research Institute, Santander, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, ISCIII), Madrid, Spain
| | - Pablo Solis
- Service of Internal Medicine, Hospital U. M. Valdecilla, University of Cantabria, Santander, Spain
| | - Jose A Riancho
- Service of Internal Medicine, Hospital U. M. Valdecilla, University of Cantabria, Santander, Spain -
- Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain
- Valdecilla Research Institute, Santander, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, ISCIII), Madrid, Spain
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2
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Morren MA, Fodstad H, Brems H, Bedoni N, Guenova E, Jacot-Guillarmod M, Busiah K, Giuliano F, Gilliet M, Atallah I. Mosaic RASopathies concept: different skin lesions, same systemic manifestations? J Med Genet 2024; 61:411-419. [PMID: 38290824 DOI: 10.1136/jmg-2023-109306] [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: 04/01/2023] [Accepted: 12/30/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Cutaneous epidermal nevi are genotypically diverse mosaic disorders. Pathogenic hotspot variants in HRAS, KRAS, and less frequently, NRAS and BRAF may cause isolated keratinocytic epidermal nevi and sebaceous nevi or several different syndromes when associated with extracutaneous anomalies. Therefore, some authors suggest the concept of mosaic RASopathies to group these different disorders. METHODS In this paper, we describe three new cases of syndromic epidermal nevi caused by mosaic HRAS variants: one associating an extensive keratinocytic epidermal nevus with hypomastia, another with extensive mucosal involvement and a third combining a small sebaceous nevus with seizures and intellectual deficiency. Moreover, we performed extensive literature of all cases of syndromic epidermal nevi and related disorders with confirmed pathogenic postzygotic variants in HRAS, KRAS, NRAS or BRAF. RESULTS Most patients presented with bone, ophthalmological or neurological anomalies. Rhabdomyosarcoma, urothelial cell carcinoma and pubertas praecox are also repeatedly reported. KRAS pathogenic variants are involved in 50% of the cases, especially in sebaceous nevi, oculoectodermal syndrome and encephalocraniocutaneous lipomatosis. They are frequently associated with eye and brain anomalies. Pathogenic variants in HRAS are rather present in syndromic keratinocytic epidermal nevi and phacomatosis pigmentokeratotica. CONCLUSION This review delineates genotype/phenotype correlations of syndromic epidermal nevi with somatic RAS and BRAF pathogenic variants and may help improve their follow-up.
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Affiliation(s)
- Marie-Anne Morren
- Pediatric Dermatology Unit, Department of Dermatology and Venereology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Heidi Fodstad
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Hilde Brems
- Department of Human Genetics, University of Leuven, Leuven, Belgium
| | - Nicola Bedoni
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanuella Guenova
- Department of Dermatology and Venereology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Martine Jacot-Guillarmod
- Pediatric Gynecology Unit, Department of Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kanetee Busiah
- Pediatric Endocrinology, Diabetology, and Obesity Unit, Department of Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michel Gilliet
- Dermatology and Venereology Department, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Isis Atallah
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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3
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Morimoto T, Hirata H, Sugita K, Paholpak P, Kobayashi T, Tanaka T, Kato K, Tsukamoto M, Umeki S, Toda Y, Mawatari M. A view on the skin-bone axis: unraveling similarities and potential of crosstalk. Front Med (Lausanne) 2024; 11:1360483. [PMID: 38500951 PMCID: PMC10944977 DOI: 10.3389/fmed.2024.1360483] [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: 12/23/2023] [Accepted: 02/12/2024] [Indexed: 03/20/2024] Open
Abstract
The phrase "skin as a mirror of internal medicine," which means that the skin reflects many of the diseases of the internal organs, is a well-known notion. Despite the phenotypic differences between the soft skin and hard bone, the skin and bone are highly associated. Skin and bone consist of fibroblasts and osteoblasts, respectively, which secrete collagen and are involved in synthesis, while Langerhans cells and osteoclasts control turnover. Moreover, the quality and quantity of collagen in the skin and bone may be modified by aging, inflammation, estrogen, diabetes, and glucocorticoids. Skin and bone collagen are pathologically modified by aging, drugs, and metabolic diseases, such as diabetes. The structural similarities between the skin and bone and the crosstalk controlling their mutual pathological effects have led to the advocacy of the skin-bone axis. Thus, the skin may mirror the health of the bones and conversely, the condition of the skin may be reflected in the bones. From the perspective of the skin-bone axis, the similarities between skin and bone anatomy, function, and pathology, as well as the crosstalk between the two, are discussed in this review. A thorough elucidation of the pathways governing the skin-bone axis crosstalk would enhance our understanding of disease pathophysiology, facilitating the development of new diagnostics and therapies for skin collagen-induced bone disease and of new osteoporosis diagnostics and therapies that enhance skin collagen to increase bone quality and density.
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Affiliation(s)
- Tadatsugu Morimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hirohito Hirata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kazunari Sugita
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Permsak Paholpak
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Takaomi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Kinshi Kato
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masatsugu Tsukamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Shun Umeki
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yu Toda
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
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4
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Abebe L, Phung K, Robinson ME, Waldner R, Carsen S, Smit K, Tice A, Lazier J, Armour C, Page M, Dover S, Rauch F, Koujok K, Ward LM. Burosumab for the treatment of cutaneous-skeletal hypophosphatemia syndrome. Bone Rep 2024; 20:101725. [PMID: 38229908 PMCID: PMC10790024 DOI: 10.1016/j.bonr.2023.101725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 01/18/2024] Open
Abstract
Cutaneous-skeletal hypophosphatemia syndrome (CSHS) is a rare bone disorder featuring fibroblast growth factor-23 (FGF23)-mediated hypophosphatemic rickets. We report a 2-year, 10-month-old girl with CSHS treated with burosumab, a novel human monoclonal antibody targeting FGF23. This approach was associated with rickets healing, improvement in growth and lower limb deformity, and clinically significant benefit to her functional mobility and motor development. This case report provides evidence for the effective use of FGF23-neutralizing antibody therapy beyond the classic FGF23-mediated disorders of X-linked hypophosphatemia and tumor-induced osteomalacia.
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Affiliation(s)
- Lillian Abebe
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Kim Phung
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
| | - Marie-Eve Robinson
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
- Division of Endocrinology and Metabolism, Department of Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Richelle Waldner
- Department of Pediatrics, University of Alberta, 116 St & 85 Av, Edmonton, AB T6G 2R3, Canada
| | - Sasha Carsen
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
- Department of surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Kevin Smit
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
- Department of surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Andrew Tice
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
- Department of surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Joanna Lazier
- Department of Genetics, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
- Department of Medical Genetics and Genomics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
| | - Christine Armour
- Department of Genetics, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
- Department of Medical Genetics and Genomics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
| | - Marika Page
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Saunya Dover
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Frank Rauch
- Shriners Hospital for Children, 1003 Decarie Blvd, Montréal, QC H4A 0A9, Canada
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, 805 rue Sherbrooke O, Montréal, Quebec H3A 0B9, Canada
| | - Khaldoun Koujok
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Leanne M. Ward
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, 550 Cumberland St, Ottawa, ON K1N 6N5, Canada
- Division of Endocrinology and Metabolism, Department of Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
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5
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Cherian KE, Paul TV. Inherited fibroblast growth factor 23 excess. Best Pract Res Clin Endocrinol Metab 2024; 38:101844. [PMID: 38044258 DOI: 10.1016/j.beem.2023.101844] [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: 12/05/2023]
Abstract
Syndromes of inherited fibroblast growth factor 23 (FGF-23) excess encompass a wide spectrum that includes X-linked hypophosphataemia (XLH), autosomal dominant and recessive forms of rickets as well as various syndromic conditions namely fibrous dysplasia/McCune Albright syndrome, osteoglophonic dysplasia, Jansen's chondrodysplasia and cutaneous skeletal hypophosphataemia syndrome. A careful attention to patient symptomatology, family history and clinical features, supported by appropriate laboratory tests will help in making a diagnosis. A genetic screen may be done to confirm the diagnosis. While phosphate supplements and calcitriol continue to be the cornerstone of treatment, in recent times burosumab, the monoclonal antibody against FGF-23 has been approved for the treatment of children and adults with XLH. While health-related outcomes may be improved by ensuring adherence and compliance to prescribed treatment with a smooth transition to adult care, bony deformities may persist in some, and this would warrant surgical correction.
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Torchia D, Happle R. Phacomatosis spilosebacea: A new name for a distinctive binary genodermatosis. J Am Acad Dermatol 2023; 89:764-773. [PMID: 33583608 DOI: 10.1016/j.jaad.2020.12.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 12/21/2022]
Abstract
Phacomatosis pigmentokeratotica (PPK) is defined by the association of papular nevus spilus arranged in a flag-like pattern and sebaceous nevus following Blaschko's lines. A systematic search of the worldwide literature retrieved 95 well-established PPK cases. An additional 30 cases were excluded for a number of reasons. Based on this study, we propose to rename PPK phacomatosis spilosebacea (PSS). Mosaic mutations of the HRAS gene are the only proven cause of PSS. The extracutaneous abnormalities of PSS result from various degrees of intermingling of Schimmelpenning syndrome and papular nevus spilus syndrome. PSS seems to be a condition at particularly high risk of developing basal cell carcinoma, urogenital malignancies, and vitamin D-resistant hypophosphatemic rickets. Extracutaneous abnormalities were detected in approximately 75% of PSS cases.
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Affiliation(s)
- Daniele Torchia
- Department of Dermatology, James Paget University Hospital, Gorleston-on-Sea, United Kingdom.
| | - Rudolf Happle
- Department of Dermatology, Medical Center-University of Freiburg, Freiburg, Germany
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7
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Zuntini R, Cattani C, Pedace L, Miele E, Caraffi SG, Gardini S, Ficarelli E, Pizzi S, Radio FC, Barone A, Piana S, Bertolini P, Corradi D, Marinelli M, Longo C, Motolese A, Zuffardi O, Tartaglia M, Garavelli L. Case Report: Sequential postzygotic HRAS mutation and gains of the paternal chromosome 11 carrying the mutated allele in a patient with epidermal nevus and rhabdomyosarcoma: evidence of a multiple-hit mechanism involving HRAS in oncogenic transformation. Front Genet 2023; 14:1231434. [PMID: 37636262 PMCID: PMC10447906 DOI: 10.3389/fgene.2023.1231434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023] Open
Abstract
We report a 7-year-old boy born with epidermal nevi (EN) arranged according to Blaschko's lines involving the face and head, right upper limb, chest, and left lower limb, who developed a left paratesticular embryonal rhabdomyosarcoma at 18 months of age. Parallel sequencing identified a gain-of-function variant (c.37G>C, p.Gly13Arg) of HRAS in both epidermal nevus and tumor but not in leukocytes or buccal mucosal epithelial cells, indicating its postzygotic origin. The variant accounted for 33% and 92% of the total reads in the nevus and tumor DNA specimens, respectively, supporting additional somatic hits in the latter. DNA methylation (DNAm) profiling of the tumor documented a signature consistent with embryonal rhabdomyosarcoma and CNV array analysis inferred from the DNAm arrays and subsequent MLPA analysis demonstrated copy number gains of the entire paternal chromosome 11 carrying the mutated HRAS allele, likely as the result of paternal unidisomy followed by subsequent gain(s) of the paternal chromosome in the tumor. Other structural rearrangements were observed in the tumours, while no additional pathogenic variants affecting genes with role in the RAS-MAPK and PI3K-AKT-MTOR pathways were identified. Our findings provide further evidence of the contribution of "gene dosage" to the multistep process driving cell transformation associated with hyperactive HRAS function.
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Affiliation(s)
- Roberta Zuntini
- Medical Genetics Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Chiara Cattani
- Medical Genetics Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Lucia Pedace
- Department of Pediatric Hematology, Oncology and Cellular and Gene Therapy, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Evelina Miele
- Department of Pediatric Hematology, Oncology and Cellular and Gene Therapy, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | | | - Stefano Gardini
- Dermatology Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Elena Ficarelli
- Dermatology Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Simone Pizzi
- Molecular Genetics and Functional Genomics Research Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Francesca Clementina Radio
- Molecular Genetics and Functional Genomics Research Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Angelica Barone
- Paediatric Hematology Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Simonetta Piana
- Department of Oncology and Advanced Technologies, Pathology Unit, Azienda USL, IRCCS, Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Patrizia Bertolini
- Paediatric Hematology Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Domenico Corradi
- Department of Medicine and Surgery, Unit of Pathology, University of Parma, Parma, Italy
| | - Maria Marinelli
- Medical Genetics Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Caterina Longo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Oncology and Advanced Technologies, Unit of Dermatology, Azienda USL, IRCCS, Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Alberico Motolese
- Dermatology Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Orsetta Zuffardi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marco Tartaglia
- Molecular Genetics and Functional Genomics Research Unit, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Livia Garavelli
- Medical Genetics Unit, Azienda USL, IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
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8
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Ovejero D, Michel Z, Cataisson C, Saikali A, Galisteo R, Yuspa SH, Collins MT, de Castro LF. Murine models of HRAS-mediated cutaneous skeletal hypophosphatemia syndrome suggest bone as the FGF23 excess source. J Clin Invest 2023; 133:e159330. [PMID: 36943390 PMCID: PMC10145192 DOI: 10.1172/jci159330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is a mosaic RASopathy characterized by the association of dysplastic skeletal lesions, congenital skin nevi of epidermal and/or melanocytic origin, and FGF23-mediated hypophosphatemia. The primary physiological source of circulating FGF23 is bone cells. However, several reports have suggested skin lesions as the source of excess FGF23 in CSHS. Consequently, without convincing evidence of efficacy, many patients with CSHS have undergone painful removal of cutaneous lesions in an effort to normalize blood phosphate levels. This study aims to elucidate whether the source of FGF23 excess in CSHS is RAS mutation-bearing bone or skin lesions. Toward this end, we analyzed the expression and activity of Fgf23 in two mouse models expressing similar HRAS/Hras activating mutations in a mosaic-like fashion in either bone or epidermal tissue. We found that HRAS hyperactivity in bone, not skin, caused excess of bioactive intact FGF23, hypophosphatemia, and osteomalacia. Our findings support RAS-mutated dysplastic bone as the primary source of physiologically active FGF23 excess in patients with CSHS. This evidence informs the care of patients with CSHS, arguing against the practice of nevi removal to decrease circulating, physiologically active FGF23.
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Affiliation(s)
- Diana Ovejero
- Musculoskeletal Research Unit, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Zachary Michel
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, Maryland, USA
| | - Christophe Cataisson
- Laboratory of Cancer Biology and Genetics, National Cancer Institute (NCI), NIH, Bethesda, Maryland, USA
| | - Amanda Saikali
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, Maryland, USA
| | - Rebeca Galisteo
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, Maryland, USA
| | - Stuart H. Yuspa
- Laboratory of Cancer Biology and Genetics, National Cancer Institute (NCI), NIH, Bethesda, Maryland, USA
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, Maryland, USA
| | - Luis F. de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, Maryland, USA
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9
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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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10
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Sugarman J, Maruri A, Hamilton DJ, Tabatabai L, Luca D, Cimms T, Krolczyk S, Roberts MS, Carpenter TO. The efficacy and safety of burosumab in two patients with cutaneous skeletal hypophosphatemia syndrome. Bone 2023; 166:116598. [PMID: 36341949 DOI: 10.1016/j.bone.2022.116598] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/02/2022]
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is an ultra-rare mosaic disorder manifesting as skeletal dysplasia and FGF23-mediated hypophosphatemia, with some experiencing extra-osseous/extra-cutaneous manifestations, including both benign and malignant neoplasms. Like other disorders of FGF23-mediated hypophosphatemia including X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO), patients with CSHS have low serum phosphorus and active 1,25-dihydroxyvitamin D levels. Current treatment options for patients with CSHS include multiple daily doses of oral phosphorus and one or more daily doses of active vitamin D analog to correct the deficits. Recently, the fully human monoclonal antibody against FGF23 burosumab received US approval for the treatment of XLH and TIO, two rare diseases characterized by FGF23-mediated hypophosphatemia leading to rickets and osteomalacia. Given the similarities between the pathobiologies of these disorders and CSHS, we investigated the impact of burosumab on two patients, one pediatric and one adult, with CSHS who participated in separate, but similarly designed trials. In both the pediatric and adult patients, burosumab therapy was well-tolerated and contributed to clinically meaningful improvements in disease outcomes including normalization of phosphorus metabolism and markers of bone health, and improvements in skeletal abnormalities, fractures, and physical function. Reported adverse events were minimal, with only mild injection site reactions attributed to burosumab therapy. Together, these findings suggest that burosumab therapy is a promising therapeutic option for patients with CSHS.
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Affiliation(s)
- Jeffrey Sugarman
- University of California, San Francisco, San Francisco, CA, USA.
| | - Ann Maruri
- Westside Pediatrics Focus Research and Development, 1477 N 2000 W, Clinton, UT 84015, USA
| | - Dale J Hamilton
- Houston Methodist Hospital and Research Institute; WCM Affiliate, Houston, TX, USA
| | - Laila Tabatabai
- Houston Methodist Hospital and Research Institute; WCM Affiliate, Houston, TX, USA
| | - Diana Luca
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
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11
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Carli D, Resta N, Ferrero GB, Ruggieri M, Mussa A. Mosaic RASopathies: A review of disorders caused by somatic pathogenic variants in the genes of the RAS/MAPK pathway. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:520-529. [PMID: 36461154 DOI: 10.1002/ajmg.c.32021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
Mosaic RASopathies are a heterogeneous group of diseases characterized by the presence at birth or early onset of congenital anomalies, cutaneous and vascular anomalies, segmental overgrowth, and increased cancer risk. They are caused by somatic pathogenic variants of the genes belonging the RAt Sarcoma Mitogen-activated protein kinase (RAS/MAPK) pathway causing its hyperactivation. Here, we review the clinical and molecular characteristics of this heterogeneous group of diseases, including the possibilities of molecular diagnosis and new therapeutic perspectives.
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Affiliation(s)
- Diana Carli
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.,Pediatric Onco-Hematology, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Nicoletta Resta
- Division of Medical Genetics, Department of Biomedical Sciences and Human Oncology (DIMO), University of Bari "Aldo Moro", Bari, Italy
| | | | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessandro Mussa
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.,Pediatric Clinical Genetics Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza, Torino, Italy
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12
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Carli D, Cardaropoli S, Tessaris D, Coppo P, La Selva R, Cesario C, Lepri FR, Pullano V, Palumbo M, Ramenghi U, Brusco A, Medico E, De Sanctis L, Ferrero GB, Mussa A. Successful treatment with MEK-inhibitor in a patient with NRAS-related cutaneous skeletal hypophosphatemia syndrome. Genes Chromosomes Cancer 2022; 61:740-746. [PMID: 35999193 PMCID: PMC9826313 DOI: 10.1002/gcc.23092] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 01/11/2023] Open
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is caused by somatic mosaic NRAS variants and characterized by melanocytic/sebaceous naevi, eye, and brain malformations, and FGF23-mediated hypophosphatemic rickets. The MEK inhibitor Trametinib, acting on the RAS/MAPK pathway, is a candidate for CSHS therapy. A 4-year-old boy with seborrheic nevus, eye choristoma, multiple hamartomas, brain malformation, pleural lymphangioma and chylothorax developed severe hypophosphatemic rickets unresponsive to phosphate supplementation. The c.182A > G;p.(Gln61Arg) somatic NRAS variant found in DNA from nevus biopsy allowed diagnosing CSHS. We administered Trametinib for 15 months investigating the transcriptional effects at different time points by whole blood RNA-seq. Treatment resulted in prompt normalization of phosphatemia and phosphaturia, catch-up growth, chylothorax regression, improvement of bone mineral density, reduction of epidermal nevus and hamartomas. Global RNA sequencing on peripheral blood mononucleate cells showed transcriptional changes under MEK inhibition consisting in a strong sustained downregulation of signatures related to RAS/MAPK, PI3 kinase, WNT and YAP/TAZ pathways, reverting previously defined transcriptomic signatures. CSHS was effectively treated with a MEK inhibitor with almost complete recovery of rickets and partial regression of the phenotype. We identified "core" genes modulated by MEK inhibition potentially serving as surrogate markers of Trametinib action.
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Affiliation(s)
- Diana Carli
- Department of Public Health and PediatricsUniversity of TorinoTorinoItaly,Pediatric Onco‐Hematology, Stem Cell Transplantation and Cell Therapy DivisionRegina Margherita Children's Hospital, Città Della Salute e Della Scienza di TorinoTorinoItaly
| | - Simona Cardaropoli
- Department of Public Health and PediatricsUniversity of TorinoTorinoItaly
| | - Daniele Tessaris
- Pediatric Endocrinology UnitRegina Margherita Children's Hospital, Città Della Salute e Della Scienza di TorinoTorinoItaly
| | - Paola Coppo
- Pediatric Endocrinology UnitRegina Margherita Children's Hospital, Città Della Salute e Della Scienza di TorinoTorinoItaly
| | - Roberta La Selva
- Pediatric Dermatology UnitRegina Margherita Children's Hospital, Città Della Salute e Della Scienza di TorinoTorinoItaly
| | - Claudia Cesario
- Translational Cytogenomics Research UnitBambino Gesù Children's Hospital, IRCCSRomeItaly
| | - Francesca Romana Lepri
- Translational Cytogenomics Research UnitBambino Gesù Children's Hospital, IRCCSRomeItaly
| | | | - Martina Palumbo
- Laboratory of OncogenomicsCandiolo Cancer Institute, FPO‐IRCCSCandioloItaly
| | - Ugo Ramenghi
- Department of Public Health and PediatricsUniversity of TorinoTorinoItaly
| | - Alfredo Brusco
- Department of Medical SciencesUniversity of TorinoTorinoItaly,Medical Genetics UnitCittà della Salute e della Scienza University HospitalTorinoItaly
| | - Enzo Medico
- Laboratory of OncogenomicsCandiolo Cancer Institute, FPO‐IRCCSCandioloItaly,Department of OncologyUniversity of TorinoTorinoItaly
| | - Luisa De Sanctis
- Department of Public Health and PediatricsUniversity of TorinoTorinoItaly,Pediatric Endocrinology UnitRegina Margherita Children's Hospital, Città Della Salute e Della Scienza di TorinoTorinoItaly
| | | | - Alessandro Mussa
- Department of Public Health and PediatricsUniversity of TorinoTorinoItaly,Pediatric Clinical Genetics UnitRegina Margherita Children HospitalTorinoItaly
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13
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Abstract
Fibroblast growth factor-23 (FGF23) controls the homeostasis of both phosphate and vitamin D. Bone-derived FGF23 can suppress the transcription of 1α-hydroxylase (1α(OH)ase) to reduce renal activation of vitamin D (1,25(OH)2D3). FGF23 can also activate the transcription of 24-hydroxylase to enhance the renal degradation process of vitamin D. There is a counter-regulation for FGF23 and vitamin D; 1,25(OH)2D3 induces the skeletal synthesis and the release of FGF23, while FGF23 can suppress the production of 1,25(OH)2D3 by inhibiting 1α(OH)ase synthesis. Genetically ablating FGF23 activities in mice resulted in higher levels of renal 1α(OH)ase, which is also reflected in an increased level of serum 1,25(OH)2D3, while genetically ablating 1α(OH)ase activities in mice reduced the serum levels of FGF23. Similar feedback control of FGF23 and vitamin D is also detected in various human diseases. Further studies are required to understand the subcellular molecular regulation of FGF23 and vitamin D in health and disease.
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Affiliation(s)
- Mohammed S Razzaque
- Department of Pathology, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, USA
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14
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Merz LM, Buerger F, Ziegelasch N, Zenker M, Wieland I, Lipek T, Wallborn T, Terliesner N, Prenzel F, Siekmeyer M, Dittrich K. A Case Report: First Long-Term Treatment With Burosumab in a Patient With Cutaneous-Skeletal Hypophosphatemia Syndrome. Front Endocrinol (Lausanne) 2022; 13:866831. [PMID: 35600592 PMCID: PMC9120998 DOI: 10.3389/fendo.2022.866831] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022] Open
Abstract
Epidermal nevus syndromes encompass a highly heterogeneous group of systemic disorders, characterized by epidermal nevi, and a spectrum of neuromuscular, ocular, and bone abnormalities. Cutaneous-skeletal hypophosphatemia syndrome (CSHS) constitutes a specific sub-entity in which elevated levels of fibroblast growth factor-23 cause hypophosphatemic rickets that are, to date, not amenable to causal therapy. Here, we report the first long-term follow-up of causal treatment with burosumab in a 3-year-old female patient with CSHS. 4 weeks after initiation of burosumab treatment, serum phosphate normalized to age-appropriate levels. Furthermore, long-term follow-up of 42 months revealed significant improvement of linear growth and gross physical functions, including respiratory insufficiency. Radiographic rickets severity as well as subjective bone pain were strongly reduced, and no side effects were observed over the course of treatment. In summary, we, here, report about a successful treatment of hypophosphatemic rickets in CSHS with burosumab over the time course of 42 months. In our patient, burosumab showed convincing efficacy and safety profile, without any loss of effect or increase of dose.
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Affiliation(s)
- Lea Maria Merz
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
- *Correspondence: Lea Maria Merz,
| | - Florian Buerger
- Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Niels Ziegelasch
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Martin Zenker
- Faculty of Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Ilse Wieland
- Faculty of Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Tobias Lipek
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Tillmann Wallborn
- Department of Pediatric Nephrology, St. Georg Hospital, Leipzig, Germany
| | - Nicolas Terliesner
- Department of Pediatric Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Freerk Prenzel
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Manuela Siekmeyer
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
| | - Katalin Dittrich
- Department of Pediatric Nephrology and Pulmonology, University Hospital Leipzig, Leipzig, Germany
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15
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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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16
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Khadora M, Mughal MZ. Burosumab treatment in a child with cutaneous skeletal hypophosphatemia syndrome: A case report. Bone Rep 2021; 15:101138. [PMID: 34660853 PMCID: PMC8502709 DOI: 10.1016/j.bonr.2021.101138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/27/2022] Open
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is a rare disorder caused by somatic mosaicism for the gain of function RAS mutations . Affected patients have segmental epidermal nevi, dysplastic cortical bony lesions, and fibroblast growth factor-23 (FGF23)–mediated hypophosphatemic rickets. Herein, we describe a case of an Emirati girl with CSHS, whose hypophosphatemic rickets and osteomalcic pseudofractures and dysplastic bony lesions failed to recover due to poor adherence to treatment with oral phosphate supplements and alfacalcidol (conventional treatment). Treatment with burosumab, a fully human immunoglobulin G1 monoclonal antibody against FGF23 for 12 months, led to normalization of serum inorganic phosphate and alkaline phosphatase levels, radiographic healing of rickets, partial healing of pseudofractures, improvement in 6-minute walk test, and the physical scale of the Pediatric Quality of Life Inventory. We conclude that burosumab is effective in treatment of CSHS, however results of the ongoing phase 2 trial in adults (NCT02304367) are awaited. Cutaneous skeletal hypophosphatemia syndrome (CSHS) is caused by somatic gain-of-function RAS mutations. It is associated with fibroblast growth factor-23 (FGF23) mediated hypophosphatemic rickets. Burosumab, a monoclonal antibody to FGF23 may have a role in the treatment of CSHS.
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Affiliation(s)
- Manal Khadora
- Department of Pediatric Endocrinology, Latifa Hospital, Oud Metha Road, Al Jaddaf, Dubai, United Arab Emirates
| | - M Zulf Mughal
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester M13 9PL, UK
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17
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Chang CA, Perrier R, Kurek KC, Estrada-Veras J, Lehman A, Yip S, Hendson G, Diamond C, Pinchot JW, Tran JM, Arkin LM, Drolet BA, Napier MP, O'Neill SA, Balci TB, Keppler-Noreuil KM. Novel findings and expansion of phenotype in a mosaic RASopathy caused by somatic KRAS variants. Am J Med Genet A 2021; 185:2829-2845. [PMID: 34056834 DOI: 10.1002/ajmg.a.62356] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 11/11/2022]
Abstract
Mosaic KRAS variants and other RASopathy genes cause oculoectodermal, encephalo-cranio-cutaneous lipomatosis, and Schimmelpenning-Feuerstein-Mims syndromes, and a spectrum of vascular malformations, overgrowth and other associated anomalies, the latter of which are only recently being characterized. We describe eight individuals in total (six unreported cases and two previously reported cases) with somatic KRAS variants and variably associated features. Given the findings of somatic overgrowth (in seven individuals) and vascular or lymphatic malformations (in eight individuals), we suggest mosaic RASopathies (mosaic KRAS variants) be considered in the differential diagnosis for individuals presenting with asymmetric overgrowth and lymphatic or vascular anomalies. We expand the association with embryonal tumors, including the third report of embryonal rhabdomyosarcoma, as well as novel findings of Wilms tumor and nephroblastomatosis in two individuals. Rare or novel findings in our series include the presence of epilepsy, polycystic kidneys, and T-cell deficiency in one individual, and multifocal lytic bone lesions in two individuals. Finally, we describe the first use of targeted therapy with a MEK inhibitor for an individual with a mosaic KRAS variant. The purposes of this report are to expand the phenotypic spectrum of mosaic KRAS-related disorders, and to propose possible mechanisms of pathogenesis, and surveillance of its associated findings.
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Affiliation(s)
- Caitlin A Chang
- Department of Medical Genetics, BC Women and Children's Hospital, Vancouver, British Columbia, Canada
| | - Renee Perrier
- Department of Medical Genetics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kyle C Kurek
- Department of Pathology, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Juvianee Estrada-Veras
- Medical Genetics Service, Walter Reed National Military Medical Center, Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anna Lehman
- Department of Medical Genetics, BC Women and Children's Hospital, Vancouver, British Columbia, Canada
| | - Stephen Yip
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Glenda Hendson
- Department of Pathology, BC Women and Children's Hospital, Vancouver, British Columbia, Canada
| | - Carol Diamond
- Department of Hematology-Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jason W Pinchot
- Department of Interventional Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jennifer M Tran
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lisa M Arkin
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Beth A Drolet
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Melanie P Napier
- Medical Genetics Program of Southwestern Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Sarah A O'Neill
- Medical Genetics Program of Southwestern Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Tugce B Balci
- Medical Genetics Program of Southwestern Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Kim M Keppler-Noreuil
- Division of Genetics and Metabolism, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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18
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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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19
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Abstract
FGF23 is a phosphotropic hormone produced by the bone. FGF23 works by binding to the FGF receptor-Klotho complex. Klotho is expressed in several limited tissues including the kidney and parathyroid glands. This tissue-restricted expression of Klotho is believed to determine the target organs of FGF23. FGF23 reduces serum phosphate by suppressing the expression of type 2a and 2c sodium-phosphate cotransporters in renal proximal tubules. FGF23 also decreases 1,25-dihydroxyvitamin D levels by regulating the expression of vitamin D-metabolizing enzymes, which results in reduced intestinal phosphate absorption. Excessive actions of FGF23 cause several types of hypophosphatemic rickets/osteomalacia characterized by impaired mineralization of bone matrix. In contrast, deficient actions of FGF23 result in hyperphosphatemic tumoral calcinosis with high 1,25-dihydroxyvitamin D levels. These results indicate that FGF23 is a physiological regulator of phosphate and vitamin D metabolism and indispensable for the maintenance of serum phosphate levels.
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20
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Litaiem N, Chabchoub I, Bacha T, Slouma M, Zeglaoui F, Khachemoune A. Rickets in association with skin diseases and conditions: A review with emphasis on screening and prevention. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2020; 36:339-350. [PMID: 32645757 DOI: 10.1111/phpp.12590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/01/2020] [Accepted: 07/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Rickets is a common disease worldwide. In the developed world, its prevalence dramatically decreased but still diagnosed in at-risk populations. The skin plays a critical role in vitamin D synthesis. Therefore, several skin diseases, especially keratinization disorders, could lead to impaired vitamin D metabolism and vitamin D deficient rickets. OBJECTIVE The article aimed to summarize the current knowledge of skin diseases and conditions associated with rickets. METHODS To examine the association between rickets and skin diseases, we performed a systematic review of the literature using PubMed database. The search included studies published from the database inception to August 2019. RESULTS A total number of 75 articles were included. Identified conditions associated with rickets were ichthyosis being a more common skin diseases, alopecia, epidermal and melanocytic nevi, xeroderma pigmentosum, mastocytosis, psoriasis, and atopic dermatitis. Three types of rickets were identified: vitamin D-dependent rickets, hypocalcemic vitamin D-dependent rickets type 2, and hypophosphatemic rickets. Cutaneous skeletal hypophosphatemia syndrome is a newly described and under-recognized condition. It is defined by the association of epidermal or melanocytic nevi, hypophosphatemic rickets, and elevated levels of fibroblast growth factor 23. Rickets in patients with ichthyosis was mainly due to impaired ability of ichthyotic skin to synthesize vitamin D, poor UV penetration of the skin caused by keratinocyte proliferation, and dark phototype. The latter may be considered a risk factor for rickets in patients with ichthyosis. CONCLUSION Despite its rarity, these associations should be properly recognized by dermatologists. Early diagnosis of rickets is important to prevent growth retardation and skeletal deformities.
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Affiliation(s)
- Noureddine Litaiem
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis, Tunisia
| | - Ines Chabchoub
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis, Tunisia
| | - Takwa Bacha
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis, Tunisia
| | - Maroua Slouma
- Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis, Tunisia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
| | - Faten Zeglaoui
- Department of Dermatology, Charles Nicolle Hospital, Tunis, Tunisia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
| | - Amor Khachemoune
- State University of New York Downstate and Veterans Affairs Medical Center, Brooklyn, NY, USA
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21
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Mestach L, Polubothu S, Calder A, Denayer E, Gholam K, Legius E, Levtchenko E, Van Laethem A, Brems H, Kinsler VA, Morren MA. Keratinocytic epidermal nevi associated with localized fibro-osseous lesions without hypophosphatemia. Pediatr Dermatol 2020; 37:890-895. [PMID: 32662096 DOI: 10.1111/pde.14254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 05/07/2020] [Accepted: 05/30/2020] [Indexed: 11/28/2022]
Abstract
Keratinocytic epidermal nevi (KEN) are characterized clinically by permanent hyperkeratosis in the distribution of Blaschko's lines and histologically by hyperplasia of epidermal keratinocytes. KEN with underlying RAS mutations have been associated with hypophosphatemic rickets and dysplastic bone lesions described as congenital cutaneous skeletal hypophosphatemia syndrome. Here, we describe two patients with keratinocytic epidermal nevi, in one associated with a papular nevus spilus, who presented with distinct localized congenital fibro-osseous lesions in the lower leg, diagnosed on both radiology and histology as osteofibrous dysplasia, in the absence of hypophosphatemia or rickets, or significantly raised FGF23 levels but with distinct mosaic HRAS mutations. This expands the spectrum of cutaneous/skeletal mosaic RASopathies and alerts clinicians to the importance of evaluating for bony disease even in the absence of bone profile abnormalities.
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Affiliation(s)
- Lien Mestach
- Department of Dermatology, University Hospitals of Leuven, Leuven, Belgium
| | - Satyamaanasa Polubothu
- Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, UK.,Paediatric Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Alistair Calder
- Paediatric Radiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ellen Denayer
- Center for Human Genetics, University Hospital Leuven, Leuven, Belgium
| | - Karolina Gholam
- Paediatric Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Eric Legius
- Center for Human Genetics, University Hospital Leuven, Leuven, Belgium.,Department of Human Genetics, KU Leuven - University of Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Pediatric Nephrology, University Hospitals of Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - An Van Laethem
- Department of Dermatology, University Hospitals of Leuven, Leuven, Belgium
| | - Hilde Brems
- Center for Human Genetics, University Hospital Leuven, Leuven, Belgium.,Department of Human Genetics, KU Leuven - University of Leuven, Leuven, Belgium
| | - Veronica A Kinsler
- Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, UK.,Paediatric Dermatology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Marie-Anne Morren
- Department of Dermatology, University Hospitals of Leuven, Leuven, Belgium
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Castel P, Rauen KA, McCormick F. The duality of human oncoproteins: drivers of cancer and congenital disorders. Nat Rev Cancer 2020; 20:383-397. [PMID: 32341551 PMCID: PMC7787056 DOI: 10.1038/s41568-020-0256-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2020] [Indexed: 01/29/2023]
Abstract
Human oncoproteins promote transformation of cells into tumours by dysregulating the signalling pathways that are involved in cell growth, proliferation and death. Although oncoproteins were discovered many years ago and have been widely studied in the context of cancer, the recent use of high-throughput sequencing techniques has led to the identification of cancer-associated mutations in other conditions, including many congenital disorders. These syndromes offer an opportunity to study oncoprotein signalling and its biology in the absence of additional driver or passenger mutations, as a result of their monogenic nature. Moreover, their expression in multiple tissue lineages provides insight into the biology of the proto-oncoprotein at the physiological level, in both transformed and unaffected tissues. Given the recent paradigm shift in regard to how oncoproteins promote transformation, we review the fundamentals of genetics, signalling and pathogenesis underlying oncoprotein duality.
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Affiliation(s)
- Pau Castel
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA.
| | - Katherine A Rauen
- MIND Institute, Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Frank McCormick
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
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23
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de Castro LF, Ovejero D, Boyce AM. DIAGNOSIS OF ENDOCRINE DISEASE: Mosaic disorders of FGF23 excess: Fibrous dysplasia/McCune-Albright syndrome and cutaneous skeletal hypophosphatemia syndrome. Eur J Endocrinol 2020; 182:R83-R99. [PMID: 32069220 PMCID: PMC7104564 DOI: 10.1530/eje-19-0969] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
Fibrous dysplasia/McCune-Albright Syndrome (FD/MAS), arising from gain-of-function mutations in Gαs, and cutaneous skeletal hypophosphatemia syndrome (CSHS), arising from gain-of-function mutations in the Ras/MAPK pathway, are strikingly complex, mosaic diseases with overlapping phenotypes. Both disorders are defined by mosaic skin and bone involvement, and both are complicated by increased FGF23 production. These similarities have frequently led to mis-diagnoses, primarily in patients with CSHS who are often assumed to have FD/MAS. The intriguing similarities in skeletal involvement in these genetically distinct disorders have led to novel insights into FGF23 physiology, making an understanding of FD/MAS and CSHS relevant to both clinicians and researchers interested in bone and endocrine disorders. This review will give an overview of FD/MAS and CSHS, focusing on the roles of mosaicism and FGF23 in the pathogenesis and clinical presentation of these disorders.
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Affiliation(s)
- Luis F de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Diana Ovejero
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
- Musculoskeletal Research Unit, Hospital del Mar Institute of Medical Investigation (IMIM), Barcelona, Spain
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
Genodermatoses are inherited disorders presenting with cutaneous manifestations with or without the involvement of other systems. The majority of these disorders, particularly in cases that present with a cutaneous patterning, may be explained in the context of genetic mosaicism. Despite the barriers to the genetic analysis of mosaic disorders, next-generation sequencing has led to a substantial progress in understanding their pathogenesis, which has significant implications for the clinical management and genetic counseling. Advances in paired and deep sequencing technologies in particular have made the study of mosaic disorders more feasible. In this review, we provide an overview of genetic mosaicism as well as mosaic cutaneous disorders and the techniques required to study them.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Genetics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Young Lim
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Genetics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Keith A Choate
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Genetics, Yale School of Medicine, New Haven, Connecticut, USA.
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25
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Florenzano P, Cipriani C, Roszko KL, Fukumoto S, Collins MT, Minisola S, Pepe J. Approach to patients with hypophosphataemia. Lancet Diabetes Endocrinol 2020; 8:163-174. [PMID: 31924563 DOI: 10.1016/s2213-8587(19)30426-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
Phosphate metabolism is an evolving area of basic and clinical research. In the past 15 years, knowledge on disturbances of phosphate homoeostasis has expanded, as has the discovery of new targeted therapies. Hypophosphataemia might be the biochemical finding in several diseases, and its clinical evaluation should initially focus on the assessment of pathophysiological mechanisms leading to low serum phosphate concentrations. Clinical consequences of hypophosphataemia can involve multiple organ systems and vary depending on several factors, the most important being the underlying disorder. This Review focuses on the approach to patients with hypophosphataemia and how underlying pathophysiological mechanisms should be understood in the evaluation of differential diagnosis. We define an algorithm for the assessment of hypophosphataemia and review the most up-to-date literature on specific therapies. Continuous research in this area will result in a better understanding and management of patients with hypophosphataemia.
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Affiliation(s)
- Pablo Florenzano
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy.
| | - Kelly L Roszko
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Michael T Collins
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
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26
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Abstract
PURPOSE OF REVIEW To review the differential diagnosis of low bone mineral density (BMD). RECENT FINDINGS Osteoporosis is the most common cause of low BMD in adults; however, non-osteoporotic causes of low BMD should be considered in the differential diagnosis of patients with low BMD. Mild osteogenesis imperfecta, osteomalacia, and mineral and bone disorder of chronic kidney disease as well as several other rare diseases can be characterized by low BMD. This review summarizes the differential diagnosis of low BMD. It is important to differentiate osteoporosis from other causes of low BMD since treatment regimens can vary tremendously between these different disease processes. In fact, some treatments for osteoporosis could worsen or exacerbate the mineral abnormalities in other causes of low BMD.
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Affiliation(s)
- Smita Jha
- Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA.
- Section on Congenital Disorders, National Institutes of Health Clinical Center, 10 Center Drive, Bldg. 10-CRC, Room 1-5362, MSC-1504, Bethesda, MD, 20892, USA.
| | - Marquis Chapman
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Kelly Roszko
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 20892, USA
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27
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Ozeki M, Aoki Y, Nozawa A, Yasue S, Endo S, Hori Y, Matsuoka K, Niihori T, Funayama R, Shirota M, Nakayama K, Fukao T. Detection of NRAS mutation in cell-free DNA biological fluids from patients with kaposiform lymphangiomatosis. Orphanet J Rare Dis 2019; 14:215. [PMID: 31511039 PMCID: PMC6737666 DOI: 10.1186/s13023-019-1191-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022] Open
Abstract
Background Kaposiform lymphangiomatosis (KLA) has recently been distinguished as a novel subtype of generalized lymphatic anomaly (GLA) with foci of spindle endothelial cells. All cases of KLA involve multiple organs and have an unfavorable prognosis. However, the molecular pathogenesis is unknown, and there are no useful biomarkers. In the present study, we performed genetic analysis to elucidate the cause of this disease and detect biomarkers for it. Methods We performed whole-exome sequencing of DNA samples from leukocytes and a biopsy specimen and analyzed cell-free DNA (cfDNA) from plasma and pleural effusion of patients to identify the NRAS c.182A > G (p.Q61R) mutation using the droplet digital polymerase chain reaction (ddPCR). Results All KLA patients (patients 1–5) had invasive and aggressive features (hemorrhagic pleural effusions, coagulation disorder, and thrombocytopenia) and characteristic findings of KLA in their pathological examinations. In whole exome sequencing for patient 1, c.182A > G missense variant (p.Q61R) in NRAS was identified in fresh frozen samples of a mass on the left chest wall at a frequency of 5% of total alleles but not in his blood leukocytes. Furthermore, the same mutation was detected in cfDNA isolated from plasma and pleural effusion by using ddPCR. ddPCR analysis of plasma/pleural effusion samples from an additional four KLA patients showed that the same mutation was detected in isolated cfDNA in three of the four, as well as in a tissue sample from one of the three plasma/effusion-positive patients that had been obtained to confirm the mutation. Conclusion These results provide the first evidence that NRAS oncogenic variant was identified in DNA samples from KLA patients from not only two affected lesions but also plasma and pleural effusion.
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Affiliation(s)
- Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu, 501-1194, Japan.
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, 980-8574, Japan.
| | - Akifumi Nozawa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Yumiko Hori
- Department of Pathology, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, Saitama, 343-8555, Japan
| | - Tetsuya Niihori
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, 980-8574, Japan
| | - Ryo Funayama
- Division of Cell Proliferation, United Centers for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Matsuyuki Shirota
- Division of Interdisciplinary Medical Science, United Centers for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Keiko Nakayama
- Division of Cell Proliferation, United Centers for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Yanagido 1-1, Gifu, 501-1194, Japan
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28
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Abstract
The discoveries of new genes underlying genetic skin diseases have occurred at a rapid pace, supported by advances in DNA sequencing technologies. These discoveries have translated to an improved understanding of disease mechanisms at a molecular level and identified new therapeutic options based on molecular targets. This article highlights just a few of these recent discoveries for a diverse group of skin diseases, including tuberous sclerosis complex, ichthyoses, overgrowth syndromes, interferonopathies, and basal cell nevus syndrome, and how this has translated into novel targeted therapies and improved patient care.
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29
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Posey JE, O'Donnell-Luria AH, Chong JX, Harel T, Jhangiani SN, Coban Akdemir ZH, Buyske S, Pehlivan D, Carvalho CMB, Baxter S, Sobreira N, Liu P, Wu N, Rosenfeld JA, Kumar S, Avramopoulos D, White JJ, Doheny KF, Witmer PD, Boehm C, Sutton VR, Muzny DM, Boerwinkle E, Günel M, Nickerson DA, Mane S, MacArthur DG, Gibbs RA, Hamosh A, Lifton RP, Matise TC, Rehm HL, Gerstein M, Bamshad MJ, Valle D, Lupski JR. Insights into genetics, human biology and disease gleaned from family based genomic studies. Genet Med 2019; 21:798-812. [PMID: 30655598 PMCID: PMC6691975 DOI: 10.1038/s41436-018-0408-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/05/2018] [Indexed: 12/16/2022] Open
Abstract
Identifying genes and variants contributing to rare disease phenotypes and Mendelian conditions informs biology and medicine, yet potential phenotypic consequences for variation of >75% of the ~20,000 annotated genes in the human genome are lacking. Technical advances to assess rare variation genome-wide, particularly exome sequencing (ES), enabled establishment in the United States of the National Institutes of Health (NIH)-supported Centers for Mendelian Genomics (CMGs) and have facilitated collaborative studies resulting in novel "disease gene" discoveries. Pedigree-based genomic studies and rare variant analyses in families with suspected Mendelian conditions have led to the elucidation of hundreds of novel disease genes and highlighted the impact of de novo mutational events, somatic variation underlying nononcologic traits, incompletely penetrant alleles, phenotypes with high locus heterogeneity, and multilocus pathogenic variation. Herein, we highlight CMG collaborative discoveries that have contributed to understanding both rare and common diseases and discuss opportunities for future discovery in single-locus Mendelian disorder genomics. Phenotypic annotation of all human genes; development of bioinformatic tools and analytic methods; exploration of non-Mendelian modes of inheritance including reduced penetrance, multilocus variation, and oligogenic inheritance; construction of allelic series at a locus; enhanced data sharing worldwide; and integration with clinical genomics are explored. Realizing the full contribution of rare disease research to functional annotation of the human genome, and further illuminating human biology and health, will lay the foundation for the Precision Medicine Initiative.
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Affiliation(s)
- Jennifer E Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
| | - Anne H O'Donnell-Luria
- Analytic and Translational Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Jessica X Chong
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Tamar Harel
- Department of Genetic and Metabolic Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shalini N Jhangiani
- The Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Zeynep H Coban Akdemir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Steven Buyske
- Department of Genetics, Rutgers University, Piscataway, NJ, USA
- Department of Statistics, Rutgers University, Piscataway, NJ, USA
| | - Davut Pehlivan
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Claudia M B Carvalho
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Samantha Baxter
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Nara Sobreira
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pengfei Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Baylor Genetics Laboratory, Houston, TX, USA
| | - Nan Wu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jill A Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Sushant Kumar
- Computational Biology and Bioinformatics Program, Yale University Medical School, New Haven, CT, USA
| | - Dimitri Avramopoulos
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Janson J White
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kimberly F Doheny
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Corinne Boehm
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Donna M Muzny
- The Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Eric Boerwinkle
- The Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
- Human Genetics Center, University of Texas Health Science Center, Houston, TX, USA
| | - Murat Günel
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | | | - Shrikant Mane
- Yale Center for Genome Analysis, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Daniel G MacArthur
- Analytic and Translational Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Richard A Gibbs
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- The Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Ada Hamosh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Richard P Lifton
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Tara C Matise
- Department of Genetics, Rutgers University, Piscataway, NJ, USA
| | - Heidi L Rehm
- Analytic and Translational Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mark Gerstein
- Computational Biology and Bioinformatics Program, Yale University Medical School, New Haven, CT, USA
| | - Michael J Bamshad
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - David Valle
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - James R Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
- The Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA.
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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Bustelo XR, Crespo P, Fernández-Pisonero I, Rodríguez-Fdez S. RAS GTPase-dependent pathways in developmental diseases: old guys, new lads, and current challenges. Curr Opin Cell Biol 2018; 55:42-51. [PMID: 30007125 PMCID: PMC7615762 DOI: 10.1016/j.ceb.2018.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 05/14/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
Deregulated RAS signaling is associated with increasing numbers of congenital diseases usually referred to as RASopathies. The spectrum of genes and mutant alleles causing these diseases has been significantly expanded in recent years. This progress has triggered new challenges, including the origin and subsequent selection of the mutations driving these diseases, the specific pathobiological programs triggered by those mutations, the type of correlations that exist between the genotype and the clinical features of patients, and the ancillary genetic factors that influence the severity of the disease in patients. These issues also directly impinge on the feasibility of using RAS pathway drugs to treat RASopathy patients. Here, we will review the main developments and pending challenges in this research topic.
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Affiliation(s)
- Xosé R Bustelo
- Centro de Investigación del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain; Instituto de Biología Molecular y Celular del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain.
| | - Piero Crespo
- CIBERONC, CSIC-University of Cantabria, 39011 Santander, Spain; Instituto de Biomedicina y Biotecnología de Cantabria, CSIC-University of Cantabria, 39011 Santander, Spain
| | - Isabel Fernández-Pisonero
- Centro de Investigación del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain; Instituto de Biología Molecular y Celular del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain
| | - Sonia Rodríguez-Fdez
- Centro de Investigación del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain; Instituto de Biología Molecular y Celular del Cáncer, Consejo Superior de Investigaciones Científicas (CSIC)-University of Salamanca, 37007 Salamanca, Spain
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31
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Garcias-Ladaria J, Cuadrado Rosón M, Pascual-López M. Nevus epidérmicos y síndromes relacionados. Parte 2: Nevus derivados de estructuras anexiales. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:687-698. [DOI: 10.1016/j.ad.2018.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/16/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023] Open
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32
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Garcias-Ladaria J, Cuadrado Rosón M, Pascual-López M. Epidermal Nevi and Related Syndromes —Part 2: Nevi Derived from Adnexal Structures. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Rickets is a bone disease associated with abnormal serum calcium and phosphate levels. The clinical presentation is heterogeneous and depends on the age of onset and pathogenesis but includes bowing deformities of the legs, short stature and widening of joints. The disorder can be caused by nutritional deficiencies or genetic defects. Mutations in genes encoding proteins involved in vitamin D metabolism or action, fibroblast growth factor 23 (FGF23) production or degradation, renal phosphate handling or bone mineralization have been identified. The prevalence of nutritional rickets has substantially declined compared with the prevalence 200 years ago, but the condition has been re-emerging even in some well-resourced countries; prematurely born infants or breastfed infants who have dark skin types are particularly at risk. Diagnosis is usually established by medical history, physical examination, biochemical tests and radiography. Prevention is possible only for nutritional rickets and includes supplementation or food fortification with calcium and vitamin D either alone or in combination with sunlight exposure. Treatment of typical nutritional rickets includes calcium and/or vitamin D supplementation, although instances infrequently occur in which phosphate repletion may be necessary. Management of heritable types of rickets associated with defects in vitamin D metabolism or activation involves the administration of vitamin D metabolites. Oral phosphate supplementation is usually indicated for FGF23-independent phosphopenic rickets, whereas the conventional treatment of FGF23-dependent types of rickets includes a combination of phosphate and activated vitamin D; an anti-FGF23 antibody has shown promising results and is under further study.
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Minisola S, Peacock M, Fukumoto S, Cipriani C, Pepe J, Tella SH, Collins MT. Tumour-induced osteomalacia. Nat Rev Dis Primers 2017; 3:17044. [PMID: 28703220 DOI: 10.1038/nrdp.2017.44] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Tumour-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare paraneoplastic disorder caused by tumours that secrete fibroblast growth factor 23 (FGF23). Owing to the role of FGF23 in renal phosphate handling and vitamin D synthesis, TIO is characterized by decreased renal tubular reabsorption of phosphate, by hypophosphataemia and by low levels of active vitamin D. Chronic hypophosphataemia ultimately results in osteomalacia (that is, inadequate bone mineralization). The diagnosis of TIO is usually suspected when serum phosphate levels are chronically low in the setting of bone pain, fragility fractures and muscle weakness. Locating the offending tumour can be very difficult, as the tumour is often very small and can be anywhere in the body. Surgical removal of the tumour is the only definitive treatment. When the tumour cannot be located or when complete resection is not possible, medical treatment with phosphate salts or active vitamin D is necessary. One of the most promising emerging treatments for unresectable tumours that cause TIO is the anti-FGF23 monoclonal antibody KRN23. The recent identification of a fusion of fibronectin and fibroblast growth factor receptor 1 (FGFR1) as a molecular driver in some tumours not only sheds light on the pathophysiology of TIO but also opens the door to a better understanding of the transcription, translocation, post-translational modification and secretion of FGF23, as well as suggesting approaches to targeted therapy. Further study will reveal if the FGFR1 pathway is also involved in tumours that do not harbour the translocation.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Munro Peacock
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Seijii Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Sri Harsha Tella
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA.,Endocrinology and Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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Ovejero D, Lim YH, Boyce AM, Gafni RI, McCarthy E, Nguyen TA, Eichenfield LF, DeKlotz CMC, Guthrie LC, Tosi LL, Thornton PS, Choate KA, Collins MT. Cutaneous skeletal hypophosphatemia syndrome: clinical spectrum, natural history, and treatment. Osteoporos Int 2016; 27:3615-3626. [PMID: 27497815 PMCID: PMC6908308 DOI: 10.1007/s00198-016-3702-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 07/06/2016] [Indexed: 12/01/2022]
Abstract
UNLABELLED Cutaneous skeletal hypophosphatemia syndrome (CSHS), caused by somatic RAS mutations, features excess fibroblast growth factor-23 (FGF23) and skeletal dysplasia. Records from 56 individuals were reviewed and demonstrated fractures, scoliosis, and non-congenital hypophosphatemia that in some cases were resolved. Phosphate and calcitriol, but not skin lesion removal, were effective at controlling hypophosphatemia. No skeletal malignancies were found. PURPOSE CSHS is a disorder defined by the association of epidermal and/or melanocytic nevi, a mosaic skeletal dysplasia, and an FGF23-mediated hypophosphatemia. To date, somatic RAS mutations have been identified in all patients whose affected tissue has undergone DNA sequencing. However, the clinical spectrum and treatment are poorly defined in CSHS. The purpose of this study is to determine the spectrum of the phenotype, natural history of the disease, and response to treatment of hypophosphatemia. METHODS Five CSHS subjects underwent prospective data collection at clinical research centers. A review of the literature identified 45 reports that included a total of 51 additional patients, in whom the findings were compatible with CSHS. Data on nevi subtypes, bone histology, mineral and skeletal disorders, abnormalities in other tissues, and response to treatment of hypophosphatemia were analyzed. RESULTS Fractures, limb deformities, and scoliosis affected most CSHS subjects. Hypophosphatemia was not present at birth. Histology revealed severe osteomalacia but no other abnormalities. Skeletal dysplasia was reported in all anatomical compartments, though less frequently in the spine; there was no clear correlation between the location of nevi and the skeletal lesions. Phosphate and calcitriol supplementation was the most effective therapy for rickets. Convincing data that nevi removal improved blood phosphate levels was lacking. An age-dependent improvement in mineral abnormalities was observed. A spectrum of extra-osseous/extra-cutaneous manifestations that included both benign and malignant neoplasms was present in many subjects, though osteosarcoma remains unreported. CONCLUSION An understanding of the spectrum, natural history, and efficacy of treatment of hypophosphatemia in CSHS may improve the care of these patients.
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Affiliation(s)
- D Ovejero
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National ADDRESSES, references BRACKETS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Y H Lim
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - A M Boyce
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National ADDRESSES, references BRACKETS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA
| | - R I Gafni
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National ADDRESSES, references BRACKETS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA
| | - E McCarthy
- Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA
| | - T A Nguyen
- Albert Einstein College of Medicine, Bronx, NY, USA
- Departments of Dermatology and Pediatrics, San Diego and Rady Children's Hospital, University of California, San Diego, CA, USA
| | - L F Eichenfield
- Departments of Dermatology and Pediatrics, San Diego and Rady Children's Hospital, University of California, San Diego, CA, USA
| | - C M C DeKlotz
- Division Dermatology, Department of Medicine and Department of Pediatrics, Georgetown University Medical Center, Washington, DC, USA
| | - L C Guthrie
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National ADDRESSES, references BRACKETS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA
| | - L L Tosi
- Bone Health Program, Division of Orthopaedics and Sports Medicine, Children's National Health System, Washington, DC, USA
| | - P S Thornton
- Department of Endocrinology and Diabetes, Cook Children Medical Center, Fort Worth, TX, USA
| | - K A Choate
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - M T Collins
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National ADDRESSES, references BRACKETS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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