1
|
Memon SS, Patel MA, Lila A, Jadhav S, Sarathi V, Karlekar M, Barnabas R, Patil V, Kulkarni S, Rathod K, Shah N, Bandgar T. Long-Term Follow-Up Data of Tumor-Induced Osteomalacia Managed with Surgery and/or Radiofrequency Ablation from a Single Center. Calcif Tissue Int 2024; 115:242-250. [PMID: 38922426 DOI: 10.1007/s00223-024-01249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/17/2024] [Indexed: 06/27/2024]
Abstract
Data on radiofrequency ablation (RFA) in tumor-induced osteomalacia (TIO) are restricted to case reports (~ 11 patients) and long-term follow-up data are further scarce. We describe our experience on managing TIO from a tertiary care center in India. Retrospective study of patients with localized TIO was performed and clinical, biochemical, treatment and follow-up details were retrieved. Normalization of serum phosphorus in absence of phosphate supplementation was defined as remission. Of 33 patients (23 males), 24 patients underwent surgery as first-line treatment, and early remission, delayed remission (> 1 month for phosphorus normalization) and persistence were observed 12, 3, and 9 patients at a median follow-up of 5 (4-9) years. The gender, age, tumor size, location of tumors and FGF23 levels were not statistically different in patients who were in remission after surgery versus those with persistent disease. Second/third line treatment included conventional medical treatment and/or repeat surgery (n = 3), radiotherapy (n = 3), peptide receptor radionuclide therapy (n = 1), RFA (n = 1). Two patients had transient worsening (weeks) of weakness post-surgery. 10 patients underwent RFA (first-line n = 9); at the last follow-up 5 (4-10) years, 7 are in remission. Two of three persistent disease patients had large tumors (5.6 and 3.6 cm). There were no RFA-related complications except local ulcer in one. Although persistent disease was present in a few patients in both arms, there was no recurrence in either RFA or surgical cohort. RFA provide durable response similar to surgery, persistence requires multi-modality treatment.
Collapse
Affiliation(s)
- Saba Samad Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Mohd Asif Patel
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Anurag Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Swati Jadhav
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, 560066, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, 560066, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Rohit Barnabas
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Suyash Kulkarni
- Department of Radiodiagnosis, Tata Memorial Centre, Parel, Mumbai, Maharashtra, 400012, India
| | - Krantikumar Rathod
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra, 400012, India.
| |
Collapse
|
2
|
Gu J, Ge C, Joshi G, Most M, Tai R. Phosphaturic mesenchymal tumor: two cases highlighting differences in clinical and radiologic presentation. Skeletal Radiol 2024; 53:995-1002. [PMID: 37792035 DOI: 10.1007/s00256-023-04462-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023]
Abstract
Phosphaturic mesenchymal tumors are rare, usually benign neoplasms that occur in the soft tissue or bone and are the cause of nearly all cases of tumor-induced osteomalacia. Tumor-induced osteomalacia due to phosphaturic mesenchymal tumor is a challenging diagnosis to make-patients present with variable clinical and radiologic findings and the culprit neoplasm is often small and can occur anywhere head to toe. We present two cases of phosphaturic mesenchymal tumor in the scapular body and plantar foot. In both cases, the patient endured years of debilitating symptoms before a tissue diagnosis was eventually reached. Descriptions of clinical presentation, laboratory workup, surgical resection, and imaging characteristics, with a focus on CT, MRI, and functional imaging, are provided to assist with the diagnosis and management of this rare entity. A brief review of current literature and discussion of the differential diagnoses of phosphaturic mesenchymal tumor is also provided.
Collapse
Affiliation(s)
- Joey Gu
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA.
| | - Connie Ge
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ganesh Joshi
- University of Massachusetts Chan Medical School, Worcester, MA, USA
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Mathew Most
- University of Massachusetts Chan Medical School, Worcester, MA, USA
- Division of Orthopedic Oncology, Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ryan Tai
- University of Massachusetts Chan Medical School, Worcester, MA, USA
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
3
|
Jadhav SS, Shah R, Patil V. Tumor-induced osteomalacia: An overview. Best Pract Res Clin Endocrinol Metab 2024; 38:101834. [PMID: 37935612 DOI: 10.1016/j.beem.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Tumor-induced osteomalacia (TIO) is rare paraneoplastic syndrome of hypophosphatemic osteomalacia, caused by phosphaturic factors secreted by small mesenchymal origin tumors with distinct pathological features, called 'phosphaturic mesenchymal tumors'. FGF23 is the most well-characterized of the phosphaturic factors. Tumors are often small and located anywhere in the body from head to toe, which makes the localisation challenging. Functional imaging by somatostatin receptor-based PET imaging is the first line investigation, which should be followed with CT or MRI based anatomical imaging. Once localised, complete surgical excision is the treatment of choice, which brings dramatic resolution of symptoms. Medical management in the form of phosphate and active vitamin D supplements is given as a bridge to surgical management or in inoperable/non-localised patients. This review provides an overview of the epidemiology, pathophysiology, pathology, clinical features, diagnosis, and treatment of TIO, including the recent advances and directions for future research in this field.
Collapse
Affiliation(s)
| | - Ravikumar Shah
- Harikrushna Hormone Clinic, 304, 3rd Floor, Ashwamegh, Opposite Vyamshala, Anand, Gujarat, India.
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, India.
| |
Collapse
|
4
|
Liu Y, He H, Zhang C, Zeng H, Tong X, Liu Q. Phosphaturic Mesenchymal Tumors: Rethinking the Clinical Diagnosis and Surgical Treatment. J Clin Med 2022; 12:jcm12010252. [PMID: 36615052 PMCID: PMC9821698 DOI: 10.3390/jcm12010252] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The diagnosis of phosphaturic mesenchymal tumors (PMT) is easily delayed clinically, and their surgical treatment is unstandardized. This study aimed to evaluate our experience in the diagnosis and treatment of PMT and provide a research basis for the accurate and standardized treatment of PMT. MATERIALS AND METHODS Twelve patients diagnosed with PMT in our department and who underwent surgical treatment were included in this study. Preoperative demographic and clinical information were recorded. CT, MRI, and technetium-99m (Tc99m)-octreotide PET/CT imaging techniques were used to evaluate the general conditions and lesion boundaries of the tumors. Surgical treatment was performed using radical resection and microwave ablation-assisted extended curettage according to the lesion location and size. Patients were strictly followed up with and evaluated for oncological prognosis, radiological results, bone healing, serum ion levels, limb function, and pain level; the occurrence of complications was also recorded. RESULTS Three patients underwent radical resection, and nine underwent microwave ablation-assisted extended curettage. The average duration of symptoms in this group was 1.5 years (9-35 months) before diagnosis. Serum phosphate and AKP levels returned to normal one and two weeks postoperatively, respectively. There was no apparent specificity in the pathological findings; however, the immunohistochemistry of FGF-23 was positive, and the original fracture sites were effectively healed during the follow-up. The limb function and pain scores were significantly improved. The MSTS score increased from 15.3 to 29.0, and the VAS score decreased from 5.3 to 0.4. All patients recovered, and 90% resumed their original jobs. CONCLUSIONS Accurate diagnosis and standardized surgical treatment are crucial to achieving a clinical cure for PMT. Combining clinical manifestations, biochemical examinations, imaging characteristics, and pathological findings is an effective way to diagnose PMT accurately. Radical resection and microwave ablation-assisted extended curettage are reliable surgical treatment methods for PMT.
Collapse
Affiliation(s)
- Yupeng Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Hongbo He
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Can Zhang
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Hao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
| | - Xiaopeng Tong
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
| | - Qing Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
- Correspondence: ; Tel.: +86-1820-742-5349
| |
Collapse
|
5
|
Garg B, Mehta N, Goyal A, Khadgawat R. Oncogenic osteomalacia due to phosphaturic mesenchymal tumour in the upper thoracic spine. BMJ Case Rep 2020; 13:e238209. [PMID: 33328210 PMCID: PMC7745698 DOI: 10.1136/bcr-2020-238209] [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] [Accepted: 11/23/2020] [Indexed: 11/04/2022] Open
Abstract
Oncogenic osteomalacia (OO) is an uncommon paraneoplastic syndrome occurring due to the presence of a tumour that oversecretes fibroblast growth factor-23, which impairs renal phosphate handling. In most cases, the tumour is a morphologically distinct entity called 'phosphaturic mesenchymal tumour' (PMT). Spinal tumours causing OO are exceedingly rare. A 55-year-old man presented with multiple bone pain and proximal muscle weakness in the lower limbs. The constellation of biochemical findings (hypophosphataemia, normocalcaemia, increased alkaline phosphatase, low-normal serum vitamin D and hyperphosphaturia) with radiographical rarefaction of the skeleton and pseudofractures led us to consider OO as a possibility. Functional imaging (68Ga DOTA-NOC positron emission tomography/CT scan) localised the tumour to the D2 vertebra. Complete surgical resection led to resolution of symptoms, improved ambulatory status, normalisation of biochemical parameters and healing of pseudofractures. PMT should be considered in the differential diagnosis of hypophosphataemic osteomalacia with hyperphosphaturia. Tumour localisation with functional imaging and complete surgical resection produces satisfactory outcome.
Collapse
Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Archit Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|