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Pannu CD, Baxter D, Anwar H. Spinal phosphaturic mesenchymal tumors: a rare etiology causing tumor-induced osteomalacia-a review of experience at a UK tertiary referral center and literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1911-1920. [PMID: 37964171 DOI: 10.1007/s00586-023-08031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE This article aims to provide a comprehensive review of the management challenges associated with Spinal Phosphaturic Mesenchymal tumors (PMTs) and evaluates the surgical management outcomes for this rare entity linked to Tumor-induced osteolysis. The primary objective of this study is to enhance the familiarity of treating physicians with the clinical features, diagnosis, and treatment options for Spinal PMTs. METHODS A retrospective analysis was conducted, reviewing electronic medical records of patients diagnosed with spinal PMTs at our hospital between January 2019 and December 2022. The data collected included demographic information, clinical presentation, radiological findings, surgical details, and follow-up outcomes. RESULTS A total of three cases of Spinal PMTs causing Tumor-induced osteomalacia were identified. The diagnosis of Spinal PMTs presented challenges, with incidental detection often occurring during routine imaging. Surgical management was undertaken, resulting in successful symptom resolution and normalization of phosphate levels. The application of 68 Ga-DOTA-TATE PET/CT scans facilitated tumor localization, aiding in surgical planning. Spinal PMTs demonstrated a favorable response to surgical intervention. CONCLUSION Spinal PMTs play a significant role in Tumor-induced osteolysis, warranting timely and accurate diagnosis. Although diagnosing Spinal PMTs presents challenges, surgical management has proven to yield favorable outcomes, effectively alleviating symptoms and restoring phosphate levels. A multidisciplinary approach and continued vigilance are essential in ensuring early diagnosis, effective treatment, and long-term monitoring for patients affected by spinal PMTs.
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Affiliation(s)
- Chaitanya Dev Pannu
- Royal National Orthopedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP, UK.
| | - David Baxter
- Royal National Orthopedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP, UK
| | - Hanny Anwar
- Royal National Orthopedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP, UK
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Jadhav SS, Shah R, Patil V. Tumor-induced osteomalacia: An overview. Best Pract Res Clin Endocrinol Metab 2024; 38:101834. [PMID: 37935612 DOI: 10.1016/j.beem.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Tumor-induced osteomalacia (TIO) is rare paraneoplastic syndrome of hypophosphatemic osteomalacia, caused by phosphaturic factors secreted by small mesenchymal origin tumors with distinct pathological features, called 'phosphaturic mesenchymal tumors'. FGF23 is the most well-characterized of the phosphaturic factors. Tumors are often small and located anywhere in the body from head to toe, which makes the localisation challenging. Functional imaging by somatostatin receptor-based PET imaging is the first line investigation, which should be followed with CT or MRI based anatomical imaging. Once localised, complete surgical excision is the treatment of choice, which brings dramatic resolution of symptoms. Medical management in the form of phosphate and active vitamin D supplements is given as a bridge to surgical management or in inoperable/non-localised patients. This review provides an overview of the epidemiology, pathophysiology, pathology, clinical features, diagnosis, and treatment of TIO, including the recent advances and directions for future research in this field.
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Affiliation(s)
| | - Ravikumar Shah
- Harikrushna Hormone Clinic, 304, 3rd Floor, Ashwamegh, Opposite Vyamshala, Anand, Gujarat, India.
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, India.
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Hacisahinogullari H, Tekin S, Tanrikulu S, Saribeyliler G, Yalin GY, Bilgic B, Isik EG, Salduz A, Tuncer S, Gul N, Uzum AK, Aral F, Tanakol R, Selcukbiricik OS. Diagnosis and management of tumor-induced osteomalacia: a single center experience. Endocrine 2023; 82:427-434. [PMID: 37480497 DOI: 10.1007/s12020-023-03450-3] [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: 04/17/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE The aim of this study is to review the clinical and laboratory characteristics, diagnostic and treatment modalities of tumor-induced osteomalacia (TIO) cases managed in a single center. MATERIAL METHODS Demographic and clinical features, biochemical findings, diagnostic procedures, treatment modalities, and outcomes of nine patients who had the diagnosis of TIO were reviewed retrospectively. RESULTS Mean age of the study group (F/M: 4/5) was 45.8 ± 10.8 years, and mean time from the onset of symptoms to diagnosis was 4.7 ± 2.8 years. The clinical manifestations were muscle weakness and difficulty in walking (8/9), hip pain (3/9), multiple fractures (2/9), stress fracture (2/9). Mean plasma phosphorus concentration was 1.28 ± 0.4 mg/dl at presentation. We performed radionuclide imaging modalities (18F-FDG PET/CT, Ga68-DOTATATE PET/CT, octreotide scintigraphy) in seven of nine patients, and tumor was detected in all. Lower extremity (n = 6; %67), head region (n = 2; %22) and thorax (n = 1; %11) were the tumor locations of our cases. Eight patients underwent surgery and remission was achieved postoperatively in all of the operated patients and plasma phosphorus level normalized in 4 ± 2 days. Pathological examination revealed mesenchymal tumors with different subtypes. Recurrence occurred in three patients at 13 ± 10.5 months after the first surgery. Two patients were reoperated and radiotherapy was also performed in one of them. CONCLUSION Hypophosphatemia necessitates careful evaluation for the etiology. TIO is one of the important causes of adult-onset hypophosphatemic osteomalacia. Diagnosis of TIO is essential because the laboratory and clinical findings resolve after appropriate treatment.
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Affiliation(s)
- Hulya Hacisahinogullari
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey.
| | - Sakin Tekin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Zonguldak Bulent Ecevit University, Faculty of Medicine, Zonguldak, Turkey
| | - Seher Tanrikulu
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Goktug Saribeyliler
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Gulsah Yenidunya Yalin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Bilge Bilgic
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Emine Goknur Isik
- Department of Nuclear Medicine, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ahmet Salduz
- Department of Orthopedics and Traumatology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Samuray Tuncer
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Nurdan Gul
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ayse Kubat Uzum
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ferihan Aral
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Refik Tanakol
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ozlem Soyluk Selcukbiricik
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
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Li B, Duan L, Li X, Shi J, Li H, Liu H, Cheng X, Wu X, Gao Y. Diagnostic accuracy of 99mTc-HYNIC-TOC SPECT/CT for detecting osteomalacia-associated tumors. Front Oncol 2023; 13:1228575. [PMID: 37554164 PMCID: PMC10405922 DOI: 10.3389/fonc.2023.1228575] [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: 05/25/2023] [Accepted: 07/06/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES Tumor-induced osteomalacia (TIO) is a rare acquired paraneoplastic disorder characterized by hypophosphatemia resulting from tumor-secreted fibroblast growth factor-23 (FGF23). Surgical resection of the culprit TIO is the first choice of treatment. However, TIO is difficult to detect with conventional diagnostic tools due to its small size and variable location in the body. Somatostatin receptor scintigraphy (SSR) has recently emerged as a functional molecular imaging choice for TIO detection and localization. This research was undertaken to evaluate the efficacy of 99mTc-labeled hydrazinonicotinyl-Tyr3-octreotide (99mTc-HYNIC-TOC) SPECT/CT in detecting TIO. METHODS 99mTc-HYNIC-TOC SPECT/CT and the available clinical data of 25 patients with suspected TIO were analyzed retrospectively. The 99mTc-HYNIC-TOC SPECT/CT findings were compared with the post-surgical pathology diagnosis and clinical follow-up results. RESULTS Using 99mTc-HYNIC-TOC SPECT/CT, suspicious tumors were found in 18 of the 25 patients, and 15 of them underwent surgical resection. The post-operative pathology confirmed a TIO in those 13 patients whose symptoms and biochemical anomalies gradually resolved after the surgery. The remaining five patients were finally considered false positives. Moreover, the 99mTc-HYNIC-TOC SPECT/CT results were negative in seven patients, with six patients being true negative (4 patients were diagnosed with acquired Fanconi syndrome and 2 patients responded well to conservative therapy) and one being false negative. Therefore, the sensitivity and specificity values of 99mTc-HYNIC-TOC SPECT/CT in the evaluation of TIO were 92.9% (13/14) and 54.5% (6/11), respectively. The overall accuracy of 99mTc-HYNIC-TOC SPECT/CT for detecting TIO was 76.0% (19/25). CONCLUSIONS The 99mTc-HYNIC-TOC SPECT/CT is an accurate imaging modality for locating culprit tumors in TIO.
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Affiliation(s)
- Bo Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Lili Duan
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Xiali Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Jingqi Shi
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Huiqiang Li
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Huimin Liu
- Department of Oncology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Xiaoliang Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xinyu Wu
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
| | - Yongju Gao
- Department of Nuclear Medicine, Henan Key Laboratory of Novel Molecular Probes and Clinical Translation in Nuclear Medicine, Henan Provincial People’s Hospital; Zhengzhou University People’s Hospital, Henan University People’s Hospital, Zhengzhou, China
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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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Clegg SM, Eiel ES, Fine S, Gafni RI, Most MJ. Atypical Fragility Fractures due to Bony or Soft Tissue Phosphaturic Mesenchymal Tumors: A Report of Two Cases. Case Rep Orthop 2023; 2023:5614065. [PMID: 37090040 PMCID: PMC10115527 DOI: 10.1155/2023/5614065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 03/13/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disorder where patients present with hypophosphatemia, chronic diffuse bone pain, and occasionally fractures. Benign phosphaturic mesenchymal tumors (PMT) are responsible for the TIO and are largely soft tissue tumors. Cases Two male patients with TIO secondary to PMT were reported-one in the bony scapula and the other in the plantar foot soft tissue. The first case describes a 63-year-old Caucasian male, who sustained an intertrochanteric proximal femur stress fracture and approximately two years of diffuse bone pain and hypophosphatemia. Wide excision of a left scapula boney lesion resulted in immediate resolution of his electrolyte abnormalities and bone pain. Case 2 describes a 58-year-old male with four years of multifocal bone pain and atraumatic fractures. A 68Ga-DOTATATE-positron emission tomography/computed tomography (PET/CT) scan identified a soft tissue tumor in his plantar foot, which was ultimately excised. He also experienced near immediate resolution of his pain and no additional fractures. Conclusion TIO is a rare condition presenting with chronic multifocal bone pain, stress fractures, and hypophosphatemia. These two cases highlight that the causative tumor may originate in soft tissue or bone. Furthermore, a high index of suspicion, along with fibroblast growth factor-23 testing and DOTATATE-PET/CT localization, can help with diagnosis and minimize treatment delays.
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Affiliation(s)
- Stephanie M. Clegg
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Emily S. Eiel
- University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3737 Market Street, Philadelphia, PA 19104, USA
| | - Sara Fine
- Department of Pathology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Rachel I. Gafni
- National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Dr. MSC 4320, Bethesda, MD 20892, USA
| | - Mathew J. Most
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
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Kato H, Koga M, Kinoshita Y, Hidaka N, Hoshino Y, Takashi Y, Arai M, Kobayashi H, Katsura M, Nakamoto Y, Makise N, Ushiku T, Hoshi K, Nangaku M, Makita N, Fukumoto S, Ito N. Utility of Multimodality Approach Including Systemic FGF23 Venous Sampling in Localizing Phosphaturic Mesenchymal Tumors. J Endocr Soc 2022; 7:bvac181. [PMID: 36540156 PMCID: PMC9757682 DOI: 10.1210/jendso/bvac181] [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: 08/18/2022] [Indexed: 11/27/2022] Open
Abstract
Context Tumor-induced osteomalacia (TIO) is one of the most common forms of acquired fibroblast growth factor 23 (FGF23)-related hypophosphatemia and is usually caused by phosphaturic mesenchymal tumors (PMTs). Although the complete resection of PMTs can cure TIO, preoperative localization of tumors by standard imaging modalities is often challenging. In addition to 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (FDG-PET) and 111In-pentetreotide scintigraphy (SRS), systemic FGF23 venous sampling (FGF23VS) has been used to help localize PMTs in specialized institutions. Objective This study aimed to evaluate the diagnostic performance of each imaging test and their combinations in localizing PMTs. Methods In an observational retrospective study of patients with adult-onset FGF23-related osteomalacia who underwent all 3 imaging studies (FDG-PET, SRS, and FGF23VS), the rate of successful preoperative localization of the tumors was evaluated only in the patients with pathological diagnoses of PMTs, considering the possibility that pathogenesis of patients without identified tumors might be due to other causes such as late-onset hereditary FGF23-related hypophosphatemia. Results A total of 30 Japanese patients with TIO (median age, 60 years [range, 28-87 years]; 10 women [33.3%]) were included in the study. The success rate of preoperative localization for each test and combinations of 2 or 3 tests among 18 patients with PMTs was as follows: 72% (FDG-PET), 72% (SRS), 94% (FGF23VS), 89% (FDG-PET, SRS), 100% (FDG-PET, FGF23VS), 94% (SRS, FGF23VS), and 100% (FDG-PET, SRS, and FGF23VS). Conclusion We observed the highest localization rate of PMTs in patients with identified PMTs with the combination of FDG-PET and FGF23VS.
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Affiliation(s)
| | | | - Yuka Kinoshita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yoshitomo Hoshino
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yuichi Takashi
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, 814-0180, Japan
| | - Makoto Arai
- Division of Molecular Physiology and Metabolism, Faculty of Medicine, Tohoku University, Miyagi, 980-8575, Japan
| | - Hiroshi Kobayashi
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masaki Katsura
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, Kyoto, 606-8507, Japan
| | - Naohiro Makise
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan,Division of Surgical Pathology, Chiba Cancer Center, Chiba, 260-8717, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8655, Japan
| | - Kazuto Hoshi
- Department of Oral-maxillofacial Surgery, Dentistry and Orthodontics, and Division of Tissue Engineering, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Noriko Makita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan,Osteoporosis Center, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, 770-8503, Japan
| | - Nobuaki Ito
- Correspondence: Nobuaki Ito, MD, PhD, Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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8
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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9
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Helgebostad R, Revheim ME, Johnsrud K, Amlie K, Alavi A, Connelly JP. Clinical Applications of Somatostatin Receptor (Agonist) PET Tracers beyond Neuroendocrine Tumors. Diagnostics (Basel) 2022; 12:diagnostics12020528. [PMID: 35204618 PMCID: PMC8870812 DOI: 10.3390/diagnostics12020528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
Somatostatin receptor (SSTR) agonist tracers used in nuclear medicine scans are classically used for neuroendocrine tumor diagnosis and staging. SSTR are however, expressed more widely in a variety of cells as seen in the distribution of physiological tracer uptake during whole body scans. This provides opportunities for using these tracers for applications other than NETs and meningiomas. In this qualitative systematic review, novel diagnostics in SSTR-PET imaging are reviewed. A total of 70 studies comprised of 543 patients were qualitatively reviewed. Sarcoidosis, atherosclerosis and phosphaturic mesenchymal tumors represent the most studied applications currently with promising results. Other applications remain in progress where there are many case reports but a relative dearth of cohort studies. [18F]FDG PET provides the main comparative method in many cases but represents a well-established general PET technique that may be difficult to replace, without prospective clinical studies.
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Affiliation(s)
- Rasmus Helgebostad
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kjersti Johnsrud
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Kristine Amlie
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA;
| | - James Patrick Connelly
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Correspondence:
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10
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Beil FT, Stürznickel J, Rolvien T, Amling M, Oheim R. [Tumor localization and treatment of tumor-induced osteomalacia]. Z Rheumatol 2022; 81:182-188. [PMID: 35103802 DOI: 10.1007/s00393-022-01160-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/29/2022]
Abstract
Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia (OOM) is a rare paraneoplastic renal phosphate wasting syndrome. The disease is mostly triggered by small, benign mesenchymal tumors that express somatostatin receptors (SSTR) and produce excessive levels of fibroblast growth factor 23 (FGF 23) or other phosphatonins. These reduce the phosphate back resorption in the proximal tubules of the kidneys, thereby causing hypophosphatemia and lead to an absolute or relatively low calcitriol serum concentration. The main symptoms include muscle weakness, bone pain and recurrent insufficiency fractures secondary to sometimes pronounced osteomalacia. The suspected diagnosis can only be confirmed by determination of the phosphate level. It can often take years before the tumor is successfully localized. The necessary tumor localization is often the most difficult step in the treatment before the OOM can be curatively treated by open surgical resection of the tumor. In recent years new approaches for faster tumor localization and treatment of the tumor have been developed. Positron emission tomography (PET) in co-registration with computed tomography (68Ga-DOTA-TATE PET/CT) is currently the most sensitive imaging methodology for tumor detection. The application of the monoclonal FGF 23 antibody burosumab represents a promising new option in the treatment of inoperable adult OOM.
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Affiliation(s)
- Frank Timo Beil
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julian Stürznickel
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.,Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Tim Rolvien
- Lehrstuhl für Orthopädie, Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Michael Amling
- Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ralf Oheim
- Institut für Osteologie und Biomechanik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,National Bone Board am Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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11
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Frank FA, Gerber L, Cornelius A, Baumhoer D, Krieg AH. FGF-23 transmitted tumor - induced hypophosphatemic osteomalacia: a rare case of a young woman with recurrent fractures and review of the literature. J Bone Oncol 2022; 33:100413. [PMID: 35169537 PMCID: PMC8829074 DOI: 10.1016/j.jbo.2022.100413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 12/31/2022] Open
Abstract
Tumor-transmitted osteomalacia is a rare FGF 23 transmitted phosphaturic disease. Delay of diagnosis is common due to small and clinically silent underlying tumors. The most sensitive imaging modality is 68Ga-DOTA-TOC-PET/CT-scan. Complete resection of the tumor mass cures this paraneoplastic disease.
We present a case of tumor-induced osteomalacia (TIO) in a young woman of 22 years. The fibroblast growth factor 23 transmitting tumor in her left foot remained undetected for several years. She suffered several fractures including insufficiency fractures of both femoral necks requiring bilateral proximal femoral nailing. After phosphaturia was diagnosed any known genetic etiology was excluded. Even advanced imaging modalities were unable to detect the clinically silent tumor until an 68Ga-DOTA-TOC-PET/CT-scan revealed a mass with paraneoplastic activity in the left foot. Complete resection of the tumor proved to cure her condition after 9 years of uncertainty and suffering. Serum phosphate levels returned to normal within days. After presentation of the case report, the current literature on published cases of TIO between 1956 and 2021 is summarized to emphasize the importance of an accurate and early diagnosis. Our case report aims to illustrate that a long latency period of diagnosis may be avoided utilizing the latest imaging techniques to spare affected patients from long treatment of symptoms instead of finding the underlying cause.
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12
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Zavatta G, Altieri P, Vandi G, Vicennati V, Pagotto U, Vescini F. Phosphate Metabolism and Pathophysiology in Parathyroid Disorders and Endocrine Tumors. Int J Mol Sci 2021; 22:ijms222312975. [PMID: 34884774 PMCID: PMC8657508 DOI: 10.3390/ijms222312975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/27/2022] Open
Abstract
The advent of new insights into phosphate metabolism must urge the endocrinologist to rethink the pathophysiology of widespread disorders, such as primary hyperparathyroidism, and also of rarer endocrine metabolic bone diseases, such as hypoparathyroidism and tumor-induced hypophosphatemia. These rare diseases of mineral metabolism have been and will be a precious source of new information about phosphate and other minerals in the coming years. The parathyroid glands, the kidneys, and the intestine are the main organs affecting phosphate levels in the blood and urine. Parathyroid disorders, renal tubule defects, or phosphatonin-producing tumors might be unveiled from alterations of such a simple and inexpensive mineral as serum phosphate. This review will present all these disorders from a ‘phosphate perspective’.
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Affiliation(s)
- Guido Zavatta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Paola Altieri
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Giulia Vandi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.Z.); (P.A.); (G.V.); (V.V.); (U.P.)
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University Hospital Udine, 33100 Udine, Italy
- Correspondence:
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13
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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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14
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Brandi ML, Clunie GPR, Houillier P, Jan de Beur SM, Minisola S, Oheim R, Seefried L. Challenges in the management of tumor-induced osteomalacia (TIO). Bone 2021; 152:116064. [PMID: 34147708 DOI: 10.1016/j.bone.2021.116064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare acquired paraneoplastic disease, which is challenging to diagnose and treat. TIO is characterized by hypophosphatemia resulting from excess levels of tumor-secreted fibroblast growth factor 23 (FGF23), one of the key physiological regulators of phosphate metabolism. Elevated FGF23 results in renal phosphate wasting and compromised vitamin D activation, ultimately resulting in osteomalacia. Patients typically present with progressive and non-specific symptoms, including bone pain, multiple pathological fractures, and progressive muscle weakness. Diagnosis is often delayed or missed due to the non-specific nature of complaints and lack of disease awareness. Additionally, the disease-causing tumour is often difficult to detect and localize because they are often small, lack localizing symptoms and signs, and dwell in widely variable anatomical locations. Measuring serum/urine phosphate should be an inherent diagnostic component when assessing otherwise unexplained osteomalacia, fractures and weakness. In cases of hypophosphatemia with inappropriate (sustained) phosphaturia and inappropriately normal or frankly low 1,25-dihydroxy vitamin D, differentiation of the potential causes of renal phosphate wasting should include measurement of FGF23, and TIO should be considered. While patients experience severe disability without treatment, complete excision of the tumour is typically curative and results in a dramatic reversal of symptoms. Two additional key current unmet needs in optimizing TIO management are: (1 and 2) the considerable delay in diagnosis and consequent delay between the onset of symptoms and surgical resection; and (2) alternative management. These may be addressed by raising awareness of TIO, and taking into consideration the accessibility and variability of different healthcare infrastructures. By recognizing the challenges associated with the diagnosis and treatment of TIO and by applying a stepwise approach with clear clinical practice guidelines, patient care and outcomes will be improved in the future.
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Affiliation(s)
- Maria Luisa Brandi
- FirmoLab, FIRMO Foundation, Stabilimento Chimici Farmaceutico Militare di Firenze, Via Reginaldo Giuliani 201, 50141 Florence, Italy.
| | - Gavin P R Clunie
- Cambridge University Hospitals, Box 204, Hills Road, Cambridge CB2 0QQ, UK.
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Suzanne M Jan de Beur
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA.
| | | | - Ralf Oheim
- University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Lothar Seefried
- Julius-Maximilians University, Brettreichstr. 11, 97074 Würzburg, Germany.
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15
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Hussein MAM, Cafarelli FP, Paparella MT, Rennie WJ, Guglielmi G. Phosphaturic mesenchymal tumors: radiological aspects and suggested imaging pathway. Radiol Med 2021; 126:1609-1618. [PMID: 34453276 PMCID: PMC8702419 DOI: 10.1007/s11547-021-01412-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review.
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Affiliation(s)
| | - Francesco Pio Cafarelli
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Maria Teresa Paparella
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Winston J Rennie
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy.
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16
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Abrahamsen B, Smith CD, Minisola S. Epidemiology of Tumor-Induced Osteomalacia in Denmark. Calcif Tissue Int 2021; 109:147-156. [PMID: 33818653 PMCID: PMC8273058 DOI: 10.1007/s00223-021-00843-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare, acquired condition of phosphate wasting due to phosphaturic mesenchymal tumors. Because the incidence and prevalence of TIO is unknown, we conducted an observational cohort study using national Danish health registers for the period 2008 to 2018 to obtain such information. The study also aimed to describe the demographics of the TIO population and the prognosis. The operational definition was based on hypophosphatemia or adult osteomalacia diagnoses, combined with prescriptions used in the initial management and procedures consistent with advanced imaging used for locating tumors. The incidence of TIO in Denmark was found to be below 0.13 per 100,000 person years for the total population of the country and 0.10 per 100,000 in adult-onset disease. The prevalence of TIO was estimated to be no more than 0.70 per 100,000 persons for the total population and 0.43 per 100,000 in adults. In 2018, there were a maximum of nine new cases of TIO in Danish adults. Mortality was low but few patients fulfilled the protocol cure criterion during the observation period. TIO has no ICD-10 code and limitations to the study include lack of information on serum biochemistry and on the use of phosphate supplements. Strengths include the use of long-term longitudinal, national hospital and prescription data from a country with universal healthcare. Given the very small patient population with TIO and the known delay to diagnosis and cure, management of patients with suspected TIO should be centralized.
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Affiliation(s)
- Bo Abrahamsen
- Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, 5000, Odense C, Denmark.
- Department of Medicine, Holbæk Hospital, 4300, Holbæk, Denmark.
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX2 6NN, UK.
| | - Christopher D Smith
- Open Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, 5000, Odense C, Denmark
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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17
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Extended Whole-body Ga-68 DOTATATE PET-CT in evaluating Tumour-Induced Osteomalacia: Case report and review of literature. Nucl Med Mol Imaging 2021; 55:130-135. [PMID: 34109008 DOI: 10.1007/s13139-021-00695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
Tumour-induced osteomalacia is a rare paraneoplastic syndrome that manifests as chronic hypophosphataemia, non-specific bone pain and muscle weakness. It is generally caused by phosphaturic mesenchymal tumour (PMT), which is uncommonly associated with synchronous tumours. However, diagnosis is often delayed for several years due to the rarity, indolent growing nature and non-specific symptoms of the disease, often resulting in an overlook by clinicians during assessments. The patient initially presented with hypophosphataemia and generalised skeletal pain with multiple atraumatic fractures. Blood tests revealed serum calcium levels at the upper limit and extremely low inorganic phosphate levels. Herein, we report a case where two synchronous PMTs from two different sites were detected by 'extended' whole-body Ga-68 DOTATATE PET-CT, leading to remission of the disease after complete surgical removal. Early detection and diagnosis of PMT neoplasm is crucial, as complete surgical resection of this tumour is the only definitive treatment currently known. Upon excision, this curable disease will result in complete resolution of symptoms and blood parameters, leading to remission of the disease which significantly improves the patient's quality of life. PMT often over-expresses somatostatin receptors (SSTR), predominantly subtype 2A, and Ga-68 DOTATATE PET-CT is a selective SSTR imaging that targets this characteristic over-expression in these tumours. The high diagnostic accuracy of Ga-68 DOTATATE PET-CT should be the primary imaging modality for full evaluation of this disease.
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18
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Agrawal K, Padhy BM, Meher BR, Mohanty RR. Diagnostic utility of Ga-68 DOTA-SSTR and F-18 FDG PET/CT in the detection of culprit tumours causing osteomalacia: a systematic review and meta-analysis. Nucl Med Commun 2021; 42:646-655. [PMID: 33625187 DOI: 10.1097/mnm.0000000000001379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tumour-induced osteomalacia (TIO) or oncogenic osteomalacia is a rare variant of paraneoplastic syndrome secondary to a small benign phosphaturic mesenchymal tumour that secretes phosphaturic substances. Complete tumour excision is often curative. However, the localization of these offending tumours has always remained a challenge because of their small size, slow-growing nature, and presence in atypical locations. We performed a systemic review and meta-analysis on the sensitivity and specificity of F-18 FDG PET/CT and Ga-68 DOTA-SSTR PET/CT to detect tumours causing osteomalacia. METHODS Pub Med, SCOPUS, the Cochrane Library and Web of Science were searched for articles on F-18 FDG and Ga-68 DOTA-SSTR PET/CT in the detection of culprit tumours in TIO till September 2020. Both retrospective and prospective studies having three or more patients were included. The methodological quality of included studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies-2 checklist. A random-effect model was used for the statistical pooling of sensitivity and specificity. Pooled data were presented with 95% confidence intervals (95% CI) and displayed using Forest plots. Heterogeneity was expressed using the I2 statistic. RESULTS The pooled sensitivity of Ga-68 DOTA-SSTR PET/CT in detecting the culprit tumour derived from all included studies is 86% (95% CI: 79-91%). There is moderate statistical heterogeneity among the included studies (I2 = 72.7%). The pooled sensitivity of F-18 FDG PET/CT in detecting the offending tumour derived from all included studies is 73% (95% CI: 61-84%) with moderate statistical heterogeneity among the included studies (I2 = 45.4%). CONCLUSION In the detection of offending tumours in TIO, Ga-68 DOTA-SSTR PET/CT has better sensitivity than F-18 FDG PET/CT and should be used as first-line imaging modality due to very high sensitivity.
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Affiliation(s)
| | | | | | - Rashmi Ranjan Mohanty
- Department of General Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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19
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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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20
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Metastatic intracranial solitary fibrous tumors/hemangiopericytomas: description of two cases with radically different behaviors and review of the literature. Anticancer Drugs 2021; 31:646-651. [PMID: 31972591 DOI: 10.1097/cad.0000000000000900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Solitary fibrous tumor/hemangiopericytoma with primary tumor location in the central nervous system accounts for less than 1% of all central nervous system tumors. Despite the relatively indolent clinical course, extracranial metastases are reported in 28% of cases. In recent years, NAB2-STAT6 gene fusion has been recognized as the pathognomonic molecular feature of solitary fibrous tumor/hemangiopericytoma and STAT6 immunohistochemistry has been shown to be a sensitive and specific surrogate for the identification of the gene fusion in these patients. Here we report two cases of patients who experienced occurrence of diffuse extracranial metastases several years after successful surgery for an intracranial solitary fibrous tumor/hemangiopericytoma. In the first patient, the metastases had maintained similar histological features to the primary tumor; in contrast, in the second case, a dedifferentiation occurred with loss of expression of CD34 and Bcl-2. These different histological features were associated with radically different behaviors. Whereas the first case experienced an indolent course of the disease, the second patient had a rapid disease progression and deterioration of clinical conditions. The molecular imaging findings in these two cases and the role of functional imaging for tumor detection, disease staging and monitoring in this rare cancer are also discussed. Recurrences and metastases maintained high expression of somatostatin receptors confirmed by somatostatin receptor imaging in the first case. In contrast, in the second patient, the abrupt transition into a highly aggressive form was associated with the absence of somatostatin receptors at 111In Pentetreotide scan and intense hypermetabolism at 18F-FDG PET.
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21
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Kato A, Nakamoto Y, Ishimori T, Hayakawa N, Ueda M, Temma T, Sano K, Shimizu Y, Saga T, Togashi K. Diagnostic performance of 68Ga-DOTATOC PET/CT in tumor-induced osteomalacia. Ann Nucl Med 2021; 35:397-405. [PMID: 33582980 DOI: 10.1007/s12149-021-01575-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia (TIO) is caused by typically small tumors that secrete fibroblast growth factor 23 (FGF23). As tumor resection is the only effective treatment for TIO, it is important to detect the culprit tumor. We aimed to assess the utility of 68Gallium-DOTA-D-Phe(1)-Tyr(3)-octreotide (68Ga-DOTATOC) PET/CT in TIO and the correlation between biochemical parameters and the PET/CT results. METHODS Thirty-five patients with clinically suspected TIO who had undergone 68Ga-DOTATOC PET/CT were retrospectively analyzed. 68Ga-DOTATOC PET/CT results were compared with biochemical parameters and the final diagnosis, including histopathology. RESULTS 68Ga-DOTATOC PET/CT detected focal uptake consistent with TIO in 21/35 patients, one of which was considered false positive. In 16 patients, the cause of osteomalacia was confirmed histologically as phosphaturic mesenchymal tumor (n = 15) or fibrous dysplasia (n = 1). The other four patients were judged clinically as true positive by subsequent MRI and the clinical course. Overall, the detection rate of 68Ga-DOTATOC PET/CT was 57% (20/35). Median tumor maximum standardized uptake value (SUVmax) was 6.9 (range 1.5-37.7). There was no significant difference in serum intact FGF23 level between DOTATOC-positive and DOTATOC-negative cases, and no significant correlation was observed between intact FGF23 level and tumor SUVmax. CONCLUSIONS 68Ga-DOTATOC PET/CT was clinically useful in detecting culprit tumors and subsequent patient management in TIO.
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Affiliation(s)
- Ayako Kato
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takayoshi Ishimori
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Nobuyuki Hayakawa
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Diagnostic Imaging, Kyoto City Hospital, Kyoto, Japan
| | - Masashi Ueda
- Department of Biofunction Imaging Analysis, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Temma
- Department of Biofunctional Analysis, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Kohei Sano
- Laboratory of Biophysical Chemistry, Kobe Pharmaceutical University, Kobe, Japan
| | - Yoichi Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tsuneo Saga
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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22
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Usefulness of 68Ga-DOTATOC PET/CT to localize the culprit tumor inducing osteomalacia. Sci Rep 2021; 11:1819. [PMID: 33469091 PMCID: PMC7815743 DOI: 10.1038/s41598-021-81491-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/21/2020] [Indexed: 12/26/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome presenting with sustained hypophosphatemia. Treatment of choice is removal of the tumor causing the TIO, but identification of the culprit tumor by routine imaging is challenging. This study aimed to assess the usefulness of somatostatin receptor imaging, called 68Ga-DOTATOC PET/CT, in the management of patients with TIO. Twelve patients who were suspected of having TIO underwent 68Ga-DOTATOC PET/CT. Lesion detectability and maximum standardized uptake value (SUVmax) were determined and retrospectively compared with the clinical/imaging surveillance and histopathologic diagnosis. The median duration of suspected TIO with hypophosphatemia was 7.8 years (range 2.1–21.0). Conventional radiologic and/or nuclear medicine images failed to identify the culprit tumors. However, 68Ga-DOTATOC PET/CT scans showed that 8 of the 12 patients had positive lesions, suggesting the presence of focal culprit tumors. The SUVmax of positive tumors was 1.9–45.7 (median: 11.5). Six skeletal lesions and two extra-skeletal lesions were identified. Seven of the lesions were pathologically confirmed as potential culprits of TIO. Hypophosphatemia was resolved in five patients who underwent lesion excision. The 68Ga-DOTATOC PET/CT is a useful whole-body imaging modality for the detection of causative tumors in patients with suspected TIO.
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Performance of 68Ga-DOTA-SST PET/CT, octreoscan SPECT/CT and 18F-FDG PET/CT in the detection of culprit tumors causing osteomalacia: a meta-analysis. Nucl Med Commun 2021; 41:370-376. [PMID: 32000173 PMCID: PMC7077972 DOI: 10.1097/mnm.0000000000001163] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objectives The objective of this study was to assess and compare the performance of 68Ga-DOTA-conjugated-somatostatin-receptor-targeting-peptides (68Ga-DOTA-SST) PET/CT, octreoscan-SPECT/CT and 18F-FDG-PET/CT in the detection of tumor-induced osteomalacia (TIO). Methods Relevant studies reporting the performance 68Ga-DOTA-SST PET/CT, octreoscan-SPECT/CT and 18F-FDG-PET/CT in TIO were identified by searching PubMed, EMBASE, and Web of Science (last updated June 2019). Two authors independently extracted the numbers of true and false positives, and true and false negatives. The pooled estimates on a per-patient basis were calculated with 95% confidence interval (CI) obtained using a random-effects model. Results Fourteen studies comprising 346 patients were included in this meta-analysis. The meta-analysis provided the following results on a per-patient analysis. The pooled sensitivities of both 68Ga-DOTA-SST PET/CT (90%, 95% CI 82–95%) and octreoscan-SPECT/CT (83%, 95% CI 75–89%) were found to be significantly higher (P < 0.005) than that of 18F-FDG PET/CT (67%, 95% CI 53–80%). There was no statistically significant difference between the sensitivity of 68Ga-DOTA-SST PET/CT and octreoscan-SPECT/CT (P = 0.161). Owing to the low number of articles with true negative findings, the pooled specificities were not calculated. A total of 287 tumors were identified in 287 patients according to the data the included studies offered. The majority of the tumors were located in the lower extremities (59.6%, 171/287), followed by craniofacial regions (24.0%, 69/287), torso (9.4%%, 27/287), and upper extremities (6.9%, 20/287). Conclusion This meta-analysis demonstrates that somatostatin receptor-based imaging modalities outperformed 18F-FDG PET/CT in the detection of TIO, with 68Ga-DOTA-SST PET/CT performing slightly better than octreoscan-SPECT/CT.
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24
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Florenzano P, Hartley IR, Jimenez M, Roszko K, Gafni RI, Collins MT. Tumor-Induced Osteomalacia. Calcif Tissue Int 2021; 108:128-142. [PMID: 32504138 DOI: 10.1007/s00223-020-00691-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral production of fibroblast growth factor 23 (FGF23). The hallmark biochemical features include hypophosphatemia due to renal phosphate wasting, inappropriately normal or frankly low 1,25-dihydroxy-vitamin D, and inappropriately normal or elevated FGF23. TIO is caused by typically small, slow growing, benign phosphaturic mesenchymal tumors (PMTs) that are located almost anywhere in the body from the skull to the feet, in soft tissue or bone. The recent identification of fusion genes in a significant subset of PMTs has provided important insights into PMT tumorigenesis. Although management of this disease may seem straightforward, considering that complete resection of the tumor leads to its cure, locating these often-tiny tumors is frequently a challenge. For this purpose, a stepwise, systematic approach is required. It starts with thorough medical history and physical examination, followed by functional imaging, and confirmation of identified lesions by anatomical imaging. If the tumor resection is not possible, medical therapy with phosphate and active vitamin D is indicated. Novel therapeutic approaches include image-guided tumor ablation and medical treatment with the anti-FGF23 antibody burosumab or the pan-FGFR tyrosine kinase inhibitor, BGJ398/infigratinib. Great progress has been made in the diagnosis and treatment of TIO, and more is likely to come, turning this challenging, debilitating disease into a gratifying cure for patients and their providers.
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Affiliation(s)
- Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
| | - Iris R Hartley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - Kelly Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Skeletal Disorders and Mineral Homeostasis Section, NIDCR, NIH, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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25
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Athonvarangkul D, Insogna KL. New Therapies for Hypophosphatemia-Related to FGF23 Excess. Calcif Tissue Int 2021; 108:143-157. [PMID: 32504139 DOI: 10.1007/s00223-020-00705-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
FGF23 is a hormone produced by osteocytes in response to an elevation in the concentration of extracellular phosphate. Excess production of FGF23 by bone cells, or rarely by tumors, is the hormonal basis for several musculoskeletal syndromes characterized by hypophosphatemia due to renal phosphate wasting. FGF23-dependent chronic hypophosphatemia causes rickets and osteomalacia, as well as other skeletal complications. Genetic disorders of FGF23-mediated hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets (ADHR), autosomal recessive hypophosphatemic rickets (ARHR), fibrous dysplasia of bone, McCune-Albright syndrome, and epidermal nevus syndrome (ENS), also known as cutaneous skeletal hypophosphatemia syndrome (CSHS). The principle acquired form of FGF23-mediated hypophosphatemia is tumor-induced osteomalacia (TIO). This review summarizes current knowledge about the pathophysiology and clinical presentation of the most common FGF23-mediated conditions, with a focus on new treatment modalities. For many decades, calcitriol and phosphate supplements were the mainstay of therapy. Recently, burosumab, a monoclonal blocking antibody to FGF23, has been approved for treatment of XLH in children and adults, and an active comparator trial in children has shown good efficacy and safety for this drug. The remainder of FGF23-mediated hypophosphatemic disorders continue to be treated with phosphate and calcitriol, although ongoing trials with burosumab for treatment of tumor-induced osteomalacia show early promise. Burosumab may be an effective treatment for the remainder of FGF23-mediated disorders, but clinical trials to support that possibility are at present not available.
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Affiliation(s)
- Diana Athonvarangkul
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA.
| | - Karl L Insogna
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA
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26
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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.
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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
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27
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Obo T, Koriyama N, Tokito A, Ogiso K, Nishio Y. Neurofibromatosis type 1 associated with hypophosphatemic osteomalacia due to hypersecretion of fibroblast growth factor 23: a case report. J Med Case Rep 2020; 14:56. [PMID: 32384911 PMCID: PMC7210688 DOI: 10.1186/s13256-020-02381-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurofibromatosis type 1 is characterized by multiple café au lait spots and cutaneous and plexiform neurofibromas, and is one of the most common autosomal dominant hereditary disorders caused by mutations of the neurofibromatosis type 1 tumor suppressor gene. Osteomalacia in neurofibromatosis type 1 is very rare and is characterized by later onset in adulthood. In humans, fibroblast growth factor 23, which is a causative factor of tumor-induced osteomalacia, is not only a paracrine and autocrine factor, but is also a physiological regulator of phosphate balance in normal serum. CASE PRESENTATION Our patient was a 65-year-old Japanese woman whose neurofibromas began to appear when she was in elementary school. At age 28, she was diagnosed as having neurofibromatosis type 1. A spinal compression fracture and multiple rib fractures were identified in 2012 and 2017, respectively. Her laboratory findings revealed hypophosphatemia due to renal phosphate wasting and a high serum level of fibroblast growth factor 23. Neurofibromas located on the surface of her right forearm and left upper arm, in which a slight abnormal accumulation of tracers was observed on 111indium-pentetreotide scintigraphy, were surgically removed, but there was no improvement in hypophosphatemia or serum fibroblast growth factor 23 after surgery. Therefore, we administered eldecalcitol, which also failed to produce improvement in abnormal data. Subsequent combination with dibasic calcium phosphate hydrate led to improvement in some of the abnormalities, including hypophosphatemia. Immunohistochemical staining using anti-human fibroblast growth factor 23 antibody revealed slightly positive results, however, only one out of three amplifications of the fibroblast growth factor 23 gene was observed by real-time polymerase chain reaction, and no clear fibroblast growth factor 23 gene expression in the resected neurofibromas could be confirmed. CONCLUSIONS We here describe a first rare case of a 65-year-old woman with neurofibromatosis type 1 associated with hypophosphatemic osteomalacia in which a high serum fibroblast growth factor 23 level was confirmed.
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Affiliation(s)
- Takahiko Obo
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.,Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Nobuyuki Koriyama
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.
| | - Akinori Tokito
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan
| | - Kazuma Ogiso
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima, 892-0853, Japan.,Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yoshihiko Nishio
- Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
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28
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Wu N, Zhang Z, Zhou X, Zhao H, Ming Y, Wu X, Zhang X, Yang XZ, Zhou M, Bao H, Chen W, Wu Y, Liu S, Wang H, Niu Y, Li Y, Zheng Y, Shao Y, Gao N, Yang Y, Liu Y, Li W, Liu J, Zhang N, Yang X, Xu Y, Li M, Sun Y, Su J, Zhang J, Xia W, Qiu G, Liu Y, Liu J, Wu Z. Mutational landscape and genetic signatures of cell-free DNA in tumour-induced osteomalacia. J Cell Mol Med 2020; 24:4931-4943. [PMID: 32277576 PMCID: PMC7205804 DOI: 10.1111/jcmm.14991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 11/24/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022] Open
Abstract
Tumour‐induced osteomalacia (TIO) is a very rare paraneoplastic syndrome with bone pain, fractures and muscle weakness, which is mostly caused by phosphaturic mesenchymal tumours (PMTs). Cell‐free DNA (cfDNA) has been regarded as a non‐invasive liquid biopsy for many malignant tumours. However, it has not been studied in benign tumours, which prompted us to adopt the targeted next‐generation sequencing approach to compare cfDNAs of 4 TIO patients, four patients with bone metastasis (BM) and 10 healthy controls. The mutational landscapes of cfDNA in TIO and BM groups were similar in the spectrum of allele frequencies and mutation types. Markedly, deleterious missense mutations in FGFR1 and loss‐of‐function mutations in MED12 were found in 3/4 TIO patients but none of BM patients. The gene ontology analysis strongly supported that these mutated genes found in TIOs would play a potential role in PMTs' process. The genetic signatures and corresponding change in expression of FGFR1 and FGF23 were further validated in PMT tissues from a test cohort of another three TIO patients. In summary, we reported the first study of the mutational landscape and genetic signatures of cfDNA in TIO/PMTs.
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Affiliation(s)
- Nan Wu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Key laboratory of big data for spinal deformities, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhen Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China
| | - Xi Zhou
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hengqiang Zhao
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,School of Biomedical Engineering, School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yue Ming
- PET-CT Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Wu
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, ON, Canada
| | - Xian Zhang
- Nanjing Geneseeq Technology Inc., Nanjing, China
| | - Xin-Zhuang Yang
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Meng Zhou
- School of Biomedical Engineering, School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hua Bao
- Translational Medicine Research Institute, Geneseeq Technology Inc., Toronto, ON, Canada
| | - Weisheng Chen
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
| | - Yong Wu
- Nanjing Geneseeq Technology Inc., Nanjing, China
| | - Sen Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Key laboratory of big data for spinal deformities, Chinese Academy of Medical Sciences, Beijing, China
| | - Huizi Wang
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuchen Niu
- Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yalun Li
- Department of Breast Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Yu Zheng
- Beijing Ekitech Co. Ltd., Beijing, China
| | - Yang Shao
- Nanjing Geneseeq Technology Inc., Nanjing, China
| | - Na Gao
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenli Li
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Na Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xu Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yingli Sun
- Key Laboratory of Genomic and Precision Medicine, China Gastrointestinal Cancer Research Center, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Jianzhong Su
- School of Biomedical Engineering, School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Jianguo Zhang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Key laboratory of big data for spinal deformities, Chinese Academy of Medical Sciences, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guixing Qiu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Key laboratory of big data for spinal deformities, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaqi Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihong Wu
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Key laboratory of big data for spinal deformities, Chinese Academy of Medical Sciences, Beijing, China.,Department of Central Laboratory, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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29
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Day AL, Gutiérrez OM, Guthrie BL, Saag KG. Burosumab in tumor-induced osteomalacia: A case report. Joint Bone Spine 2020; 87:81-83. [DOI: 10.1016/j.jbspin.2019.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/26/2019] [Indexed: 11/27/2022]
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30
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Shah R, Lila AR, Jadhav RS, Patil V, Mahajan A, Sonawane S, Thadani P, Dcruz A, Pai P, Bal M, Kane S, Shah N, Bandgar T. Tumor induced osteomalacia in head and neck region: single center experience and systematic review. Endocr Connect 2019; 8:1330-1353. [PMID: 31505461 PMCID: PMC6790902 DOI: 10.1530/ec-19-0341] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023]
Abstract
Tumor-induced osteomalacia in the head and neck region remains a challenging diagnosis to manage. Literature pertaining to management and outcome details remains sparse. We describe two cohorts: cohort 1 included seven patients from a single center in Western India with tumors located in paranasal sinuses (n = 3), intracranial (n = 2) and maxilla (n = 2). The unique features from our series is the management of persistent disease with radiation therapy (n = 2) and peptide receptor radionuclide therapy (PRRT) (n = 1). Cohort two has 163 patients identified from 109 publications for systematic review. Paranasal sinuses, mandible, intracranial disease, maxilla and oral cavity, in descending order, are reportedly common tumor sites. Within this cohort, mean age was 46 ± 14 years at presentation with 44.1% having local symptoms. Duration of symptoms varied from 1 to 240 months. Pre-surgery mean serum phosphorus was 1.4 ± 0.4 mg/dL and median FGF-23 levels were 3.6 (IQR:1.8-6.8) times of normal upper limit of normal. Majority (97.5%) were managed primarily with surgical excision; however, primary radiotherapy (n = 2) and surgery combined with radiotherapy (n = 2) were also reported. Twenty patients had persistent disease while nine patients had recurrence, more commonly noted with intracranial and oral cavity tumors. Surgery was the most common second mode of treatment employed succeeded by radiotherapy. Four patients had metastatic disease. The most common histopathological diagnosis reported is PMT mixed connective tissue, while the newer terminology 'PMT mixed epithelial and connective tissue type' has been described in 15 patients.
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Affiliation(s)
- Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Anurag R Lila
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
- Correspondence should be addressed to A R Lila:
| | - Ramteke-Swati Jadhav
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sushil Sonawane
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Puja Thadani
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Anil Dcruz
- Department of Head Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Prathamesh Pai
- Department of Head Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Subhada Kane
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
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31
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Phosphaturic Mesenchymal Tumor of Soft Tissue of the Foot: Report of a Case With Review of the Literature. Adv Anat Pathol 2019; 26:320-328. [PMID: 31261249 DOI: 10.1097/pap.0000000000000240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm that ectopically secretes fibroblast growth factor 23, a bone cell-derived protein that regulates phosphate homeostasis. The overproduction of fibroblast growth factor 23 causes a paraneoplastic syndrome characterized by hyperphosphaturia, hypophosphatemia, hypovitaminosis D, and vitamin D refractory rickets/osteomalacia, effects that disappear with tumor removal. The PMT may occur in several anatomic regions, mainly in the limbs, usually involving both soft tissue and bone. Acral locations occur in 10% to 15% of the cases, mostly in the feet, with 95 cases reported in this anatomic region to date. We report a case of a PMT in a young adult male who presented in 2007 with the classic constellation of signs and symptoms. A small soft-tissue tumor was detected in his right heel, 3 years after exhaustively seeking for it by various imaging techniques performed at different institutions. Before the tumor was detected, attempts to manage this patient's osteomalacia with phosphate and vitamin D (both calcitriol and ergocalciferol) supplementation were unsuccessful. Following surgical resection, the patient experienced prompt correction of the phosphaturia and gradual reconstitution of his bone mineralization. The pathologic diagnosis was (benign) PMT, mixed connective tissue type. In 2019, 12 years after resection, the patient is asymptomatic, and his bone mineral homeostasis has been restored.
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Yang M, Doshi KB, Roarke MC, Nguyen BD. Molecular Imaging in Diagnosis of Tumor-induced Osteomalacia. Curr Probl Diagn Radiol 2019; 48:379-386. [DOI: 10.1067/j.cpradiol.2018.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/31/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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Tumor-induced osteomalacia – Current imaging modalities and a systematic approach for tumor localization. Clin Imaging 2019; 56:114-123. [DOI: 10.1016/j.clinimag.2019.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
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Mishra T, Desouza MA, Patel K, Mazumdar GA. Phosphaturic Mesenchymal Tumors Involving Skull Bones: Report of Two Rare Cases. Asian J Neurosurg 2019; 14:253-255. [PMID: 30937047 PMCID: PMC6417335 DOI: 10.4103/ajns.ajns_176_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare tumor causing oncogenic osteomalacia (OO). Most such tumors occur in soft tissue and bones of extremities and appendicular skeleton. Intracranial location and involvement of temporal–occipital bone is extremely rare. We report two unusual cases: The first was intracranial, involving the temporal bone, while the other was a skull base tumor arising from the occipital–temporal bone. Both of them presented with paraneoplastic syndrome of OO, resembled a meningioma radiologically, and underwent gross total resection of tumor. Histologically, both of them were diagnosed as PMT, mixed connective tissue variant.
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Affiliation(s)
- Toshi Mishra
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Maria Alina Desouza
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Keyuri Patel
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Girish A Mazumdar
- Department of Histopathology, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Review of paraneoplastic syndromes in children. Pediatr Radiol 2019; 49:534-550. [PMID: 30877339 DOI: 10.1007/s00247-019-04371-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/24/2019] [Accepted: 02/21/2019] [Indexed: 12/27/2022]
Abstract
Paraneoplastic syndromes are defined as clinical syndromes that are not related to direct tumor invasion or compression but are secondary to tumor secretion of functional peptides/hormones or related to immune cross-reactivity with normal host tissue. Paraneoplastic syndromes have a wide range of presentations and can present before the primary malignancy or tumor recurrence is diagnosed. They can mimic non-neoplastic processes, making detection, diagnosis and treatment difficult. However, they can also provide clues to the presence of an underlying malignancy. In this paper, we reviewed a range of paraneoplastic syndromes that can occur in children including: (1) neurologic (opsoclonus-myoclonus, limbic, anti-N-methyl-d-aspartate [NMDA] and anti-Ma2 encephalitis and myasthenia gravis); (2) endocrine (neuroendocrine tumors, hypercalcemia, SIADH [syndrome of inappropriate antidiuretic hormone secretion], osteomalacia/rickets and ROHHAD [rapid onset of obesity, hypoventilation, hypothalamic dysfunction and autonomic dysregulation]); and (3) dermatologic/rheumatologic syndromes (hypertrophic osteoarthropathy and paraneoplastic pemphigus). Familiarity with these syndromes can aid in early diagnosis, treatment and imaging optimization.
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Paul J, Cherian KE, Kapoor N, Paul TV. Treating osteoporosis: a near miss in an unusual case of FGF-23 mediated bone loss. BMJ Case Rep 2019; 12:12/3/e228375. [PMID: 30878966 DOI: 10.1136/bcr-2018-228375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oncogenic osteomalacia is a potentially curable condition caused by phosphaturic mesenchymal tumours. We present the case of 54-year-old woman who presented with bony pains and muscle weakness, and was erroneously treated with bisphosphonates elsewhere on the basis of Dual Energy X-ray Absorptiometry (bone density) scan that showed 'severe osteoporosis'. Further evaluation revealed the presence of hypophosphatemia, with a 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid avid lesion involving left mandible on PET scan. Surgical excision of lesion led to improvement in her symptoms with normalisation of phosphorus, and histopathology was diagnostic of mesenchymal phosphaturic tumour. A diagnosis of oncogenic osteomalacia was made. A repeat bone mineral density assessment done a year later showed dramatic improvement. A meticulous examination and evaluation is warranted for any patient presenting with bony pains and muscle weakness. The detection of hypophosphatemia in an elderly individual should prompt the consideration of oncogenic osteomalacia, as localisation and excision of tumour usually results in cure.
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Affiliation(s)
- Jinson Paul
- Endocrinology, Christian MedicalCollege, Vellore, Tamil Nadu, India
| | | | - Nitin Kapoor
- Christian Medical College, Vellore, Tamil Nadu, India
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Broski SM, Folpe AL, Wenger DE. Imaging features of phosphaturic mesenchymal tumors. Skeletal Radiol 2019; 48:119-127. [PMID: 29987349 DOI: 10.1007/s00256-018-3014-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/11/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the CT and MR imaging features of phosphaturic mesenchymal tumors (PMTs). MATERIALS AND METHODS With IRB approval, our institutional radiology/pathology database was reviewed for pathologically-proven PMTs. CT and MRI examinations were reviewed in consensus noting several imaging features, and if available, comparative molecular imaging tests were analyzed. RESULTS We identified 39 patients (21 male, 18 females) with 40 PMTs [mean age, 52.9 ± 14.9 years (range, 14-78)], including 20 bone and 20 soft tissue lesions. Mean maximal lesion diameter was 3.4 ± 2.0 cm (range, 1.1-9.8). 12/18 primary bone lesions (66.6%) were osteolytic and 15/20 (75.0%) had a narrow zone of transition. Internal matrix was present in 18/32 (56.3%) lesions. PMTs were most commonly T1 isointense (31/37, 83.8%), T2 hyperintense (14/36, 38.9%), and solidly enhancing (21/30, 70.0%). The majority (32/36, 88.9%) contained areas of dark T2 signal. 8/9 PMTs were positive by 99mTc-sestamibi scintigraphy, 2/4 by 111In-pentetreotide scintigraphy, 2/2 by 68Ga-DOTATATE PET/CT and 11/13 by 18F-FDG PET/CT. On FDG PET/CT, the mean SUVmax was 4.1 ± 2.5 (range, 1.5-10.8). CONCLUSIONS Osseous PMTs are commonly osteolytic with a narrow zone of transition. Both bone and soft tissue PMTs often contain matrix and areas of dark T2 signal on MRI, independent of the presence of matrix. However, PMTs may mimic other bone and soft tissue neoplasms, including fibrous dysplasia, tenosynovial giant cell tumor, and even atypical lipomatous tumor. As such, clinical presentation and laboratory correlation are critical to PMT recognition and accurate diagnosis.
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Affiliation(s)
- Stephen M Broski
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Doris E Wenger
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Abi-Ghanem AS, Chouairy CJ, Meguerian Z, Azar L. A 49-Year-Old Man With Debilitating Aches and Pains and a Mysterious Culprit. Arthritis Care Res (Hoboken) 2018; 72:1-8. [PMID: 30414354 DOI: 10.1002/acr.23807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/06/2018] [Indexed: 11/08/2022]
Affiliation(s)
| | - Camil J Chouairy
- Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Zarouhie Meguerian
- Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Lama Azar
- Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
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Abstract
Ga-DOTATATE PET/CT was performed in a 60-year-old man to detect culprit tumor responsible for tumor-induced osteomalacia (TIO). The images revealed multiple foci of abnormal activity in soft tissue lesion, which were not typical of tumor causing TIO in Ga-DOTATATE PET/CT. Considering other neoplastic processes, FDG PET/CT were subsequently performed, which showed all same lesions, although the lesions with highest activity were different between the scans. Pathological examination demonstrated that the patient experienced TIO caused by 1 lesion, but other lesions were due to IgG4-related lymphadenopathy.
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Misgar RA, Sahu D, Sehgal A, Malik SA, Mohsin M, Wani AI, Bashir MI, Masoodi SR. Tumor-Induced Osteomalacia due to Hitherto Undiagnosed Subcutaneous Phosphaturic Mesenchymal Tumor. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Diagnostic performance and impact on patient management of 68Ga-DOTA-TOC PET/CT for detecting osteomalacia-associated tumours. Eur J Nucl Med Mol Imaging 2018. [PMID: 29532101 DOI: 10.1007/s00259-018-3971-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Oncogenic osteomalacia is an endocrine disorder induced by small benign tumours (TIO) producing excessive fibroblast growth factor-23 (FGF23). The only way of curing oncogenic osteomalacia is surgical resection of the culprit TIO, which is extremely difficult to detect using conventional imaging modalities due to its small size and variable location in the body. Since TIO frequently overexpress somatostatin receptors, a clinical utility of SPECT or PET with radiolabelled somatostatin analogues has been reported. Among them, 68Ga-DOTA-TOC has recently been granted a marketing authorization, facilitating its routine application. We report here the results of the first series evaluating the diagnostic performance of 68Ga-DOTA-TOC PET/CT in detecting TIO and its impact on patient management. METHODS 68Ga-DOTA-TOC PET/CT and clinical and imaging data from 15 patients with clinical and biochemical signs of oncogenic osteomalacia were retrospectively reviewed. The 68Ga-DOTA-TOC PET/CT findings were compared with the results of post-surgical pathology and clinical and biochemical follow-up. RESULTS 68Ga-DOTA-TOC PET/CT resulted in the detection of one focus suspicious for TIO in nine of 15 patients (60%), and a tumour was surgically removed in eight. Post-operative pathology confirmed a TIO in those eight patients whose symptoms diminished promptly and biochemical anomalies resolved. 68Ga-DOTA-TOC PET/CT sensitivity, specificity and accuracy were 73%, 67% and 71%, respectively. 68Ga-DOTA-TOC PET/CT findings affected patient management in 67% of cases. In particular, 68Ga-DOTA-TOC PET/CT was able to detect the TIO with a negative or a false-positive result of a previous 111In-pentetreotide SPECT/CT in 5/8 patients (63%) or a previous FDG PET/CT in 7/11 patients (64%). No close relationship was found between the positivity of 68Ga-DOTA-TOC PET/CT and the serum level of a biochemical marker. However, a true-positive result of 68Ga-DOTA-TOC PET/CT was obtained in only one patient with a non-elevated serum level of FGF23. CONCLUSION 68Ga-DOTA-TOC PET/CT is an accurate imaging modality in the detection of TIO; in particular, it is worthwhile after failure of somatostatin receptor SPECT(/CT) or FDG PET/CT.
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Shi Z, Deng Y, Li X, Li Y, Cao D, Coossa VS. CT and MR imaging features in phosphaturic mesenchymal tumor-mixed connective tissue: A case report. Oncol Lett 2018; 15:4970-4978. [PMID: 29552133 PMCID: PMC5840497 DOI: 10.3892/ol.2018.7945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/19/2017] [Indexed: 01/25/2023] Open
Abstract
Phosphaturic mesenchymal tumor-mixed connective tissue (PMT-MCT) is rare and usually benign and slow-growing. The majority of these tumors is associated with sporadic tumor-induced osteomalacia (TIO) or rickets, affect middle-aged individuals and are located in the extremities. Previous imaging studies often focused on seeking the causative tumors of TIO, not on the radiological features of these tumors, especially magnetic resonance imaging (MRI) features. PMT-MCT remains a largely misdiagnosed, ignored or unknown entity by most radiologists and clinicians. In the present case report, a review of the known literature of PMT-MCT was conducted and the CT and MRI findings from three patient cases were described for diagnosing the small subcutaneous tumor. Typical MRI appearances of PMT-MCT were isointense relative to the muscles on T1-weighted imaging, and markedly hyperintense on T2-weighted imaging containing variably flow voids, with markedly heterogeneous/homogenous enhancement on post contrast T1-weighted fat-suppression imaging. Short time inversion recovery was demonstrated to be the optimal sequence in localizing the tumor.
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Affiliation(s)
- Zhenshan Shi
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yiqiong Deng
- Department of Radiology, Fuzhou Children's Hospital, Fuzhou, Fujian 350005, P.R. China
| | - Xiumei Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yueming Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Dairong Cao
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
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Schober HC, Kneitz C, Fieber F, Hesse K, Schroeder H. Selective blood sampling for FGF-23 in tumor-induced osteomalacia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170006. [PMID: 29026610 PMCID: PMC5633052 DOI: 10.1530/edm-17-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/08/2017] [Indexed: 01/26/2023] Open
Abstract
Tumor-induced osteomalacia (TIO) is caused by the hormone fibroblast growth factor 23 (FGF-23). It is mainly produced in the tissue of mesenchymal tumors. Patients with TIO frequently suffer from a chronic decompensated pain syndrome and/or muscle weakness with postural deformity. Despite the severity of the disease, the diagnosis is frequently established late. In some cases, it takes several years to establish the condition. This case report concerning a 68-year old woman demonstrates the selective blood sampling for FGF-23 as path-breaking diagnostics to confirm the diagnosis of a neuroendocrine tumor. LEARNING POINTS Tumor-induced osteomalacia is a rare condition compared to other paraneoplastic syndromes.It causes complex symptoms such as progressive reduction of physical capacity, exhaustion, fatigue, a decompensated pain syndrome of the musculoskeletal system and fractures of several bones.Elevated serum levels of FGF-23 implicate massive phosphate elimination and resulting hypophosphatemia.The diagnosis is often established over a period of several years because the localization of small FGF-23-producing tumors is complicated.It is the combination of MRI and selective blood sampling for FGF-23 which permits reliable identification of tumors causing TIO and leads to accurate localization.In a patient with generalized pain and reduced physical capacity, osteological parameters such as phosphate, 25-OH vitamin D3 and 1,25-(OH)2D3, as well as bone-specific alkaline phosphatase levels in serum should be determined. Hypophosphatemia should always lead to further diagnostic investigations aiming at the detection of an FGF-23-producing tumor.
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Affiliation(s)
- Hans-Christof Schober
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Christian Kneitz
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Franziska Fieber
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Kathrin Hesse
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Henry Schroeder
- Department of Neurosurgery, Universitätsmedizin Greifswald, Greifswald, Germany
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Lee JY, Park HS, Han S, Lim JK, Hong N, Park SI, Rhee Y. Localization of Oncogenic Osteomalacia by Systemic Venous Sampling of Fibroblast Growth Factor 23. Yonsei Med J 2017; 58:981-987. [PMID: 28792142 PMCID: PMC5552653 DOI: 10.3349/ymj.2017.58.5.981] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/22/2017] [Accepted: 05/29/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Tumor-induced osteomalacia (TIO) is characterized by hypophosphatemia caused by a phosphaturic mesenchymal tumor. While surgical resection of the tumor leads to a cure, identification of the responsible tumor is challenging. Recently, several studies showed that systemic sampling of fibroblast growth factor 23 (FGF23) is helpful for localization of tumors. The present study aimed to evaluate the clinical utility of this method in Korean patients. MATERIALS AND METHODS Six patients compatible with TIO who were admitted to our hospital between 2006 and 2015 were analyzed. Systemic venous sampling of FGF23 was performed to detect blind lesions or to confirm a suspicious lesion identified in previous imaging studies. RESULTS Venous sampling helped confirming the tumor in five of the six patients. Three patients underwent surgery after sampling, and in two patients, the lesions were detected after 3 years by means of ⁶⁸Ga-DOTATOC positron emission tomography with computed tomography. In one patient, there was a local elevation of serum FGF23 without any related lesion on additional imaging. CONCLUSION Our data strengthened the value of venous sampling of FGF23 in predicting the location of tumors and suggested that it can be more effective in the presence of the relevant lesion in subsequent imaging analyses.
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Affiliation(s)
- Ji Yeon Lee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Park
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seunghee Han
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Feng J, Jiang Y, Wang O, Li M, Xing X, Huo L, Li F, Yu W, Zhong DR, Jin J, Liu Y, Qi F, Lv W, Zhou L, Meng XW, Xia WB. The diagnostic dilemma of tumor induced osteomalacia: a retrospective analysis of 144 cases. Endocr J 2017; 64:675-683. [PMID: 28450684 DOI: 10.1507/endocrj.ej16-0587] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diagnostic delay of tumor induced osteomalacia (TIO) is common in clinic practice. To investigate the diagnostic condition of TIO in China and raise clinicians' awareness of TIO, we retrospectively analyzed clinical manifestations, biochemical features, and specially evaluated missed diagnoses and misdiagnoses among 144 TIO patients from Peking Union Medical College Hospital during December 1982 to December 2014. Clinical presentations of TIO mainly included bone pain, difficulty in walking, pathological fractures, muscle weakness, and height loss. TIO patients demonstrated hypophosphatemia (0.48±0.13 mmol/L), elevated serum alkaline phosphatase (277.9±152.6 U/L), reduced tubular maximum for phosphorus/glomerular filtration rate (0.39±0.14) and markedly elevated serum fibroblast growth factor 23 (FGF23) (median level 302.9 pg/mL). The average time from onset to a correct diagnosis was 2.9±2.3 years while the mean duration from onset to tumor resection was 5.4±4.2 years. The initial misdiagnosis rate was 95.1% (137/144) and 240 case-times of misdiagnoses occurred among the 144 cases. The most frequent misdiagnoses were intervertebral disc herniation, spondyloarthritis (including ankylosing spondylitis) and osteoporosis. A total of 43.1% (62/144) cases with hypophosphatemia presented on their laboratory sheets were neglected and missed diagnosed. Our study showed that TIO was frequently misdiagnosed and missed diagnosed due to its rarity, insidious onset, nonspecific clinical manifestations and clinicians' poor recognition. It is necessary to test serum phosphorus in patients with musculoskeletal symptoms and difficulty in walking. The measurement of serum FGF23 is rather valuable. Once hypophosphatemia is discovered, TIO should be suspected and it is highly recommended to search for tumors and perform curative surgery.
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MESH Headings
- Beijing
- Biomarkers/blood
- Cohort Studies
- Diagnosis, Differential
- Diagnostic Errors
- Female
- Fibroblast Growth Factor-23
- Fibroblast Growth Factors/blood
- Hospitals, Teaching
- Humans
- Hypophosphatemia/blood
- Hypophosphatemia/etiology
- Hypophosphatemia/physiopathology
- Intervertebral Disc Displacement/blood
- Intervertebral Disc Displacement/diagnosis
- Intervertebral Disc Displacement/diagnostic imaging
- Intervertebral Disc Displacement/physiopathology
- Male
- Medical Records
- Neoplasms, Connective Tissue/blood
- Neoplasms, Connective Tissue/diagnosis
- Neoplasms, Connective Tissue/diagnostic imaging
- Neoplasms, Connective Tissue/physiopathology
- Osteomalacia/blood
- Osteomalacia/diagnosis
- Osteomalacia/diagnostic imaging
- Osteomalacia/physiopathology
- Osteoporosis/blood
- Osteoporosis/diagnosis
- Osteoporosis/diagnostic imaging
- Osteoporosis/physiopathology
- Paraneoplastic Syndromes
- Retrospective Studies
- Spondylitis, Ankylosing/blood
- Spondylitis, Ankylosing/diagnosis
- Spondylitis, Ankylosing/diagnostic imaging
- Spondylitis, Ankylosing/physiopathology
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Affiliation(s)
- Juan Feng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Li
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ding-Rong Zhong
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yong Liu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Qi
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Lv
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xun-Wu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei-Bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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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: 188] [Impact Index Per Article: 26.9] [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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Chazal T, Khanine V, Lidove O, Godot S, Ziza JM. Ostéomalacie secondaire à une tumeur mésenchymateuse phosphaturique de révélation tardive. Rev Med Interne 2017; 38:412-415. [PMID: 27659744 DOI: 10.1016/j.revmed.2016.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 01/29/2023]
Affiliation(s)
- T Chazal
- Service de médecine interne et rhumatologie, groupe hospitalier diaconesses Croix-Saint-Simon, 125, rue d'Avron, 75020 Paris, France.
| | - V Khanine
- Service de médecine interne et rhumatologie, groupe hospitalier diaconesses Croix-Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - O Lidove
- Service de médecine interne et rhumatologie, groupe hospitalier diaconesses Croix-Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - S Godot
- Service de médecine interne et rhumatologie, groupe hospitalier diaconesses Croix-Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - J-M Ziza
- Service de médecine interne et rhumatologie, groupe hospitalier diaconesses Croix-Saint-Simon, 125, rue d'Avron, 75020 Paris, France
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Yu WJ, He JW, Fu WZ, Wang C, Zhang ZL. Reports of 17 Chinese patients with tumor-induced osteomalacia. J Bone Miner Metab 2017; 35:298-307. [PMID: 27085966 DOI: 10.1007/s00774-016-0756-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 03/06/2016] [Indexed: 12/17/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare acquired form of hypophosphatemic osteomalacia, which is usually attributed to the overproduction of fibroblast growth factor 23 (FGF-23) by benign mesenchymal neoplasms. Localization and thereafter surgical resection of tumors lead to a cure. The present study aimed to investigate the clinical data, diagnostic methods, and follow-up after tumor resection at one medical center in Shanghai to characterize the profile of this rare disorder and to share our successful experience in diagnosis and treatment. Twenty-three patients with adult-onset hypophosphatemia osteomalacia seen in Shanghai Sixth People's Hospital from 2009 to 2014 and 95 normal individuals were enrolled. After taking a medical history and performing a physical examination, we analyzed the laboratory results (including the serum FGF-23 levels) and localized the tumors by 18F-fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT), 99mTc-octreotide (99mTc-OCT) scintigraphy, and magnetic resonance imaging (MRI). On the basis of the results of laboratory tests and imaging findings, tumor resection was conducted in 17 patients with a certain diagnosis of TIO. The results demonstrated that the 17 patients (nine men and eight women, average age 46.6 ± 12.9 years) had TIO. FGF-23 level was elevated in 94.1 % of patients (16 of 17 patients) . Serum phosphorus level decreased in 100 % of patients. 18F-FDG PET/CT revealed five tumors, 99mTc-OCT scintigraphy revealed two tumors, physical examination revealed nine tumors, and MRI revealed one tumor, among which 58.8 % of the causative tumors (10 of 17 tumors) were located in the lower extremities. After tumor resection, serum phosphorus levels normalized in 100 % of patients (all 17 patients) in 4-21 days and FGF-23 levels decreased in 90 % of patients (nine of ten patients). We found 64.7 % of the tumors (11 of 17 tumors) were phosphaturic mesenchymal tumors or a phosphaturic mesenchymal tumor mixed connective tissue variant. Measurement of serum phosphorus and FGF-23 levels in patients with suspected TIO is of paramount importance for diagnosing of TIO. 18F-FDG PET/CT, 99mTc-OCT scintigraphy, and physical examination play a considerable role in revealing TIO-associated tumors. TIO-associated tumors were more frequently located in the lower extremities than in other places; thus, the lower extremities need to be carefully checked. Complete surgical resection results in normalization of parameters in laboratory tests and relief of symptoms of TIO patients.
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Affiliation(s)
- Wei-Jia Yu
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Jin-Wei He
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Wen-Zhen Fu
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Chun Wang
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China.
| | - Zhen-Lin Zhang
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China.
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Aziz KT, McCarthy EF, Morris CD. Oncogenic Osteomalacia Secondary to a Metastatic Phosphaturic Mesenchymal Tumor in the Talus: A Case Report and Review of the Literature. JBJS Case Connect 2017; 7:e40. [PMID: 29244678 DOI: 10.2106/jbjs.cc.16.00172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We report the case of a 50-year-old woman with oncogenic osteomalacia secondary to a metastatic phosphaturic mesenchymal tumor (PMT) that presented, to our knowledge, with the first reported lesion in the talus. CONCLUSION Oncogenic osteomalacia is a rare condition with a unique serum biochemical profile that requires a high index of suspicion for diagnosis. A PMT is a rare neoplasm that can lead to oncogenic osteomalacia through secretion of fibroblast growth factor 23. Symptoms can be debilitating, and diagnostic delays are extremely common. This case report emphasizes the importance of comprehensive anatomic assessment and the need for fastidious postoperative monitoring.
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Affiliation(s)
- Keith T Aziz
- Departments of Orthopaedic Surgery (K.T.A.) and Pathology (E.F.M), and the Division of Orthopaedic Oncology (C.D.M.), The Johns Hopkins Hospital, Baltimore, Maryland
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Abstract
Fibroblast growth factor 23 (FGF23) is an important regulator of phosphate and vitamin D metabolism and its excessive or insufficient production leads to a wide variety of skeletal disorders. This article reviews the FGF23-α-Klotho signaling pathway, highlighting the latest developments in FGF23 regulation and action, and describes the disorders associated with FGF23 excess or deficiency.
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Affiliation(s)
- Anda R Gonciulea
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M Jan De Beur
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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