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Dwabe S, Chow W. Phosphaturic mesenchymal tumor with de novo liver metastases: a case report and literature review. Ther Adv Med Oncol 2024; 16:17588359241232092. [PMID: 38455709 PMCID: PMC10919134 DOI: 10.1177/17588359241232092] [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: 09/06/2023] [Accepted: 01/24/2024] [Indexed: 03/09/2024] Open
Abstract
Phosphaturic mesenchymal tumors (PMTs) are rare tumors that can cause tumor-induced osteomalacia (TIO) through overproduction of FGF23, a peptide hormone that causes renal phosphate wasting and reduced osteoblastic activity. The diagnosis of PMTs can be difficult to make as the presenting symptoms are non-specific. Although PMT is a rare entity, most cases are benign in nature, not requiring further intervention after surgery, as resection is typically curative. Here, we present a unique case of malignant PMT with de novo liver metastasis in a female patient who presented with TIO and underwent surgical resection of her primary lesion with subsequent regression of her liver metastasis. Moreover, we analyze a review of literature and discuss the importance of a timely diagnosis of this rare phenomenon. It is encouraged that providers strongly consider a diagnosis of PMT in patients with otherwise unexplained bone pain, fatigue, weakness, especially if accompanied with hypophosphatemia. Further studies are also warranted to identify prognostic factors that predict a PMT's malignant potential as they may help identify possible therapeutic targets.
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Affiliation(s)
- Sami Dwabe
- Division of Hematology/Oncology, University of California Irvine, 101 The City Dr., Orange, CA 92868, USA
| | - Warren Chow
- Division of Hematology/Oncology, University of California Irvine, Orange, CA, USA
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Marques JVO, Moreira CA, Borba VZC. New treatments for rare bone diseases: hypophosphatemic rickets/osteomalacia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:658-665. [PMID: 36382755 PMCID: PMC10118827 DOI: 10.20945/2359-3997000000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Phosphorus is one of the most abundant minerals in the human body; it is required to maintain bone integrity and mineralization, in addition to other biological processes. Phosphorus is regulated by parathyroid hormone, 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], and fibroblast growth factor 23 (FGF-23) in a complex set of processes that occur in the gut, skeleton, and kidneys. Different molecular mechanisms - overproduction of FGF-23 by tumors responsible for oncogenic osteomalacia, generation of an FGF-23 mutant that is resistant to cleavage by enzymes, and impaired FGF-23 degradation due to a reduction in or loss of the PHEX gene - can lead to FGF-23-stimulating activity and the consequent waste of urinary phosphate and low levels of 1,25(OH)2D3. Conventional treatment consists of multiple daily doses of oral phosphate salts and vitamin D analogs, which may improve radiographic rickets but do not normalize growth. Complications of the conventional long-term treatment consist of hypercalcemia, hypercalciuria, nephrolithiasis, nephrocalcinosis, impaired renal function, and potentially chronic kidney disease. Recently, burosumab, an antibody against FGF-23, was approved as a novel therapy for children and adults with X-linked hypophosphatemia and patients with tumor-induced osteomalacia. Burosumab showed good performance in different trials in children and adults. It increased and sustained the serum phosphorus levels, decreased the rickets severity and pain scores, and improved mineralization. It offers a new perspective on the treatment of chronic and disabling diseases.
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Stürznickel J, Heider F, Delsmann A, Gödel M, Grünhagen J, Huber TB, Kornak U, Amling M, Oheim R. Clinical Spectrum of Hereditary Hypophosphatemic Rickets With Hypercalciuria (HHRH). J Bone Miner Res 2022; 37:1580-1591. [PMID: 35689455 DOI: 10.1002/jbmr.4630] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/19/2022] [Accepted: 06/04/2022] [Indexed: 11/11/2022]
Abstract
Hereditary hypophosphatemic rickets with hypercalciuria (HHRH) represents an FGF23-independent disease caused by biallelic variants in the solute carrier family 34-member 3 (SLC34A3) gene. HHRH is characterized by chronic hypophosphatemia and an increased risk for nephrocalcinosis and rickets/osteomalacia, muscular weakness, and secondary limb deformity. Biochemical changes, but no relevant skeletal changes, have been reported for heterozygous SLC34A3 carriers. Therefore, we assessed the characteristics of individuals with biallelic and monoallelic SLC34A3 variants. In 8 index patients and 5 family members, genetic analysis was performed using a custom gene panel. The skeletal assessment comprised biochemical parameters, areal bone mineral density (aBMD), and bone microarchitecture. Pathogenic SLC34A3 variants were revealed in 7 of 13 individuals (2 homozygous, 5 heterozygous), whereas 3 of 13 carried monoallelic variants of unknown significance. Whereas both homozygous individuals had nephrocalcinosis, only one displayed a skeletal phenotype consistent with HHRH. Reduced to low-normal phosphate levels, decreased tubular reabsorption of phosphate (TRP), and high-normal to elevated values of 1,25-OH2 -D3 accompanied by normal cFGF23 levels were revealed independently of mutational status. Interestingly, individuals with nephrocalcinosis showed significantly increased calcium excretion and 1,25-OH2 -D3 levels but normal phosphate reabsorption. Furthermore, aBMD Z-score <-2.0 was revealed in 4 of 8 heterozygous carriers, and HR-pQCT analysis showed a moderate decrease in structural parameters. Our findings highlight the clinical relevance also of monoallelic SLC34A3 variants, including their potential skeletal impairment. Calcium excretion and 1,25-OH2 -D3 levels, but not TRP, were associated with nephrocalcinosis. Future studies should investigate the effects of distinct SLC34A3 variants and optimize treatment and monitoring regimens to prevent nephrocalcinosis and skeletal deterioration. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Julian Stürznickel
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Heider
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alena Delsmann
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Gödel
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Grünhagen
- Labor Berlin Charité Vivantes GmbH-corporate member of Institute for Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias B Huber
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Kornak
- Institute for Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,BIH Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Institute of Human Genetics, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Shetty S, Ravindra S, Acharya H, Rao S. A mysterious case of recurrent fracture: Tumour-induced osteomalacia. J Family Med Prim Care 2022; 11:1204-1207. [PMID: 35495830 PMCID: PMC9051695 DOI: 10.4103/jfmpc.jfmpc_947_21] [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: 05/22/2021] [Revised: 10/08/2021] [Accepted: 10/29/2021] [Indexed: 11/06/2022] Open
Abstract
We report a case of tumour-induced osteomalacia in a 59-year-old man who presented with a long-standing history of myalgia, bone pain and pathological fracture of the bilateral femur at different intervals in the past 4 years. A biochemical evaluation revealed hypophosphatemia secondary to phosphaturia. Localization study by Ga-68 DOTANOC PET-CT for adult-onset hypophosphatemic osteomalacia revealed a tumour in the right femoral head. Resection of the tumour resulted in clinical improvement as well as normalization of biochemical parameters.
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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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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: 10] [Impact Index Per Article: 3.3] [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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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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Chen DW, Clines GA, Collins MT, Douyon L, Choksi PU. A rare cause of atraumatic fractures: case series of four patients with tumor-induced osteomalacia. Clin Diabetes Endocrinol 2020; 6:12. [PMID: 32655879 PMCID: PMC7339413 DOI: 10.1186/s40842-020-00101-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/28/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome that presents with hypophosphatemia, bone pain, muscle weakness and fractures. We report a case series of four patients with TIO that resulted in significant muscle weakness and multiple atraumatic fractures. CASE PRESENTATION Four patients were referred to an endocrinology clinic for the evaluation of multiple atraumatic fractures, muscle weakness, generalized muscle and joint pain. Laboratory evaluation was notable for persistent hypophosphatemia due to urinary phosphate wasting, low to low-normal 1,25-dihydroxyvitamin D, elevated alkaline phosphatase and elevated fibroblast growth factor 23 (FGF23). Tumor localization was successful, and all four patients underwent resection of phosphaturic mesenchymal tumors. Post-operatively, patients exhibited normalization of serum phosphorus, in addition to significant improvement in their ambulatory function. CONCLUSION Hypophosphatemia with elevated FGF23 and low 1,25-dihydroxyvitamin D level in the setting of multiple atraumatic fractures necessitates careful evaluation for biochemical evidence of tumor-induced osteomalacia.
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Affiliation(s)
- Debbie W. Chen
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI USA
| | - Gregory A. Clines
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI USA
- Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, MI USA
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD USA
| | - Liselle Douyon
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI USA
| | - Palak U. Choksi
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI USA
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Tang D, Wang XM, Zhang YS, Mi XX. Oncogenic osteomalacia caused by a phosphaturic mesenchymal tumor of the femur: A case report. World J Clin Cases 2019; 7:2081-2086. [PMID: 31423441 PMCID: PMC6695531 DOI: 10.12998/wjcc.v7.i15.2081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/04/2019] [Accepted: 06/21/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Oncogenic osteomalacia caused by phosphaturic mesenchymal tumors is very difficult to detect. We report a case of tumor-induced osteomalacia caused by a phosphaturic mesenchymal tumor of the left femur in a middle-aged woman after medical imaging and biopsy.
CASE SUMMARY A 57-year-old woman presented with progressive bone pain for five years. She was diagnosed with hypophosphatemic osteomalacia, as her laboratory data showed low serum phosphorus and low serum calcium. Her knee joint radiography revealed an osteolytic lesion of the left femur. A computed tomography scan showed mixed density shadows in the left femur. Magnetic resonance imaging of the left femur showed the presence of an oval area with a hypointense signal in T1-weighted magnetic resonance imaging (MRI) and high-low mixed signal in T2-weighted MRI. Biopsy samples revealed the presence of short spindle cells, vascularization, and characteristics of phosphaturic mesenchymal tumors. Tumor resection was performed, and the clinical presentations and laboratory abnormalities were reversed.
CONCLUSION Diagnosis of oncogenic osteomalacia is difficult due to the varieties and localization of source tumors and absence of pathognomonic biomedical signs. Our case highlights the importance of a combination of medical imaging and biopsy in the diagnosis of oncogenic osteomalacia caused by a phosphaturic mesenchymal tumor.
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Affiliation(s)
- Dong Tang
- Department of Medical Imaging (Radiology), The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, Zhejiang Province, China
| | - Xiao-Man Wang
- Department of Ultrasound, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, Zhejiang Province, China
| | - Yong-Sheng Zhang
- Department of Radiology, Hangzhou Hospital of Traditional Medicine, Hangzhou 310015, Zhejiang Province, China
- Department of Radiology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310015, Zhejiang Province, China
| | - Xiao-Xiao Mi
- Institute of Translational Medicine, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, Zhejiang Province, China
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11
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Hadelsberg UP, Doviner V, Frankel M, Gonen L, Munter G, Margalit N. A rare brain tumor encountered: Phosphaturic mesenchymal tumor. Case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2018.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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12
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Giant Cell Tumor of Tendon Sheath Revealed on 68Ga-DOTA-TATE PET/CT in a Patient With Suspicious Tumor-Induced Osteomalacia. Clin Nucl Med 2019; 44:496-498. [DOI: 10.1097/rlu.0000000000002550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ectopic expression of Klotho in fibroblast growth factor 23 (FGF23)-producing tumors that cause tumor-induced rickets/osteomalacia (TIO). Bone Rep 2018; 10:100192. [PMID: 30627598 PMCID: PMC6321977 DOI: 10.1016/j.bonr.2018.100192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/28/2018] [Accepted: 12/27/2018] [Indexed: 02/03/2023] Open
Abstract
Tumor-induced rickets/osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumors that ectopically express fibroblast growth factor 23 (FGF23). FGF23 is a bone-derived hormone that regulates serum phosphate concentrations. Patients with TIO develop hypophosphatemic rickets/osteomalacia due to FGF23 excess and suffer from symptoms such as leg deformities, bone pain, skeletal muscle myopathy, and multiple fractures/pseudofractures. Usually, successful surgical removal of the causative tumors normalizes serum FGF23 and phosphate concentrations in patients with TIO. Most FGF23-producing tumors associated with TIO are histologically called phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). The precise mechanism by which these tumors ectopically overproduce FGF23 outside of bone is yet to be clarified. Therefore, we performed an RNA sequencing analysis of a PMTMCT that was found in the left parotid gland of a patient with TIO. Among the upregulated genes, we focused on Klotho, the protein product of which is a single pass transmembrane protein that works along with an FGF receptor 1c as a receptor complex for FGF23. Subsequent histological analysis confirmed the ectopic expression of Klotho in other PMTMCTs. From these results, we assume that the ectopic expression of Klotho in PTMMCTs enables a positive feedback loop in FGF23 production via the activation of FGF receptor 1c and exacerbates disease manifestations in TIO. Klotho is ectopically expressed in the FGF23-producing mesenchymal tumors. Klotho enables the activation of the FGFR signaling pathway in PMTMCTs. Klotho enables the autocrine/paracrine effects of FGF23 in PMTMCTs.
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Boland JM, Tebben PJ, Folpe AL. Phosphaturic mesenchymal tumors: what an endocrinologist should know. J Endocrinol Invest 2018; 41:1173-1184. [PMID: 29446010 DOI: 10.1007/s40618-018-0849-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/15/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as "oncogenic osteomalacia", is a rare cause of osteomalacia. TIO often has an insidious onset characterized clinically by progressive muscle weakness and bone pain with fractures. The hallmark biochemical finding is a persistent low serum phosphorus concentration due to renal phosphate wasting. The vast majority of cases of TIO result from production of the phosphaturic hormone fibroblast growth factor 23 (FGF23) by a histologically distinctive mesenchymal tumor, termed "phosphaturic mesenchymal tumor" (PMT). Circulating FGF23 induces internalization of renal sodium/phosphate co-transporters resulting in reduced proximal tubular phosphate reabsorption. FGF23 also inhibits production of 1α,25-dihydroxyvitamin D which is inappropriately low or normal in the context of hypophosphatemia. Diagnosis is often delayed owing to the rarity of the condition and an underappreciation for the role of phosphorus as a cause for the constellation of symptoms. Primary treatment for TIO is identification of the offending tumor and surgical removal. However, these tumors are notoriously difficult to find, precluding the opportunity for a curative surgery in many. In such cases, phosphate and calcitriol therapy is used to improve symptoms and heal the osteomalacia. Recently, molecular genetic studies have shown recurrent genetic events in PMT, including the novel fusions FN1-FGFR1 and less commonly FN1-FGF1. These fusion events are hypothesized to result in autocrine/paracrine signaling loops within the tumor, spurring tumorigenesis. This review will cover the clinical features, imaging characteristics, pathologic features, molecular genetic aspects, and therapy of PMT, with a brief discussion of other neoplasms that may cause TIO.
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Affiliation(s)
- J M Boland
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - P J Tebben
- Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - A L Folpe
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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Kinoshita Y, Fukumoto S. X-Linked Hypophosphatemia and FGF23-Related Hypophosphatemic Diseases: Prospect for New Treatment. Endocr Rev 2018; 39:274-291. [PMID: 29381780 DOI: 10.1210/er.2017-00220] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/23/2018] [Indexed: 12/21/2022]
Abstract
Phosphate plays essential roles in many biological processes, and the serum phosphate level is tightly controlled. Chronic hypophosphatemia causes impaired mineralization of the bone matrix and results in rickets and osteomalacia. Fibroblast growth factor 23 (FGF23) is a bone-derived hormone that regulates phosphate metabolism. FGF23 excess induces hypophosphatemia via impaired phosphate reabsorption in the renal proximal tubules and decreased phosphate absorption in the intestines. There are several types of genetic and acquired FGF23-related hypophosphatemic diseases. Among these diseases, X-linked hypophosphatemia (XLH), which is caused by inactivating mutations in the phosphate-regulating endopeptidase homolog, X-linked (PHEX) gene, is the most prevalent form of genetic FGF23-related hypophosphatemic rickets. Another clinically relevant form of FGF23-related hypophosphatemic disease is tumor-induced osteomalacia (TIO), a paraneoplastic syndrome associated with FGF23-producing tumors. A combination of active vitamin D and phosphate salts is the current medical therapy used to treat patients with XLH and inoperative TIO. However, this therapy has certain efficacy- and safety-associated limitations. Several measures to inhibit FGF23 activity have been considered as possible new treatments for FGF23-related hypophosphatemic diseases. In particular, a humanized monoclonal antibody for FGF23 (burosumab) is a promising treatment in patients with XLH and TIO. This review will focus on the phosphate metabolism and the pathogenesis and treatment of FGF23-related hypophosphatemic diseases.
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Affiliation(s)
- Yuka Kinoshita
- Division of Nephrology and Endocrinology, Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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Role of pyrophosphate in vascular calcification in chronic kidney disease. Nefrologia 2017; 38:250-257. [PMID: 29137892 DOI: 10.1016/j.nefro.2017.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 07/06/2017] [Accepted: 07/20/2017] [Indexed: 01/29/2023] Open
Abstract
Vascular calcification is a pathology characterized by the deposition of calcium-phosphate in cardiovascular structures, mainly in the form of hydroxyapatite crystals, resulting in ectopic calcification. It is correlated with increased risk of cardiovascular disease and myocardial infarction in diabetic patients and in those with chronic kidney disease (CKD). Vascular smooth muscle cells are sensitive to changes in inorganic phosphate (Pi) levels. They are able to adapt and modify some of their functions and promote changes which trigger calcification. Pi is regulated by parathyroid hormone and 1,25-dihydroxyvitamin D. Changes in the transport of Pi are the primary factor responsible for the regulation of Pi homeostasis and the calcification process. Synthesis of calcification inhibitors is the main mechanism by which cells are able to prevent vascular calcification. Extracellular pyrophosphate (PPi) is a potent endogenous inhibitor of calcium-phosphate deposition both in vivo and in vitro. Patients with CKD show lower levels of PPi and increased activity of the enzyme alkaline phosphatase. Numerous enzymes implicated in the metabolism of PPi have been associated with vascular calcifications. PPi is synthesized from extracellular ATP by nucleotide pyrophosphatase/phosphodiesterase from extracellular ATP hydrolysis. PPi is hydrolyzed into Pi by tissue-nonspecific alkaline phosphatase. ATP can be hydrolyzed to Pi via the ectonucleoside triphosphate diphosphohydrolase family. All these enzymes must be in balance, thereby preventing calcifications. However, diseases like CKD or diabetes induce alterations in their levels. Administration of PPi could open up new treatment options for these patients.
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Shen G, Zhang Y, Hu S, Liu B, Kuang A. Adult-onset hypophosphatemic osteomalacia associated with Sjogren syndrome: Clinical case report. Medicine (Baltimore) 2017; 96:e6493. [PMID: 28353596 PMCID: PMC5380280 DOI: 10.1097/md.0000000000006493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Hypophosphatemic osteomalacia (HO) is a metabolic bone disease, exhibiting different etiologies such as genetic mutation, tumor induction, dysimmunity, or renal disease. Sjogren's syndrome (SS) is a connective tissue disorder commonly involving exocrine glands; however kidney involvement is also encountered, leading to abnormal phosphorus metabolism, even HO. PATIENT CONCERNS A 47-year-old female patient presented progressively worsening pain in the chest wall, back and bilateral lower extremities as well as muscle weakness was referred to our department. DIAGNOSES, INTERVENTIONS AND OUTCOMES Due to the laboratory test results, radiographic findings and pathologic results, she was diagnosed with adult-onset HO associated with SS. She was then treated with alkalinization, steroids, neutral phosphate, calcium supplements together with activated vitamin D. So far, she recovered uneventfully with relieved pain and increased serum phosphorus level. LESSONS HO may be secondary to renal tubular acidosis of SS patients, and it might be a diagnostic challenge when the kidney involvement in SS is latent and precede the typical sicca symptoms.
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Affiliation(s)
- Guohua Shen
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Yuwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Shuang Hu
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Bin Liu
- Department of Nuclear Medicine, West China Hospital of Sichuan University
| | - Anren Kuang
- Department of Nuclear Medicine, West China Hospital of Sichuan University
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Abstract
Significant hypophosphatemia is commonly due to Vitamin D deficiency. Any sporadic onset of hypophosphatemia in adults warrants workup to identify alternate causes. Hypophosphatemia may also be the only manifestation of an occult malignancy. A high index of clinical suspicion can help diagnose such conditions in early stages. Prompt treatment of the cause can correct this biochemical abnormality. We describe a case report of a woman presenting with severe hypophosphatemia and osteomalacia, leading eventually to the diagnosis of a phosphaturic mesenchymal tumor of the temporo-occipital bone. Surgical resection of tumor led to normalization of the biochemical parameters as well as a complete clinical recovery.
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Affiliation(s)
- M Mulani
- Department of Nephrology, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - K Somani
- Department of Nephrology, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - S Bichu
- Department of Nephrology, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - V Billa
- Department of Nephrology, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
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Neves RL, Chiarantin GMD, Nascimento FD, Pesquero JB, Nader HB, Tersariol ILS, McKee MD, Carmona AK, Barros NMT. Expression and inactivation of osteopontin-degrading PHEX enzyme in squamous cell carcinoma. Int J Biochem Cell Biol 2016; 77:155-164. [PMID: 27270332 DOI: 10.1016/j.biocel.2016.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/19/2016] [Indexed: 11/19/2022]
Abstract
Proteolytic enzymes mediate the activation or inactivation of many physiologic and pathologic processes. The PHEX gene (Phosphate-regulating gene with homologies to endopeptidase on the X chromosome) encodes a metallopeptidase, which is mutated in patients with a prevalent form (1:20,000) of inherited rickets-X-linked hypophosphatemia (XLH). XLH shows growth retardation, hypophosphatemia, osteomalacia, and defective renal phosphate reabsorption and metabolism of vitamin D. Most PHEX studies have focused on bone, and recently we identified osteopontin (OPN) as the first protein substrate for PHEX, demonstrating in the murine model of XLH (Hyp mice) an increase in OPN that contributes to the osteomalacia. Besides its role in bone mineralization, OPN is expressed in many tissues, and therein has different functions. In tumor biology, OPN is known to be associated with metastasis. Here, we extend our PHEX-OPN studies to investigate PHEX expression in a squamous cell carcinoma (SCC) cell line and its possible involvement in modulating OPN function. Real-time PCR showed PHEX-OPN co-expression in SCC cells, with sequencing of the 22 exons showing no mutation of the PHEX gene. Although recombinant PHEX hydrolyze SCC-OPN fragments, unlike in bone cells, SCC-PHEX protein was not predominantly at the plasma membrane. Enzymatic activity assays, FACs and immunoblotting analyses demonstrated that membrane PHEX is degraded by cysteine proteases and the decreased PHEX activity could contribute to inappropriate OPN regulation. These results highlight for the first time PHEX in tumor biology.
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Affiliation(s)
- Raquel L Neves
- Departamento de Biofísica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Departamento de Ciências Biológicas, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
| | - Gabrielly M D Chiarantin
- Departamento de Biofísica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Departamento de Ciências Biológicas, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil
| | | | - João B Pesquero
- Departamento de Biofísica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Helena B Nader
- Departamento de Bioquímica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Ivarne L S Tersariol
- Departamento de Bioquímica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Centro Interdisciplinar de Investigação Bioquímica, Universidade de Mogi das Cruzes, Mogi das Cruzes, São Paulo, Brazil
| | - Marc D McKee
- Faculty of Dentistry, McGill University, Montreal, Quebec, Canada; Department of Anatomy and Cell Biology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Adriana K Carmona
- Departamento de Biofísica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil.
| | - Nilana M T Barros
- Departamento de Biofísica, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Departamento de Ciências Biológicas, Universidade Federal de São Paulo, Diadema, São Paulo, Brazil.
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20
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Intravenous iron administration and hypophosphatemia in clinical practice. Int J Rheumatol 2015; 2015:468675. [PMID: 26000018 PMCID: PMC4426778 DOI: 10.1155/2015/468675] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/12/2015] [Accepted: 04/19/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction. Parenteral iron formulations are frequently used to correct iron deficiency anemia (IDA) and iron deficiency (ID). Intravenous formulation efficacy on ferritin and hemoglobin level improvement is greater than that of oral formulations while they are associated with lower gastrointestinal side effects. Ferric carboxymaltose- (FCM-) related hypophosphatemia is frequent and appears without clinical significance. The aim of this study was to assess the prevalence, duration, and potential consequences of hypophosphatemia after iron injection. Patients and Methods. The medical records of all patients who underwent parenteral iron injection between 2012 and 2014 were retrospectively reviewed. Pre- and postinjection hemoglobin, ferritin, plasma phosphate, creatinine, and vitamin D levels were assessed. Patients who developed moderate (range: 0.32–0.80 mmol/L) or severe (<0.32 mmol/L) hypophosphatemia were questioned for symptoms. Results. During the study period, 234 patients received iron preparations but 104 were excluded because of missing data. Among the 130 patients included, 52 received iron sucrose (FS) and 78 FCM formulations. Among FS-treated patients, 22% developed hypophosphatemia versus 51% of FCM-treated patients, including 13% who developed profound hypophosphatemia. Hypophosphatemia severity correlated with the dose of FCM (p = 0.04) but not with the initial ferritin, hemoglobin, or vitamin D level. Mean hypophosphatemia duration was 6 months. No immediate clinical consequence was found except for persistent fatigue despite anemia correction in some patients. Conclusions. Hypophosphatemia is frequent after parenteral FCM injection and may have clinical consequences, including persistent fatigue. Further studies of chronic hypophosphatemia long-term consequences, especially bone assessments, are needed.
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Kouloulias V, Tolia M, Tsoukalas N, Papaloucas C, Pistevou-Gombaki K, Zygogianni A, Mystakidou K, Kouvaris J, Papaloucas M, Psyrri A, Kyrgias G, Gennimata V, Leventakos K, Panayiotides I, Liakouli Z, Kelekis N, Papaloucas A. Is there any Potential Clinical Impact of Serum Phosphorus and Magnesium in Patients with Lung Cancer at First Diagnosis? A Multi-institutional Study. Asian Pac J Cancer Prev 2015; 16:77-81. [DOI: 10.7314/apjcp.2015.16.1.77] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Sapir-Koren R, Livshits G. Bone mineralization is regulated by signaling cross talk between molecular factors of local and systemic origin: the role of fibroblast growth factor 23. Biofactors 2014; 40:555-68. [PMID: 25352227 DOI: 10.1002/biof.1186] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 10/06/2014] [Indexed: 01/07/2023]
Abstract
Body phosphate homeostasis is regulated by a hormonal counter-balanced intestine-bone-kidney axis. The major systemic hormones involved in this axis are parathyroid hormone (PTH), 1,25-dihydroxyvitamin-D, and fibroblast growth factor-23 (FGF23). FGF23, produced almost exclusively by the osteocytes, is a phosphaturic hormone that plays a major role in regulation of the bone remodeling process. Remodeling composite components, bone mineralization and resorption cycles create a continuous influx-efflux loop of the inorganic phosphate (Pi) through the skeleton. This "bone Pi loop," which is formed, is controlled by local and systemic factors according to phosphate homeostasis demands. Although FGF23 systemic actions in the kidney, and for the production of PTH and 1,25-dihydroxyvitamin-D are well established, its direct involvement in bone metabolism is currently poorly understood. This review presents the latest available evidence suggesting two aspects of FGF23 bone local activity: (a) Regulation of FGF23 production by both local and systemic factors. The suggested local factors include extracellular levels of Pi and pyrophosphate (PPi), (the Pi/PPi ratio), and another osteocyte-derived protein, sclerostin. In addition, 1,25-dihydroxyvitamin-D, synthesized locally by bone cells, may contribute to regulation of FGF23 production. The systemic control is achieved via PTH and 1,25-dihydroxyvitamin-D endocrine functions. (b) FGF23 acts as a local agent, directly affecting bone mineralization. We support the assumption that under balanced physiological conditions, sclerostin, by para- autocrine signaling, upregulates FGF23 production by the osteocyte. FGF23, in turn, acts as a mineralization inhibitor, by stimulating the generation of the major mineralization antagonist-PPi.
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Affiliation(s)
- Rony Sapir-Koren
- Human Population Biology Research Unit, Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Biber J, Murer H, Mohebbi N, Wagner C. Renal Handling of Phosphate and Sulfate. Compr Physiol 2014; 4:771-92. [DOI: 10.1002/cphy.c120031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Teeth are mineralized organs composed of three unique hard tissues, enamel, dentin, and cementum, and supported by the surrounding alveolar bone. Although odontogenesis differs from osteogenesis in several respects, tooth mineralization is susceptible to similar developmental failures as bone. Here we discuss conditions fitting under the umbrella of rickets, which traditionally referred to skeletal disease associated with vitamin D deficiency but has been more recently expanded to include newly identified factors involved in endocrine regulation of vitamin D, phosphate, and calcium, including phosphate-regulating endopeptidase homolog, X-linked, fibroblast growth factor 23, and dentin matrix protein 1. Systemic mineral metabolism intersects with local regulation of mineralization, and factors including tissue nonspecific alkaline phosphatase are necessary for proper mineralization, where rickets can result from loss of activity of tissue nonspecific alkaline phosphatase. Individuals suffering from rickets often bear the additional burden of a defective dentition, and transgenic mouse models have aided in understanding the nature and mechanisms involved in tooth defects, which may or may not parallel rachitic bone defects. This report reviews dental effects of the range of rachitic disorders, including discussion of etiologies of hereditary forms of rickets, a survey of resulting bone and tooth mineralization disorders, and a discussion of mechanisms, known and hypothesized, involved in the observed dental pathologies. Descriptions of human pathology are augmented by analysis of transgenic mouse models, and new interpretations are brought to bear on questions of how teeth are affected under conditions of rickets. In short, the rachitic tooth will be revealed.
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Affiliation(s)
- Brian L Foster
- National Institute for Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland 20892
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25
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Papaloucas CD, Papaloucas MD, Kouloulias V, Neanidis K, Pistevou-Gompaki K, Kouvaris J, Zygogianni A, Mystakidou K, Papaloucas AC. Measurement of blood phosphorus: a quick and inexpensive method for detection of the existence of cancer in the body. Too good to be true, or forgotten knowledge of the past? Med Hypotheses 2013; 82:24-5. [PMID: 24252275 DOI: 10.1016/j.mehy.2013.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/15/2013] [Accepted: 10/28/2013] [Indexed: 11/16/2022]
Abstract
The possible elevation of phosphorous (P) in cancer patients blood serum has been reported in the past. This however seems to have passed unnoticed. One hundred individuals, divided into two groups of fifty each, i.e. cancer patients (group A) and healthy individuals (group B), were included in this retrospective study. The incidence of cancer by site in group A was 24% head and neck, 50% non-small cell lung cancer (SCLC) and 26% cervical cancer. In all cancer patients in group A the serum P was over the normal values, in contrast with the normal values of P measured in group B. The mean value of serum P in group A and B were 7.80 (± 2.24) and 3.38 (± 0.58), respectively (P<0.001, Mann Whitney test). Increased amount of phosphorus in the blood, when other causes justifying the increase were excluded, should be considered as indicative for the existence of unidentified cancerous lesions.
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Affiliation(s)
| | | | - V Kouloulias
- National University of Athens, Medical School, 2nd Dpt. Radiology, ATTIKO Hospital, Rimini 1, Xaidari, Greece.
| | - K Neanidis
- Medical Oncologist, 424 Military Hospital, Thessaloniki, Greece
| | | | - J Kouvaris
- National University of Athens, Medical School, Greece
| | - A Zygogianni
- National University of Athens, Medical School, Greece
| | - K Mystakidou
- National University of Athens, Medical School, Greece
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Ledford CK, Zelenski NA, Cardona DM, Brigman BE, Eward WC. The phosphaturic mesenchymal tumor: why is definitive diagnosis and curative surgery often delayed? Clin Orthop Relat Res 2013; 471:3618-25. [PMID: 23868423 PMCID: PMC3792251 DOI: 10.1007/s11999-013-3178-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 07/08/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia is a paraneoplastic syndrome resulting in renal phosphate wasting and decreased bone mineralization. Phosphaturic mesenchymal tumors represent a rare etiology of tumor-induced osteomalacia. Nonspecific symptoms of fatigue, bone pain, and musculoskeletal weakness make the diagnosis elusive and lead to a delay in surgical treatment. QUESTIONS/PURPOSES In this case series, the following three questions were asked: (1) How do the clinical presentation and features of phosphaturic mesenchymal tumors delay the diagnosis? (2) What is the clinical course after surgical treatment of phosphaturic mesenchymal tumors? (3) How frequently do phosphaturic mesenchymal tumors recur and are there factors associated with recurrence? METHODS This study retrospectively reviewed the cases of five adults diagnosed and treated for phosphaturic mesenchymal tumors. Patients were identified through an internal orthopaedic oncology database with clinical, surgical, and histologic data obtained through a systematic chart review. RESULTS Five patients presented with a long-standing history of osteomalacia, generalized fatigue, pain, and weakness before the diagnosis was reached at an average of 7.2 years (range, 2-12 years) after initial symptom onset. The diagnosis appeared to be delayed owing to the cryptic medical presentation, difficulty in locating tumor by imaging, and confirming histologic appearance. Two patients treated with wide surgical resection did not experience recurrence compared with three patients who did show recurrent signs and symptoms after marginal excision. A postoperative increase in fibroblast-derived growth factor-23 was associated with recurrent disease. CONCLUSIONS Although uncommon, the diagnosis of phosphaturic mesenchymal tumor should be considered in any patient who presents with hypophosphaturic osteomalacia and no other physiologic cause. Definitive treatment is early, wide surgical resection.
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Affiliation(s)
- Cameron K. Ledford
- Department of Orthopaedic Surgery, Duke University Medical Centerm, 200 Trent Drive, Box 2923, Durham, NC 27710 USA
| | - Nicole A. Zelenski
- Department of Orthopaedic Surgery, Duke University Medical Centerm, 200 Trent Drive, Box 2923, Durham, NC 27710 USA
| | - Diana M. Cardona
- Department of Pathology, Duke University Medical Centerm, 200 Trent Drive, Box 2923, Durham, NC 27710 USA
| | - Brian E. Brigman
- Department of Orthopaedic Surgery, Duke University Medical Centerm, 200 Trent Drive, Box 2923, Durham, NC 27710 USA
| | - William C. Eward
- Department of Orthopaedic Surgery, Duke University Medical Centerm, 200 Trent Drive, Box 2923, Durham, NC 27710 USA
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Cantalejo Moreira M, Veiga Cabello RM, Ruiz Giardín JM. Osteomalacia provocada por un tumor hiperfosfatúrico. ACTA ACUST UNITED AC 2013; 9:250-1. [DOI: 10.1016/j.reuma.2012.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 10/26/2022]
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Chokyu I, Ishibashi K, Goto T, Ohata K. Oncogenic osteomalacia associated with mesenchymal tumor in the middle cranial fossa: a case report. J Med Case Rep 2012; 6:181. [PMID: 22747833 PMCID: PMC3514377 DOI: 10.1186/1752-1947-6-181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/16/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED INTRODUCTION Tumor-induced osteomalacia is a paraneoplastic syndrome of hypophosphatemia. Osteomalacia causes multiple bone fractures and severe pain. CASE PRESENTATION We report the case of a 57-year-old Japanese man with tumor-induced osteomalacia associated with a middle cranial fossa bone tumor. The tumor was successfully resected by using a middle fossa epidural approach. His phosphate level recovered to a normal range immediately after the surgery. CONCLUSIONS It is rare that tumor-induced osteomalacia originates from the middle skull base. This report suggests that, if patients have a clinical and biochemical picture suggestive of tumor-induced osteomalacia, it is crucial to perform a meticulous examination to detect the tumor or the lesion responsible for the tumor. The serum level of fibroblast growth factor 23 is the most reliable marker for evaluating the treatment outcome of tumor-induced osteomalacia.
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Affiliation(s)
- Isao Chokyu
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
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Lederer E, Miyamoto KI. Clinical consequences of mutations in sodium phosphate cotransporters. Clin J Am Soc Nephrol 2012; 7:1179-87. [PMID: 22516291 DOI: 10.2215/cjn.09090911] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Three families of sodium phosphate cotransporters have been described. Their specific roles in human health and disease have not been defined. Review of the literature reveals that the type II sodium phosphate cotransporters play a significant role in transepithelial transport in a number of tissues including kidney, intestine, salivary gland, mammary gland, and lung. The type I transporters seem to play a major role in renal urate handling and mutations in these proteins have been implicated in susceptibility to gout. The ubiquitously expressed type III transporters play a lesser role in phosphate homeostasis but contribute to cellular phosphate uptake, mineralization, and inflammation. The recognition of species differences in the expression, regulation, and function of these transport proteins suggests an urgent need to find ways to study them in humans.
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Affiliation(s)
- Eleanor Lederer
- University of Louisville School of Medicine, Louisville, KY 40202, USA.
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de Carvalho CCCR, Caramujo MJ. Tumour metastasis as an adaptation of tumour cells to fulfil their phosphorus requirements. Med Hypotheses 2012; 78:664-7. [PMID: 22391031 DOI: 10.1016/j.mehy.2012.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
Abstract
Inorganic phosphate (Pi) is a vital component of nucleotides, membrane phospholipids, and phosphorylated intermediates in cellular signalling. The Growth Rate Hypothesis (GRH) states that fast growing organisms should be richer in phosphorus (relatively low C:P and N:P cell content) than slow developing organisms as a result of high ribosome biogenesis. Cells that proliferate rapidly, such as cancer cells, require a high amount of ribosomes and other P-rich RNA components that are necessary to manufacture proteins. The GRH hypothesis may be applied to cancer predicting that tumour cells are richer in phosphorus than the surrounding tissue, and that they resort to metastasis in order to meet their nutrient demands. Considering that the cells most P-deprived should be located in the inner parts of the tumour we propose that changes in the membrane of these cells favour the detachment of the more peripheral cells.
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Affiliation(s)
- Carla C C R de Carvalho
- IBB-Institute for Biotechnology and Bioengineering, Centre for Biological and Chemical Engineering, Instituto Superior Técnico, Av. Rovisco Pais, 1049-001 Lisboa, Portugal.
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Imanishi Y, Hashimoto J, Ando W, Kobayashi K, Ueda T, Nagata Y, Miyauchi A, Koyano HM, Kaji H, Saito T, Oba K, Komatsu Y, Morioka T, Mori K, Miki T, Inaba M. Matrix extracellular phosphoglycoprotein is expressed in causative tumors of oncogenic osteomalacia. J Bone Miner Metab 2012; 30:93-9. [PMID: 21739089 DOI: 10.1007/s00774-011-0290-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 06/05/2011] [Indexed: 01/23/2023]
Abstract
Oncogenic osteomalacia (OOM), or tumor-induced osteomalacia, is a rare disease characterized by renal phosphate wasting and osteomalacia. It arises due to the secretion of fibroblast growth factor 23 (FGF-23) from causative tumors. Matrix extracellular phosphoglycoprotein (MEPE) is predominantly expressed in odontoblasts, osteoblasts, and osteocytes. Although the presence of MEPE mRNA has been reported in some OOM tumors, little is known about the prevalence of MEPE expression in OOM tumors. In this study, the expression of MEPE and FGF-23 in OOM tumors was investigated at the transcriptional and translational levels. Eleven causative OOM tumors were analyzed by quantitative real-time reverse transcription-polymerase chain reaction and immunohistochemistry for MEPE and FGF-23 expression. Hemangiopericytomas and giant cell tumors, pathological diagnoses that are common in cases of OOM, were obtained from non-osteomalacic patients and analyzed as controls. The gene expression level of FGF23 and MEPE in OOM tumors was 10(4)- and 10(5)-times higher, respectively, than in non-OOM tumors. Immunohistochemical staining revealed that FGF-23 protein was expressed in all OOM tumors, and MEPE was expressed in 10 out of 11 OOM tumors. Thus, MEPE expression was common in OOM tumors, similar to FGF-23. These results indicate that, in addition to the hypophosphatemic effects of FGF-23, MEPE or the MEPE-derived acidic serine aspartate-rich MEPE-associated motif peptide may contribute to decreased bone mineralization in OOM patients.
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Affiliation(s)
- Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
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Kim IS, Jeong SJ, Kim SH, Jung JH, Park YG, Kim SH. Special AT-rich sequence-binding protein 2 and its related genes play key roles in the differentiation of MC3T3-E1 osteoblast like cells. Biochem Biophys Res Commun 2011; 417:697-703. [PMID: 22166200 DOI: 10.1016/j.bbrc.2011.11.157] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 11/30/2011] [Indexed: 12/15/2022]
Abstract
Special AT-rich sequence-binding protein (SATB) plays a critical role in bone generation and osteoblast differentiation. In the present study, the differentially expressed genes by SATB2 overexpression were analyzed in MC3T3-E1 osteoblast-like cells using Alizarin red S staining, wound healing assay and Agilent's Human Oligo Microarray. Calcium mineralization and motility were significantly enhanced in SATB2-overexpressed cells compared with untreated control. In addition, using the GeneSpringGX 7.3 program to compare the identified genes expressed in SATB2-overexpresed cells with untreated control, we found several unique genes closely associated with osteoblast differentiation, including SOX2, MBP2, WNT11 and MEN1 (up-regulated genes), and ILK, FGF23, FGFR2, and SNAI1 (down-regulated genes). Consistent with microarray data, real-time RT-PCR confirmed the significant up- and down-regulation of these genes at mRNA level in SATB2-overexpressed MC3T3-E1 cells. Overall, our findings suggest that the molecular regulation of SATB2 can be an attractive approach to develop a novel therapeutic strategy for bone-related diseases.
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Affiliation(s)
- In-Suk Kim
- Department of Orthodontics, Kyung-Hee University College of Dental Medicine, Seoul 130-701, Republic of Korea
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Radaideh ARM, Jaradat D, Abu-Kalaf MM, Nusier MK. Resolution of severe oncogenic hypophosphatemic osteomalacia after resection of a deeply located soft-tissue tumour. ACTA ACUST UNITED AC 2011; 16:87-90. [PMID: 19862367 PMCID: PMC2768508 DOI: 10.3747/co.v16i5.412] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Oncogenic osteomalacia is a rare metabolic bone disease characterized by phosphate leakage from the kidney and subsequent hypophosphatemia. It is caused by a phosphaturic factor produced by certain tumours. Removal of such tumours can completely cure the condition. Here, we report the case of a patient who was crippled with oncogenic osteomalacia. Extensive study revealed a tumour deeply located in the pelvis; removal of the tumour resulted in complete recovery. The tumour was identified as a mesenchymal tumour (mixed connective-tissue variant). The diagnostic evaluation, differential diagnosis, and treatment are discussed.
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Affiliation(s)
- A R M Radaideh
- Departments of Medicine, Prince Basma Teaching Hospital, Ministry of Health, Irbid, Jordan
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Suryawanshi P, Agarwal M, Dhake R, Desai S, Rekhi B, Reddy KB, Jambhekar NA. Phosphaturic mesenchymal tumor with chondromyxoid fibroma-like feature: an unusual morphological appearance. Skeletal Radiol 2011; 40:1481-5. [PMID: 21533894 DOI: 10.1007/s00256-011-1159-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/15/2011] [Accepted: 03/17/2011] [Indexed: 02/02/2023]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare and distinctive tumor almost always associated with oncogenic osteomalacia. This tumor is often misdiagnosed due to its widely varied histomorphological spectrum. More recently the term PMT or its variants has been used whatever the histomorphological features. Herein, we present a case of a 32-year-old woman who presented with a 2-year history of oncogenic osteomalacia. The clinical examination failed to detect any tumor. The F-18 FDG PET scan and subsequent MRI revealed a tumor in the soft tissues of the right popliteal fossa. The histological features resembled a chondromyxoid fibroma (CMF), a feature documented only in two cases so far.
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Affiliation(s)
- Pallavi Suryawanshi
- Department of Pathology, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, India
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35
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Saito T, Shimizu Y, Hori M, Taguchi M, Igarashi T, Fukumoto S, Fujitab T. A patient with hypophosphatemic rickets and ossification of posterior longitudinal ligament caused by a novel homozygous mutation in ENPP1 gene. Bone 2011; 49:913-6. [PMID: 21745613 DOI: 10.1016/j.bone.2011.06.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 06/13/2011] [Accepted: 06/23/2011] [Indexed: 01/13/2023]
Abstract
X-linked hypophosphatemic rickets/osteomalacia (XLH), autosomal dominant hypophosphatemic rickets/osteomalacia (ADHR) and autosomal recessive hypophosphatemic rickets/osteomalacia (ARHR1 or ARHR2) are hereditary fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets showing similar clinical features. We here show a patient with hypophosphatemic rickets and widespread ossification of posterior longitudinal ligament (OPLL). The proband is a 62-year-old female. Her parents are first cousins and showed no signs of rickets or osteomalacia. She showed hypophosphatemic rickets with elevated FGF23 level and had been clinically considered to be suffering from XLH. However, direct sequencing of all coding exons and exon-intron junctions of phosphate regulating gene with homologies to endopeptidases on the X chromosome (PHEX), FGF23 and dentin matrix protein 1 (DMP1) genes, responsible genes for XLH, ADHR and ARHR1, respectively, showed no mutation. A novel homozygous splice donor site mutation was found at the exon-intron junction of exon 21 of ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) gene responsible for ARHR2 (IVS21+1_3(GTA>CACC)). Subsequent analysis of mRNA revealed that this mutation caused skipping of exon 21 which created a premature stop codon in exon 22. These results indicate that genetic analysis is mandatory for the correct diagnosis of hereditary FGF23-related hypophosphatemic rickets. Because Enpp1 knockout mouse is a model of OPLL, this case also suggests that OPLL is associated with ARHR2.
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Affiliation(s)
- Tasuku Saito
- Division of Pediatrics, University of Tokyo Hospital, Tokyo, Japan
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Cheng CY, Kuro-o M, Razzaque MS. Molecular regulation of phosphate metabolism by fibroblast growth factor-23-klotho system. Adv Chronic Kidney Dis 2011; 18:91-7. [PMID: 21406293 DOI: 10.1053/j.ackd.2010.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 11/11/2010] [Accepted: 11/30/2010] [Indexed: 11/11/2022]
Abstract
Phosphorus is an essential nutrient and is routinely assimilated through consumption of food. The body's need of phosphate is usually fulfilled by intestinal absorption of this element from the consumed food, whereas its serum level is tightly regulated by renal excretion or reabsorption. Sodium-dependent phosphate transporters, located in the luminal side of the proximal tubular epithelial cells, have a molecular control on renal phosphate excretion and reabsorption. The systemic regulation of phosphate metabolism is a complex multiorgan process, and the identification of fibroblast growth factor-23 (FGF23)-Klotho system as a potent phosphatonin has provided new mechanistic insights into the homeostatic control of phosphate. Hypophosphatemia as a result of an increase in urinary phosphate wasting after activation of the FGF23-Klotho system is a common phenomenon, observed in both animal and human studies, whereas suppression of the FGF23-Klotho system leads to the development of hyperphosphatemia. This article will briefly summarize how delicate interactions of the FGF23-klotho system can regulate systemic phosphate homeostasis.
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Mavrogenis AF, Sakellariou VI, Soultanis K, Mahera H, Korres DS, Papagelopoulos PJ. A nonphosphaturic mesenchymal tumor mixed connective tissue variant of the sacrum. Orthopedics 2010; 33:851. [PMID: 21053876 DOI: 10.3928/01477447-20100924-27] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tumor-induced or oncogenic osteomalacia is a rare paraneoplastic syndrome characterized by overproduction of fibroblast growth factor-23 as a phosphaturic agent and renal phosphate wasting. A range of predominantly mesenchymal neoplasms have been associated with tumor-induced osteomalacia and classified as phosphaturic mesenchymal tumor mixed connective tissues. However, phosphaturic mesenchymal tumor mixed connective tissues could be nonphosphaturic in the first stage of the disease, either because the tumors are resected early in the clinical course or because the patient's osteomalacia was attributed to another cause. This article presents a case of a 42-year-old woman with a 2-year history of low back and right leg pain. Laboratory examinations including serum and urine calcium and phosphorous were within normal values. Imaging of the lumbar spine and pelvis showed an osteolytic lesion occupying the right sacral wing. Histology was unclear. Reverse-transcription polymerase chain reaction analysis for fibroblast growth factor-23 was positive and confirmed the diagnosis of phosphaturic mesenchymal tumor mixed connective tissues. Preoperative selective arterial embolization and complete intralesional excision, bone grafting, and instrumented fusion from L4 to L5 to the iliac wings bilaterally was performed. Postoperative recovery was uneventful. Neurological deficits were not observed. A lumbopelvic corset was applied for 3 months. At 12 months, the patient was asymptomatic. Serum and urine values of calcium and phosphorous were normal throughout the follow-up evaluation.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopedics, Athens University Medical School, Athens, Greece
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Ito N, Shimizu Y, Suzuki H, Saito T, Okamoto T, Hori M, Akahane M, Fukumoto S, Fujita T. Clinical utility of systemic venous sampling of FGF23 for identifying tumours responsible for tumour-induced osteomalacia. J Intern Med 2010; 268:390-4. [PMID: 20698924 DOI: 10.1111/j.1365-2796.2010.02262.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Amatschek S, Haller M, Oberbauer R. Renal phosphate handling in human--what can we learn from hereditary hypophosphataemias? Eur J Clin Invest 2010; 40:552-60. [PMID: 20412291 DOI: 10.1111/j.1365-2362.2010.02286.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Renal reabsorption of inorganic phosphate is critical for the maintenance of phosphate homeostasis. The sodium dependent phosphate cotransporters NaPi-IIa and NaPi-IIc have been identified to fulfill this task at the brush border membrane of proximal tubule cells. Various factors including dietary phosphate intake, parathyroid hormone, or the so called phosphatonins such as FGF23 have been shown to regulate activity of these transporters. DESIGN This review seeks to give an update on our current knowledge about regulatory mechanisms involved in human renal phosphate reabsorption. RESULTS Recently, an increasing number of genes have been identified that are directly associated with inherited phosphate wasting disorders (Klotho, PHEX, DMP1 and NHERF1). Several of these genes are predominantly expressed by osteocytes and osteoclasts in the bone suggesting indispensable signalling pathways between kidneys and the skeleton. CONCLUSION In this review, the affected gene products in these inherited hypophosphataemias and their contribution to phosphate homeostasis are discussed.
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Ishii A, Imanishi Y, Kobayashi K, Hashimoto J, Ueda T, Miyauchi A, Koyano HM, Kaji H, Saito T, Oba K, Komatsu Y, Kurajoh M, Nagata Y, Goto H, Wakasa K, Sugimoto T, Miki T, Inaba M, Nishizawa Y. The levels of somatostatin receptors in causative tumors of oncogenic osteomalacia are insufficient for their agonist to normalize serum phosphate levels. Calcif Tissue Int 2010; 86:455-62. [PMID: 20458578 DOI: 10.1007/s00223-010-9369-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 04/12/2010] [Indexed: 12/17/2022]
Abstract
Oncogenic osteomalacia (OOM) is a rare disease characterized by renal phosphate wasting and osteomalacia and is caused by the secretion of fibroblast growth factor 23 (FGF-23) from causative tumors. Scintigraphy with octreotide, which binds to somatostatin receptors (SSTRs), is a useful way to locate causative tumors in OOM patients. However, the therapeutic effects of octreotide acetate are still controversial. Two OOM patients were administered octreotide acetate intramuscularly. Ten causative OOM tumors, including two resected from the patients participating in the octreotide administration study, were examined for expression of genes encoding SSTRs by quantitative real-time RT-PCR and immunohistochemistry. Octreotide therapy did not improve hypophosphatemia in either case, despite temporal decreases in FGF-23 levels in one patient. The mean expression levels of SSTR1, SSTR3, and SSTR5 were similar in the OOM and non-OOM tumors. Expression of SSTR2 was significantly higher in the OOM tumors than in the non-OOM tumors. Immunohistochemical examinations revealed the presence of SSTR2A, SSTR2B, and SSTR5 in both the OOM and non-OOM tumors. The expression of SSTR genes in OOM tumors contributes to positive imaging using octreotide scintigraphy. However, the levels of SSTRs seem to be insufficient for the octreotide therapy to improve hypophosphatemia. Further studies are needed to clarify the mechanisms by which FGF-23 secretion from OOM tumors is suppressed by octreotide acetate.
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Affiliation(s)
- Akira Ishii
- Department of Metabolism, Endocrinology & Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
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42
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Brownstein CA, Zhang J, Stillman A, Ellis B, Troiano N, Adams DJ, Gundberg CM, Lifton RP, Carpenter TO. Increased bone volume and correction of HYP mouse hypophosphatemia in the Klotho/HYP mouse. Endocrinology 2010; 151:492-501. [PMID: 19952276 PMCID: PMC2817612 DOI: 10.1210/en.2009-0564] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 10/28/2009] [Indexed: 11/19/2022]
Abstract
Inactivating mutations of PHEX cause X-linked hypophosphatemia and result in increased circulating fibroblast growth factor 23 (FGF23). FGF23 action is dependent upon Klotho, which converts FGF receptor 1 into an FGF23-specific receptor. Disruption of Klotho results in a complex bone phenotype and hyperphosphatemia, the converse phenotype of X-linked hypophosphatemia. We examined effects of disrupting both Klotho and PHEX by creating a double-knockout (Klotho/HYP) mouse. The combined disruption corrected the hypophosphatemia in HYP mice, indicating that Klotho is epistatic to PHEX. FGF23 levels remained elevated in all groups except wild-type, indicating that Klotho is necessary for FGF23-dependent phosphaturic activity. 1,25-Dihydroxyvitamin D levels, reduced in HYP mice, were comparably elevated in Klotho and Klotho/HYP mice, demonstrating that Klotho is necessary for FGF23's effect on vitamin D metabolism. Serum PTH levels were reduced in both Klotho and Klotho/HYP mice. Moreover, the Klotho null phenotype persisted in Klotho/HYP, maintaining the runty phenotype and decreased life span of Klotho null mice. Notably, microcomputed tomography analysis demonstrated greater trabecular bone volume fraction in Klotho/HYP mice than that in all other groups (Klotho/HYP, 56.2 +/- 6.3%; Klotho, 32.5 +/- 10.3%; HYP, 8.6 +/- 7.7%; and wild type, 21.4 +/- 3.4%; P < 0.004). Histomorphometric analysis confirmed the markedly increased trabecular bone density in Klotho/HYP mice and the well-established increase in osteoid volume in HYP mice. These observations suggest that with addition of Klotho loss of function, the overabundant osteoid typically produced in HYP mice (but fails to mineralize) is produced and mineralized in the double knockout, resulting in markedly enhanced trabecular bone density.
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Affiliation(s)
- Catherine A Brownstein
- Department of Genetics, Yale University School of Medicine, 333 Cedar Street, SHM I-308, New Haven, Connecticut 06510, USA
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Abstract
Oncogenic osteomalacia is a rare association between mesenchymal tumors and hypophosphatemic rickets. It is more of a biochemical entity than a clinical one. The pathophysiology of the tumor is not clear. However, it has been seen that the clinical and biochemical parameters become normal if the lesion responsible for producing the osteomalacia is excised. For a clinical diagnosis a high index of suspicion is necessary. We present three such cases where in one the oncogenic osteomalacia reversed while in rest it did not. We present this case report to sensitize about the entity.
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Affiliation(s)
- Ish K Dhammi
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Anil K Jain
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Ajay Pal Singh
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India,Address for correspondence: Dr. Ajay Pal Singh, Residential Complex, D-13. UCMS and GTB Hospital, Dilshad Garden, New Delhi, India. E-mail:
| | - Puneet Mishra
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
| | - Saurabh Jain
- Department of Orthopedics, UCMS and GTB Hospital, Delhi, India
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44
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Woo VL, Landesberg R, Imel EA, Singer SR, Folpe AL, Econs MJ, Kim T, Harik LR, Jacobs TP. Phosphaturic mesenchymal tumor, mixed connective tissue variant, of the mandible: report of a case and review of the literature. ACTA ACUST UNITED AC 2009; 108:925-32. [PMID: 19828339 DOI: 10.1016/j.tripleo.2009.07.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 06/26/2009] [Accepted: 07/02/2009] [Indexed: 12/11/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome that results in renal phosphate wasting with hypophosphatemia. In most cases, the underlying cause of TIO is a small mesenchymal neoplasm that is often difficult to detect, resulting in delayed diagnosis. One such neoplasm is the phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT), an unusual entity with unique morphologic and biochemical features. Most of these tumors are found at appendicular sites with only rare cases reported in the jaws. We describe a PMTMCT involving the mandible in a patient with a protracted history of osteomalacia. A review of the current literature is provided with emphasis on the clinical and histologic features, etiopathogenesis, and management of PMTMCT in the setting of TIO.
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Affiliation(s)
- Victoria L Woo
- Department of Biomedical Sciences, School of Dental Medicine, University of Nevada, Las Vegas, NV 89106, USA.
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45
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Xu M, Zhang Q, Peng D. A distal tibial tumor accompanied by tumor-induced osteomalacia. Orthop Surg 2009; 1:245-9. [PMID: 22009850 DOI: 10.1111/j.1757-7861.2009.00035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Min Xu
- Department of Orthopaedics, Second Xiangya Hospital of Central South University, Changsha, China
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46
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Abstract
Vitamin D deficiency is the most common cause of rickets mainly in breast-fed dark-skinned, African or Asian children receiving inadequate sunlight exposure. We report a case of a 1.5 year-old Afro-Italian male infant living in South Italy who came to our observation with the typical clinical picture of vitamin D deficiency rickets. The child was exclusively breast-fed for 8 months without vitamin D supplements. Owing to the rarity of vitamin D deficiency rickets in the South of Italy he underwent several investigations, which demonstrated the association with an abdominal ganglioneuroblastoma. To our knowledge, ganglioneuroblastoma has never been reported in association with vitamin D deficiency rickets. Although the association between these 2 rare conditions may be coincidental, the protective action of vitamin D against cancer suggests that vitamin D deficiency might have contributed to the development of ganglioneuroblastoma in our patient.
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47
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Habra MA, Jimenez C, Huang SCE, Cote GJ, Murphy WA, Gagel RF, Hoff AO. Expression analysis of fibroblast growth factor-23, matrix extracellular phosphoglycoprotein, secreted frizzled-related protein-4, and fibroblast growth factor-7: identification of fibroblast growth factor-23 and matrix extracellular phosphoglycoprotein as major factors involved in tumor-induced osteomalacia. Endocr Pract 2009; 14:1108-14. [PMID: 19158050 DOI: 10.4158/ep.14.9.1108] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the expression of various phosphaturic factors in the tumor of a patient with tumor-induced osteomalacia (TIO) and to analyze serum levels of fibroblast growth factor (FGF)-23 in TIO and healthy subjects. METHODS We measured serum FGF-23 levels in 2 patients with TIO and 6 healthy volunteers. Expression of FGF-23, matrix extracellular phosphoglycoprotein (MEPE), FGF-7, and secreted frizzled-related protein-4 (sFRP-4) was analyzed in a hemangiopericytoma from a patient with TIO, in a hemangiopericytoma from a patient without TIO, and in various control cell lines. RESULTS Serum FGF-23 levels were substantially higher in patients with TIO in comparison with those in healthy control subjects and normalized with successful resection of the tumor. Tissue expression analysis showed preferential expression of FGF-23 and MEPE in TIO-related hemangiopericytoma, whereas FGF-7 and sFRP-4 were widely expressed in all studied cell lines and tissues. CONCLUSION These results support the use of FGF-23 measurements for the diagnosis and follow-up of patients with TIO. In addition, the specific expression of FGF-23 and MEPE in the TIO-associated tumor suggests an important role of these two phosphatonins in the pathogenesis of TIO. Because of the limited number of patients in our report, further studies are needed to clarify the role of different phosphatonins in the development of the clinical features of TIO.
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Affiliation(s)
- Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Affiliation(s)
- Brendan M Reilly
- Department of Medicine, Weill Cornell Medical Center, New York, NY 10065, USA.
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49
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Gore MO, Welch BJ, Geng W, Kabbani W, Maalouf NM, Zerwekh JE, Moe OW, Sakhaee K. Renal phosphate wasting due to tumor-induced osteomalacia: a frequently delayed diagnosis. Kidney Int 2008; 76:342-7. [PMID: 18668025 DOI: 10.1038/ki.2008.355] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- M Odette Gore
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8885, USA
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50
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Lewiecki EM, Urig EJ, Williams RC. Tumor-induced osteomalacia: lessons learned. ACTA ACUST UNITED AC 2008; 58:773-7. [PMID: 18311810 DOI: 10.1002/art.23278] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Tumor-induced osteomalacia is a rare acquired metabolic disorder characterized by hypophosphatemia and inappropriately low serum levels of 1,25-dihydroxyvitamin D. Symptoms include chronic muscle and bone pain, weakness, and fatigue in association with a high risk of fragility fractures due to osteomalacia. The diagnosis is commonly delayed for years due to the nonspecific nature of the presenting symptoms, failure to include determination of serum phosphorus levels in blood chemistry testing, and difficulty in identifying the responsible tumor. The pathogenesis of tumor-induced osteomalacia involves tumor expression of fibroblast growth factor 23, a hormone that inhibits proximal renal tubular reabsorption of phosphate and down-regulates renal conversion of 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D. The metabolic abnormalities may be partially or completely corrected with phosphate supplementation and calcitriol. A definitive diagnosis and treatment require excision of the responsible tumor.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research and Osteoporosis Center, Albuquerque, NM 87106, USA.
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