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Pang Q, Zhou R, Ni X, Liu Y, Jin J, Wu H, Huo L, Yu W, Chi Y, Li X, Wang O, Li M, Xing X, Jiang Y, Jiajue R, Xia W. Clinical characteristics and surgical outcomes of vertebral lesions associated with tumor-induced osteomalacia: report of 16 patients and review of the literature. Osteoporos Int 2024:10.1007/s00198-024-07178-2. [PMID: 39093437 DOI: 10.1007/s00198-024-07178-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/28/2024] [Indexed: 08/04/2024]
Abstract
Vertebral tumors in patients with tumor-induced osteomalacia (TIO) have a low diagnostic rate and poor postoperative outcomes. The application of 68 Ga-DOTATATE-PET/CT significantly increased the detection rate. Compared with tumor curettage, segmental resection was recommended as the preferred surgical type due to its high recovery rate. PURPOSE Tumor-induced osteomalacia (TIO) is an acquired hypophosphatemic osteomalacia, and surgery is the first-line therapy. Most TIO tumors are found in the bones of the appendicular skeleton, cranium, and paranasal sinuses but rarely in the vertebrae. Tumor curettage and segmental resection are the two main surgical options for vertebral TIO patients. However, research on the clinical characteristics and surgical prognosis of vertebral TIO patients is rare. In the present study, for the first time, we investigated the clinical characteristics of 16 vertebral TIO patients and compared the surgical outcomes of patients who underwent surgery via two different surgical methods. METHODS This was a retrospective cohort study. In this study, we included 16 adult TIO patients with lesions in vertebrae from Peking Union Medical College Hospital (PUMCH), all of whom underwent surgery. Baseline laboratory data were collected through medical records review. Technetium-99 m octreotide scintigraphy (99Tcm-OCT) and 68gallium-DOTA-TATE-positron emission tomography/computed tomography (68 Ga-DOTATATE-PET/CT) were conducted at the Department of Nuclear Medicine of PUMCH. The tumor histopathology was confirmed by a senior pathologist at our center. RESULTS Vertebral TIO patients had lower serum phosphorus and TmP/GFR and higher serum alkaline phosphatase (ALP), serum parathyroid hormone (PTH), and serum C-terminal cross-linked telopeptide of type I collagen (β-CTX) levels than the normal range. The sensitivity of 68 Ga‒DOTATATE PET/CT was 100%, significantly greater than that of 99Tcm-OCT (40%). After comparing the outcomes between the two surgical methods, we found that the recovery rate after segmental resection (62.5%) was greater than that after tumor curettage (12.5%). In the thoracic and sacral vertebrae, segmental resection surgery had a good prognosis. CONCLUSION 68 Ga-DOTATATE PET/CT could serve as the first diagnostic tool in patients with vertebral TIO, and segmental resection could be used as the preferred surgery. This study would raise awareness of the clinical features and management of these rare vertebral TIO patients.
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Affiliation(s)
- Qianqian Pang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Ruotong Zhou
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Xiaolin Ni
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Yong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jin Jin
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Yu
- Department of Radiology, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, PekingBeijing, China
| | - Yue Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Xiang Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
| | - Ruizhi Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China.
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, China
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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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Chen D, Zhang L, Zhang J, Yin M, Gao X, Huang Q, Li L, Yang X. Treatment and Diagnose of Spinal Phosphaturic Mesenchymal Tumor: A Case Report and a Systematic Literature Review. World Neurosurg 2024; 184:65-73. [PMID: 38218444 DOI: 10.1016/j.wneu.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Spinal phosphaturic mesenchymal tumor (PMT) is a rare disorder but can be cured once the diagnosis is clear and a complete removal by surgery is performed. To the best of our knowledge, only 22 cases in the spine have been described, and we report a case with the largest number of spinal segments (T12-L5) affected among spine PMT cases. METHODS A comprehensive literature search was performed until May 23, 2023, following the Preferred Reporting Items for Systematic Reviews guidelines. Studies were chosen through relevant PubMed, Web of Science, and EMBASE searches to prioritize obtaining the largest studies. The Medical Subject Headings and Boolean operators employed for this search were ("PMT" or "TIO" or "Tumor-induced osteomalacia" or "phosphaturic mesenchymal tumor") and ("spine" or "spinal"). Two researchers (L.S.Z. and D.B.C) independently reviewed and evaluated the included articles. Any differing opinions were discussed until a consensus was reached. A total of 18 studies were included. A case report is also presented. RESULTS We report a case of spinal PMT. The full text of the relevant articles was construed. A total of 18 studies were reviewed and consolidated. These articles are roughly divided into the following 5 subcategories: 1) clinical features and baseline distribution, 2) laboratory and imaging findings, 3) pathological manifestations, and 4) surgical methods and treatment options. CONCLUSIONS Spinal PMT is very rare with a high rate of misdiagnosis and debilitating complications, so it is of significance to increase awareness of the disease among spine surgeons consulted by patients with spinal PMT. 68Ga-DOTATOC-PET/CT shows very high sensitivity to the spinal PMT but there is no way to exactly determine the location of the tumor. PMT has unique immunohistochemical characteristics and malignant PMT is rare. Once diagnosed, complete surgical excision is the recommended treatment. Burosumab is one of the available options, especially in cases that are recurrent and difficult to surgically resect.
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Affiliation(s)
- Dingbang Chen
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Luosheng Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Jie Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Mengchen Yin
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xin Gao
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Quan Huang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Lin Li
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xinghai Yang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China.
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Liu S, Zhou X, Liu Y, Zhang J, Xia W. Preoperative evaluation and orthopedic surgical strategies for tumor-induced osteomalacia. J Bone Oncol 2024; 45:100600. [PMID: 38577550 PMCID: PMC10990903 DOI: 10.1016/j.jbo.2024.100600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is very rare, with about 1000 reported cases globally. Removing most TIO culprit tumors requires the evaluation and intervention of orthopedic doctors. However, orthopedic doctors often have a poor understanding of the optical treatment of TIO due to its rarity. In addition, most TIO patients lack specific clinical manifestations. Also, the clinical localization and qualitative diagnosis of TIO are difficult and thus can easily be misdiagnosed and mistreated. Furthermore, the true incidence rate of TIO may be underestimated. Although many breakthroughs have been made in exploring the pathogenesis, clinical diagnosis, and treatment of TIO, rational and standardized orthopedic surgical treatment experience summary and sorting for TIO patients are lacking. In this article, the recent experience and progress in the field of orthopedic surgical treatment for TIO globally have been summarized, providing a theoretical basis and new clinical practice guidance for the rational treatment of TIO patients.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, National Health Commission Key Laboratory of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Cianferotti L, Delli Poggi C, Bertoldo F, Caffarelli C, Crotti C, Gatti D, Giannini S, Gonnelli S, Mazzantini M, Ombretta V, Sella S, Setti A, Varenna M, Zucchi F, Brandi ML. Persistence and recurrence in tumor-induced osteomalacia: A systematic review of the literature and results from a national survey/case series. Endocrine 2022; 76:709-721. [PMID: 35381903 PMCID: PMC9156492 DOI: 10.1007/s12020-022-03039-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Tumor induced osteomalacia (TIO) is a rare disease of mineral metabolism, whose clinical picture is dominated by hypophosphatemia usually due to an excess of circulating FGF23 produced by small mesenchymal tumors. Data on the real prevalence of the disease are lacking, with the knowledge of the disease mainly relying on case reports and small case series. No estimate is available on the prevalence of uncured TIO. METHODS National multi-center, cross-sectional and retrospective study on persistent or recurrent cases of TIO followed in referral centers for bone diseases; systematic review of the published persistent and recurrent cases of TIO. Data from patients consecutively evaluated in referral Italian centers for bone diseases were collected; a PubMed search on persistent, recurrent and unoperable cases of TIO was carried out. RESULTS Sixteen patients (mean age at diagnosis 52.5 ± 10.6 years) with persistent (n = 6, 37,5%), recurrent (n = 7, 43.7%) or not operable (n = 3, 18.8%) TIO were described. Delay in diagnosis (2.5 ± 1.3 years) was demonstrated. All patients experienced fragility fractures or pseudofractures and disabling bone and muscle pain. BMD was significantly reduced (mean T-score -2.7 ± 1.7 and -2.7 ± 0.9 at lumbar spine and femoral neck, respectively). Fourteen patients were maintained under therapy with phosphate salts and calcitriol, while in 2 patients therapy with burosumab, an anti-FGF23 antibody, was commenced. CONCLUSION A significant number of patients with TIO remain either undiagnosed for tumor localization or tumor recur or persist after surgery. These patients with active disease represent possible candidates for burosumab treatment.
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Affiliation(s)
- Luisella Cianferotti
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Bone Metabolic Diseases Unit, University Hospital of Florence, largo Palagi 1, 50139, Florence, Italy
| | - Chiara Delli Poggi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Bone Metabolic Diseases Unit, University Hospital of Florence, largo Palagi 1, 50139, Florence, Italy
| | - Francesco Bertoldo
- Department of Medicine, University of Verona, Piazzale LA Scuro 10, Policlinico GB Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Carla Caffarelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Chiara Crotti
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
| | - Davide Gatti
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, Policlinico G.B. Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Sandro Giannini
- Department of Medicine (DIMED), Clinica Medica Uno, University of Padua, via Nicolò Giustiniani, 2, 35128, Padua, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, Viale Bracci 2, 53100, Siena, Italy
| | - Maurizio Mazzantini
- Rheumatology Unit, and Fracture Liaison Service, University Hospital of Pisa, via Roma 67, 56126, Pisa, Italy
| | - Viapiana Ombretta
- Rheumatology Section, Department of Medicine, University of Verona Hospital Trust, Policlinico G.B. Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Stefania Sella
- Department of Medicine (DIMED), Clinica Medica Uno, University of Padua, via Nicolò Giustiniani, 2, 35128, Padua, Italy
| | - Angela Setti
- Department of Medicine, University of Verona, Piazzale LA Scuro 10, Policlinico GB Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Massimo Varenna
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
| | - Francesca Zucchi
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Via Pini, 9, Milan, 20122, Italy
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Li X, Jiang Y, Huo L, Wu H, Liu Y, Jin J, Yu W, Lv W, Zhou L, Xia Y, Wang O, Li M, Xing X, Chi Y, Jiajue R, Cui L, Meng X, Xia W. Nonremission and Recurrent Tumor-Induced Osteomalacia: A Retrospective Study. J Bone Miner Res 2020; 35:469-477. [PMID: 31643101 PMCID: PMC7140180 DOI: 10.1002/jbmr.3903] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome. It is curable by excision of the causative tumor. However, a few cases may persist or relapse after tumor resection. We aimed to investigate the rate of these events and related factors. We retrospectively studied TIO patients treated with surgery in a tertiary hospital. TIO was established based on a pathologic examination or the reversion of hypophosphatemia. Refractory TIO patients consisted of those with nonremission or recurrent hypophosphatemia after surgery. A total of 230 patients were confirmed as having TIO. After primary surgery, 26 (11.3%) cases persisted, and 16 (7.0%) cases recurred. The overall refractory rate was 18.3%. The median time of recurrence was 33 months. Compared with patients in the recovery group, patients in the refractory group were more likely to be female (59.5% versus 41.0%, p = .029) and have a lower serum phosphate level (0.44 ± 0.13 versus 0.50 ± 0.11 mmol/L, p = .002). The refractory rate was lowest in head/neck tumors (7.5%) and highest in spine tumors (77.8%). Regarding the tissue involved of tumor location, the refractory rate was higher in tumors involving bone than tumors involving soft tissue (32.7% versus 7.0%, p < .001). The outcomes of malignant tumors were worse than those of benign tumors (p < .001): nonremission rate, 21.4% versus 9.7%; recurrence rate, 28.6% versus 6.5%. In the multivariate regression analysis, female sex, spine tumors, bone tissue-involved tumors, malignancy, and low preoperation serum phosphorus levels were identified as risk factors for refractory outcomes. High preoperative fibroblast growth factor 23 (FGF23) levels were also associated with refractory after adjusting for involving tissue and tumor malignancy. In summary, we are the first to report the rate and clinical characteristics of refractory TIO in a large cohort. For patients with multiple risk factors, especially spine tumors, clinical practitioners should be aware of a poor surgical prognosis. © 2019 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Xiang Li
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jin Jin
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Lv
- Department of Ear, Nose, and Throat (ENT), Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu Xia
- Department of Ultrasound Diagnosis, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yue Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruizhi Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lijia Cui
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xunwu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Liu S, Zhou X, Song A, Huo Z, Wang Y, Liu Y. Surgical treatment of recurrent spinal phosphaturic mesenchymal tumor-induced osteomalacia: A case report. Medicine (Baltimore) 2020; 99:e18603. [PMID: 31977851 PMCID: PMC7004693 DOI: 10.1097/md.0000000000018603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Tumor-induced osteomalacia (TIO) is a highly unusual disease with enormous difficulties in clinical diagnosis and curative managements. The objective of this study is to report a very rare case who underwent surgical treatment of recurrent spinal phosphaturic mesenchymal tumor. The management of these unique cases has yet to be further elucidated. PATIENT CONCERNS A 52-year-old man presented with a 3-year history of back pain and 1-year history of continuous and progressive systemic bone pain. The patient, who had been diagnosed of TIO for 3 years, received surgical treatment of extended resection of spinal phosphaturic mesenchymal tumor at L5. Somatostatin receptor tomography revealed the expression of somatostatin in the spine increased significantly, with high suspicion of recurrent phosphaturic mesenchymal tumor. DIAGNOSIS Magnetic resonance imaging of spine and positron emission tomography-computed tomography showed the mass in L5, which was highly indicative of the recurrent pathogenic tumor. Postoperative pathology confirmed the diagnosis of phosphaturic mesenchymal tumor in the spinal region. INTERVENTIONS The patient underwent posterior L5 tumor resection, bone cement reconstruction, L4-S1 spinal canal decompression, and L3-S2 internal fixation. OUTCOMES The patient's symptoms improved significantly after the surgery, and we noticed that his hypophosphatemia was successfully corrected after the 2nd operation. Follow-up at 1 month after surgery revealed no recurrence, and the serum phosphorus level of the patient turned to be normal postoperatively. There were no complications associated with the operation during the follow-up period. LESSONS Taken together, the lesion's clinical features, imaging results, and pathologic characteristics are unique. Combined efforts of specialists from orthopedics, endocrinology, nuclear medicine, radiology, pathology, and medical oncology led to the successful diagnosis and management of this patient. TIO, although rare, should be part of the differential diagnosis when the patient has a history of hypophosphatemia and systemic multiple bone pain. We recommend surgical treatment of the phosphaturic mesenchymal tumor in the spinal region. Osteoplasty by bone cement may be a treatment option for patients with TIO who cannot undergo appropriate surgery or decline open surgery.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Zhen Huo
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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Infiltrative nature of tumor-induced osteomalacia lesions in bone: Correlation between radiological and histopathological features. J Orthop Sci 2019; 24:900-905. [PMID: 30797665 DOI: 10.1016/j.jos.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/29/2019] [Accepted: 02/04/2019] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Tumor-induced osteomalacia is a rare paraneoplastic syndrome usually caused by phosphaturic mesenchymal tumors, which commonly occur in bone. This study aimed to investigate the radiological features of tumor-induced osteomalacia lesions in bone, and their correlation with its histopathology. MATERIALS AND METHODS This study included 13 patients with tumor-induced osteomalacia treated between January 2000 and April 2018 at our hospital. All patients were surveyed to detect the tumor causing the condition. Diagnostic imaging studies of the suspected tumors were obtained before tumor removal. We evaluated the radiological features of all tumors, investigated histopathological findings in 10 cases that underwent surgery, and obtained evaluable tumor specimens. RESULTS The tumors were classified into the following three types by CT: sclerotic (n = 4), lytic (n = 7), and mixed (n = 2). In two cases, lytic lesions focally invaded the surrounding cancellous bone, detected by the soft tissue-window of CT, not the bone-window. Histopathology revealed inter-trabecular invasion in all cases, regardless of radiological features. Osteoclasts were seen in lytic types, and creeping substitution-like thickened trabecular bone and calcification were observed in sclerotic types. In all cases, focal invasion of the tumor into cortical bone was seen. CONCLUSIONS Tumor-induced osteomalacia lesions in bone showed a wide variety of radiological features, and tended to invade into cancellous and cortical bone. These findings suggest that extended curettage or resection of thinned cortical bone may be necessary. This might improve the cure rate of surgeries for tumor-induced osteomalacia lesions in bones.
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Liu S, Zhou X, Song A, Huo Z, Wang Y, Xia W, Liu Y. Successful treatment of tumor-induced osteomalacia causing by phosphaturic mesenchymal tumor of the foot. Medicine (Baltimore) 2019; 98:e16296. [PMID: 31277164 PMCID: PMC6635285 DOI: 10.1097/md.0000000000016296] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Tumor-induced osteomalacia causing by phosphaturic mesenchymal tumor of the foot is exceedingly rare, thus may bring great challenges to the timely and proper diagnosis and treatment of clinicians. The only definitive management is removal of the phosphaturic mesenchymal tumor completely. The objective of this article is to report 2 unusual cases with tumor-induced osteomalacia causing by phosphaturic mesenchymal tumor of the foot.We describe 2 patients with phosphaturic mesenchymal tumor involving the foot who were successfully treated with tumor resection. On presentation to our institution, the patients both had signs of severe osteomalacia, and the patients' most outstanding complaints were diffuse bone pain, general weakness, and disabled walking. A 53-year-old female underwent surgical excision of pathogenic tumor on the sole of left foot. A 62-year-old female underwent complete excision of pathogenic tumor of right plantar. The patients showed appropriate destruction of the tumor, adequate pain relief, and the elevated blood phosphorus levels compared with the previous status.Surgical resection is the most effective treatment option for patients with tumor-induced osteomalacia who can undergo appropriate surgical treatment. This represents a safe and reasonable approach to sustainably relieve pain and other symptoms with tumor-induced osteomalacia in the foot.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Zhen Huo
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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Spinal phosphaturic mesenchymal tumors: Case report and literature review. J Clin Neurosci 2019; 63:234-239. [DOI: 10.1016/j.jocn.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/04/2019] [Indexed: 01/08/2023]
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Li Y, Li Y, Hui M, Liu Y, Liu X, Jin J, Gao P. Comparison of surgical treatments of tumor-induced osteomalacia in different locations in the lower limbs: A retrospective study. Medicine (Baltimore) 2019; 98:e14846. [PMID: 30882679 PMCID: PMC6426539 DOI: 10.1097/md.0000000000014846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare disease that behaves benignly. Very few reports about the features of the responsible tumors according to anatomical locations have been presented.In this retrospective study of 53 patients with TIO-associated tumors in the foot/ankle, tibia and femur, we compared preoperative, postoperative, and follow-up courses, including alkaline phosphatase, phosphorus, and fibroblast growth factor 23, to compare the characteristics of TIO-associated tumors in these 3 locations (level of evidence: therapeutic level III).Patients in the foot/ankle group had longer disease courses and therefore a significantly higher complication rate (P < .001). All TIO-associated tumors in the foot/ankle group involved soft tissue (P = .021), whereas most lesions in the tibia group involved bone, and therefore had much higher concentrations of alkaline phosphatase (P = .020). Additionally, serum phosphorus took much longer to normalize after surgery in the foot/ankle group than that in the other 2 groups (P = .004). Consequently, symptom remission was much better in the tibia and femur groups (P = .008). Moreover, the Ki 67 index in TIO-associated tumors was significantly higher in the foot/ankle group (P < .001) and the recurrence rate in this group was markedly higher (P = .002).The TIO-associated tumors in the foot/ankle are characteristically of occult onset, more soft-tissue involvement, and more readily recurrence. More knowledge and examinations are necessary to enable early diagnosis, radical treatments, and minimize recurrence. New therapies are welcomed and needed.
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Affiliation(s)
- Ye Li
- Department of Orthopedics
| | | | - Min Hui
- Department of Internal Medicine
| | | | - Xiaoding Liu
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
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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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