1
|
Mammu S, Veluthedath R, Chacko VHN, Sabique MP, Uwais P, Hussain KN. A Rare Case of Phosphaturic Mesenchymal Tumor Distal Femur in a Young Female. J Orthop Case Rep 2024; 14:36-40. [PMID: 39253663 PMCID: PMC11381056 DOI: 10.13107/jocr.2024.v14.i09.4720] [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: 06/08/2024] [Revised: 07/14/2024] [Indexed: 09/11/2024] Open
Abstract
Introduction Phosphaturic mesenchymal tumors (PMTs) are rare bone neoplasms with diverse clinical presentations, often posing diagnostic challenges. Case Report We describe the case of a 37-year-old female schoolteacher with a PMT localized in the distal femur. Diagnostic indicators included hypophosphatemia, hyperphosphaturia, elevated fibroblast growth factor-23 levels, and clinical symptoms of osteomalacia. Surgical management involved tumor resection and limb salvage surgery with a megaprosthesis. The post-operative period was uneventful, leading to a stable discharge. On follow-up, the patient showed no signs of recurrence, regained full ambulation, remained pain-free, and resumed teaching comfortably. Conclusion This case highlights the importance of considering PMT in patients with unusual clinical symptoms, accompanied by hypophosphatemia, hyperphosphaturia, and osteomalacia, and demonstrates successful surgical management, leading to a favorable outcome.
Collapse
Affiliation(s)
- Sharafuddeen Mammu
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| | - Ravikumar Veluthedath
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| | - V H Nidhin Chacko
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| | - M P Sabique
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| | - P Uwais
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| | - K Nejil Hussain
- Department of Orthopaedic Surgery, Government Medical College, Kozhikode, Kerala, India
| |
Collapse
|
2
|
Parameshwar VC, Rekhi B, Duggad A, Ramadwar M. Phosphaturic mesenchymal tumor: Clinicopathological features with outcomes in 10 patients with review of literature. INDIAN J PATHOL MICR 2024; 67:306-311. [PMID: 38394416 DOI: 10.4103/ijpm.ijpm_295_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal tumors, associated with long-standing, non-specific but often debilitating symptoms in the affected patients. These tumors display characteristic histopathological features and in case, identified timely, can be a boon for patients, given an excision is completely curative. AIMS To evaluate the clinical and histopathological features of 10 PMTs, diagnosed at our institution, along with clinical outcomes in those patients. MATERIALS AND METHODS This was a retrospective study, wherein 10 PMTs, diagnosed from January 2013 to July 2022, were included. RESULTS The average age at the time of diagnosis was 40 years with an M:F ratio of 4:1. Clinical features included lumps, weakness, bone pain, difficulty in moving and walking, and pathologic fractures. The biochemical analysis showed normal serum calcium levels (average = 9.5 mg/dL), with low serum phosphorus (average = 2.2 mg/dL) and raised serum fibroblast growth factor 23 (FGF23) levels, in all the cases, wherever available. On histopathology, all tumors showed cells arranged in a hemangiopericytomatous pattern, including oval to short spindle forms. Multinucleate giant cells were present in nine tumors, and characteristic "grungy calcifications" was observed in eight tumors. Prominent pseudo cystic spaces were seen in eight tumors. A significant number of mitotic figures and tumor necrosis were not seen in any tumor. In five cases where follow-up was available, there was complete resolution of symptoms post-resection with no recurrence or metastasis. All those patients were free of disease until the last follow-up. CONCLUSION This constitutes the first largest comprehensive study on these rare tumors from our country. PMTs can be diagnosed based on certain histopathological features and correlation with clinicoradiological and biochemical findings. These are invariably benign neoplasms. Patients are relieved of their debilitating symptoms after adequate surgical tumor resection. Therefore, their correct and timely diagnosis is crucial.
Collapse
Affiliation(s)
| | - Bharat Rekhi
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
| | - Ashwini Duggad
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
| | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
| |
Collapse
|
3
|
Montazer M, Meibodi NT, Teymouri E, Mousavi Z, Reisian S, Ebrahimnejad M. Prolonged generalized osteomalacia associated with a sinonasal cavity phosphaturic mesenchymal tumor: A case report. Clin Case Rep 2024; 12:e8448. [PMID: 38292224 PMCID: PMC10825882 DOI: 10.1002/ccr3.8448] [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: 08/28/2023] [Revised: 12/23/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare disorder primarily affecting the extremities. It is notable for its correlation with hypophosphatemic osteomalacia and high FGF23 serum levels, which results in renal phosphate wasting and clinical symptoms associated with low serum phosphorus. We presented a patient with a 5-year history of progressive osteomalacia who recently experienced a major pathological bone fracture. Laboratory findings showed a persistent low serum phosphate, normal calcium, elevated alkaline phosphatase activity, high parathyroid hormone levels, and increased renal excretion of phosphate. According to ultrasonography and nuclear imaging, there was no evidence of parathyroid adenoma. During further diagnostic assessment, a sinonasal cavity tumor was found and resected. Histologically, the tumor was composed of bland spindle cell proliferation in the background of a calcified matrix with foci of osteoid formation, hemangiopericytoma-like (HPC-like) vasculature, and osteoclast-like giant cells. Tumor cells showed variable positivity for SMA, but CD34, S100, CD99, Melan-A, p63, and desmin were all nonreactive. Regarding the clinical context, histological and immunohistological findings, a final diagnosis of tumor-induced osteomalacia (TIO) secondary to a PMT was made. After surgery, laboratory results returned to normal, clinical symptoms disappeared, and the patient did not experience a recurrence during a six-month follow-up.
Collapse
Affiliation(s)
- Mehdi Montazer
- Department of PathologyMashhad University of Medical SciencesMashhadIran
| | - Naser Tayyebi Meibodi
- Cutaneous Leishmaniasis Research CenterMashhad University of Medical SciencesMashhadIran
| | - Elmira Teymouri
- Department of PathologyMashhad University of Medical SciencesMashhadIran
| | - Zohreh Mousavi
- Metabolic Syndrome Research CenterMashhad University of Medical SciencesMashhadIran
| | - Sedigheh Reisian
- Metabolic Syndrome Research CenterMashhad University of Medical SciencesMashhadIran
| | | |
Collapse
|
4
|
Zhang Y, Wang P, Jing H. Lung Nodule as Culprit Lesion Causing Recurrent Tumor-Induced Osteomalacia Revealed by 68Ga-DOTATATE PET/CT. Clin Nucl Med 2023:00003072-990000000-00643. [PMID: 37486706 DOI: 10.1097/rlu.0000000000004771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
ABSTRACT Neoplasms that cause tumor-induced osteomalacia are very rarely located in the lung. A 27-year-old man underwent a surgery in the right femoral head to remove the tumor that induced osteomalacia 8 years ago with complete symptomatic relief. However, his bone pain occurred again recently, which lead to suspicion of a recurrent tumor-induced osteomalacia. 68Ga-DOTATATE PET/CT images showed a pulmonary nodule with mildly increased uptake along with increased activity in the left foot. The pulmonary nodule was subsequently resected and was pathologically confirmed as a phosphaturic mesenchymal tumor. The symptoms were completely relieved postsurgery.
Collapse
Affiliation(s)
- Yuwei Zhang
- From the Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, BeijingKey Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | | | | |
Collapse
|
5
|
Liu Y, He H, Zhang C, Zeng H, Tong X, Liu Q. Phosphaturic Mesenchymal Tumors: Rethinking the Clinical Diagnosis and Surgical Treatment. J Clin Med 2022; 12:jcm12010252. [PMID: 36615052 PMCID: PMC9821698 DOI: 10.3390/jcm12010252] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The diagnosis of phosphaturic mesenchymal tumors (PMT) is easily delayed clinically, and their surgical treatment is unstandardized. This study aimed to evaluate our experience in the diagnosis and treatment of PMT and provide a research basis for the accurate and standardized treatment of PMT. MATERIALS AND METHODS Twelve patients diagnosed with PMT in our department and who underwent surgical treatment were included in this study. Preoperative demographic and clinical information were recorded. CT, MRI, and technetium-99m (Tc99m)-octreotide PET/CT imaging techniques were used to evaluate the general conditions and lesion boundaries of the tumors. Surgical treatment was performed using radical resection and microwave ablation-assisted extended curettage according to the lesion location and size. Patients were strictly followed up with and evaluated for oncological prognosis, radiological results, bone healing, serum ion levels, limb function, and pain level; the occurrence of complications was also recorded. RESULTS Three patients underwent radical resection, and nine underwent microwave ablation-assisted extended curettage. The average duration of symptoms in this group was 1.5 years (9-35 months) before diagnosis. Serum phosphate and AKP levels returned to normal one and two weeks postoperatively, respectively. There was no apparent specificity in the pathological findings; however, the immunohistochemistry of FGF-23 was positive, and the original fracture sites were effectively healed during the follow-up. The limb function and pain scores were significantly improved. The MSTS score increased from 15.3 to 29.0, and the VAS score decreased from 5.3 to 0.4. All patients recovered, and 90% resumed their original jobs. CONCLUSIONS Accurate diagnosis and standardized surgical treatment are crucial to achieving a clinical cure for PMT. Combining clinical manifestations, biochemical examinations, imaging characteristics, and pathological findings is an effective way to diagnose PMT accurately. Radical resection and microwave ablation-assisted extended curettage are reliable surgical treatment methods for PMT.
Collapse
Affiliation(s)
- Yupeng Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Hongbo He
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Can Zhang
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
| | - Hao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
| | - Xiaopeng Tong
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
| | - Qing Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha 410008, China
- Correspondence: ; Tel.: +86-1820-742-5349
| |
Collapse
|
6
|
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.
Collapse
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
| | | |
Collapse
|
7
|
Benson JC, Trejo-Lopez JA, Nassiri AM, Eschbacher K, Link MJ, Driscoll CL, Tiegs RD, Sfeir J, DeLone DR. Phosphaturic Mesenchymal Tumor. AJNR Am J Neuroradiol 2022; 43:817-822. [PMID: 35589138 DOI: 10.3174/ajnr.a7513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/17/2022] [Indexed: 11/07/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are neoplasms associated with tumor-induced osteomalacia. Patients typically present with pathologic fractures in the setting of chronic hypophosphatemic hyperphosphaturic osteomalacia, as well as gradual muscle weakness, bone pain, and difficulty walking. Because of their rarity and nonspecific symptomatology, phosphaturic mesenchymal tumors often go undiagnosed for years. Even when discovered on imaging, the tumors can be diagnostically challenging for radiologists. Phosphaturic mesenchymal tumors often tend to be small and can be located nearly anywhere in the body, and, therefore, can mimic many other tumors. This case highlights the imaging and pathologic markers of a phosphaturic mesenchymal tumor, often found in a patient with tumor-induced osteomalacia.
Collapse
Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., D.R.D.)
| | | | | | - K Eschbacher
- Laboratory Medicine and Pathology (J.A.T.-L., K.E.)
| | | | | | - R D Tiegs
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - J Sfeir
- Endocrinology (R.D.T., J.S.), Mayo Clinic, Rochester, Minnesota
| | - D R DeLone
- From the Departments of Radiology (J.C.B., D.R.D.)
| |
Collapse
|
8
|
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
|
9
|
Brandi ML, Clunie GPR, Houillier P, Jan de Beur SM, Minisola S, Oheim R, Seefried L. Challenges in the management of tumor-induced osteomalacia (TIO). Bone 2021; 152:116064. [PMID: 34147708 DOI: 10.1016/j.bone.2021.116064] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/16/2022]
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare acquired paraneoplastic disease, which is challenging to diagnose and treat. TIO is characterized by hypophosphatemia resulting from excess levels of tumor-secreted fibroblast growth factor 23 (FGF23), one of the key physiological regulators of phosphate metabolism. Elevated FGF23 results in renal phosphate wasting and compromised vitamin D activation, ultimately resulting in osteomalacia. Patients typically present with progressive and non-specific symptoms, including bone pain, multiple pathological fractures, and progressive muscle weakness. Diagnosis is often delayed or missed due to the non-specific nature of complaints and lack of disease awareness. Additionally, the disease-causing tumour is often difficult to detect and localize because they are often small, lack localizing symptoms and signs, and dwell in widely variable anatomical locations. Measuring serum/urine phosphate should be an inherent diagnostic component when assessing otherwise unexplained osteomalacia, fractures and weakness. In cases of hypophosphatemia with inappropriate (sustained) phosphaturia and inappropriately normal or frankly low 1,25-dihydroxy vitamin D, differentiation of the potential causes of renal phosphate wasting should include measurement of FGF23, and TIO should be considered. While patients experience severe disability without treatment, complete excision of the tumour is typically curative and results in a dramatic reversal of symptoms. Two additional key current unmet needs in optimizing TIO management are: (1 and 2) the considerable delay in diagnosis and consequent delay between the onset of symptoms and surgical resection; and (2) alternative management. These may be addressed by raising awareness of TIO, and taking into consideration the accessibility and variability of different healthcare infrastructures. By recognizing the challenges associated with the diagnosis and treatment of TIO and by applying a stepwise approach with clear clinical practice guidelines, patient care and outcomes will be improved in the future.
Collapse
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.
| |
Collapse
|
10
|
Liang JF, Li ZY, Nong DX, Tang AZ. A pediatric case of a phosphaturic mesenchymal tumor: A “nonphosphaturic” variant in the infratemporal skull base. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
11
|
Qin H, Zeng H, Li H, Yuan S, Yang J. Malignant phosphaturic mesenchymal tumor-ossifying fibroma-like subtype: a case report and literature review. BMC Musculoskelet Disord 2021; 22:677. [PMID: 34376178 PMCID: PMC8356443 DOI: 10.1186/s12891-021-04558-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 07/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A phosphaturic mesenchymal tumor (PMT) is classified into four histological subtypes: mixed connective tissue, osteoblast-like, non-ossifying fibroma-like, and ossifying fibroma-like. The ossifying fibroma-like subtype being extremely rare. Most PMTs are benign, with a minimal number becoming malignant after recurrence. In this study, we report a case of recurrence and malignant transformation of PMT-ossifying fibroma-like subtype in the left hip bone. CASE PRESENTATION Here, we report the clinical manifestations, histology, pathological features, and treatment of a 57-year-old Chinese woman with a recurrent and malignant ossifying fibroma-like subtype PMT of the left iliac bone. The tumor was first discovered 3 years ago when the patient underwent surgery to remove the tumor. Precisely 2 years and 6 months after the operation, the pain in the left hip reappeared. After 6 months, the patient went to our hospital for treatment. After the tumor resection, the postoperative symptoms improved significantly, and the serum alkaline phosphatase level returned to normal. Based on clinical manifestations, evaluation of serum biochemical indicators, X-ray examination, computerized tomography scan of the pelvis, and histopathological examination of the two operations, the patient was finally diagnosed with a recurring and malignant transformation of the left iliac bone phosphaturic mesenchymal tumor-ossifying fibroma-like subtype. No tumor recurrence was found during the follow-up 15 months after the operation. CONCLUSIONS This case increases the awareness of a rare malignant subtype of PMT and provides a valuable reference for the diagnosis of this disease.
Collapse
Affiliation(s)
- Hongyu Qin
- The First Affiliated Hospital of Guangxi Medical University, Shuangyong Rd, Qingxiu District, Nanning, GuangXi, China
| | - Hao Zeng
- The First Affiliated Hospital of Guangxi Medical University, Shuangyong Rd, Qingxiu District, Nanning, GuangXi, China
| | - Hao Li
- The First Affiliated Hospital of Guangxi Medical University, Shuangyong Rd, Qingxiu District, Nanning, GuangXi, China
| | - Shuangshuang Yuan
- The First Affiliated Hospital of Guangxi Medical University, Shuangyong Rd, Qingxiu District, Nanning, GuangXi, China
| | - Jinsong Yang
- The First Affiliated Hospital of Guangxi Medical University, Shuangyong Rd, Qingxiu District, Nanning, GuangXi, China.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Xian MF, Pan KM, Zhang JC, Cheng MQ, Huang H, Chen LD, Zhao ZX, Wang W. Application of ultrasound-guided biopsy and percutaneous radiofrequency ablation in 2 cases with phosphaturic mesenchymal tumor and literature review. Clin Hemorheol Microcirc 2021; 77:61-69. [PMID: 32924995 DOI: 10.3233/ch-200921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a vanishingly rare paraneoplastic syndrome which is usually caused by phosphaturic mesenchymal tumors (PMTs). The conventional treatment for PMTs is total resection, and ultrasound-guided radiofrequency ablation (RFA) can also be used for the treatment of PMTs patients, especially for patients in whom complete resection may lead to serious complications. We report two cases with PMT who presented syndrome with progressive musculoskeletal complaints and performed ultrasound-guided biopsy and RFA. Ultrasound-guided RFA, which is a safe and effective minimally invasive treatment option, appears to be a valuable alternative to surgery for patients presenting with PMT. We are the first reported case of RFA guided by ultrasonography in the treatment of PMT.
Collapse
Affiliation(s)
- Meng-Fei Xian
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kang-Ming Pan
- Department of Hepatobiliary Surgery, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian-Chao Zhang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mei-Qing Cheng
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hui Huang
- Department of Medical Ultrasounics, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li-Da Chen
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhen-Xian Zhao
- Department of Hepatobiliary Surgery, East Division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Ultrasomics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
14
|
Kato A, Nakamoto Y, Ishimori T, Hayakawa N, Ueda M, Temma T, Sano K, Shimizu Y, Saga T, Togashi K. Diagnostic performance of 68Ga-DOTATOC PET/CT in tumor-induced osteomalacia. Ann Nucl Med 2021; 35:397-405. [PMID: 33582980 DOI: 10.1007/s12149-021-01575-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia (TIO) is caused by typically small tumors that secrete fibroblast growth factor 23 (FGF23). As tumor resection is the only effective treatment for TIO, it is important to detect the culprit tumor. We aimed to assess the utility of 68Gallium-DOTA-D-Phe(1)-Tyr(3)-octreotide (68Ga-DOTATOC) PET/CT in TIO and the correlation between biochemical parameters and the PET/CT results. METHODS Thirty-five patients with clinically suspected TIO who had undergone 68Ga-DOTATOC PET/CT were retrospectively analyzed. 68Ga-DOTATOC PET/CT results were compared with biochemical parameters and the final diagnosis, including histopathology. RESULTS 68Ga-DOTATOC PET/CT detected focal uptake consistent with TIO in 21/35 patients, one of which was considered false positive. In 16 patients, the cause of osteomalacia was confirmed histologically as phosphaturic mesenchymal tumor (n = 15) or fibrous dysplasia (n = 1). The other four patients were judged clinically as true positive by subsequent MRI and the clinical course. Overall, the detection rate of 68Ga-DOTATOC PET/CT was 57% (20/35). Median tumor maximum standardized uptake value (SUVmax) was 6.9 (range 1.5-37.7). There was no significant difference in serum intact FGF23 level between DOTATOC-positive and DOTATOC-negative cases, and no significant correlation was observed between intact FGF23 level and tumor SUVmax. CONCLUSIONS 68Ga-DOTATOC PET/CT was clinically useful in detecting culprit tumors and subsequent patient management in TIO.
Collapse
Affiliation(s)
- Ayako Kato
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takayoshi Ishimori
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Nobuyuki Hayakawa
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Diagnostic Imaging, Kyoto City Hospital, Kyoto, Japan
| | - Masashi Ueda
- Department of Biofunction Imaging Analysis, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Takashi Temma
- Department of Biofunctional Analysis, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Kohei Sano
- Laboratory of Biophysical Chemistry, Kobe Pharmaceutical University, Kobe, Japan
| | - Yoichi Shimizu
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tsuneo Saga
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine Kyoto University, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| |
Collapse
|
15
|
Sun L, Dehner C, Kenney J, McNulty SM, Zhu X, Pfeifer JD, Maluf HM, Chrisinger JSA. Clinicopathologic and molecular features of six cases of phosphaturic mesenchymal tumor. Virchows Arch 2020; 478:757-765. [PMID: 33151412 DOI: 10.1007/s00428-020-02963-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/19/2020] [Accepted: 10/30/2020] [Indexed: 12/31/2022]
Abstract
Phosphaturic mesenchymal tumors (PMT) are rare neoplasms characterized by secretion of FGF23, resulting in renal phosphate wasting and osteomalacia. This tumor-induced osteomalacia (TIO) is cured by complete resection; thus, diagnosis is important, particularly on biopsy. Although PMT have a classic histologic appearance of bland spindled cells with conspicuous vascular network and characteristic smudgy basophilic matrix, there is a broad histologic spectrum and variant histologic patterns can make recognition difficult. Recent studies have demonstrated FN1-FGFR1 and FN1-FGF1 gene fusions in PMT; however, approximately 50% of cases are negative for these fusions. We sought to characterize 6 cases of PMT in-depth, compare fusion detection methods, and determine whether alternative fusions could be uncovered by targeted RNA sequencing. Of the 6 cases of PMT in our institutional archive, 3 were not given diagnoses of PMT at the time of initial pathologic examination. We characterized the immunoprofile (SMA, D2-40, CD56, S100 protein, desmin, SATB2, and ERG) and gene fusion status (FN1 and FGFR1 rearrangements by fluorescent in situ hybridization (FISH) and two targeted RNA sequencing approaches) in these cases. Tumors were consistently positive for SATB2 and negative for desmin, with 5/6 cases expressing ERG and CD56. One specimen was acid-decalcified and failed FISH and RNA sequencing. We found FN1 gene rearrangements by FISH in 2/5 cases, and a FN1-FGFR1 fusion by targeted RNA sequencing. No alternative gene fusions were identified by RNA sequencing. Our findings suggest that IHC and molecular analysis can aid in the diagnosis of PMT, guiding excision of the tumor and resolution of osteomalacia.
Collapse
Affiliation(s)
- Lulu Sun
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Carina Dehner
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Jason Kenney
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Samantha M McNulty
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Xiaopei Zhu
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - John D Pfeifer
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Horacio M Maluf
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - John S A Chrisinger
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA.
| |
Collapse
|
16
|
El-Karim GA, Almalki Y, Alolabi B. Stumbling upon the unexpected: A unique presentation of phosphaturic mesenchymal tumor in the hindfoot. Radiol Case Rep 2020; 15:858-862. [PMID: 32382367 PMCID: PMC7200620 DOI: 10.1016/j.radcr.2020.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022] Open
Abstract
We describe an unexpected and unique case of phosphaturic mesenchymal tumor in a 38-year-old female presenting with a painful lump in the plantar hindfoot. Phosphaturic mesenchymal tumors are extremely rare, generally benign soft tissue or osseous tumors, which are associated with overexpression of fibroblast growth factor-23 and tumor-associated osteomalacia. Patients often present with progressive signs and symptoms including systemic bone pain, muscle weakness, and insufficiency fractures, and timely diagnosis is paramount to appropriate therapy. Tumor resection is almost always curative with normalization of laboratory markers and resolution of symptomatology.
Collapse
Affiliation(s)
- Ghassan Awad El-Karim
- University of Toronto, Faculty of Medicine, 1 King's College Circle, 63 McCaul St 4th floor, Toronto, ON M5S 1A8, Canada
| | - Youssef Almalki
- Department of Radiology, Bluewater Health, Sarnia, ON, Canada
| | - Bashar Alolabi
- Department of Surgery, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| |
Collapse
|
17
|
Oyama N, Kojima-Ishii K, Toda N, Matsuo T, Tocan V, Ohkubo K, Oba U, Koga Y, Setsu N, Yamada Y, Kohashi K, Nakashima Y, Oda Y, Ihara K, Ohga S. Malignant transformation of phosphaturic mesenchymal tumor: a case report and literature review. Clin Pediatr Endocrinol 2020; 29:69-75. [PMID: 32313375 PMCID: PMC7160461 DOI: 10.1297/cpe.29.69] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/26/2019] [Indexed: 11/12/2022] Open
Abstract
Phosphaturic mesenchymal tumor, mixed connective tissue variant (PMT-MCT) causes
tumor-induced osteomalacia (TIO). Most cases follow a benign clinical course, with rare
occurrences of malignant transformation. We report a case of malignant PMT-MCT and review
previous malignant cases to identify predictive factors for transformation. A 13-yr-old
female, who presented with hypophosphatemic rickets, elevated serum intact fibroblast
growth factor 23 (FGF23) levels, and a nodule in the back, received a diagnosis of TIO
because of the benign PMT histopathology. After resection of the primary tumor, regular
imaging analyses did not indicate any relapse. At 17 years of age, a tumor developed in
the left leg and increased in size. The resected tumor showed a histopathology of
pleomorphic sarcoma positive for the TP53 mutation. Despite amputation of
the affected leg, the patient died due to multiple metastases at 18 years of age. A
literature review revealed that 14 out of 15 reported malignant PMT-MCT tumors occurred in
adults, and found no predictive factors for malignant transformation and treatment
outcome. Changes in size or number of the tumors along with intact FGF23 levels have been
considered as the only sign of malignant transformation. This pediatric case report and
literature review indicate the need for prolonged regular monitoring for PMT-MCT.
Collapse
Affiliation(s)
- Noriko Oyama
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kanako Kojima-Ishii
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naoko Toda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Terumichi Matsuo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Vlad Tocan
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiro Ohkubo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Utako Oba
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nokitaka Setsu
- Department of Orthopedics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuichi Yamada
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Kohashi
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuharu Nakashima
- Department of Orthopedics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ihara
- Department of Pediatrics, Oita University Faculty of Medicine, Yufu, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
18
|
Kawthalkar AS, Janu AK, Deshpande MS, Gala KB, Gulia A, Puri A. Phosphaturic Mesenchymal Tumors from Head to Toe: Imaging Findings and Role of the Radiologist in Diagnosing Tumor-Induced Osteomalacia. Indian J Orthop 2020; 54:215-223. [PMID: 32257040 PMCID: PMC7096593 DOI: 10.1007/s43465-019-00005-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/11/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed at evaluating the imaging findings of phosphaturic mesenchymal tumors and tumor-induced osteomalacia and assess the clinical and biochemical profiles of patients with tumor-induced osteomalacia. MATERIALS AND METHODS Imaging findings in six patients with tumor-induced osteomalacia and histopathologically proven phosphaturic mesenchymal tumors were evaluated. Clinical and biochemical profiles of these patients were also assessed. RESULTS Along with having a characteristic biochemical profile, patients with phosphaturic mesenchymal tumors also have certain imaging findings which can aid in the diagnosis such as increased uptake on DOTA PET-CT and homogeneous post-contrast enhancement on CT and MRI. CONCLUSION Patients with tumor-induced osteomalacia have characteristic symptoms, imaging and biochemical profiles. For radiologists, raising the suspicion of a phosphaturic mesenchymal tumor in patients with refractory hypophosphatemic osteomalacia as well as localizing the tumor on imaging is crucial, as complete excision of the tumor leads to resolution of the osteomalacia and the patient's clinical symptoms.
Collapse
Affiliation(s)
- Ameya S. Kawthalkar
- grid.413283.f0000 0001 2152 2922Department of Radiology, Grant Medical College and Sir JJ Hospital, Mumbai, India
| | - Amit K. Janu
- grid.410871.b0000 0004 1769 5793Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mrunmayee S. Deshpande
- grid.413161.00000 0004 1766 9130Department of General Medicine, Topiwala Nair Medical College and BYL Nair Hospital, Mumbai, India
| | - Kunal B. Gala
- grid.410871.b0000 0004 1769 5793Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Ashish Gulia
- grid.410871.b0000 0004 1769 5793Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, India
| | - Ajay Puri
- grid.410871.b0000 0004 1769 5793Bone and Soft Tissue Services, Tata Memorial Hospital, Mumbai, India
| |
Collapse
|
19
|
Phosphaturic Mesenchymal Tumor of Soft Tissue of the Foot: Report of a Case With Review of the Literature. Adv Anat Pathol 2019; 26:320-328. [PMID: 31261249 DOI: 10.1097/pap.0000000000000240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm that ectopically secretes fibroblast growth factor 23, a bone cell-derived protein that regulates phosphate homeostasis. The overproduction of fibroblast growth factor 23 causes a paraneoplastic syndrome characterized by hyperphosphaturia, hypophosphatemia, hypovitaminosis D, and vitamin D refractory rickets/osteomalacia, effects that disappear with tumor removal. The PMT may occur in several anatomic regions, mainly in the limbs, usually involving both soft tissue and bone. Acral locations occur in 10% to 15% of the cases, mostly in the feet, with 95 cases reported in this anatomic region to date. We report a case of a PMT in a young adult male who presented in 2007 with the classic constellation of signs and symptoms. A small soft-tissue tumor was detected in his right heel, 3 years after exhaustively seeking for it by various imaging techniques performed at different institutions. Before the tumor was detected, attempts to manage this patient's osteomalacia with phosphate and vitamin D (both calcitriol and ergocalciferol) supplementation were unsuccessful. Following surgical resection, the patient experienced prompt correction of the phosphaturia and gradual reconstitution of his bone mineralization. The pathologic diagnosis was (benign) PMT, mixed connective tissue type. In 2019, 12 years after resection, the patient is asymptomatic, and his bone mineral homeostasis has been restored.
Collapse
|
20
|
|
21
|
Tumor-induced osteomalacia – Current imaging modalities and a systematic approach for tumor localization. Clin Imaging 2019; 56:114-123. [DOI: 10.1016/j.clinimag.2019.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
|
22
|
Shenbaghavalli T, Harshavardhan JKG, Menon PG. A Rare Case of Phosphaturic Tumor/Oncogenic Osteomalacia - Diagnostic Challenges and Management Algorithm. J Orthop Case Rep 2019; 9:49-52. [PMID: 31245319 PMCID: PMC6588137 DOI: 10.13107/jocr.2250-0685.1304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Introduction Oncogenic osteomalacia is a rare paraneoplastic syndrome of acquired hypophosphatemic osteomalacia, resulting from a deficit in renal tubular phosphate reabsorption, in which fibroblast growth factor 23 seems to be implicated. Case Report A 42-year-old male presented with complaints of low back pain for the past 4 years and inability to walk for the past 3 years. Blood investigations showed hypophosphatemia and elevated serum alkaline phosphatase. Radiographs and magnetic resonance imaging revealed features of osteomalacia. DOTONAC PET-computed tomography (CT) showed a lesion in the greater trochanter suggestive of a phosphaturic mesenchymal tumor. CT-guided biopsy of the lesion was done which confirmed the diagnosis. The tumor was resected by intralesional methods (burring and cementation) with correction of hypophosphatemia by oral phosphorus supplementation. Patient clinically improved and was able to walk with support at the time of discharge. Conclusion Phosphaturic tumor was localized to be in the posterior aspect of the right greater trochanter. To find the tumor was a major diagnostic challenge involving various diagnostic modalities. The occurrence of such a condition is rare and it may take even years to correctly diagnose the disease.
Collapse
Affiliation(s)
- T Shenbaghavalli
- Department of Orthopaedic Surgery, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - J K Giriraj Harshavardhan
- Department of Orthopaedic Surgery, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - P Gopinath Menon
- Department of Orthopaedics, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu. India
| |
Collapse
|
23
|
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]
|
24
|
Yin Z, Du J, Yu F, Xia W. Tumor-induced osteomalacia. Osteoporos Sarcopenia 2018; 4:119-127. [PMID: 30775554 PMCID: PMC6372818 DOI: 10.1016/j.afos.2018.12.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/02/2018] [Accepted: 12/04/2018] [Indexed: 12/30/2022] Open
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is a rare paraneoplastic syndrome characterized by hypophosphatemia resulting from decreased tubular phosphate reabsorption, with a low or inappropriately normal level of active vitamin D. The culprit tumors of TIO could produce fibroblast growth factor 23 which plays a role in regulating renal Pi handling and 25-hydroxyvitamin D 1α-hydroxylase activity. Chronic hypophosphatemia could eventually lead to inadequate bone mineralization, presenting as osteomalacia. The diagnosis should be considered when patients manifest as hypophosphatemia and osteomalacia, or rickets and needs to be differentiated from other disorders of phosphate metabolism, such as the inhereditary diseases like X-linked hypophosphataemic rickets, autosomal dominant hypophosphataemic rickets, autosomal recessive hypophosphataemic rickets and acquired diseases like vitamin D deficiency. Localization of responsible tumors could be rather difficult since the vast majority are very small and could be everywhere in the body. A combination of thorough physical examination, laboratory tests and imaging techniques should be applied and sometimes a venous sampling may come into handy. The technology of somatostatin-receptor functional scintigraphy markedly facilitates the localization of TIO tumor. Patients undergoing complete removal of the causative neoplasm generally have favorable prognoses while a few have been reported to suffer from recurrence and metastasis. For those undetectable or unresectable cases, phosphate supplements and active vitamin D should be administrated and curative intended radiotherapy or ablation is optional.
Collapse
Affiliation(s)
| | | | | | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, The National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
25
|
Yavropoulou MP, Poulios C, Foroulis C, Tournis S, Hytiroglou P, Kotsa K, Kessisoglou I, Zebekakis P. Distant lung metastases caused by a histologically benign phosphaturic mesenchymal tumor. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180023. [PMID: 29785270 PMCID: PMC5955008 DOI: 10.1530/edm-18-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 04/27/2018] [Indexed: 12/31/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare form of hypophosphatemia usually caused by phosphaturic mesenchymal tumors (PMTs); the biologic behavior of PMTs is under investigation. Herein we present a case of TIO with a protracted course over 12 years leading to a fatal outcome. A 39-year-old man presented with weakness in 2004 and was found to have decreased serum phosphorus, phosphaturia and low levels of 1,25-dihydroxyvitamin D3. Four years later he developed a painful left calf mass. The lesion was resected, but recurred causing extreme pain and dysfunction. Radiological examination showed a large cluster of soft tissue tumors affecting all the muscle compartments of the calf and a smaller lesion inside the metaphysis of the tibia. Above-knee amputation was performed. Histological examination of all lesions showed a cellular spindle cell neoplasm with variously sized vessels, wide vessel-like spaces and scattered deposits of calcified extracellular material. The tumor infiltrated skeletal muscles, subcutaneous fat and the proximal end of the fibula. The tibial lesion had identical histology. Three years after the amputation the patient presented with cough and dyspnea. Radiological examination, followed by an open biopsy, showed that there were multiple metastatic nodules of PMTs in both lungs. Shortly after the diagnosis the patient died. This case illustrates that even benign cases of PMTs may lead to a fatal outcome and the classification of PMTs into benign and malignant should be reassessed in order to correspond to its biological behavior.
Collapse
Affiliation(s)
- Maria P Yavropoulou
- Division of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Poulios
- Department of Pathology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | | | - Symeon Tournis
- Laboratory of Research of Musculoskeletal System 'Th. Garofalidis', KAT Hospital University of Athens, Greece
| | - Prodromos Hytiroglou
- Department of Pathology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Isaak Kessisoglou
- 3rd Department of Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - Pantelis Zebekakis
- Division of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| |
Collapse
|