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Sánchez Muñoz R, Sanmillan JL, Vidal Sarró N, Martín Quintero G, Martí Duce D, Gabarrós Canals A. Intracranial Phosphaturic Mesenchymal Tumors: A Systematic Literature Review of a Rare Entity. World Neurosurg 2024; 187:70-81. [PMID: 38561034 DOI: 10.1016/j.wneu.2024.03.138] [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: 12/23/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Phosphaturic Mesenchymal Tumors (PMTs) are rare mesenchymal neoplasms known for producing Tumor-induced Osteomalacia (TIO). TIO is an uncommon paraneoplastic syndrome characterized by radiographic evidence of inadequate bone mineralization and analytical abnormalites. METHODS We sought to present a case of TIO caused by skull base PMT with intracranial extension, manifesting with pain, progressive weakness, and multiple bone fractures. Furthermore, a systematic review was performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A search was conducted in PubMed database with title/abstract keywords "Phosphaturic mesenchymal tumor" and "Osteomalacia." Search results were reviewed looking for intracranial or skull base tumors. RESULTS Our systematic review included 29 reported cases of intracranial PMT. In the reviewed cases there was a significative female predominance with 22 cases (75,86%). Osteomalacia was presented in 25 cases (86,20%). Bone fractures were present in 10 cases (34,48%). The most common site of involvement was the anterior cranial fossa in 14 cases (48,27%). Surgery was performed in 27 cases (93,10%) with previous tumor embolization in 4 cases (13,79%). Total recovery of the presenting symptoms in the first year was achieved in 21 cases (72,41%). Recurrence of the disease was described in 6 cases (25%). CONCLUSIONS Skull base PMTs with intracranial extension are extremely rare tumors. Most patients are middle-aged adults with a PMT predominantly located in anterior cranial fossa. Surgery is the current treatment of choice with optimal outcome at 1-year follow-up, although recurrence could be present in almost 25% of the cases.
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Affiliation(s)
- Raúl Sánchez Muñoz
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Noemi Vidal Sarró
- Department of Pathology, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Martín Quintero
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Daniel Martí Duce
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Andreu Gabarrós Canals
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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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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3
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Okajima K, Kobayashi H, Ito N, Kato H, Ishibashi Y, Zhang L, Tsuda Y, Tanaka S. Extended curettage for tumour-induced osteomalacia in the bone. Jpn J Clin Oncol 2024; 54:463-470. [PMID: 38266040 DOI: 10.1093/jjco/hyad180] [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: 10/15/2023] [Accepted: 12/14/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND extended curettage is generally used to treat infiltrative bone tumours. However, the extent of the curettage performed in previous studies remains unclear. This study aimed to investigate the efficacy of extended curettage for bone tumour-induced osteomalacia. METHODS we included 12 patients with tumour-induced osteomalacia who underwent extended curettage at our hospital between 2000 and 2022. Extended curettage was applied in cases where tumour resection could cause functional impairment or necessitate complex reconstruction. We investigated patients' clinical and oncological outcomes. RESULTS patients had a mean age of 55 (24-81) years, and the median follow-up duration after surgery was 3.9 (1.0-14.0) years. The causative tumours were located in the pelvis and lumbar spine. Imaging revealed the tumours to be of the sclerotic, intertrabecular, lytic and mixed types. Intraoperative 3D fluoroscopy was used in 10 patients. Extended curettage with high-speed burring and adjuvant therapy with cauterization using an electric scalpel and ethanol resulted in a remission rate of 83%; no recurrence or metastasis was observed in cases of early postoperative biochemical remission. In cases where the causative tumour was at the lumbar spine and ischium close to the acetabulum, no postoperative biochemical remission was observed, and conservative treatment was continued. Except for one patient with a tumour in the lumbar spine, all patients could walk without a cane. CONCLUSIONS extended curettage for bone tumour-induced osteomalacia is oncologically and functionally favourable, especially in cases where resection of the causative tumour could cause functional impairment or necessitate complex reconstruction.
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Affiliation(s)
- Koichi Okajima
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuaki Ito
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hajime Kato
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
- Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Ishibashi
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Liuzhe Zhang
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yusuke Tsuda
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Zhang Y, Zhu J, Chen X, Bai G, Du Y, Zou Q. Challenging diagnosis and successful management of phosphaturic mesenchymal tumor mimicking ankylosing spondylitis: A case report. Int J Rheum Dis 2024; 27:e15120. [PMID: 38519428 DOI: 10.1111/1756-185x.15120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Yuan Zhang
- Department of Rheumatology and Immunology, First Affiliated Hospital of Army Military Medical University, Chongqing, China
| | - Jiang Zhu
- Institute of Pathology, First Affiliated Hospital of Army Military Medical University, Chongqing, China
| | - Xuemeng Chen
- Department of Rheumatology and Immunology, First Affiliated Hospital of Army Military Medical University, Chongqing, China
| | - Ganping Bai
- Department of Rheumatology and Immunology, First Affiliated Hospital of Army Military Medical University, Chongqing, China
| | - Yu Du
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinghua Zou
- Department of Rheumatology and Immunology, First Affiliated Hospital of Army Military Medical University, Chongqing, China
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Jadhav SS, Shah R, Patil V. Tumor-induced osteomalacia: An overview. Best Pract Res Clin Endocrinol Metab 2024; 38:101834. [PMID: 37935612 DOI: 10.1016/j.beem.2023.101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Tumor-induced osteomalacia (TIO) is rare paraneoplastic syndrome of hypophosphatemic osteomalacia, caused by phosphaturic factors secreted by small mesenchymal origin tumors with distinct pathological features, called 'phosphaturic mesenchymal tumors'. FGF23 is the most well-characterized of the phosphaturic factors. Tumors are often small and located anywhere in the body from head to toe, which makes the localisation challenging. Functional imaging by somatostatin receptor-based PET imaging is the first line investigation, which should be followed with CT or MRI based anatomical imaging. Once localised, complete surgical excision is the treatment of choice, which brings dramatic resolution of symptoms. Medical management in the form of phosphate and active vitamin D supplements is given as a bridge to surgical management or in inoperable/non-localised patients. This review provides an overview of the epidemiology, pathophysiology, pathology, clinical features, diagnosis, and treatment of TIO, including the recent advances and directions for future research in this field.
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Affiliation(s)
| | - Ravikumar Shah
- Harikrushna Hormone Clinic, 304, 3rd Floor, Ashwamegh, Opposite Vyamshala, Anand, Gujarat, India.
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400012, India.
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May M, Oheim R, Bovy L, Doess A, Maessen D, Neukirch B, Norris R, Williams A, Abrahamsen B. Epidemiology of Tumor-Induced Osteomalacia in Germany Based on Real World Data. Calcif Tissue Int 2023; 113:630-639. [PMID: 37980279 PMCID: PMC10673975 DOI: 10.1007/s00223-023-01148-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/30/2023] [Indexed: 11/20/2023]
Abstract
Tumor-induced osteomalacia (TIO) is an ultra-rare disease caused mostly by benign tumors that secrete fibroblast growth factor-23. Because of nonspecific symptoms, the diagnostic delay is long, and therapy can be challenging. Moreover, epidemiological data on TIO are scarce owing to its rarity. Therefore, this study aimed to quantify TIO's incidence rates and prevalence in Germany. Retrospective longitudinal and cross-sectional analyses were conducted using anonymized German claims data from the statutory health insurance (SHI) database. This database, which comprises the data of approximately 5 million insurants, is a representative sample of the German population and supports national projections. As there is no unique International Statistical Classification of Diseases and Related Health Problems (ICD) code for TIO, operational categories based on different surrogates were defined to determine the prevalence and incidence rates of TIO among probable patients. This study showed that TIO has a prevalence of (documented code, advanced imaging, medication, or tumor removal) 0.187 per 100,000 persons and an incidence rate of ≤ 0.094 per 100,000 person years. This analysis provides the first epidemiological insight into German patients with TIO. Despite the general limitations associated with the analysis of SHI claims data of ultra-rare diseases, we believe that this analysis provides a sound basis for further analysis, particularly with regard to the care situation of patients with TIO.
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Affiliation(s)
- Melanie May
- Department of Payer Value & Patient Access, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany.
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Hospital Hamburg-Eppendorf (UKE), Lottestraße 59, 22529, Hamburg, Germany
| | - Leonore Bovy
- InGef - Institute for Applied Health Research Berlin GmbH, InGef, Otto-Ostrowski-Straße 5, 10249, Berlin, Germany
| | - Axel Doess
- Department of Payer Value & Patient Access, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany
| | - Dirk Maessen
- Department of Franchise Nephrology, Kyowa Kirin GmbH, Monschauer Str. 1, 40549, Duesseldorf, Germany
| | - Benno Neukirch
- Hochschule Niederrhein, University of Applied Sciences, Competence Center Routine Data, Reinarzstraße 49, 47805, Krefeld, Germany
| | - Raeleesha Norris
- InGef - Institute for Applied Health Research Berlin GmbH, InGef, Otto-Ostrowski-Straße 5, 10249, Berlin, Germany
| | - Angela Williams
- Department of HEOR, Kyowa Kirin International Ltd, 2 Globeside, Fieldhouse Lane, Marlow, SL7 1HZ, UK
| | - Bo Abrahamsen
- Department of Medicine 1, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
- Department of Clinical Research, University of Southern Denmark (SDU), Campusvej 55, 5230, Odense, Denmark
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Hacisahinogullari H, Tekin S, Tanrikulu S, Saribeyliler G, Yalin GY, Bilgic B, Isik EG, Salduz A, Tuncer S, Gul N, Uzum AK, Aral F, Tanakol R, Selcukbiricik OS. Diagnosis and management of tumor-induced osteomalacia: a single center experience. Endocrine 2023; 82:427-434. [PMID: 37480497 DOI: 10.1007/s12020-023-03450-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/06/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE The aim of this study is to review the clinical and laboratory characteristics, diagnostic and treatment modalities of tumor-induced osteomalacia (TIO) cases managed in a single center. MATERIAL METHODS Demographic and clinical features, biochemical findings, diagnostic procedures, treatment modalities, and outcomes of nine patients who had the diagnosis of TIO were reviewed retrospectively. RESULTS Mean age of the study group (F/M: 4/5) was 45.8 ± 10.8 years, and mean time from the onset of symptoms to diagnosis was 4.7 ± 2.8 years. The clinical manifestations were muscle weakness and difficulty in walking (8/9), hip pain (3/9), multiple fractures (2/9), stress fracture (2/9). Mean plasma phosphorus concentration was 1.28 ± 0.4 mg/dl at presentation. We performed radionuclide imaging modalities (18F-FDG PET/CT, Ga68-DOTATATE PET/CT, octreotide scintigraphy) in seven of nine patients, and tumor was detected in all. Lower extremity (n = 6; %67), head region (n = 2; %22) and thorax (n = 1; %11) were the tumor locations of our cases. Eight patients underwent surgery and remission was achieved postoperatively in all of the operated patients and plasma phosphorus level normalized in 4 ± 2 days. Pathological examination revealed mesenchymal tumors with different subtypes. Recurrence occurred in three patients at 13 ± 10.5 months after the first surgery. Two patients were reoperated and radiotherapy was also performed in one of them. CONCLUSION Hypophosphatemia necessitates careful evaluation for the etiology. TIO is one of the important causes of adult-onset hypophosphatemic osteomalacia. Diagnosis of TIO is essential because the laboratory and clinical findings resolve after appropriate treatment.
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Affiliation(s)
- Hulya Hacisahinogullari
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey.
| | - Sakin Tekin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Zonguldak Bulent Ecevit University, Faculty of Medicine, Zonguldak, Turkey
| | - Seher Tanrikulu
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Goktug Saribeyliler
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Gulsah Yenidunya Yalin
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Bilge Bilgic
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Emine Goknur Isik
- Department of Nuclear Medicine, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ahmet Salduz
- Department of Orthopedics and Traumatology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Samuray Tuncer
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Nurdan Gul
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ayse Kubat Uzum
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ferihan Aral
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Refik Tanakol
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
| | - Ozlem Soyluk Selcukbiricik
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Capa, Istanbul, Turkey
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Gupta S, Pavamani SP. Sinonasal phosphaturic mesenchymal tumour: radiation oncologist's perspective. BMJ Case Rep 2023; 16:e255896. [PMID: 37723097 PMCID: PMC10510895 DOI: 10.1136/bcr-2023-255896] [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] [Indexed: 09/20/2023] Open
Abstract
Tumour-induced osteomalacia is a rare cause of osteomalacia, the majority of which is of mesenchymal origin. Oncogenic osteomalacia is a potentially curable condition caused by phosphaturic mesenchymal tumours. We present the case of a woman in her 30s with a sinonasal phosphaturic mesenchymal tumour, treated with surgical excision followed by adjuvant intensity-modulated radiotherapy and subsequent adjuvant chemotherapy. The patient experienced minimal adverse effects during radiation. There was good local control and cosmetic outcomes with no radiation-related toxicity at a follow-up period of 32 months.
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Affiliation(s)
- Sudharshan Gupta
- Department of Radiation Oncology, Christian Medical College Vellore, Vellore, India
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Hervier E, Gorican K, Boudabbous S, Biver E, Ferrari S, Saiji E, Garibotto V, Mainta I. Unusual phosphaturic mesenchymal tumor mimicking osteoid osteoma. Radiol Case Rep 2023; 18:2738-2743. [PMID: 37304318 PMCID: PMC10250829 DOI: 10.1016/j.radcr.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Phosphaturic mesenchymal tumor is a rare tumor characterized by paraneoplastic osteomalacia. The diagnosis is often delayed because of nonspecific symptoms and difficulty to localize the tumor. In this study we report a case of PMT of the left femur detected by Ga-68-DOTATATE PET-CT with radiological features mimicking osteoid osteoma. We report a 31-year-old female patient who presented to our hospital for evaluation due to progressive bone pain and muscle weakness. Her laboratory data showed hypophosphatemia and increased fibroblast growth factor 23 (FGF-23) together with reduced bone mineral density on bone densitometry. The diagnosis of PMT was suspected and the tumor was identified on Ga-68-DOTATATE PET-CT as a focal uptake in a lucent lesion of the left femoral head with a central sclerotic dot mimicking a nidus as seen in osteoid osteoma. The lesion was treated with percutaneous radiofrequency ablation. Laboratory tests and bone densitometry rapidly improved post-treatment. The present case emphasizes the difficulty to diagnose PMT due to its nonspecific biochemical and clinical presentation and the relevance of functional imaging for locating these tumors despite different radiological presentation.
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Affiliation(s)
- Elsa Hervier
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
| | - Karel Gorican
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Sana Boudabbous
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Emmanuel Biver
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Serge Ferrari
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Essia Saiji
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
| | - Valentina Garibotto
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ismini Mainta
- Division of Nuclear Medicine, Diagnostic Department, Geneva University Medical Center, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva, Switzerland
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van Velsen EFS, Geeraedts TEA, Bosman A, Zillikens MC. Thermal Ablation for Treating Tumor-induced Osteomalacia in a Patient With IV Phosphate Dependency. JCEM CASE REPORTS 2023; 1:luad086. [PMID: 37908985 PMCID: PMC10580436 DOI: 10.1210/jcemcr/luad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Indexed: 11/02/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome associated with tumors secreting fibroblast growth factor 23 that can be cured with complete surgical resection of the tumor. However, when these tumors are at difficult locations, less invasive modalities such as thermal ablation (TA) might be a good alternative. A 40-year-old woman was seen for a second opinion because of severe hypophosphatemia with complaints of fatigue, myalgia, and muscle weakness for which she needed IV phosphate for 15 to 18 hours per day in addition to oral alfacalcidol and phosphate. Initial laboratory results revealed hypophosphatemia (0.59 mmol/L [1.83 mg/dL]; reference range, 0.90-1.50 mmol/L [8.40-10.2 mg/dL]), increased fibroblast growth factor 23 levels (137 RU/mL; reference range, <125 RU/mL), and a reduced TmP-GFR (0.47 mmol/L; reference range, 0.8-1.4 mmol/L). Gallium-positron emission tomography/computed tomography (CT) showed moderately increased uptake at thoracic vertebra (Th) 8 and mildly increased uptake at Th7, suggestive of TIO. Complete tumor removal would have required resection of at least 1 vertebral body. Therefore, CT-guided TA was performed at Th8. No complications were observed, and in the months after, treatment with IV phosphate could be discontinued, indicating a satisfying result from the procedure. This extreme TIO case demonstrates that CT-guided TA can be an alternative to extensive or risky classical surgery.
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Affiliation(s)
- Evert F S van Velsen
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - Tychon E A Geeraedts
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - Ariadne Bosman
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
- Erasmus MC Bone Center, Erasmus University Medical Center, 3015 CE, Rotterdam, The Netherlands
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11
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Roumpou A, Yavropoulou MP, Chronopoulos E, Kassi E. Novel Therapeutic Agents for Rare Diseases of Calcium and Phosphate Metabolism. Horm Metab Res 2022; 54:645-657. [PMID: 36049757 DOI: 10.1055/a-1917-0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The last decade has been revolutionary regarding the management of rare bone diseases caused by impaired calcium and phosphate metabolism. Elucidation of the underlying genetic basis and pathophysiologic alterations has been the determinant factor for the development of new, disease-specific treatment agents. The phosphaturic hormone Fibroblast Growth Factor 23 (FGF23) possesses a critical role in the pathogenesis of various hypophosphatemic disorders. Among them, the genetic disorder of X-linked hypophosphatemia and the acquired syndrome of tumor-induced osteomalacia, although very rare, have attracted the scientific community's attention towards designing an FGF23-inhibitor as a potential specific therapy. The monoclonal antibody burosumab was approved for the treatment of children and adult patients with X-linked hypophosphatemia and recently for tumor-induced osteomalacia patients, demonstrating benefits regarding their symptoms, biochemical profile and bone mineralization status. Asfotase alfa is a hydroxyapatite-targeted recombinant alkaline phosphatase, an enzymatic replacement therapy, substituting the defective activity of tissue non-specific alkaline phosphatase, in patients suffering from hypophosphatasia. Promising data regarding its favorable effect on survival rate, bone quality, fracture healing, muscle strength, mobility, respiratory function, and general quality of life have led to the approval of the drug for the treatment of childhood-onset hypophosphatasia. Given the high costs of treatment for both agents and their limited clinical use until now, more data are needed to define patients' characteristics that make them ideal candidates for therapy. Long-term safety issues also need to be clarified.
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Affiliation(s)
- Afroditi Roumpou
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, "Aghia Sofia" Children's Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Maria P Yavropoulou
- Centre of Expertise for Rare Endocrine Diseases, C.E.R.E.D. Disorders of Calcium & Phosphate Metabolism, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Efstathios Chronopoulos
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Eva Kassi
- Laboratory for Research of the Musculoskeletal System, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Centre of Expertise for Rare Endocrine Diseases, C.E.R.E.D. Disorders of Calcium & Phosphate Metabolism, First Department of Propaedeutic and Internal Medicine, Laiko Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
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12
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Kojima D, Ohba S, Abe M, Suzuki A, Horibe S, Tateya I, Hasegawa M, Hirose Y. Intracranial phosphaturic mesenchymal tumors. A case report and review of literature. Neuropathology 2022; 42:453-458. [PMID: 35880350 DOI: 10.1111/neup.12817] [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: 10/11/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
Most osteomalacia-inducing tumors (OITs) are phosphaturic mesenchymal tumors (PMTs) that secrete fibroblast growth factor 23 (FGF23). These tumors usually occur in the bone and soft tissues, and intracranial OITs are rare. Therefore, intracranial OIT is difficult to diagnose and treat. This paper presents a case of intracranial OIT and shows a review of previous cases. A 45-year-old man underwent nasal cavity biopsy and treatment with active vitamin D3 and neutral phosphate for hypophosphatemia. Amplification of FGF23 mRNA level within the tumor was detected. Subsequently, the surgical specimen was diagnosed with a PMT and was considered the cause of the patient's osteomalacia. The patient was referred to a neurosurgery department for the excision of the intracranial tumor extending to the nasal cavity. After tumor removal, the serum levels of FGF23 and phosphorus were normalized as compared to preoperative those. The patient remains disease-free, without additional treatment, approximately 10 years after surgery, with no tumor recurrence. As per the literature, intracranial OITs usually occur in patients aged 8-69 years. Bone and muscle pain are major complaints. Approximately 60% of the patients reported previously had symptoms because of intracranial tumors. In some cases, it took several years to diagnose OIT after the onset of the osteomalacia symptoms. Laboratory data in such cases show hypophosphatemia and elevated FGF23 levels. Because FGF23 levels are associated with the severity of osteomalacia symptoms, total tumor resection is recommended. PMT and hemangiopericytoma (HPC) are histologically similar, but on immunochemistry, PMT is negative for signal transducer and activator of transcription 6 (STAT6), whereas HPC is positive. FGF23 amplification is seen in PMTs but not in HPCs. Therefore, the analysis of FGF23 and STAT6 was helpful in distinguishing PMTs from HPCs. In cases of hypophosphatemia and osteomalacia without a history of metabolic, renal, or malabsorptive diseases, the possibility of oncogenic osteomalacia should be considered.
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Affiliation(s)
- Daijiro Kojima
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Shigeo Ohba
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
| | - Masato Abe
- Department of Pathology, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Seiji Horibe
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | - Ichiro Tateya
- Department of Otolaryngology - Head and Neck Surgery, Fujita Health University, Toyoake, Japan
| | | | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Toyoake, Japan
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13
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Hartley IR, Roszko KL, Li X, Pozo K, Streit J, del Rivero J, Magone MT, Vold R, Dambkowski CL, Collins MT, Gafni RI. Infigratinib Reduces
FGF23
and Increases Blood Phosphate in
Tumor‐Induced
Osteomalacia. JBMR Plus 2022; 6:e10661. [PMID: 35991529 PMCID: PMC9382865 DOI: 10.1002/jbm4.10661] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/03/2022] [Indexed: 11/09/2022] Open
Abstract
Tumor‐induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by ectopic production of fibroblast growth factor 23 (FGF23) by phosphaturic mesenchymal tumors (PMTs). Acting on renal tubule cells, excess FGF23 decreases phosphate reabsorption and 1,25‐dihydroxy‐vitamin D (1,25D) production, leading to hypophosphatemia, impaired bone mineralization, pain, and fractures. Fibronectin 1‐fibroblast growth factor receptor 1 (FN1‐FGFR1) gene fusions have been identified as possible drivers in up to 40% of resected PMTs. Based on the presumptive role of FGFR1 signaling by chimeric FN1‐FGFR1 proteins, the effectiveness of infigratinib, a FGFR1‐3 tyrosine kinase inhibitor, was studied in an open‐label, single‐center, phase 2 trial. The primary endpoint was persistent normalization of blood phosphate and FGF23 after discontinuation. Four adults with TIO (two nonlocalized, two nonresectable PMTs) were treated with daily infigratinib for up to 24 weeks. All patients had a favorable biochemical response that included reduction in intact FGF23, and normalization of blood phosphate and 1,25D. However, these effects disappeared after drug discontinuation with biochemistries returning to baseline; no patients entered biochemical remission. In the two patients with identifiable tumors, 68Gallium (68Ga)‐DOTATATE and 18Fluoride (18F)‐Fluorodeoxyglucose (FDG) PET/CT scans showed a decrease in PMT activity without change in tumor size. Patients experienced mild to moderate, treatment‐related, dose‐limiting adverse events (AEs), but no serious AEs. Three patients had dose interruptions due to AEs; one patient continued on a low dose for the entire 24 weeks and one patient stopped therapy at 17 weeks due to an AE. The study closed early due to a failure to meet the primary endpoint and a higher‐than‐expected incidence of ocular AEs. Infigratinib treatment lowered FGF23, increased blood phosphate, and suppressed PMT activity, confirming the role of FGFR signaling in PMT pathogenesis. However, treatment‐related AEs at efficacy doses and disease persistence on discontinuation support restricting the use of infigratinib to patients with life‐limiting metastatic PMTs. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.
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Affiliation(s)
| | | | - Xiaobai Li
- Biostatistics and Clinical Epidemiology, Clinical Center NIH
| | - Karen Pozo
- National Institute of Dental and Craniofacial Research NIH
| | - Jamie Streit
- National Institute of Dental and Craniofacial Research NIH
| | | | - M. Teresa Magone
- Ophthalmology Consult Services Section National Eye Institute (NEI)
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14
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Thakur K, Singh CA, Kakkar A, Kumar R, Sharma A, Thakar A. Metastatic Malignant Phosphaturic Mesenchymal Tumor of Mandibular Alveolus: a Rare Case Report and Review of Literature. Indian J Surg Oncol 2021; 13:305-311. [DOI: 10.1007/s13193-021-01449-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022] Open
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15
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Dahir K, Zanchetta MB, Stanciu I, Robinson C, Lee JY, Dhaliwal R, Charles J, Civitelli R, Roberts MS, Krolczyk S, Weber T. Diagnosis and Management of Tumor-induced Osteomalacia: Perspectives From Clinical Experience. J Endocr Soc 2021; 5:bvab099. [PMID: 34286168 PMCID: PMC8282217 DOI: 10.1210/jendso/bvab099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 01/12/2023] Open
Abstract
Purpose Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome of abnormal phosphate and vitamin D metabolism caused by typically small endocrine tumors that secrete fibroblast growth factor 23 (FGF23). TIO is characterized clinically by progressive musculoskeletal pain, fatigue, proximal muscle weakness, and multiple fractures, leading to long-term disability. Misdiagnosis and delayed diagnosis are common because of the nonspecific symptoms, and several years may elapse before patients receive an accurate diagnosis and appropriate treatment. Thus, it is vital that awareness of the appropriate recognition and management of TIO is increased among healthcare professionals who may encounter patients with suspected TIO. Methods A roundtable meeting was held on 10 January 2020 in Dallas, TX, USA, to gather perspectives on the diagnosis and treatment of TIO. The following topics were considered: clinical presentation, patient history, differential diagnosis, laboratory assessment, imaging, venous sampling, and treatment. Results This report provides a summary of our collective experiences in the management of TIO. Main conclusions Laboratory tests are mandatory to expedite TIO diagnosis and should include measurement of fasting serum phosphorus, renal phosphate reabsorption, serum 1,25-dihydroxyvitamin D, and serum FGF23 levels. Functional and anatomical imaging are essential to locate the FGF23-secreting tumor(s) causing TIO. Surgical resection is often a curative treatment when the tumor can be localized; however, better management of patients who cannot be operated on with targeted therapies is needed. Further efforts to increase awareness of TIO within the medical community, and education on recommended diagnostic and treatment pathways are required to improve the management of this debilitating disease.
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Affiliation(s)
- Kathryn Dahir
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Irinel Stanciu
- Panorama Orthopedics and Spine Center, Golden, CO 80401, USA
| | - Cemre Robinson
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Janet Y Lee
- University of California, San Francisco, CA 94143, USA
| | - Ruban Dhaliwal
- State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Julia Charles
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | | | - Stan Krolczyk
- Ultragenyx Pharmaceutical Inc., Novato, CA 94949, USA
| | - Thomas Weber
- Duke University School of Medicine, Durham, NC 27710, USA
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16
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Successful Treatment of Tumor-Induced Osteomalacia by Multidisciplinary Therapy with Radiation to Intracranial Fibromyxoid Tumor. Case Rep Endocrinol 2021; 2021:8841259. [PMID: 34221518 PMCID: PMC8219433 DOI: 10.1155/2021/8841259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by protein fibroblast-growth-factor-23 (FGF-23) secreting tumors. Complete tumor resection is the current standard of care for TIO; however, some patients may develop tumor recurrence. Due to the rarity of this paraneoplastic syndrome, the role of radiotherapy is unclear. This case is worth reporting because it adds to our knowledge some insights about the potential role of radiotherapy in this rare condition. Case Presentation. After multidisciplinary consultation, in July 2015, postoperative adjuvant radiotherapy was offered to a 52-year-old man with a multiple recurrent ossifying fibromyxoid tumor in the right frontal sinus causing TIO. The patient had a history of multiple bone fractures and pain since more than 20 years. The tumor had been removed in 2003 for the first time. Subsequent endoscopic resections of the tumor had been performed for recurrences of TIO in May 2012, October 2013, and July 2015. Starting from October 2015, external beam radiotherapy was delivered with a volumetric modulated arc technique to the tumor bed with a daily dose of 2 Gy up to a total dose of 60 Gy. After five years from treatment, the patient is free from local tumor relapse, TIO progression, and radiation-induced side effects. Conclusions Radiotherapy may provide long-term TIO remission and tumor control, thus being a treatment option in cases where surgery is unfeasible or unsuccessful.
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17
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Florenzano P, Hartley IR, Jimenez M, Roszko K, Gafni RI, Collins MT. Tumor-Induced Osteomalacia. Calcif Tissue Int 2021; 108:128-142. [PMID: 32504138 DOI: 10.1007/s00223-020-00691-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral production of fibroblast growth factor 23 (FGF23). The hallmark biochemical features include hypophosphatemia due to renal phosphate wasting, inappropriately normal or frankly low 1,25-dihydroxy-vitamin D, and inappropriately normal or elevated FGF23. TIO is caused by typically small, slow growing, benign phosphaturic mesenchymal tumors (PMTs) that are located almost anywhere in the body from the skull to the feet, in soft tissue or bone. The recent identification of fusion genes in a significant subset of PMTs has provided important insights into PMT tumorigenesis. Although management of this disease may seem straightforward, considering that complete resection of the tumor leads to its cure, locating these often-tiny tumors is frequently a challenge. For this purpose, a stepwise, systematic approach is required. It starts with thorough medical history and physical examination, followed by functional imaging, and confirmation of identified lesions by anatomical imaging. If the tumor resection is not possible, medical therapy with phosphate and active vitamin D is indicated. Novel therapeutic approaches include image-guided tumor ablation and medical treatment with the anti-FGF23 antibody burosumab or the pan-FGFR tyrosine kinase inhibitor, BGJ398/infigratinib. Great progress has been made in the diagnosis and treatment of TIO, and more is likely to come, turning this challenging, debilitating disease into a gratifying cure for patients and their providers.
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Affiliation(s)
- Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
| | - Iris R Hartley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - Kelly Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Skeletal Disorders and Mineral Homeostasis Section, NIDCR, NIH, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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18
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Yozamp N, Hornick JL, Chiodo CP, Miller AL, Loscalzo J. The Game Is Afoot. N Engl J Med 2020; 382:2249-2255. [PMID: 32492308 DOI: 10.1056/nejmcps1913599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nicholas Yozamp
- From the Departments of Medicine (N.Y., A.L.M., J.L.), Pathology (J.L.H.), and Orthopedic Surgery (C.P.C.), Brigham and Women's Hospital, Boston
| | - Jason L Hornick
- From the Departments of Medicine (N.Y., A.L.M., J.L.), Pathology (J.L.H.), and Orthopedic Surgery (C.P.C.), Brigham and Women's Hospital, Boston
| | - Christopher P Chiodo
- From the Departments of Medicine (N.Y., A.L.M., J.L.), Pathology (J.L.H.), and Orthopedic Surgery (C.P.C.), Brigham and Women's Hospital, Boston
| | - Amy L Miller
- From the Departments of Medicine (N.Y., A.L.M., J.L.), Pathology (J.L.H.), and Orthopedic Surgery (C.P.C.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (N.Y., A.L.M., J.L.), Pathology (J.L.H.), and Orthopedic Surgery (C.P.C.), Brigham and Women's Hospital, Boston
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19
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Shah R, Lila AR, Jadhav RS, Patil V, Mahajan A, Sonawane S, Thadani P, Dcruz A, Pai P, Bal M, Kane S, Shah N, Bandgar T. Tumor induced osteomalacia in head and neck region: single center experience and systematic review. Endocr Connect 2019; 8:1330-1353. [PMID: 31505461 PMCID: PMC6790902 DOI: 10.1530/ec-19-0341] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023]
Abstract
Tumor-induced osteomalacia in the head and neck region remains a challenging diagnosis to manage. Literature pertaining to management and outcome details remains sparse. We describe two cohorts: cohort 1 included seven patients from a single center in Western India with tumors located in paranasal sinuses (n = 3), intracranial (n = 2) and maxilla (n = 2). The unique features from our series is the management of persistent disease with radiation therapy (n = 2) and peptide receptor radionuclide therapy (PRRT) (n = 1). Cohort two has 163 patients identified from 109 publications for systematic review. Paranasal sinuses, mandible, intracranial disease, maxilla and oral cavity, in descending order, are reportedly common tumor sites. Within this cohort, mean age was 46 ± 14 years at presentation with 44.1% having local symptoms. Duration of symptoms varied from 1 to 240 months. Pre-surgery mean serum phosphorus was 1.4 ± 0.4 mg/dL and median FGF-23 levels were 3.6 (IQR:1.8-6.8) times of normal upper limit of normal. Majority (97.5%) were managed primarily with surgical excision; however, primary radiotherapy (n = 2) and surgery combined with radiotherapy (n = 2) were also reported. Twenty patients had persistent disease while nine patients had recurrence, more commonly noted with intracranial and oral cavity tumors. Surgery was the most common second mode of treatment employed succeeded by radiotherapy. Four patients had metastatic disease. The most common histopathological diagnosis reported is PMT mixed connective tissue, while the newer terminology 'PMT mixed epithelial and connective tissue type' has been described in 15 patients.
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Affiliation(s)
- Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Anurag R Lila
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
- Correspondence should be addressed to A R Lila:
| | - Ramteke-Swati Jadhav
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sushil Sonawane
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Puja Thadani
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Anil Dcruz
- Department of Head Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Prathamesh Pai
- Department of Head Neck Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Subhada Kane
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Parel, Mumbai, India
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20
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Pal R, Bhadada SK, Singhare A, Bhansali A, Kamalanathan S, Chadha M, Chauhan P, Sood A, Dhiman V, Sharma DC, Saikia UN, Chatterjee D, Agashe V. Tumor-induced osteomalacia: experience from three tertiary care centers in India. Endocr Connect 2019; 8:266-276. [PMID: 30726771 PMCID: PMC6410764 DOI: 10.1530/ec-18-0552] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 12/17/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by recalcitrant hypophosphatemia. Reports from the Indian subcontinent are scarce, with most being single center experiences involving few patients. Herein, we conducted a retrospective analysis of 30 patients of TIO diagnosed at three tertiary care hospitals in India. Patients with persistent hypophosphatemia (despite correction of hypovitaminosis D), normocalcemia, elevated alkaline phosphatase, low TmP/GFR and elevated or 'inappropriately normal' FGF23 levels were labeled as having TIO. They were sequentially subjected to functional followed by anatomical imaging. Patients with a well-localized tumor underwent excision; others were put on phosphorous and calcitriol supplementation. The mean age at presentation was 39.6 years with female:male ratio of 3:2. Bone pain (83.3%) and proximal myopathy (70%) were the chief complaints; 40% of cases had fractures. The mean delay in diagnosis was 3.8 years. Tumors were clinically detectable in four patients (13.3%). The mean serum phosphate was 0.50 mmol/L with a median serum FGF23 level of 518 RU/mL. Somatostatin receptor-based scintigraphy was found to be superior to FDG-PET in tumor localization. Lower extremities were the most common site of the tumor (72%). Tumor size was positively correlated with serum FGF23 levels. Twenty-two patients underwent tumor resection and 16 of them had phosphaturic mesenchymal tumors. Surgical excision led to cure in 72.7% of patients whereas disease persistence and disease recurrence were seen in 18.2% and 9.1% of cases, respectively. At the last follow-up, serum phosphate in the surgically treated group was significantly higher than in the medically managed group.
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Affiliation(s)
- Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence should be addressed to S K Bhadada:
| | - Awesh Singhare
- Department of Endocrinology, P D Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
| | - Manoj Chadha
- Department of Endocrinology, P D Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Phulrenu Chauhan
- Department of Endocrinology, P D Hinduja Hospital and Medical Research Centre, Mumbai, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vandana Dhiman
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Uma Nahar Saikia
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Debajyoti Chatterjee
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Agashe
- Department of Orthopaedics, P D Hinduja Hospital and Medical Research Centre, Mumbai, India
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21
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Tumour-induced osteomalacia: A case report of craniofacial localization. OTOLARYNGOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.xocr.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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22
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Wu H, Bui MM, Zhou L, Li D, Zhang H, Zhong D. Phosphaturic mesenchymal tumor with an admixture of epithelial and mesenchymal elements in the jaws: clinicopathological and immunohistochemical analysis of 22 cases with literature review. Mod Pathol 2019; 32:189-204. [PMID: 30206408 DOI: 10.1038/s41379-018-0100-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
Abstract
Information on the heterogeneity of phosphaturic mesenchymal tumor, a rare entity associated with tumor-induced osteomalacia, is limited. In this retrospective analysis of 222 phosphaturic mesenchymal tumors, 22 cases exhibited mixed mesenchymal and epithelial elements, which we propose to term "phosphaturic mesenchymal tumor, mixed epithelial, and connective tissue type." Phosphaturic mesenchymal tumor of the mixed epithelial and connective tissue type showed a distinctive and significant male predominance (male:female = 2.67:1), with most patients diagnosed at <40 years old. Moreover, all tumors were mainly located in the alveolar bone with focal invasion into surrounding soft tissue and oral mucosa, which could be detected preoperatively by oral examination. The mesenchymal component, composed of spindled cells resembling fibroblasts or myofibroblasts arranged in a storiform or fascicular pattern, exhibited a less prominent vasculature and lower cellularity than the typical phosphaturic mesenchymal tumor (mixed connective tissue type). The epithelial component was typically haphazardly and diffusely distributed throughout the tumor, forming small, irregular nests resembling odontogenic epithelial nests. All cases were immunoreactive for fibroblast growth factor-23, somatostatin receptor 2A, and NSE in both components. Mostly also demonstrated positive staining for CD99 (21/22, 96%), CD56 (16/22, 73%), Bcl-2 (21/22, 96%), and D2-40 (19/22, 86%) in one or both components. S100 was positive in both components in one of seven cases. Interestingly, immunoreactivity was typically stronger and more diffuse in the epithelial than in the paired mesenchymal components. The mesenchymal component was also diffusely positive for CD68 (17/17, 100%) and showed variable focal staining for SMA (15/22, 68%) and CD34 (9/19, 47 %). These results indicate that phosphaturic mesenchymal tumor of the mixed epithelial and connective tissue type has distinctive clinicopathological characteristics and a polyimmunophenotypic profile.
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Affiliation(s)
- Huanwen Wu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Marilyn M Bui
- Department of Anatomic Pathology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Dongmei Li
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Hui Zhang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Dingrong Zhong
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China.
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23
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Agarwal N, Kale S, Kumari K. Tumor-induced Osteomalacia due to a Phosphaturic Mesenchymal Tumor in the Cervical Spine: A Case Report and Literature Review. Neurol India 2019; 67:1334-1340. [DOI: 10.4103/0028-3886.271274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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24
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John JR, Hephzibah J, Oommen R, Shanthly N, Mathew D. Ga-68 DOTATATE Positron Emission Tomography-Computed Tomography Imaging in Oncogenic Osteomalacia: Experience from a Tertiary Level Hospital in South India. Indian J Nucl Med 2019; 34:188-193. [PMID: 31293296 PMCID: PMC6593943 DOI: 10.4103/ijnm.ijnm_14_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim Utility of Ga68 DOTATATE PETCT imaging to localise cause for oncogenic osteomalacia (OOM). Materials and Methods Retrospective analysis between March 2015 to March 2018 of all patients with a clinical diagnosis (based on a combination of clinical history, hypophosphatemia and elevated FGF-23 values) of OOM who underwent Ga-68 DOTATATE PET/CT. Results Total of 27 patients had undergone Ga-68 DOTATATE PET/CT imaging in our centre from March 2015 to March 2018. Of these 16 patients with clinically suspected oncogenic osteomalacia were included in our study. Age range 18-61 years of which 12 were males. Total of 13 (81.25%) patients were found to be positive on imaging for a possible mesenchymal tumour. Most common site of tumour was the lower limb (76%). Most common presenting symptom was bone pain (81%) followed by muscle weakness (19%). Overall, 10 patients underwent surgery, all of whose biopsy was reported as phosphaturic mesenchymal tumour. During the three month follow up, serum phosphorous measured in 15/16, post-surgical/ medical treatment had normalised in all except two patients who had undergone only medical therapy with neutral phosphate. Fall in FGF-23 was more pronounced in surgically treated patients as compared to those who received medical treatment. Conclusion Ga68-DOTATE PET/CT is a useful investigatory modality for localizing cause for oncogenic osteomalacia.
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Affiliation(s)
- Junita Rachel John
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Julie Hephzibah
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Regi Oommen
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nylla Shanthly
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - David Mathew
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Xiao X, Sun X, Ni P, Huang Y, Xie T. Phosphaturic mesenchymal tumor and related wound problem. Medicine (Baltimore) 2018; 97:e12507. [PMID: 30290606 PMCID: PMC6200523 DOI: 10.1097/md.0000000000012507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/29/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Phosphaturic mesenchymal tumor mixed connective tissue type (PMT/MCT) is the most common type (up to 90%) of phosphaturic mesenchymal tumor (PMT), a rare clinicopathologic entity. Besides overproduction of fibroblast growth factor 23 (FGF23), there is a big variation of immunohistochemical characteristic across types of PMT, which makes it difficult to obtain an early diagnosis of PMT/MCT. As a benign tumor, PMT/MCT usually happens in subcutaneous tissues and leads to nonhealing of wound. A complete excision of PMT/MCT facilitates wound healing. CONCLUSIONS Review of the existing evidence indicates that early diagnosis of PMT/MCT is critically important when treating PMT/MCT wound. Hence standardization of early diagnosis for PMT/MCT is mandated.
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Affiliation(s)
- Xian Xiao
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Xiaofang Sun
- Department of Dermatology, The Second Hospital Affiliated to Jiaxing University, Jiaxing, Zhejiang, China
| | - Pengwen Ni
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yao Huang
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Ting Xie
- Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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Lee CW, Mathew H, Holick MF. Oncogenic Osteomalacia: The Search, Treatment, and Cure of a Debilitating Tumor. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2017-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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27
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The Findings on Bone Scintigraphy in Patients With Suspected Tumor-Induced Osteomalacia Should Not Be Overlooked. Clin Nucl Med 2018; 43:239-245. [PMID: 29504962 DOI: 10.1097/rlu.0000000000002012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a chronic, devastating disease. The causative tumor is usually a small benign one that is very difficult to localize. Because the presenting symptoms include diffuse bone pain, a bone scintigraphy is commonly performed to determine the cause of the pain before TIO is suspected. In this retrospective investigation, we tried to assess whether bone scintigraphy acquired will be helpful in the eventual identification of the culprit tumor. METHODS The images of bone scan and clinical charts of total 91 patients with confirmed TIO were retrospectively reviewed. The image findings were compared with the results of other imaging studies, surgical notes, histopathologic examinations and clinical follow-ups. RESULTS In 76.9% (70 of 91) of the patients, the findings of bone scintigraphy did not correspond to the sites of the causative tumors, which were subsequently located. However, in 23.1% of the patients (21 of 91), the sites of the causative tumors corresponded to one of the abnormal technetium 99m-methyl diphosphonate activity on bone scintigraphy. More importantly, 6 tumors corresponded to the dominant activity on bone scintigraphy. CONCLUSIONS Although findings of whole-body scintigraphy are nonspecific in patients with TIO, careful evaluation of bone scintigraphy results can be helpful in guiding further evaluation in some patients.
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Shi Z, Deng Y, Li X, Li Y, Cao D, Coossa VS. CT and MR imaging features in phosphaturic mesenchymal tumor-mixed connective tissue: A case report. Oncol Lett 2018; 15:4970-4978. [PMID: 29552133 PMCID: PMC5840497 DOI: 10.3892/ol.2018.7945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/19/2017] [Indexed: 01/25/2023] Open
Abstract
Phosphaturic mesenchymal tumor-mixed connective tissue (PMT-MCT) is rare and usually benign and slow-growing. The majority of these tumors is associated with sporadic tumor-induced osteomalacia (TIO) or rickets, affect middle-aged individuals and are located in the extremities. Previous imaging studies often focused on seeking the causative tumors of TIO, not on the radiological features of these tumors, especially magnetic resonance imaging (MRI) features. PMT-MCT remains a largely misdiagnosed, ignored or unknown entity by most radiologists and clinicians. In the present case report, a review of the known literature of PMT-MCT was conducted and the CT and MRI findings from three patient cases were described for diagnosing the small subcutaneous tumor. Typical MRI appearances of PMT-MCT were isointense relative to the muscles on T1-weighted imaging, and markedly hyperintense on T2-weighted imaging containing variably flow voids, with markedly heterogeneous/homogenous enhancement on post contrast T1-weighted fat-suppression imaging. Short time inversion recovery was demonstrated to be the optimal sequence in localizing the tumor.
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Affiliation(s)
- Zhenshan Shi
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yiqiong Deng
- Department of Radiology, Fuzhou Children's Hospital, Fuzhou, Fujian 350005, P.R. China
| | - Xiumei Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Yueming Li
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
| | - Dairong Cao
- Department of Radiology, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 350005, P.R. China
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Abstract
RATIONALE Tumor-induced osteomalacia (TIO) is a rare and often misdiagnosed syndrome. Surgical resection is currently the first line treatment for TIO. PATIENT CONCERNS Here we report the case of a 49-year-old woman presented with intermittent pain in the right chest and bilateral hip that had persisted for over two years. DIAGNOSES She was diagnosed of TIO caused by a phosphaturic mesenchymal tumor based on the following examinations. Laboratory tests revealed high serum alkaline phosphatase, high urinary phosphorus, hypophosphatemia and normal serum calcium levels. 18-FDG PET/CT indicated a systemic multi-site symmetrical pseudo fracture and a tumor in the 7th right rib. INTERVENTIONS Curettage of the tumor was performed, and pathological analysis also confirmed our diagnoses as a phosphaturic mesenchymal tumor. OUTCOMES At seven months post-surgery, the symptoms were relieved, proximal muscle strength was improved and serum levels of phosphorus and alkaline phosphatase normalized. The bilateral femoral neck and bilateral pubic bone fractures were blurred in the pelvic plain X-ray, suggesting that the fracture was healing. LESSONS This case report strengthened the importance of recognition of this rare disease to avoid delay of diagnosis and surgical removal of the causative tumor is recommended.
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Affiliation(s)
| | | | | | | | - Ningjun Li
- Department of Pathology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
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30
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Florenzano P, Gafni RI, Collins MT. Tumor-induced osteomalacia. Bone Rep 2017; 7:90-97. [PMID: 29021995 PMCID: PMC5633085 DOI: 10.1016/j.bonr.2017.09.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/07/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome clinically characterized by bone pain, fractures and muscle weakness. It is caused by tumoral overproduction of fibroblast growth factor 23 (FGF23) that acts primarily at the proximal renal tubule, decreasing phosphate reabsorption and 1α-hydroxylation of 25 hydroxyvitamin D, thus producing hypophosphatemia and osteomalacia. Lesions are typically small, benign mesenchymal tumors that may be found in bone or soft tissue, anywhere in the body. In up to 60% of these tumors, a fibronectin-1(FN1) and fibroblast growth factor receptor-1 (FGFR1) fusion gene has been identified that may serve as a tumoral driver. The diagnosis is established by the finding of acquired chronic hypophosphatemia due to isolated renal phosphate wasting with concomitant elevated or inappropriately normal blood levels of FGF23 and decreased or inappropriately normal 1,25-OH2-Vitamin D (1,25(OH)2D). Locating the tumor is critical, as complete removal is curative. For this purpose, a step-wise approach is recommended, starting with a thorough medical history and physical examination, followed by functional imaging. Suspicious lesions should be confirmed by anatomical imaging, and if needed, selective venous sampling with measurement of FGF23. If the tumor is not localized, or surgical resection is not possible, medical therapy with phosphate and active vitamin D is usually successful in healing the osteomalacia and reducing symptoms. However, compliance is often poor due to the frequent dosing regimen and side effects. Furthermore, careful monitoring is needed to avoid complications such us secondary/tertiary hyperparathyroidism, hypercalciuria, and nephrocalcinosis. Novel therapeutical approaches are being developed for TIO patients, such as image-guided tumor ablation and medical treatment with the anti-FGF23 monoclonal antibody KRN23 or anti FGFR medications. The case of a patient with TIO is presented to illustrate the importance of adequate and appropriate evaluation of patients with bone pain and hypophosphatemia, as well as an step-wise localization study of patients with suspected TIO.
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Key Words
- 1,25-OH2-vitamin D, 1,25(OH)2D
- CT, computerized tomography
- FDG-PET/CT, fluorodeoxyglucose positron emission tomography with computerized tomography
- FGF1, fibroblast growth factor 1
- FGF23
- FGF23, fibroblast growth factor 23
- FGFR1, fibroblast growth factor receptor-1
- FISH, fluorescence in situ hybridization
- FN1, fibronectin-1
- MAPK, mitogen-activated protein kinase
- MRI, magnetic resonance imaging
- PMT, phosphaturic mesenchymal tumor
- PTH, parathyroid hormone
- Phosphaturic mesenchymal tumors
- SPECT, single-photon emission computed tomography
- TIO, tumor-induced osteomalacia
- TRP, tubular reabsorption of phosphate
- TmP/GFR, tubular maximum reabsorption of phosphate to glomerular filtration rate
- Tumor-induced osteomalacia
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Affiliation(s)
- Pablo Florenzano
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Endocrinology Department, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rachel I Gafni
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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Kawai S, Ariyasu H, Furukawa Y, Yamamoto R, Uraki S, Takeshima K, Warigaya K, Nakamoto Y, Akamizu T. Effective localization in tumor-induced osteomalacia using 68Ga-DOTATOC-PET/CT, venous sampling and 3T-MRI. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170005. [PMID: 28469928 PMCID: PMC5409940 DOI: 10.1530/edm-17-0005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/10/2017] [Indexed: 12/11/2022] Open
Abstract
Summary Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting leading to hypophosphatemia due to excessive actions of fibroblast growth factor 23 (FGF23) produced by the tumors. Although the best way of curing TIO is complete resection, it is usually difficult to detect the culprit tumors by general radiological modalities owing to the size and location of the tumors. We report a case of TIO in which the identification of the tumor by conventional imaging studies was difficult. Nonetheless, a diagnosis was made possible by effective use of multiple modalities. We initially suspected that the tumor existed in the right dorsal aspect of the scapula by 68Ga-DOTATOC positron emission tomography/computed tomography (68Ga-DOTATOC-PET/CT) and supported the result by systemic venous sampling (SVS). The tumor could also be visualized by 3T-magnetic resonance imaging (MRI), although it was not detected by 1.5T-MRI, and eventually be resected completely. In cases of TIO, a stepwise approach of 68Ga-DOTATOC-PET/CT, SVS and 3T-MRI can be effective for confirmation of diagnosis. Learning points:
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Affiliation(s)
| | | | | | | | | | | | - Kenji Warigaya
- Department of Human Pathology, Wakayama Medical University, WakayamaJapan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, KyotoJapan
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Abate EG, Bernet V, Cortese C, Garner HW. Tumor induced osteomalacia secondary to anaplastic thyroid carcinoma: A case report and review of the literature. Bone Rep 2016; 5:81-85. [PMID: 28326350 PMCID: PMC4926825 DOI: 10.1016/j.bonr.2015.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 10/28/2015] [Accepted: 11/26/2015] [Indexed: 12/18/2022] Open
Abstract
Context Tumor induced osteomalacia related to anaplastic thyroid cancer has never been reported. Objective We describe a case of tumor induced osteomalacia (TIO) in a patient with a fibroblast growth factor 23 (FGF-23) secreting anaplastic thyroid carcinoma. The current imaging modalities are reviewed. Design and intervention Clinical, biochemical, and radiological assessments were done, including computer tomography (CT) of the neck and skull to thigh positron emission tomography (PET)/CT. The patient underwent surgical tumor debulking three days after presentation due to airway compromise. Molecular studies of the resected tissue were performed using reverse transcriptase–polymerase chain reaction (RT-PCR) and gel electrophoresis for the phosphaturic mesenchymal tumor FGF-23. Results Resected tissue demonstrated features of anaplastic thyroid cancer with positive markers for FGF-23 protein, consistent with a FGF-23 secreting paraneoplastic tumor. The patient's metastatic burden rapidly progressed as demonstrated by a dramatic rise in serum FGF-23 levels and worsening hypophosphatemia in concert with progression of the metastatic lesions on PET/CT. Conclusion We believe that our patient's rapidly progressive anaplastic thyroid cancer was responsible for persistent hypophosphatemia and osteomalacia, substantiated by the finding of FGF-23 protein within the thyroid tumor cells. Our case indicates that anaplastic thyroid cancer can cause TIO.
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Affiliation(s)
- Ejigayehu G Abate
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Victor Bernet
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Cherise Cortese
- Department of Pathology, Mayo Clinic, Jacksonville, FL 32224, United States
| | - Hillary W Garner
- Department of Radiology, Mayo Clinic, Jacksonville, FL 32224, United States
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Abstract
Tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome resulting in renal phosphate wasting and decreased bone mineralization. TIO is usually induced by small, slowly growing tumors of mesenchymal origin (phosphaturic mesenchymal tumor mixed connective tissue variant [PMTMCT]). Nonspecific symptoms including fatigue, bone pain, and musculoskeletal weakness make the diagnosis elusive and often lead to a delay in treatment. The prognosis of TIO is excellent following complete resection of the neoplasm, which leads to the rapid and complete reversal of all symptoms. If the tumor cannot be detected, treatment relies on supplementation with phosphate and active vitamin D compounds. Subsequent radiotherapy in case of incompletely resected tumors or definitive radiotherapy in unresectable tumors is an important treatment option to avoid recurrence or metastasis even though this occurs rarely. Due to the risk of recurrence or late metastases, long-term monitoring is required even in TIO patients diagnosed with a benign tumor.
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Fathalla H, Cusimano M, Di Ieva A, Karamchandani J, Fung R, Kovacs K. Osteomalacia-Inducing Tumors of the Brain: A Case Report, Review and a Hypothesis. World Neurosurg 2015; 84:189.e1-5. [DOI: 10.1016/j.wneu.2015.02.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 02/23/2015] [Accepted: 02/24/2015] [Indexed: 12/31/2022]
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Wang H, Zhong D, Liu Y, Jiang Y, Qiu G, Weng X, Xing X, Li M, Meng X, Li F, Zhu Z, Yu W, Xia W, Jin J. Surgical Treatments of Tumor-Induced Osteomalacia Lesions in Long Bones: Seventeen Cases with More Than One Year of Follow-up. J Bone Joint Surg Am 2015; 97:1084-94. [PMID: 26135075 DOI: 10.2106/jbjs.n.01299] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia is a rare and fascinating paraneoplastic syndrome usually caused by a small, benign phosphaturic mesenchymal tumor. Most tumors are treated surgically, but we are unaware of any reports that compare the results of curettage and segmental resection for lesions in long bones. METHODS Seventeen patients (ten male and seven female) with tumor-induced osteomalacia lesions in long bones, who underwent surgical treatment from December 2004 to August 2013 in our hospital, were included in this retrospective study. The mean follow-up (and standard deviation) was 35 ± 27 months (range, twelve to 116 months). The characteristics of the tumor and the effects of different surgical treatments (curettage compared with segmental resection) were evaluated. RESULTS All patients showed typical clinical characteristics of tumor-induced osteomalacia, including elevated serum fibroblast growth factor-23 (FGF-23); 82% of tumors were in the epiphysis, and 82% grew eccentrically. The mean maximum diameter of the tumors was 2.4 ± 2.0 cm. The complete resection rates were similar for curettage (67%) and segmental resection (80%). However, the recurrence rate after curettage (50%) was higher than that after segmental resection (0%). The complete resection rate for secondary segmental resection (75%) was not different from that for primary segmental resection (83%). All of our cases of tumor-induced osteomalacia were caused by phosphaturic mesenchymal tumors. After successful removal of tumors, serum FGF-23 returned to normal within twenty-four hours and serum phosphorus levels returned to normal at a mean of 6.5 ± 3.5 days. CONCLUSIONS Most lesions in long bones are located in the epiphysis, so curettage is first suggested to maintain joint function. If curettage is incomplete or there is a recurrence, secondary segmental resection should be considered curative. Changes of serum FGF-23 and phosphorus levels before and after the operation may be of prognostic help.
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Affiliation(s)
- Hai Wang
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Dingrong Zhong
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Yong Liu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Yan Jiang
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Guixing Qiu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xisheng Weng
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xiaoping Xing
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Mei Li
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xunwu Meng
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Fang Li
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Zhaohui Zhu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Wei Yu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Weibo Xia
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Jin Jin
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
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Tumor-Induced Osteomalacia: Increased Level of FGF-23 in a Patient with a Phosphaturic Mesenchymal Tumor at the Tibia Expressing Periostin. Case Rep Endocrinol 2014; 2014:729387. [PMID: 25221676 PMCID: PMC4158256 DOI: 10.1155/2014/729387] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/11/2014] [Accepted: 08/12/2014] [Indexed: 01/12/2023] Open
Abstract
In our case, a 45-year-old male patient had multiple fractures accompanied by hypophosphatemia. FGF-23 levels were significantly increased, and total body magnetic resonance imaging (MRI) revealed a tumor mass located at the distal tibia leading to the diagnosis of tumor-induced osteomalacia (TIO). After resection of the tumor, hypophosphatemia and the increased levels of FGF-23 normalized within a few days. Subsequent microscopic examination and immunohistochemical analysis revealed a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT) showing a positive expression of somatostatin receptor 2A (SSTR2A), CD68, and Periostin. Electron microscopy demonstrated a poorly differentiated mesenchymal tumor with a multifocal giant cell component and evidence of neurosecretory-granules. However, the resected margins showed no tumor-free tissue, and therefore a subsequent postoperative radiotherapy was performed. The patient is still in complete remission after 34 months. Tumor resection of PMTMCTs is the therapy of choice. Subsequent radiotherapy in case of incompletely resected tumors can be an important option to avoid recurrence or metastasis even though this occurs rarely. The prognostic value of expression of Periostin has to be evaluated more precisely in a larger series of patients with TIO.
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Khosla S. Commentary. Clin Chem 2014; 60:931-2. [DOI: 10.1373/clinchem.2013.217034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shikha Khosla
- Department of Endocrinology, Metabolism and Diabetes, Veterans Affairs Medical Center, Washington, DC
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