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Jan de Beur SM, Minisola S, Xia WB, Abrahamsen B, Body JJ, Brandi ML, Clifton-Bligh R, Collins M, Florenzano P, Houillier P, Imanishi Y, Imel EA, Khan AA, Zillikens MC, Fukumoto S. Global guidance for the recognition, diagnosis, and management of tumor-induced osteomalacia. J Intern Med 2023; 293:309-328. [PMID: 36511653 PMCID: PMC10108006 DOI: 10.1111/joim.13593] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by mesenchymal tumors that secrete fibroblast growth factor 23 (FGF23). Patients present with progressive bone pain, muscle weakness, and fragility fractures. TIO is characterized by hypophosphatemia, excess renal phosphate excretion, and low/inappropriately normal 1,25-dihydroxyvitamin D (1,25(OH)2 D) levels. Rarity and enigmatic clinical presentation of TIO contribute to limited awareness among the medical community. Accordingly, appropriate diagnostic tests may not be requested, leading to delayed diagnosis and poorer patient outcomes. We have developed a global guidance document to improve the knowledge of TIO in the medical community, enabling the recognition of patients with TIO and appropriate referral. We provide recommendations aiding diagnosis, referral, and treatment, helping promote a global standard of patient management. We reviewed the literature and conducted a three-round Delphi survey of TIO experts. Statements were drafted based on published evidence and expert opinions (≥70% consensus required for final recommendations). Serum phosphate should be measured in patients presenting with chronic muscle pain or weakness, fragility fractures, or bone pain. Physical examination should establish features of myopathy and identify masses that could be causative tumors. Priority laboratory evaluations should include urine/serum phosphate and creatinine to assess renal tubular reabsorption of phosphate and TmP/GFR, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, 1,25(OH)2 D, and FGF23. Patients with the clinical/biochemical suspicion of TIO should be referred to a specialist for diagnosis confirmation, and functional imaging should be used to localize causative tumor(s). Recommended treatment is tumor resection or, with unresectable/unidentifiable tumors, phosphate salts plus active vitamin D, or burosumab.
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Affiliation(s)
- Suzanne M Jan de Beur
- Division of Endocrinology and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Salvatore Minisola
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Wei-Bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, NHC, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bo Abrahamsen
- Open Patient data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark.,Department of Medicine, Holbaek Hospital, Holbaek, Denmark.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, University Hospital of Florence, Florence, Italy
| | - Roderick Clifton-Bligh
- Department of Endocrinology and Diabetes, Royal North Shore Hospital, Sydney, Australia.,Cancer Genetics Unit, Kolling Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Collins
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Pablo Florenzano
- Centro Traslacional de Endocrinología UC (CETREN-UC), Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pascal Houillier
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Département des Maladies Rénales et Métaboliques, Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Erik A Imel
- Division of Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, Calcium Disorders Clinic, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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Hussein MAM, Cafarelli FP, Paparella MT, Rennie WJ, Guglielmi G. Phosphaturic mesenchymal tumors: radiological aspects and suggested imaging pathway. Radiol Med 2021; 126:1609-1618. [PMID: 34453276 PMCID: PMC8702419 DOI: 10.1007/s11547-021-01412-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal neoplasms of soft tissue or bone origin that can give rise to a challenge in diagnostic imaging. These tumors are frequently associated with tumor-induced osteomalacia, also called oncogenic osteomalacia, which is a rare paraneoplastic syndrome characterized by ectopic secretion of fibroblast growth factor 23, a hormone that regulates serum phosphate level. PMTs show polymorphic features on both radiological findings and histological examination, causing problems in diagnosis owing to their similarity with other mesenchymal tumors. Thus, this paper aims to describe radiological aspects of PMTs and suggest an imaging pathway for accurate diagnosis throughout the evidence from the literature review.
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Affiliation(s)
| | - Francesco Pio Cafarelli
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Maria Teresa Paparella
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy
| | - Winston J Rennie
- Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto, 1, 71121, Foggia, Italy.
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