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Seefried L, Duplan MB, Briot K, Collins MT, Evans R, Florenzano P, Hawkins N, Javaid MK, Lachmann R, Ward LM. Anticipated effects of burosumab treatment on long-term clinical sequelae in XLH: expert perspectives. Front Endocrinol (Lausanne) 2023; 14:1211426. [PMID: 37547321 PMCID: PMC10400326 DOI: 10.3389/fendo.2023.1211426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/27/2023] [Indexed: 08/08/2023] Open
Abstract
X-linked hypophosphatemia (XLH) is a rare, progressive, genetic disease with multisystem impact that typically begins to manifest in early childhood. Two treatment options exist: oral phosphate in combination with active vitamin D ("conventional therapy") and a fully human monoclonal anti-FGF23 antibody, burosumab. The clinical benefit of conventional therapy in adults is limited, and poor tolerance and complications are common. Burosumab was first approved as a treatment for XLH in 2018 and its disease-modifying benefits in clinical trials in children suggest burosumab treatment could also alter the disease course in adults. Without long-term clinical data on multiple XLH-related sequelae available, the results of an elicitation exercise are reported, in which eight global experts in XLH posited how long-term treatment with burosumab is anticipated to impact the life course of clinical sequelae in adults with XLH. Based on their clinical experiences, the available evidence and their disease understanding, the experts agreed that some long-term benefits of using burosumab are likely in adults with XLH even if they have a misaligned skeleton from childhood. Burosumab treatment is anticipated to reduce the incidence of fractures and halt the progression of clinical sequelae associated with conventional therapy. While the trajectories for established dental abscesses are not expected to improve with burosumab treatment, dental abscess development may be prevented. Starting treatment with burosumab in childhood to increase the likelihood of an aligned skeleton and continuation into and throughout adulthood to maintain euphosphatemia may optimize patient outcomes, although future real-world investigation is required to support this hypothesis.
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Affiliation(s)
- Lothar Seefried
- Orthopedic Department, University of Würzburg, Würzburg, Germany
| | - Martin Biosse Duplan
- Service de Médecine Bucco-Dentaire, Hôpital Bretonneau, AP-HP, Paris, France
- UFR d’Odontologie, Université de Paris, Paris, France
- Institut Imagine, INSERM, Paris, France
| | - Karine Briot
- Department of Rheumatology, Hôpital Cochin, Université de Paris-Cité, Paris, France
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Rachel Evans
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Pablo Florenzano
- Department of Endocrinology, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Endocrinology, Centro Traslacional en Endocrinologia (CETREN-UC), Santiago, Chile
| | - Neil Hawkins
- Health Economics, Visible Analytics, Oxford, United Kingdom
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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2
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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: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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3
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Hartley IR, Gafni RI, Roszko KL, Brown SM, de Castro LF, Saikali A, Ferreira CR, Gahl WA, Pacak K, Blau JE, Boyce AM, Salusky IB, Collins MT, Florenzano P. Determination of FGF23 Levels for the Diagnosis of FGF23-Mediated Hypophosphatemia. J Bone Miner Res 2022; 37:2174-2185. [PMID: 36093861 PMCID: PMC9712269 DOI: 10.1002/jbmr.4702] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/22/2022] [Accepted: 09/05/2022] [Indexed: 11/09/2022]
Abstract
Fibroblast growth factor-23 (FGF23) measurement is a critical tool in the evaluation of patients with disordered phosphate homeostasis. Available laboratory reference ranges for blood FGF23 were developed using samples from normophosphatemic individuals. Reliance on such values can lead to misdiagnosis in patients with FGF23-mediated hypophosphatemia, such as X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO), in whom pathology-driving FGF23 levels can be in the "normal range." To determine FGF23 levels that are diagnostic for the identification of patients with FGF23-mediated hypophosphatemic disorders, we studied 149 patients with various disorders of FGF23-mediated and FGF23-independent hypophosphatemia and defined cut-off levels for both intact FGF23 (iFGF23) and C-terminal FGF23 (cFGF23) that can accurately distinguish between FGF23-mediated and FGF23-independent hypophosphatemia. In addition, to demonstrate the relationship between FGF23 and phosphate across the spectrum of human physiology, we assessed blood levels of FGF23 and phosphate in 434 patients with various forms of hypophosphatemia, hyperphosphatemia, and normophosphatemia. An intact FGF23 cut point of 27 pg/mL was 100% sensitive and specific in distinguishing FGF23-mediated from FGF23-independent hypophosphatemia, and a cFGF23 cut point of 90 RU/mL was 100% sensitive and specific in distinguishing specifically TIO from FGF23-independent hypophosphatemia. There was overlap in the cFGF23 range of 45-90 RU/mL between genetic forms of FGF23 excess and FGF23-independent hypophosphatemia, substantiating the superiority of iFGF23 over cFGF23 in making the diagnosis of FGF23-mediated hypophosphatemia. In this cohort, using the laboratory upper limit of normal for cFGF23 (180 RU/mL) would result in a misdiagnosis in more than half of patients with FGF23-mediated hypophosphatemia. In this, the largest study of FGF23 in chronic hypophosphatemia to date, we established iFGF23 and cFGF23 cut-off values to assist in the evaluation and diagnosis of hypophosphatemic conditions. © 2022 American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Iris R. Hartley
- 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
| | - Kelly L. Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Sydney M. Brown
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Luis F. de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Amanda Saikali
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Carlos R. Ferreira
- Metabolic Medicine Branch, National Human Genome Research Institute, National Institutes of Health
| | - William A. Gahl
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Jenny E. Blau
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Alison M. Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Isidro B. Salusky
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Michael T. Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research. National Institutes of Health, Bethesda, MD, USA
| | - Pablo Florenzano
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- School of Medicine, Pontificia Universidad Catolica de Chile, Centro Traslacional en Endocrinología UC (CETREN-UC), Santiago, Chile
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4
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Jiménez C, Schneider P, Baudrand R, García H, Martínez A, Mendoza C, Grob F, Seiltgens C, Florenzano P. [Clinical features of Chilean patients with Fibrous Dysplasia/McCune-Albright Syndrome]. Rev Med Chil 2022; 150:1275-1282. [PMID: 37358085 DOI: 10.4067/s0034-98872022001001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/27/2022] [Indexed: 06/27/2023]
Abstract
BACKGROUND Fibrous Dysplasia/McCune-Albright Syndrome (FD/MAS) is characterized by a spectrum of manifestations that may include fibrous dysplasia of bone and multiple endocrinopathies. AIM To describe the clinical spectrum, the study and follow-up of patients with FD/MAS cared at our institution. MATERIAL AND METHODS Review of medical records of 12 pediatric and adult patients (11 women) who met the clinical and genetic diagnostic criteria for FD/ MAS. RESULTS The patients' mean age at diagnosis was 4.9 ± 5.5 years. The most common initial clinical manifestation was peripheral precocious puberty (PPP) in 67% of patients and 75% had café-au-lait spots. Fibrous dysplasia was present in 75% of patients and the mean age at diagnosis was 7.9 ± 4.7 years. Ten patients had a bone scintigraphy, with an age at the first examination that varied between 2 and 38 years of age. The most frequent location of dysplasia was craniofacial and appendicular. No patient had a recorded history of cholestasis, hepatitis, or pancreatitis. In four patients, a genetic study was performed that was positive for the pathogenic variant of guanine nucleotide binding protein, alpha stimulating (GNAS). CONCLUSIONS These patients demonstrate the variable nature of the clinical presentation and study of FD/MAS. It is essential to increase the index of diagnostic suspicion and adherence to international recommendations.
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Affiliation(s)
- Catalina Jiménez
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paulina Schneider
- Unidad de Endocrinología Infantil, Hospital Herminda Martín de Chillán, Chillán, Chile
| | - Rene Baudrand
- Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hernán García
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Martínez
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Mendoza
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisca Grob
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristián Seiltgens
- Departamento de Pediatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Florenzano
- Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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5
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Jiménez M, Henríquez C, Miranda F, Olmedo M, Ivanovic-Zuvic D, Florenzano P. [A search for secondary causes of osteoporosis or low mineral density in postmenopausal women]. Rev Med Chil 2022; 150:597-602. [PMID: 37906759 DOI: 10.4067/s0034-98872022000500597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 12/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND A secondary cause can be found in up to one third of women with osteoporosis, potentially modifying their therapeutic approach. AIM To determine the prevalence of secondary causes and risk factors for decreased bone mineral density (BMD) and osteoporosis. MATERIAL AND METHODS We included postmenopausal women with a diagnosis of osteoporosis or low BMD who consulted for the first time in an endocrinology clinic between October 2018 and March 2020. A complete medical history, physical examination and a standardized laboratory assessment to identify secondary causes were performed. RESULTS During the study period, 114 women were evaluated, 30 of them with low BMD and 84 with osteoporosis. After obtaining a medical history and a structured laboratory screening, at least one secondary cause was found in 50% of patients with osteoporosis and in 67% of those with low BMD. Most patients with no identified secondary cause had at least one risk factor for fragility fractures. CONCLUSIONS A structured evaluation that includes medical history and standardized laboratory study in postmenopausal women with osteoporosis or low BMD, is a valuable tool to identify secondary causes of osteoporosis.
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Affiliation(s)
- Macarena Jiménez
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Camila Henríquez
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisca Miranda
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Olmedo
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Danisa Ivanovic-Zuvic
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Florenzano
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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6
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Aljuraibah F, Bacchetta J, Brandi ML, Florenzano P, Javaid MK, Mäkitie O, Raimann A, Rodriguez M, Siggelkow H, Tiosano D, Vervloet M, Wagner CA. An Expert Perspective on Phosphate Dysregulation With a Focus on Chronic Hypophosphatemia. J Bone Miner Res 2022; 37:12-20. [PMID: 34870347 PMCID: PMC9306528 DOI: 10.1002/jbmr.4486] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/18/2021] [Accepted: 11/27/2021] [Indexed: 12/11/2022]
Abstract
Because of their rarity, diseases characterized by chronic hypophosphatemia can be underrecognized and suboptimally managed, resulting in poor clinical outcomes. Moreover, serum phosphate may not be measured routinely in primary care practice. Authors participated in several working sessions to advance the understanding of phosphate homeostasis and the causes, consequences, and clinical implications of chronic hypophosphatemia. Phosphate levels are regulated from birth to adulthood. Dysregulation of phosphate homeostasis can result in hypophosphatemia, which becomes chronic if phosphate levels cannot be normalized. Chronic hypophosphatemia may be underrecognized as serum phosphate measurement is not always part of routine analysis in the primary care setting and results might be misinterpreted, for instance, due to age-specific differences not being accounted for and circadian variations. Clinical consequences of chronic hypophosphatemia involve disordered endocrine regulation, affect multiple organ systems, and vary depending on patient age and the underlying disorder. Signs and symptoms of chronic hypophosphatemic diseases that manifest during childhood or adolescence persist into adulthood if the disease is inadequately managed, resulting in an accumulation of clinical deficits and a progressive, debilitating impact on quality of life. Early identification and diagnosis of patients with chronic hypophosphatemia is crucial, and clinical management should be started as soon as possible to maximize the likelihood of improving health outcomes. Furthermore, in the absence of a universally accepted description for "chronic hypophosphatemia," a definition is proposed here that aims to raise awareness of these diseases, facilitate diagnosis, and guide optimal phosphate management strategies by improving monitoring and assessment of patient response to treatment. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Fahad Aljuraibah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | - Outimaija Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Marc Vervloet
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Carsten A Wagner
- University of Zurich, Zurich.,Swiss National Center of Competence in Research NCCR Kidney.CH, Zurich
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7
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Barberán M, Campusano C, Salman P, Trejo P, Silva-Figueroa A, Rivera S, Florenzano P, Velasco S, Illanes F, Trincado P, Canessa J, Solar A, Moreno M, Eugenin D, Jiménez B, Arroyo P. [An update on parathyroid carcinoma]. Rev Med Chil 2021; 149:399-408. [PMID: 34479319 DOI: 10.4067/s0034-98872021000300399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/05/2020] [Indexed: 11/17/2022]
Abstract
Parathyroid carcinoma is a rare malignant disease that presents as a sporadic or familial primary hyperparathyroidism (PHP). The latter is associated with some genetic syndromes. It occurs with equal frequency in both sexes, unlike PHP caused by parathyroid adenoma that is more common in women. It should be suspected in cases of severe hypercalcemia, with high parathyroid hormone levels and a palpable cervical mass. Given the difficulty in distinguishing between parathyroid carcinoma and adenoma prior to the surgery, the diagnosis is often made after parathyroidectomy. The only curative treatment is complete surgical resection with oncologic block resection of the primary tumor to ensure free margins. Adjuvant therapies with chemotherapy or radiation therapy do not modify overall or disease-free survival. Recurrences are common and re-operation of resectable recurrent disease is recommended. The palliative treatment of symptomatic hypercalcemia is crucial in persistent or recurrent disease after surgery since morbidity and mortality are more associated with hypercalcemia than with tumor burden.
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Affiliation(s)
| | - Claudia Campusano
- Clínica Universidad de los Andes, Facultad de Medicina, Universidad de los Andes, Chile
| | - Patricio Salman
- Escuela de Medicina, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | | | | | - Sandra Rivera
- Departamento de Endocrinología, Clínica Dávila, Santiago, Chile
| | - Pablo Florenzano
- Departamento de Endocrinología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Soledad Velasco
- Escuela de Medicina, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Francisca Illanes
- Escuela de Medicina, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | | | | | - Antonieta Solar
- Departamento de Anatomía Patológica, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marcela Moreno
- Clínica Universidad de los Andes, Facultad de Medicina, Universidad de los Andes, Chile
| | | | | | - Patricia Arroyo
- Departamento Radiología, Hospital Clínico Universidad de Chile, Santiago, Chile
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8
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Jiménez M, Ivanovic-Zuvic D, Loureiro C, Carvajal CA, Cavada G, Schneider P, Gallardo E, García C, Gonzalez G, Contreras O, Collins MT, Florenzano P. Clinical and molecular characterization of Chilean patients with X-linked hypophosphatemia. Osteoporos Int 2021; 32:1825-1836. [PMID: 33666701 DOI: 10.1007/s00198-021-05875-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/02/2021] [Indexed: 11/30/2022]
Abstract
UNLABELLED We report the most comprehensive clinical and molecular characterization of XLH patients performed in Chile. We show high prevalence of musculoskeletal burden and pain, associated with significantly impaired physical capacity and quality of life, with many relevant complications presenting more frequently than previously reported in cohorts from developed countries. INTRODUCTION Our current understanding of the clinical presentation and natural history of X-linked hypophosphatemia (XLH) comes mainly from cohorts from developed countries, with limited data on the clinical and genetic abnormalities of XLH patients in South America. OBJECTIVE To describe the clinical, biochemical, and molecular presentation of patients with XLH in Chile. METHODS Patients with XLH referred by endocrinologist throughout Chile were included. Demographic data and clinical presentation were obtained from a clinical interview. Surveys were applied for quality of life (QoL), pain, and functionality. FGF23 was measured by ELISA, and genetic testing was performed. Imaging studies were conducted to assess skeletal and renal involvement. RESULTS We included 26 patients, aged 2-64 years, from 17 unrelated Chilean families. All pediatric patients but only 40% of adults were receiving conventional therapy, while 65% of all patients had elevated alkaline phosphatase. All patients had mutations in PHEX, including 5 novel variants. Radiographic skeletal events (RSE) and enthesopathies in adults were frequent (34% and 85%, respectively). The duration of treatment was associated with fewer RSE (p < 0.05). Most adults reported pain and impaired QoL, and 50% had impaired physical capacity. The number of enthesopathies was associated with worse pain and stiffness scores (p < 0.05). CONCLUSION Chilean patients with XLH have a high prevalence of musculoskeletal burden associated with pain and impaired physical capacity and QoL, especially in adults who were generally undertreated. These data identify a significant unmet need, inform our understanding of the current status of patients, and can guide care for XLH patients in similarly socioeconomically defined countries.
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Affiliation(s)
- M Jiménez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto Piso, Santiago, Chile
| | - D Ivanovic-Zuvic
- Internal Medicine Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C Loureiro
- Department of Pediatric Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C A Carvajal
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto Piso, Santiago, Chile
- Center for Translational Research in Endocrinology, CETREN-UC, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - G Cavada
- Biostatistics division, School of Public Health, Universidad de Chile, Santiago, Chile
- School of Medicine, Universidad Finnis Terrae, Santiago, Chile
| | - P Schneider
- Department of Pediatric Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - E Gallardo
- Radiology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C García
- Radiology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - G Gonzalez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto Piso, Santiago, Chile
- Center for Translational Research in Endocrinology, CETREN-UC, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - O Contreras
- Radiology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, MD, USA
| | - P Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto Piso, Santiago, Chile.
- Center for Translational Research in Endocrinology, CETREN-UC, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, MD, USA.
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9
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Marin A, Morales P, Jiménez M, Borja E, Ivanovic-Zuvic D, Collins MT, Florenzano P. Characterization of Oral Health Status in Chilean Patients with X-Linked Hypophosphatemia. Calcif Tissue Int 2021; 109:132-138. [PMID: 33839802 DOI: 10.1007/s00223-021-00841-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/18/2021] [Indexed: 01/22/2023]
Abstract
X-Linked Hypophosphatemia (XLH) is the most common cause of inherited hypophosphatemic rickets. Dental involvement, including spontaneous abscesses and/or fistulae, is an important part of the disease and has not been completely defined, especially in cohorts from developing countries. To describe oral health status in a cohort of Chilean patients with XLH and explore its correlation with biochemical presentation and treatment, we conducted a cross-sectional observational study of patients with PHEX mutation-confirmed XLH. All patients had an oral clinical exam, radiographic evaluation; clinical and biochemical data were obtained to determine their association with oral features. Twenty-six patients were included, 77% adults and 23% children. Most adults (89%) had past or current dental pulp pathology (abscesses and/or fistulae). Pulpal chamber enlargement and radiolucent apical lesions were common radiological features (94 and 74%, respectively). In children, abscess and/or fistulae were also common (33%). Caries index, which was determined by dmft/DMFT, was higher than the Chilean national average. Early and long-term therapy with phosphate and activated vitamin D was associated with lower carious index and attachment loss. XLH patients frequently present with high pulpal involvement and carious index. Conventional therapy was associated with lower carious index and attachment loss. These data highlight the importance of early and periodical dental care in order to prevent dental damage and assure a good quality of oral health for XLH patients.
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Affiliation(s)
- Alejandro Marin
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pilar Morales
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Jiménez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 262, Cuarto piso, Santiago, Chile
| | - Eugenia Borja
- Faculty of Medicine, School of Dentistry, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Danisa Ivanovic-Zuvic
- Internal Medicine Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 262, Cuarto piso, Santiago, Chile.
- Center for Translational Research in Endocrinology, CETREN-UC, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, MD, USA.
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10
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Ivanovic-Zuvic D, Santander MJ, Jiménez M, Novoa I, Winter M, Florenzano P. Characterization of otologic involvement in patients with X-Linked Hypophosphatemia. Clin Otolaryngol 2021; 46:1251-1256. [PMID: 34170626 DOI: 10.1111/coa.13825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/08/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Danisa Ivanovic-Zuvic
- Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María Jesús Santander
- Department of Otolaringology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Jiménez
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Iván Novoa
- Department of Otolaringology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Matías Winter
- Department of Otolaringology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Florenzano
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Center for Translational Research in Endocrinology. CETREN-UC, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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11
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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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12
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Hartley IR, Miller CB, Papadakis GZ, Bergwitz C, Del Rivero J, Blau JE, Florenzano P, Berglund JA, Tassone J, Roszko KL, Moran S, Gafni RI, Isaacs R, Collins MT. Targeted FGFR Blockade for the Treatment of Tumor-Induced Osteomalacia. N Engl J Med 2020; 383:1387-1389. [PMID: 32905668 PMCID: PMC7561341 DOI: 10.1056/nejmc2020399] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Iris R Hartley
- National Institute of Dental and Craniofacial Research, Bethesda, MD
| | | | | | | | | | - Jenny E Blau
- National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD
| | | | - Jason A Berglund
- University of Texas Health Science Center at Houston, Houston, TX
| | | | - Kelly L Roszko
- National Institute of Dental and Craniofacial Research, Bethesda, MD
| | | | - Rachel I Gafni
- National Institute of Dental and Craniofacial Research, Bethesda, MD
| | - Randi Isaacs
- Novartis Institutes of Biomedical Research, East Hanover, NJ
| | - Michael T Collins
- National Institute of Dental and Craniofacial Research, Bethesda, MD
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13
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Ivanovic-Zuvic D, Fischman A, Jiménez M, Martínez A, Ernst D, Toro L, Guarda FJ, Florenzano P. [Hypophosphatemia induced by carboxymaltose iron and imatinib. Report of two cases]. Rev Med Chil 2020; 148:404-408. [PMID: 32730387 DOI: 10.4067/s0034-98872020000300404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/26/2020] [Indexed: 11/17/2022]
Abstract
Hypophosphatemia is a relatively frequent and a potentially serious adverse drug effect. Clinically it is characterized by bone pain and muscle weakness. There are several mechanisms by which a drug can induce hypophosphatemia and they can be classified according to whether or not they are mediated by an excess of Fibroblast Growth Factor 23 (FGF23). We report two patients with the condition: (i) A 49-year-old woman with Chronic Myeloid Leukemia (CML) and gastric sleeve surgery at 46 years of age. After receiving intravenous carboxymaltose iron in one occasion due to refractory anemia, she developed symptomatic hypophosphatemia. Urinary phosphate losses associated with high FGF23 levels were confirmed. Plasma phosphate returned to normal values 90 days after the iron administration. (ii) A 40-year-old man with a history of CML in whom imatinib was started. He developed symptomatic hypophosphatemia due to non FGF23-mediated hyperphosphaturia. As treatment with imatinib could not be interrupted, hypophosphatemia and its symptoms resolved with oral phosphate intake. These cases illustrate the importance of recognizing and treating drug-induced hypophosphatemia in a timely manner, and thus avoid the morbidity associated with this entity.
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Affiliation(s)
- Danisa Ivanovic-Zuvic
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexandra Fischman
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Jiménez
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandra Martínez
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel Ernst
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Toro
- Sección de Nefrología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Francisco J Guarda
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Florenzano
- Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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14
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Florenzano P, Jimenez M, Ferreira CR, Nesterova G, Roberts MS, Tella SH, Fernandez de Castro L, Gafni RI, Wolf M, Jüppner H, Gales B, Wesseling-Perry K, Markovich D, Gahl WA, Salusky IB, Collins MT. Nephropathic Cystinosis: A Distinct Form of CKD-Mineral and Bone Disorder that Provides Novel Insights into the Regulation of FGF23. J Am Soc Nephrol 2020; 31:2184-2192. [PMID: 32631973 DOI: 10.1681/asn.2019111172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/18/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The rare lysosomal storage disease nephropathic cystinosis presents with renal Fanconi syndrome that evolves in time to CKD. Although biochemical abnormalities in common causes of CKD-mineral and bone disorder have been defined, it is unknown if persistent phosphate wasting in nephropathic cystinosis is associated with a biochemical mineral pattern distinct from that typically observed in CKD-mineral and bone disorder. METHODS We assessed and compared determinants of mineral homeostasis in patients with nephropathic cystinosis across the predialysis CKD spectrum to these determinants in age- and CKD stage-matched patients, with causes of CKD other than nephropathic cystinosis. RESULTS The study included 50 patients with nephropathic cystinosis-related CDK and 97 with CKD from other causes. All major aspects of mineral homeostasis were differentially effected in patients with CKD stemming from nephropathic cystinosis versus other causes. Patients with nephropathic cystinosis had significantly lower percent tubular reabsorption of phosphate and fibroblast growth factor-23 (FGF23) at all CKD stages, and lower blood phosphate in CKD stages 3-5. Linear regression analyses demonstrated lower FGF23 levels in nephropathic cystinosis participants at all CKD stages when corrected for eGFR and age, but not when adjusted for serum phosphate. CONCLUSIONS Nephropathic cystinosis CKD patients have mineral abnormalities that are distinct from those in CKD stemming from other causes. Persistently increased urinary phosphate excretion maintains serum phosphate levels within the normal range, thus protecting patients with nephropathic cystinosis from elevations of FGF23 during early CKD stages. These findings support the notion that phosphate is a significant driver of increased FGF23 levels in CKD and that mineral abnormalities associated with CKD are likely to vary depending on the underlying renal disease.
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Affiliation(s)
- Pablo Florenzano
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland .,Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos R Ferreira
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Galina Nesterova
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary Scott Roberts
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Sri Harsha Tella
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Luis Fernandez de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Barbara Gales
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Katherine Wesseling-Perry
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Daniela Markovich
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - William A Gahl
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Isidro B Salusky
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
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15
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Florenzano P, Cipriani C, Roszko KL, Fukumoto S, Collins MT, Minisola S, Pepe J. Approach to patients with hypophosphataemia. Lancet Diabetes Endocrinol 2020; 8:163-174. [PMID: 31924563 DOI: 10.1016/s2213-8587(19)30426-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
Phosphate metabolism is an evolving area of basic and clinical research. In the past 15 years, knowledge on disturbances of phosphate homoeostasis has expanded, as has the discovery of new targeted therapies. Hypophosphataemia might be the biochemical finding in several diseases, and its clinical evaluation should initially focus on the assessment of pathophysiological mechanisms leading to low serum phosphate concentrations. Clinical consequences of hypophosphataemia can involve multiple organ systems and vary depending on several factors, the most important being the underlying disorder. This Review focuses on the approach to patients with hypophosphataemia and how underlying pathophysiological mechanisms should be understood in the evaluation of differential diagnosis. We define an algorithm for the assessment of hypophosphataemia and review the most up-to-date literature on specific therapies. Continuous research in this area will result in a better understanding and management of patients with hypophosphataemia.
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Affiliation(s)
- Pablo Florenzano
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy.
| | - Kelly L Roszko
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Michael T Collins
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
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16
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Papadakis GZ, Manikis GC, Karantanas AH, Florenzano P, Bagci U, Marias K, Collins MT, Boyce AM. 18 F-NaF PET/CT IMAGING IN FIBROUS DYSPLASIA OF BONE. J Bone Miner Res 2019; 34:1619-1631. [PMID: 31116487 PMCID: PMC6744316 DOI: 10.1002/jbmr.3738] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/20/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Fibrous dysplasia (FD) is a mosaic skeletal disorder resulting in fractures, deformity, and functional impairment. Clinical evaluation has been limited by a lack of surrogate endpoints capable of quantitating disease activity. The purpose of this study was to investigate the utility of 18 F-NaF PET/CT imaging in quantifying disease activity in patients with FD. Fifteen consecutively evaluated subjects underwent whole-body 18 F-NaF PET/CT scans, and FD burden was assessed by quantifying FD-related 18 F-NaF activity. 18 F-NaF PET/CT parameters obtained included (i) SUVmax (standardized uptake value [SUV] of the FD lesion with the highest uptake); (ii) SUVmean (average SUV of all 18 F-NaF-positive FD lesions); (iii) total volume of all 18 F-NaF-positive FD lesions (TV); and (iv) total FD lesion activity determined as the product of TV multiplied by SUVmean (TA = TV × SUVmean ) (TA). Skeletal outcomes, functional outcomes, and bone turnover markers were correlated with 18 F-NaF PET/CT parameters. TV and TA of extracranial FD lesions correlated strongly with skeletal outcomes including fractures and surgeries (p values ≤ 0.003). Subjects with impaired ambulation and scoliosis had significantly higher TV and TA values (P < 0.05), obtained from extracranial and spinal lesions, respectively. Craniofacial surgeries correlated with TV and TA of skull FD lesions (P < 0.001). Bone turnover markers, including alkaline phosphatase, N-telopeptides, and osteocalcin, were strongly correlated with TV and TA (P < 0.05) extracted from FD lesions in the entire skeleton. No associations were identified with SUVmax or SUVmean . Bone pain and age did not correlate with 18 F-NaF PET/CT parameters. FD burden evaluated by 18 F-NaF-PET/CT facilitates accurate assessment of FD activity, and correlates quantitatively with clinically-relevant skeletal outcomes. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Georgios Z Papadakis
- Foundation for Research and Technology (FORTH), Institute of Computer Science (ICS), Heraklion, Greece.,Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health, Bethesda, MD, USA.,Department of Radiology, Medical School, University of Crete, Heraklion, Greece
| | - Georgios C Manikis
- Foundation for Research and Technology (FORTH), Institute of Computer Science (ICS), Heraklion, Greece
| | - Apostolos H Karantanas
- Foundation for Research and Technology (FORTH), Institute of Computer Science (ICS), Heraklion, Greece.,Department of Radiology, Medical School, University of Crete, Heraklion, Greece
| | - Pablo Florenzano
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health, Bethesda, MD, USA.,Endocrinology Department, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Ulas Bagci
- Center for Research in Computer Vision, University of Central Florida, Orlando, FL, USA
| | - Kostas Marias
- Foundation for Research and Technology (FORTH), Institute of Computer Science (ICS), Heraklion, Greece
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health, Bethesda, MD, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health, Bethesda, MD, USA
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17
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Florenzano P, Pan KS, Brown SM, Paul SM, Kushner H, Guthrie LC, de Castro LF, Collins MT, Boyce AM. Age-Related Changes and Effects of Bisphosphonates on Bone Turnover and Disease Progression in Fibrous Dysplasia of Bone. J Bone Miner Res 2019; 34:653-660. [PMID: 30645769 PMCID: PMC6983318 DOI: 10.1002/jbmr.3649] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/13/2018] [Accepted: 11/19/2018] [Indexed: 11/09/2022]
Abstract
Fibrous dysplasia (FD) is a mosaic disease in which bone is replaced with fibro-osseous tissue. Lesions expand during childhood, reaching final burden by age 15 years. In vitro data suggest that disease activity decreases in adulthood; however, there is no clinical data to support this concept. Bone turnover markers (BTMs) have been used as markers of disease activity in FD; however, the natural history of BTM changes, the effects of antiresorptive treatment, and their association to clinical outcomes have not been described. The goals of this study are to describe 1) the natural history of FD disease activity and its association with pain; 2) the impact of bisphosphonates on the natural history of BTMs; and 3) the effect of bisphosphonates on progression of FD burden during childhood. Disease burden scores and alkaline phosphatase, osteocalcin, NTx, FGF23, and RANKL levels from 178 subjects in an FD/MAS natural history study were reviewed, including 73 subjects treated with bisphosphonates. BTMs, RANKL, and FGF23 demonstrated a sustained reduction with age. Bisphosphonate treatment did not significantly impact this age-dependent decrease in BTMs. Pain was more prevalent and severe in adults compared with children and was not associated with BTMs. In children, the progression of disease burden was not affected by bisphosphonates. In conclusion, FD is associated with an age-dependent decline in bone turnover and other markers of disease activity. Pain, in contrast, is more frequent and severe in adults with FD and is not related to bone turnover. Bisphosphonate treatment does not significantly impact the age-dependent decrease in bone turnover, nor does it prevent the progression of FD disease burden in children. These findings, in association with the established adverse effects of antiresorptives, should be considered when evaluating use and response to bisphosphonates in patients being treated for FD and in any study using BTMs as surrogate endpoints. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Pablo Florenzano
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Kristen S Pan
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Sydney M Brown
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Scott M Paul
- Rehabilitation Medicine Department, Mark O. Hatfield Clinical Research Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey Kushner
- Biomedical Computer Research Institute, Philadelphia, PA, USA
| | - Lori C Guthrie
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Luis Fernandez de Castro
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Alison M Boyce
- Skeletal Diseases and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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18
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Barberán M M, Campusano M C, Trincado M P, Oviedo G S, Brantes G S, Sapunar Z J, Canessa J, Cid P, Escobar F, Eugenin D, Florenzano P, Gajardo H, González G, Illanes F, Jiménez B, Martínez C, Miranda E, Rivera S, Salman P. [Guidelines of the Chilean Endocrinology Society for the correct clinical use of bone densitometry]. Rev Med Chil 2019; 146:1471-1480. [PMID: 30848752 DOI: 10.4067/s0034-98872018001201471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022]
Abstract
Osteoporosis is a silent and frequent disease, which increases fracture risk. Approximately half of women and one of five men over 50 years old will suffer an osteoporotic fracture throughout their lives. Dual-energy x-ray absorptiometry (DXA) allows a real bone mineral density (BMD) measurement in different parts of the skeleton and is considered the "gold standard" for quantifying osteoporosis with high accuracy and precision. The Board of the Chilean Society of Endocrinology and Diabetes (SOCHED) required from the Bone Disease Study Group to develop a consensus about the "Correct use of bone densitometry in clinical practice in Chilean population". Therefore, we elaborated 25 questions which addressed key aspects about the indications for a DXA scan, and the details of how to perform and report this test. Since some of the evidence obtained was of low quality or inconclusive, we decided to create a multidisciplinary group of national experts in osteoporosis to develop a consensus in this subject. The group consisted of 22 physicians including endocrinologists, gynecologists, geriatricians, radiologists, rheumatologists and nuclear medicine specialists. Using the Delphi methodology to analyze previously agreed questions, we elaborated statements that were evaluated by the experts who expressed their degree of agreement. The final report of this consensus was approved by the SOCHED board.
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Affiliation(s)
| | | | | | | | | | | | | | - Pía Cid
- Clínica Universidad de los Andes, Santiago, Chile
| | | | | | | | | | | | | | | | | | | | | | - Patricio Salman
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
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de Castro LF, Burke AB, Wang HD, Tsai J, Florenzano P, Pan KS, Bhattacharyya N, Boyce AM, Gafni RI, Molinolo AA, Robey PG, Collins MT. Activation of RANK/RANKL/OPG Pathway Is Involved in the Pathophysiology of Fibrous Dysplasia and Associated With Disease Burden. J Bone Miner Res 2019; 34:290-294. [PMID: 30496606 PMCID: PMC6983320 DOI: 10.1002/jbmr.3602] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/24/2018] [Accepted: 10/06/2018] [Indexed: 01/08/2023]
Abstract
Fibrous dysplasia of bone (FD) is a mosaic disease caused by mutations in GNAS. Constitutive activation of the α-subunit of the Gs stimulatory protein (Gαs) leads to dysregulated proliferation of bone marrow stromal cells (BMSCs), generating expansile lesions of fibrotic tissue and abnormal bone. Local bone remodeling regulation by BMSCs is also altered, and FD tissue is characterized by abundant osteoclast-like cells that may be essential for lesion expansion. Animal models show local expression of RANKL in bone lesions, and treatment with the RANKL neutralizing antibody denosumab decreased lesion expansion rate in a patient with aggressive FD. However, the role of RANKL/osteoprotegerin (OPG) in FD pathophysiology is not yet understood. We measured serum levels of RANKL, OPG, and inactive RANKL-OPG complexes in FD patients of known disease burden and in healthy volunteers (HVs). RANK, RANKL, and Ki67 immunohistochemistry were assessed in FD tissue. Cultured FD and HV BMSCs were stimulated with prostaglandin E2 (PGE2 ) and 1,25 vitamin D3 to increase RANKL expression, and media levels of RANKL and OPG were measured. Osteoclastogenic induction by FD or HV BMSCs was assessed in co-cultures with HV peripheral monocytes. FD patients showed a 16-fold increase in serum RANKL compared to HVs. OPG was moderately increased (24%), although RANKL/OPG ratio was 12-fold higher in FD patients than in HVs. These measurements were positively correlated with the skeletal burden score (SBS), a validated marker of overall FD burden. No differences in serum inactive RANKL-OPG complexes were observed. In FD tissue, RANKL+ and Ki67+ fibroblastic cells were observed near RANK+ osteoclasts. High levels of RANKL were released by FD BMSCs cultures, but were undetectable in HV cultures. FD BMSC released less OPG than HV BMSCs. FD, but not HV BMSCs, induced osteoclastogenesis in monocyte co-cultures, which was prevented by denosumab addition. These data are consistent with the role of RANKL as a driver in FD-induced osteoclastogenesis. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Luis F de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Andrea B Burke
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA, USA
| | - Howard D Wang
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Medical Research Scholars Program (MRSP), National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Tsai
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA, USA
| | - Pablo Florenzano
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Department of Endocrinology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Kristen S Pan
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Medical Research Scholars Program (MRSP), National Institutes of Health, Bethesda, MD, USA
| | - Nisan Bhattacharyya
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Alfredo A Molinolo
- Biorepository and Tissue Technology Shared Resource, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Pamela G Robey
- Skeletal Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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20
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Florenzano P, Ferreira C, Nesterova G, Roberts MS, Tella SH, de Castro LF, Brown SM, Whitaker A, Pereira RC, Bulas D, Gafni RI, Salusky IB, Gahl WA, Collins MT. Skeletal Consequences of Nephropathic Cystinosis. J Bone Miner Res 2018; 33:1870-1880. [PMID: 29905968 DOI: 10.1002/jbmr.3522] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/18/2018] [Accepted: 06/06/2018] [Indexed: 01/03/2023]
Abstract
Nephropathic cystinosis is a rare lysosomal storage disorder. Patients present in the first year of life with renal Fanconi syndrome that evolves to progressive chronic kidney disease (CKD). Despite the multiple risk factors for bone disease, the frequency and severity of skeletal disorders in nephropathic cystinosis have not been described. We performed systematic bone and mineral evaluations of subjects with cystinosis seen at the NIH (n = 30), including history and physical examination, serum and urine biochemistries, DXA, vertebral fracture assessment, skeletal radiographs, and renal ultrasound. Additionally, histomorphometric analyses are reported on six subjects seen at the UCLA Bone and Mineral Metabolism Clinic. In NIH subjects, mean age was 20 years (range, 5 to 44 years), 60% were CKD stages G1 to G4, and 40% had a renal transplant. Mean bone mineral density (BMD) Z-scores were decreased in the femoral neck, total hip, and 1/3 radius (p < 0.05). Low bone mass at one or more sites was present in 46% of subjects. Twenty-seven percent of subjects reported one or more long bone fractures. Thirty-two percent of subjects had incidental vertebral fractures, which were unrelated to transplant status. Long-bone deformity/bowing was present in 64%; 50% had scoliosis. Diffuse osteosclerosis was present in 21% of evaluated subjects. Risk factors included CKD, phosphate wasting, hypercalciuria, secondary hyperparathyroidism, hypovitaminosis D, male hypogonadism, metabolic acidosis, and glucocorticoid/immunosuppressive therapy. Sixty-one percent of the non-transplanted subjects had ultrasonographic evidence of nephrocalcinosis or nephrolithiasis. Histomorphometric analyses showed impaired mineralization in four of six studied subjects. We conclude that skeletal deformities, decreased bone mass, and vertebral fractures are common and relevant complications of nephropathic cystinosis, even before renal transplantation. Efforts to minimize risk factors for skeletal disease include optimizing mineral metabolism and hormonal status, combined with monitoring for nephrocalcinosis/nephrolithiasis. © 2018 This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Pablo Florenzano
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA.,Endocrinology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Carlos Ferreira
- Medical Genetics Branch, National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Galina Nesterova
- Medical Genetics Branch, National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Mary Scott Roberts
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Sri Harsha Tella
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Luis Fernandez de Castro
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Sydney M Brown
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Adom Whitaker
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Renata C Pereira
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Dorothy Bulas
- Division of Radiology, Children's National Health System, Washington, DC, USA
| | - Rachel I Gafni
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Isidro B Salusky
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - William A Gahl
- Medical Genetics Branch, National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, MD, USA
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21
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Peña C, Pinochet C, Florenzano P, Mendoza C, Garfias C, Aracena M, Mellado C, González G. [Pseudohypoparathyroidism: report of two cases of late presentation]. Rev Med Chil 2018; 146:116-121. [PMID: 29806686 DOI: 10.4067/s0034-98872018000100116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/30/2018] [Indexed: 11/17/2022]
Abstract
Pseudohypoparathyroidism (PHP) is a group of rare genetic disorders that share organ targeted resistance to the action of parathyroid hormone (PTH) as a common feature. Biochemically, they may present with hypocalcemia, hyperphosphatemia and elevated PTH. Some forms present with a specific phenotype: short stature, round facies, short neck, obesity, brachydactyly and subcutaneous calcifications, called Albrigth's Hereditary Osteodystrophy (AHO). This spectrum of disorders are caused by several alterations in the gene coding for the alpha subunit of the G protein (GNAS): an ubiquitous signaling protein that mediates the action of numerous hormones such as PTH, TSH, gonadotropins, and ACTH, among others. According to their inheritance with maternal or paternal imprinting, they may manifest in a diversity of clinical forms. Although most commonly diagnosed during childhood, PHP may manifest clinically during adolescence or early adulthood. We report two late presenting cases of pseudohypoparathyroidism. A 21-year-old female with biochemical abnormalities characteristic of pseudohypoparathyroidism who was misdiagnosed as epilepsy and a 13-year-old boy with the classic AHO phenotype but without alterations in phospho-calcium metabolism, compatible with pseudopseudohypoparathyrodism.
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Affiliation(s)
- Carolina Peña
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Constanza Pinochet
- Departamento de Pediatría, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Florenzano
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Mendoza
- Departamento de Pediatría, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Garfias
- Departamento de Pediatría, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marcela Aracena
- Departamento de Pediatría, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cecilia Mellado
- Departamento de Pediatría, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gilberto González
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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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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González G, Baudrand R, Sepúlveda MF, Vucetich N, Guarda FJ, Villanueva P, Contreras O, Villa A, Salech F, Toro L, Michea L, Florenzano P. Tumor-induced osteomalacia: experience from a South American academic center. Osteoporos Int 2017; 28:2187-2193. [PMID: 28341900 DOI: 10.1007/s00198-017-4007-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/10/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED The majority of tumor-induced osteomalacia cases have been reported in the Northern Hemisphere and Asia. In this first series of South American patients, we show that the clinical presentation and sensitivity of plasmatic fibroblast growth factor 23 and somatostatin analog-based imaging are similar to those described in other populations. INTRODUCTION Describe the experience of clinical presentation, diagnostic study, and treatment of patients with tumor-induced osteomalacia (TIO) in a South American academic center in comparison to literature. METHODS Analysis of the records of patients diagnosed with TIO. The clinical presentation, diagnostic studies, and treatment were analyzed. Fibroblast growth factor 23 (FGF23) was measured by ELISA. RESULTS Six patients were diagnosed with TIO during the studied period. The patients' median age was 53 years (range 22-64). All patients presented with weakness and pain in the extremities. Four experienced fractures during their evolution. The median time to diagnosis was 4.5 years (1-20). Biochemical studies showed hypophosphatemia, median of 1.4 mg/dL (1.2-1.6), with low maximum rates of tubular reabsorption of phosphate adjusted for glomerular filtration rate. FGF23 was elevated in 4/6 patients and inappropriately normal in the other two. In three patients, the location of the tumor was clinically evident and confirmed with anatomical imaging. In the remaining patients, two tumors were located with 68Ga DOTATATE-PET/CT and one with OctreoScan. The causal tumors were located in the lower extremities in five patients and invading the frontal sinus in one patient. In all patients, tumors were successfully removed. Within 14 days, there was normalization of phosphate and FGF23 levels and resolution of clinical symptoms in all patients. In all cases, the histopathology was compatible with a phosphaturic mesenchymal tumor. CONCLUSIONS The clinical presentation, delay time to diagnosis, FGF23 diagnostic sensitivity and histopathology in this first series of South American patients is similar to those described in other populations. The success of localization by somatostatin analog-based imaging, suggests this may the optimal imaging modality.
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Affiliation(s)
- G González
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - R Baudrand
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - M F Sepúlveda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - N Vucetich
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - F J Guarda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - P Villanueva
- Departamento de Neurocirugía, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - O Contreras
- Departamento de Radiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - A Villa
- Departamento de Traumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - F Salech
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Toro
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Michea
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - P Florenzano
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
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Acevedo F, Pérez V, Pérez-Sepúlveda A, Florenzano P, Artigas R, Medina L, Sánchez C. High prevalence of vitamin D deficiency in women with breast cancer: The first Chilean study. Breast 2016; 29:39-43. [DOI: 10.1016/j.breast.2016.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 02/01/2023] Open
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Florenzano P, Ernst D, Lustig N, Rojas P, Ramírez P, Campusano C. Salud ósea en pacientes sometidos a trasplante de precursores hematopoyéticos: un nuevo problema a considerar. Rev Med Chil 2016; 144:1119-1124. [DOI: 10.4067/s0034-98872016000900004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/21/2016] [Indexed: 11/17/2022]
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26
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Florenzano P, Mezzano V, Le-Bert M, González G. [Bone involvement in systemic mastocytosis: Report of two cases]. Rev Med Chil 2016; 144:401-5. [PMID: 27299829 DOI: 10.4067/s0034-98872016000300018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/12/2016] [Indexed: 11/17/2022]
Abstract
Systemic mastocytosis (SM) is characterized by pathologic expansion and activation of mast cells. The main clinical manifestations of SM include skin involvement, gastrointestinal symptoms and anaphylaxis due to the release of its mediators. Thirty percent of pat ients with SM have a low bone mass and 20% fractures. At the same time, SM affects 10% of male patients with idiopathic osteoporosis. Measuring serum tryptase is essential for the screening of MS. We report two cases of SM with bone involvement. A 25-year- old woman with prior diagnosis of SM, based on skin involvement, flushing, high serum tryptase and compatible bone marrow (BM) biopsy and genetic study. Low bone mass was diagnosed and treatment was started with calcium and vitamin D plus oral bisphosphona tes with adequate response. A 47 years old man who presented with multiple osteoporotic vertebral fractures and low bone mass. Treatment with vitamin D and alendronate was started, but the patient developed new vertebral fractures. The study was extended w ith measurement of serum tryptase that was elevated. Diagnosis of SM was confirmed with BM biopsy and the patient was referred to hematology for specific care. These cases emphasize the importance of bone assessment in SM, as well as the need to rule out S M in patients with osteoporosis and no evident cause.
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Florenzano P, Guarda FJ, Jaimovich R, Droppelmann N, González H, Domínguez JM. Radioactive Iodine Administration Is Associated with Persistent Related Symptoms in Patients with Differentiated Thyroid Cancer. Int J Endocrinol 2016; 2016:2586512. [PMID: 27867395 PMCID: PMC5102728 DOI: 10.1155/2016/2586512] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/14/2016] [Indexed: 11/17/2022] Open
Abstract
Context. Radioiodine (RAI) administration has adverse effects in patients treated for thyroid cancer (DTC), but there is scarce information regarding their intensity and duration. Objective. To evaluate frequency and intensity of early and late RAI-related symptoms in patients with DTC. Design. Observational prospective study. Patients. DTC patients who underwent thyroidectomy, with or without RAI. Measurements. Patients answered 2 surveys: (1) from 0 to 6 months and (2) between 6 and 18 months after initial treatment. Results. 110 patients answered the first survey and 61 both. Nearly 80 percent received RAI. Among early symptoms, periorbital edema, excessive tearing, salivary gland disturbances, dry mouth, taste disorders, and nausea were more frequent and intense among RAI patients. Regarding late symptoms, periorbital edema, salivary gland pain and swelling, and dry mouth were more frequent and intense in RAI patients. Frequency and intensity of adverse effects were not different between low and high RAI doses (50 versus ≥100 mCi). Conclusion. RAI-related symptoms are frequent and usually persist after 6 months of administration, even when low doses are given. This finding must be considered when deciding RAI administration, especially in low risk patients, among whom RAI benefit is controversial.
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Affiliation(s)
- Pablo Florenzano
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco J. Guarda
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo Jaimovich
- Department of Nuclear Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Droppelmann
- Department of Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hernán González
- Department of Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José M. Domínguez
- Department of Endocrinology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- *José M. Domínguez:
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Lustig N, Florenzano P, Sanhueza LM, Cid X, Ramos G, Thone N, Fullerton DA. [Constrictive pericarditis as a serious and rare presentation of systemic lupus erythematosus: Report of one case]. Rev Med Chil 2015; 142:1065-8. [PMID: 25424680 DOI: 10.4067/s0034-98872014000800015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 08/18/2014] [Indexed: 11/17/2022]
Abstract
Constrictive Pericarditis (CP) is an unusual disease. Its most common causes are idiopathic or secondary to cardiac surgery. Less frequently it is caused by connective tissue diseases. We report a 30 years old woman hospitalized due to progressive dyspnea, chest pain and signs of right sided heart failure. During her stay, a Systemic Lupus Erythematosus (SLE) was diagnosed. The echocardiogram suggested a CP and the diagnosis was confirmed by cardiac catheterization. Pericardiectomy was successfully performed. The biopsy confirmed a nonspecific chronic pericarditis, with extensive fibrosis and absence of caseating granulomas. The patient had a satisfactory recovery.
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Ernst D, Florenzano P, Campusano C, Jara V, Bertin P, Ramirez PA. Bone Health Assessment in Patients Undergoing Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015. [DOI: 10.1016/j.bbmt.2014.11.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Reyes C, Florenzano P, Contreras Á, González A, Beltrán D, Aravena C, Grassi B. Un curso de docencia clínica para residentes mejora la autopercepción de preparación para enseñar. Rev Med Chil 2012; 140:1431-6. [DOI: 10.4067/s0034-98872012001100008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/04/2012] [Indexed: 11/17/2022]
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