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Abstract
Tumor-induced osteomalacia (TIO), also known as "oncogenic osteomalacia", is a rare cause of osteomalacia. TIO often has an insidious onset characterized clinically by progressive muscle weakness and bone pain with fractures. The hallmark biochemical finding is a persistent low serum phosphorus concentration due to renal phosphate wasting. The vast majority of cases of TIO result from production of the phosphaturic hormone fibroblast growth factor 23 (FGF23) by a histologically distinctive mesenchymal tumor, termed "phosphaturic mesenchymal tumor" (PMT). Circulating FGF23 induces internalization of renal sodium/phosphate co-transporters resulting in reduced proximal tubular phosphate reabsorption. FGF23 also inhibits production of 1α,25-dihydroxyvitamin D which is inappropriately low or normal in the context of hypophosphatemia. Diagnosis is often delayed owing to the rarity of the condition and an underappreciation for the role of phosphorus as a cause for the constellation of symptoms. Primary treatment for TIO is identification of the offending tumor and surgical removal. However, these tumors are notoriously difficult to find, precluding the opportunity for a curative surgery in many. In such cases, phosphate and calcitriol therapy is used to improve symptoms and heal the osteomalacia. Recently, molecular genetic studies have shown recurrent genetic events in PMT, including the novel fusions FN1-FGFR1 and less commonly FN1-FGF1. These fusion events are hypothesized to result in autocrine/paracrine signaling loops within the tumor, spurring tumorigenesis. This review will cover the clinical features, imaging characteristics, pathologic features, molecular genetic aspects, and therapy of PMT, with a brief discussion of other neoplasms that may cause TIO.
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Affiliation(s)
- J M Boland
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - P J Tebben
- Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - A L Folpe
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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Colangelo L, Cipriani C, Pepe J, Corsi A, Sonato C, Follacchio G, Cilli M, Gianni W, Ferrone F, Moreschini O, Fitzpatrick LA, Minisola S. A Challenging Case of Tumor-Induced Osteomalacia: Pathophysiological and Clinical Implications. Calcif Tissue Int 2018; 103:465-468. [PMID: 29736882 DOI: 10.1007/s00223-018-0429-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 02/14/2018] [Accepted: 04/30/2018] [Indexed: 01/01/2023]
Abstract
We investigated the usefulness of fibroblast growth factor 23 (FGF23) intraoperative assay to monitor tumor resection in patients with oncogenic osteomalacia. A 33-year-old man with 5 years' history of lumbar and pelvis pain together with multiple vertebral fractures was admitted to our hospital. He was diagnosed with ankylosing spondylitis 1 year before. Laboratory investigation showed low tubular reabsorption of phosphate (0.41 mmol/L) despite chronic hypophosphatemia (0.39/L). Increased plasma values of FGF23 (673 pg/mL; n.v. < 95 pg/mL) were also observed. A full-body CT scan showed two suspicious areas in the head of the right femur and in the right tibia; however, the Octreoscan™ showed an increased uptake of the tracer only in the femur. We decided to remove first the head femur lesion and perform intraoperative FGF23 assay to confirm tumor resection; if this had been unsuccessful, we would have extended the operation to excise the second bone lesion. FGF23 basal values and 10, 60, and 225 min after excision of the femoral head were 423, 127, 56, and 30 pg/mL, respectively. The brisk fall of FGF23 values suggested that the head femur lesion was responsible for the syndrome. Histological examination revealed a mesenchymal highly vascular tumor. This is the first report showing the possibility of intraoperative FGF23 assay to monitor tumor resection in patients with tumor-induced osteomalacia.
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Affiliation(s)
- Luciano Colangelo
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine, "Sapienza" University, Rome, Italy
| | - Chiara Sonato
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Giulia Follacchio
- Department of Radiology, Oncology and Human Pathology, "Sapienza" University, Rome, Italy
| | - Mirella Cilli
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Walter Gianni
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federica Ferrone
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy
| | - Oreste Moreschini
- Department of Anatomical Sciences, Histological, Forensic Medicine and Locomotive System, "Sapienza" University, Rome, Italy
| | | | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza" University, Viale del Policlinico 155, 00161, Rome, Italy.
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Abstract
Three cases of connective tissue tumors causing hypophosphatemic osteomalacia are reported and the literature is reviewed. In two of our patients the tumors were completely excised with total disappearance of the symptoms. In one case a total excision was not possible and the symptoms of this patient have not completely disappeared. The substance responsible for the syndrome has not been identified yet, but probably interferes with vitamin D renal hy-droxylation, thus causing osteomalacia. As more than 30 per cent of cases of this condition have been reported in the last 5 years, it is suggested that these tumors are more frequent than previously believed.
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Affiliation(s)
- M Papotti
- Dipartimento di Scienze Biomediche e Oncologia Umana, Università di Torino, Italia
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Tella SH, Amalou H, Wood BJ, Chang R, Chen CC, Robinson C, Millwood M, Lori G, Xu S, Levy E, Krishnasamy V, Gafni RI, Collins MT. Multimodality Image-Guided Cryoablation for Inoperable Tumor-Induced Osteomalacia. J Bone Miner Res 2017; 32:2248-2256. [PMID: 28718983 PMCID: PMC5685881 DOI: 10.1002/jbmr.3219] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 06/03/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 12/18/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a debilitating paraneoplastic condition caused by small phosphaturic mesenchymal tumors (PMTs) that secrete large amounts of the phosphate-regulating and vitamin D-regulating hormone, FGF23. Tumor removal results in cure. However, because of high perioperative comorbidity, either from tumor location or host factors, surgery is sometimes not an option. Tumor destruction via cryoablation may be an effective option for inoperable PMTs. Three subjects with a confirmed diagnosis of TIO were studied. All three underwent cryoablation of suspected PMTs rather than surgery due to significant medical comorbidities or challenging anatomical location. Subject 3 had tumor embolization 24 hours prior to cryoablation because of the size and hypervascularity of the tumor. The success of the tumor cryoablation was defined by normalization of serum phosphate and FGF23. Cryoablation resulted in a rapid decrease in plasma intact FGF23 by 24 hours postprocedure in all three subjects (0, 2, and 9 pg/mL, respectively) with normalization of blood phosphate by postprocedure day 3. Three-day renal tubular reabsorption of phosphate increased to 76%, 94%, and 95.2%, respectively; 1, 25(OH)2 vitamin D increased to 84, 138, and 196 pg/ml, respectively. All three had dramatic clinical improvement in pain and weakness. Two subjects tolerated the procedure well with no complications; one had significant prolonged procedure-related localized pain. Although surgery remains the treatment of choice, cryoablation may be an effective, less invasive, and safe treatment for patients with difficult to remove tumors or who are poor surgical candidates. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sri Harsha Tella
- Department of Endocrinology, Diabetes and Metabolism, National Institute of Child Health and Human Development, National Institutes of Health (NICHD/NIH), Bethesda, MD
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Hayet Amalou
- Interventional Radiology and Center for Interventional Oncology, National Institutes of Health (NIH), Bethesda, MD
| | - Bradford J Wood
- Interventional Radiology and Center for Interventional Oncology, National Institutes of Health (NIH), Bethesda, MD
| | - Richard Chang
- Endocrine and Venous Services Section, Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
| | - Clara C. Chen
- Nuclear Medicine section, National Institutes of Health, Bethesda, MD
| | - Cemre Robinson
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Michelle Millwood
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Guthrie Lori
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Sheng Xu
- Interventional Radiology and Center for Interventional Oncology, National Institutes of Health (NIH), Bethesda, MD
| | - Elliot Levy
- Interventional Radiology and Center for Interventional Oncology, National Institutes of Health (NIH), Bethesda, MD
| | - Venkatesh Krishnasamy
- Interventional Radiology and Center for Interventional Oncology, National Institutes of Health (NIH), Bethesda, MD
| | - Rachel I. Gafni
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Michael T. Collins
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
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Lee JY, Park HS, Han S, Lim JK, Hong N, Park SI, Rhee Y. Localization of Oncogenic Osteomalacia by Systemic Venous Sampling of Fibroblast Growth Factor 23. Yonsei Med J 2017; 58:981-987. [PMID: 28792142 PMCID: PMC5552653 DOI: 10.3349/ymj.2017.58.5.981] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/22/2017] [Accepted: 05/29/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Tumor-induced osteomalacia (TIO) is characterized by hypophosphatemia caused by a phosphaturic mesenchymal tumor. While surgical resection of the tumor leads to a cure, identification of the responsible tumor is challenging. Recently, several studies showed that systemic sampling of fibroblast growth factor 23 (FGF23) is helpful for localization of tumors. The present study aimed to evaluate the clinical utility of this method in Korean patients. MATERIALS AND METHODS Six patients compatible with TIO who were admitted to our hospital between 2006 and 2015 were analyzed. Systemic venous sampling of FGF23 was performed to detect blind lesions or to confirm a suspicious lesion identified in previous imaging studies. RESULTS Venous sampling helped confirming the tumor in five of the six patients. Three patients underwent surgery after sampling, and in two patients, the lesions were detected after 3 years by means of ⁶⁸Ga-DOTATOC positron emission tomography with computed tomography. In one patient, there was a local elevation of serum FGF23 without any related lesion on additional imaging. CONCLUSION Our data strengthened the value of venous sampling of FGF23 in predicting the location of tumors and suggested that it can be more effective in the presence of the relevant lesion in subsequent imaging analyses.
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Affiliation(s)
- Ji Yeon Lee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Park
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seunghee Han
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Feng J, Jiang Y, Wang O, Li M, Xing X, Huo L, Li F, Yu W, Zhong DR, Jin J, Liu Y, Qi F, Lv W, Zhou L, Meng XW, Xia WB. The diagnostic dilemma of tumor induced osteomalacia: a retrospective analysis of 144 cases. Endocr J 2017; 64:675-683. [PMID: 28450684 DOI: 10.1507/endocrj.ej16-0587] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [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] [Indexed: 11/23/2022] Open
Abstract
Diagnostic delay of tumor induced osteomalacia (TIO) is common in clinic practice. To investigate the diagnostic condition of TIO in China and raise clinicians' awareness of TIO, we retrospectively analyzed clinical manifestations, biochemical features, and specially evaluated missed diagnoses and misdiagnoses among 144 TIO patients from Peking Union Medical College Hospital during December 1982 to December 2014. Clinical presentations of TIO mainly included bone pain, difficulty in walking, pathological fractures, muscle weakness, and height loss. TIO patients demonstrated hypophosphatemia (0.48±0.13 mmol/L), elevated serum alkaline phosphatase (277.9±152.6 U/L), reduced tubular maximum for phosphorus/glomerular filtration rate (0.39±0.14) and markedly elevated serum fibroblast growth factor 23 (FGF23) (median level 302.9 pg/mL). The average time from onset to a correct diagnosis was 2.9±2.3 years while the mean duration from onset to tumor resection was 5.4±4.2 years. The initial misdiagnosis rate was 95.1% (137/144) and 240 case-times of misdiagnoses occurred among the 144 cases. The most frequent misdiagnoses were intervertebral disc herniation, spondyloarthritis (including ankylosing spondylitis) and osteoporosis. A total of 43.1% (62/144) cases with hypophosphatemia presented on their laboratory sheets were neglected and missed diagnosed. Our study showed that TIO was frequently misdiagnosed and missed diagnosed due to its rarity, insidious onset, nonspecific clinical manifestations and clinicians' poor recognition. It is necessary to test serum phosphorus in patients with musculoskeletal symptoms and difficulty in walking. The measurement of serum FGF23 is rather valuable. Once hypophosphatemia is discovered, TIO should be suspected and it is highly recommended to search for tumors and perform curative surgery.
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MESH Headings
- Beijing
- Biomarkers/blood
- Cohort Studies
- Diagnosis, Differential
- Diagnostic Errors
- Female
- Fibroblast Growth Factor-23
- Fibroblast Growth Factors/blood
- Hospitals, Teaching
- Humans
- Hypophosphatemia/blood
- Hypophosphatemia/etiology
- Hypophosphatemia/physiopathology
- Intervertebral Disc Displacement/blood
- Intervertebral Disc Displacement/diagnosis
- Intervertebral Disc Displacement/diagnostic imaging
- Intervertebral Disc Displacement/physiopathology
- Male
- Medical Records
- Neoplasms, Connective Tissue/blood
- Neoplasms, Connective Tissue/diagnosis
- Neoplasms, Connective Tissue/diagnostic imaging
- Neoplasms, Connective Tissue/physiopathology
- Osteomalacia/blood
- Osteomalacia/diagnosis
- Osteomalacia/diagnostic imaging
- Osteomalacia/physiopathology
- Osteoporosis/blood
- Osteoporosis/diagnosis
- Osteoporosis/diagnostic imaging
- Osteoporosis/physiopathology
- Paraneoplastic Syndromes
- Retrospective Studies
- Spondylitis, Ankylosing/blood
- Spondylitis, Ankylosing/diagnosis
- Spondylitis, Ankylosing/diagnostic imaging
- Spondylitis, Ankylosing/physiopathology
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Affiliation(s)
- Juan Feng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Li
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ding-Rong Zhong
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yong Liu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Fang Qi
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei Lv
- ENT Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xun-Wu Meng
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wei-Bo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Abstract
Tumor-induced osteomalacia (TIO) is a rare acquired form of hypophosphatemic osteomalacia, which is usually attributed to the overproduction of fibroblast growth factor 23 (FGF-23) by benign mesenchymal neoplasms. Localization and thereafter surgical resection of tumors lead to a cure. The present study aimed to investigate the clinical data, diagnostic methods, and follow-up after tumor resection at one medical center in Shanghai to characterize the profile of this rare disorder and to share our successful experience in diagnosis and treatment. Twenty-three patients with adult-onset hypophosphatemia osteomalacia seen in Shanghai Sixth People's Hospital from 2009 to 2014 and 95 normal individuals were enrolled. After taking a medical history and performing a physical examination, we analyzed the laboratory results (including the serum FGF-23 levels) and localized the tumors by 18F-fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT), 99mTc-octreotide (99mTc-OCT) scintigraphy, and magnetic resonance imaging (MRI). On the basis of the results of laboratory tests and imaging findings, tumor resection was conducted in 17 patients with a certain diagnosis of TIO. The results demonstrated that the 17 patients (nine men and eight women, average age 46.6 ± 12.9 years) had TIO. FGF-23 level was elevated in 94.1 % of patients (16 of 17 patients) . Serum phosphorus level decreased in 100 % of patients. 18F-FDG PET/CT revealed five tumors, 99mTc-OCT scintigraphy revealed two tumors, physical examination revealed nine tumors, and MRI revealed one tumor, among which 58.8 % of the causative tumors (10 of 17 tumors) were located in the lower extremities. After tumor resection, serum phosphorus levels normalized in 100 % of patients (all 17 patients) in 4-21 days and FGF-23 levels decreased in 90 % of patients (nine of ten patients). We found 64.7 % of the tumors (11 of 17 tumors) were phosphaturic mesenchymal tumors or a phosphaturic mesenchymal tumor mixed connective tissue variant. Measurement of serum phosphorus and FGF-23 levels in patients with suspected TIO is of paramount importance for diagnosing of TIO. 18F-FDG PET/CT, 99mTc-OCT scintigraphy, and physical examination play a considerable role in revealing TIO-associated tumors. TIO-associated tumors were more frequently located in the lower extremities than in other places; thus, the lower extremities need to be carefully checked. Complete surgical resection results in normalization of parameters in laboratory tests and relief of symptoms of TIO patients.
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Affiliation(s)
- Wei-Jia Yu
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Jin-Wei He
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Wen-Zhen Fu
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China
| | - Chun Wang
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China.
| | - Zhen-Lin Zhang
- Metabolic Bone Disease and Genetic Research Unit, Department of Osteoporosis and Bone Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yi-Shan Rd, Shanghai, 200233, People's Republic of China.
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Abstract
CONTEXT We report a case of tumor-induced osteomalacia with evidence of synchronous multifocal fibroblast growth factor 23 (FGF23) production. OBJECTIVE The aim is to present a case of tumor-induced osteomalacia and to highlight the fact that incomplete removal of multifocal FGF23-producing tumors, which are not entirely picked up by functional imaging, could be the cause of treatment failure. SETTING The patient was treated in the Department of Endocrinology of a tertiary care center in India. PATIENT We report the case of a 42-year-old male with tumor-induced osteomalacia. INTERVENTION We treated the tumor-induced osteomalacia with staged surgery of the two tumors. The 18F-fluorodeoxyglucose (FDG)-avid lesion (considered the sole culprit lesion after functional imaging) was resected first, followed by the non-FDG-avid lesion. The sequential removal of both tumors resulted in complete cure. RESULTS The patient had hypophosphatemia and hyperphosphaturia. C-Terminal FGF23 level was elevated. Positron emission tomography-computed tomography showed two lesions-an FDG-avid lesion in the right leg, and a non-avid lesion in the left thigh. After removal of the FDG-avid lesion, the hypophosphatemia persisted, and the FGF23 level showed only modest reduction. The patient had complete clinical and biochemical resolution only after removal of the second non-FDG-avid tumor. CONCLUSIONS We present the case of a tumor-induced osteomalacia whose biochemical parameters did not improve after removal of the FDG-avid tumor initially. The possibility of multifocal FGF23 production was considered, and the second, non-FDG-avid lesion was resected, which resulted in complete cure. Thorough clinical examination and meticulous follow-up with documentation of the biochemical resolution are necessary for management of all patients with this rare disorder.
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Affiliation(s)
- Jayaprakash Sahoo
- Departments of Endocrinology (J.S., K.B., S.K., A.K.D.), Orthopedics (D.K.P.), Nuclear Medicine (D.H.), and Pathology (B.B.), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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Nagata Y, Imanishi Y, Ishii A, Kurajoh M, Motoyama K, Morioka T, Naka H, Mori K, Miki T, Emoto M, Inaba M. Evaluation of bone markers in hypophosphatemic rickets/osteomalacia. Endocrine 2011; 40:315-7. [PMID: 21822687 DOI: 10.1007/s12020-011-9512-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 07/20/2011] [Indexed: 11/30/2022]
Abstract
N-terminal propeptide of type I procollagen (PINP) is a marker of newly formed type I collagen. However, its role in hypophosphatemic rickets/osteomalacia has not yet been established. Metabolic bone markers were examined in patients with oncogenic osteomalacia (OOM) and X-linked hypophosphatemic rickets (XLH), and in healthy controls. OOM and XLH patients were found to have hypophosphatemia secondary to elevated levels of serum fibroblast growth factor 23 (FGF-23). OOM patients had reduced levels of 1,25-dihydroxy vitamin D (1,25D) compared with XLH patients and healthy controls, despite attenuation of the reduction in these levels in the XLH patients secondary to active vitamin D supplementation. In contrast to patients with XLH, OOM patients showed a significant increase in serum PINP, which is suggestive of accelerated bone matrix formation. Bone alkaline phosphatase (BAP) and the BAP/PINP ratio were also increased in OOM but not in XLH patients, suggesting the presence of a disturbance in bone mineralization in OOM. Long-term supplementation of active form vitamin D and inorganic phosphate (IP) may have attenuated the defect in bone mineralization in the XLH patients, resulting in the normalization of PINP, BAP, and the BAP/PINP ratio. The present results suggest that, as with BAP, PINP is an appropriate metabolic bone marker in the assessment of hypophosphatemic rickets/osteomalacia.
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Wexler T, Niculescu N, Schwartzenberg T. [Benign connective tissue and epithelial tumors in children and their relation to the distribution of ABO and Rh blood groups]. Rev Med Chir Soc Med Nat Iasi 1968; 72:185-91. [PMID: 4967832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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