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Vollmer S, Olsson K. Tumour-induced osteomalacia: the long road to diagnosis and recovery. BMJ Case Rep 2024; 17:e258858. [PMID: 38697682 PMCID: PMC11085914 DOI: 10.1136/bcr-2023-258858] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
Tumour-induced osteomalacia is caused by tumorous production of fibroblast growth factor 23 (FGF23) leading to urinary phosphate wasting, hypophosphataemia and decreased vitamin D activation. The resulting osteomalacia presents with muscle weakness and bone pain but progresses to multiple pathological fractures. Patients often remain undiagnosed for years with severe physical, psychological and economic ramifications. A young woman presented with multiple spontaneous fractures including bilateral femoral fractures. Laboratory tests revealed severe hypophosphataemia, elevated bone turnover markers and low to normal calcium and 25-hydroxy-vitamin D levels. Treatment with phosphate, alfalcalcidol, calcium and magnesium was initiated. 68Gallium-DOTATOC positron emission tomography imaging revealed a mass in the right foot and venous sampling of FGF23 from all extremities confirmed this tumour as the culprit. Biopsy and histology were consistent with a phosphaturic mesenchymal tumour, which was surgically resected. Phosphate levels quickly normalised postoperatively but a long convalescence with hungry bone syndrome, fracture healing and physical therapy followed.
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Affiliation(s)
- Shobitha Vollmer
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Karin Olsson
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Zhang Y, Hu M, Guo C, Yang X, Xiang S, Xu H. Phosphaturic mesenchymal tumor-induced bilateral osteomalacia femoral neck fractures: a case report. Front Endocrinol (Lausanne) 2024; 15:1373794. [PMID: 38689735 PMCID: PMC11058989 DOI: 10.3389/fendo.2024.1373794] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024] Open
Abstract
Phosphaturic mesenchymal tumors (PMT) are rare and distinctive tumors that typically result in paraneoplastic syndrome known as tumor-induced osteomalacia (TIO). We report a case of bilateral osteoporotic femoral neck fracture caused by PMT. PMT was surgically resected, followed by sequential treatment of bilateral femoral neck fractures with total hip arthroplasty (THA). A 49-year-old perimenopausal woman experienced consistent bone pain with limb weakness persisting for over 2 years. Initially, she was diagnosed with early osteonecrosis of the femoral head and received nonsurgical treatment. However, from 2020 to 2022, her pain extended to the bilateral shoulders and knees with increased intensity. She had no positive family history or any other genetic diseases, and her menstrual cycles were regular. Physical examination revealed tenderness at the midpoints of the bilateral groin and restricted bilateral hip range of motion, with grade 3/5 muscle strength in both lower extremities. Laboratory findings revealed moderate anemia (hemoglobin 66 g/L), leukopenia (2.70 × 109/L), neutropenia (1.28 × 109/L), hypophosphatemia (0.36 mmol/L), high alkaline phosphatase activity (308.00 U/L), and normal serum calcium (2.22 mmol/L). After surgery, additional examinations were performed to explore the cause of hypophosphatemic osteomalacia. After definitive diagnosis, the patient underwent tumor resection via T11 laminectomy on August 6, 2022. Six months after the second THA, the patient regained normal gait with satisfactory hip movement function without recurrence of PMT-associated osteomalacia or prosthesis loosening. By providing detailed clinical data and a diagnostic and treatment approach, we aimed to improve the clinical understanding of femoral neck fractures caused by TIO.
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Affiliation(s)
- Yifan Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Mingwei Hu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Cuicui Guo
- Department of Sports Medicine, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Xue Yang
- Department of Operation Room, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
| | - Hao Xu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Shandong, China
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Chen D, Zhang L, Zhang J, Yin M, Gao X, Huang Q, Li L, Yang X. Treatment and Diagnose of Spinal Phosphaturic Mesenchymal Tumor: A Case Report and a Systematic Literature Review. World Neurosurg 2024; 184:65-73. [PMID: 38218444 DOI: 10.1016/j.wneu.2024.01.032] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Spinal phosphaturic mesenchymal tumor (PMT) is a rare disorder but can be cured once the diagnosis is clear and a complete removal by surgery is performed. To the best of our knowledge, only 22 cases in the spine have been described, and we report a case with the largest number of spinal segments (T12-L5) affected among spine PMT cases. METHODS A comprehensive literature search was performed until May 23, 2023, following the Preferred Reporting Items for Systematic Reviews guidelines. Studies were chosen through relevant PubMed, Web of Science, and EMBASE searches to prioritize obtaining the largest studies. The Medical Subject Headings and Boolean operators employed for this search were ("PMT" or "TIO" or "Tumor-induced osteomalacia" or "phosphaturic mesenchymal tumor") and ("spine" or "spinal"). Two researchers (L.S.Z. and D.B.C) independently reviewed and evaluated the included articles. Any differing opinions were discussed until a consensus was reached. A total of 18 studies were included. A case report is also presented. RESULTS We report a case of spinal PMT. The full text of the relevant articles was construed. A total of 18 studies were reviewed and consolidated. These articles are roughly divided into the following 5 subcategories: 1) clinical features and baseline distribution, 2) laboratory and imaging findings, 3) pathological manifestations, and 4) surgical methods and treatment options. CONCLUSIONS Spinal PMT is very rare with a high rate of misdiagnosis and debilitating complications, so it is of significance to increase awareness of the disease among spine surgeons consulted by patients with spinal PMT. 68Ga-DOTATOC-PET/CT shows very high sensitivity to the spinal PMT but there is no way to exactly determine the location of the tumor. PMT has unique immunohistochemical characteristics and malignant PMT is rare. Once diagnosed, complete surgical excision is the recommended treatment. Burosumab is one of the available options, especially in cases that are recurrent and difficult to surgically resect.
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Affiliation(s)
- Dingbang Chen
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Luosheng Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Jie Zhang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Mengchen Yin
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xin Gao
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Quan Huang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Lin Li
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xinghai Yang
- Orthopaedic Oncology Center, Department of Orthopedics, Changzheng Hospital, Naval Military Medical University, Shanghai, China.
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Гронская СА, Белая ЖЕ, Рожинская ЛЯ, Мельниченко ГА, Дубовицкая ТА, Мамедова ЕО, Родионова СС, Буклемишев ЮВ, Пигарова ЕА, Дегтярев МВ, Бабаева ДМ, Владимирова ВП, Тарбаева НВ, Серженко СС, Григорьев АЮ, Дзеранова ЛК, Карпенко ВЮ, Карасев АЛ, Федотов РН, Ульянова ИН, Торопцова НВ, Лесняк ОМ, Мокрышева НГ, Дедов ИИ. [Clinical features, diagnostics and treatment of FGF23 secreting tumors: series of 40 clinical cases]. Probl Endokrinol (Mosk) 2023; 69:25-38. [PMID: 37968949 PMCID: PMC10680540 DOI: 10.14341/probl13221] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Tumor-induced osteomalacia is an acquired rare disease manifested by hypophosphatemic osteomalacia due to excessive secretion of fibroblast growth factor 23 (FGF23). FGF 23 is a non-classical hormone secreted by bone tissue (osteocytes) and regulates phosphorus metabolism.The aim of this work is to present clinical experience in the diagnosis, treatment and rehabilitation of patients with tumor-induced osteomalacia. MATERIALS AND METHODS 40 patients with clinically-confirmed tumor-induced osteomalacia were included in the study, 34 of whom had the tumor localized, 27 underwent surgical treatment and 21 achieved stable remission. RESULTS The median age was 48 [41; 63] years, 43% were men, the time left from the the onset of the disease was 8 [4; 10] years. Biochemical findings were hypophosphatemia 0.47 [0.4; 0.53] mmol/l, a decrease in the tubular reabsorption phosphate 62 [52; 67]%, and an increase in alkaline phosphatase of 183 [112; 294] units/l. At the time of diagnosis, 100% had multiple pathological fractures, only 10% could move independently, and 77.5% classified the pain as unbearable (8-10 points according to the 10-point pain syndrome scale ). Among the methods used to detect tumors, the most sensitive were scintigraphy with tectrotide with SPECT/CT 71.4% (20/28) and MRI 90% (18/20). In 35% of cases, the tumor was localized in soft tissues and in 65% in bone tissue; The tumor was most often detected in the lower extremities, followed by the head in frequency of localization. 18 patients currently have no remission and they receive conservative treatment (phosphorus and alfacalcidol n=15 and burosumab n=3). In case of achieving remission (n=21), regression of clinical symptoms and restoration of bone and muscle mass was observed. Extensive excision of the tumor without prior biopsy resulted in the best percentage of remission - 87%. CONCLUSION Tumor-induced osteomalacia is characterized by severe damage to bone and muscle tissue with the development of multiple fractures, muscle weakness and severe pain syndrome. In laboratory diagnostics, attention should be paid to hypophosphatemia, a decrease in the tubular reabsorption phosphate index and increased alkaline phosphatase. The use of functional diagnostic methods with a labeled somatostatin analogue to the subtype 2 receptor and MRI with contrast enhancement are the most accurate methods of topical diagnostics. In case of localization of the tumor, a wide excision without a preliminary biopsy is recommended.
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Affiliation(s)
- С. А. Гронская
- Национальный медицинский исследовательский центр эндокринологии
| | - Ж. Е. Белая
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | | | | | - Е. О. Мамедова
- Национальный медицинский исследовательский центр эндокринологии
| | - С. С. Родионова
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Ю. В. Буклемишев
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | - М. В. Дегтярев
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. М. Бабаева
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Н. В. Тарбаева
- Национальный медицинский исследовательский центр эндокринологии
| | - С. С. Серженко
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Ю. Григорьев
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. К. Дзеранова
- Национальный медицинский исследовательский центр эндокринологии
| | - В. Ю. Карпенко
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - А. Л. Карасев
- Национальный медицинский исследовательский центр травматологии и ортопедии им. Н.Н. Приорова
| | - Р. Н. Федотов
- Московский государственный медико-стоматологический университет им. А.И. Евдокимова
| | - И. Н. Ульянова
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Торопцова
- Научно-исследовательский институт ревматологии им. В.А. Насоновой
| | - О. М. Лесняк
- Северо-Западный государственный медицинский университет им. И.И. Мечникова
| | - Н. Г. Мокрышева
- Национальный медицинский исследовательский центр эндокринологии
| | - И. И. Дедов
- Национальный медицинский исследовательский центр эндокринологии
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Koga K, Iwasaki H, Nabeshima K. Phosphaturic mesenchymal tumor: A chondromyxoid fibroma-like type. J Dermatol 2023; 50:1484-1487. [PMID: 37350024 DOI: 10.1111/1346-8138.16870] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/23/2023] [Accepted: 06/10/2023] [Indexed: 06/24/2023]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm that causes tumor-induced osteomalasia (TIO) in most affected patients, usually through the production of fibroblast growth factor 23 (FGF23). This tumor is often misdiagnosed due to its relative rarity and its widely varied histomorphologic spectrum. Here we describe a case of a 78-year-old woman who presented with a left middle tumor without symptoms of TIO. The histological features resembled chondromyxoid fibroma with smudgy calcification in the tumor matrix. In addition, we evaluated FGF23 expression through immunohistochemical study and reverse transcription polymerase chain reaction. PMT with chondromyxoid fibroma features are extremely rare. Examining the expression of FGF23 is useful in the diagnosis of PMT.
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Affiliation(s)
- Kaori Koga
- Department of Pathology, Fukuoka University Hospital, Fukuoka, Japan
| | - Hiroshi Iwasaki
- Pathology and Cytology Center Fukuoka, PCL Japan, Fukuoka, Japan
| | - Kazuki Nabeshima
- Department of Clinical Pathology, Pathological Diagnosis Center, Fukuoka Tokushukai Hospital, Fukuoka, Japan
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Ovchinnikov AY, Khon EM, Bakotina AV, Miroshnichenko NA, Gronskaia SA, Belaya ZE. [FGF23 tumor induced osteomalacia with localization of neoplasm in the tympanic cavity]. Vestn Otorinolaringol 2023; 88:91-96. [PMID: 38153899 DOI: 10.17116/otorino20238806191] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Tumor induced osteomalacia is a rare paraneoplastic syndrome caused by mesenchymal tumors that secrete fibroblast growth factor 23 (FGF23). Patients complain of progressive bone pain, muscle weakness and brittle fractures. Delayed diagnosis of osteomalacia caused by a tumor is often found in clinical practice. When verifying the exact localization of the neoplasm, radical removal within healthy tissues is recommended. The article considers a clinical example of FGF23 tumor induced osteomalacia with localization of neoplasm in the tympanic cavity.
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Affiliation(s)
- A Yu Ovchinnikov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - E M Khon
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A V Bakotina
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - N A Miroshnichenko
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - S A Gronskaia
- National Medical Research Center for Endocrinology, Moscow, Russia
| | - Zh E Belaya
- National Medical Research Center for Endocrinology, Moscow, Russia
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Wang F, He W, Ma D, Xu W, Xie J, Yuan G. Sphenoid sinus is a rare site for tumor-induced osteomalacia: A case report and literature review. Front Endocrinol (Lausanne) 2023; 14:1116793. [PMID: 37033241 PMCID: PMC10081489 DOI: 10.3389/fendo.2023.1116793] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/30/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND In this paper, we present a rare case of tumor-induced osteomalacia (TIO) and a literature review of this rare disease. METHODS A case of TIO of the isolated sphenoid sinus was reported. Furthermore, the clinical features of TIO in the sphenoid sinus and other sinonasal sinuses were also reviewed and summarized. RESULTS A 35-year-old man with muscle weakness and lower back pain came to the Department of Neurology. No obvious neurological disease was found; however, magnetic resonance imaging of the extremities accidentally showed a tumor in the axilla. Bone scintigraphy showed suspicious bone metastasis. Hypophosphatemia was neglected. Interestingly, 2-deoxy-2-[fluorine-18]fluoro-d-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) detected a tumor in the axilla and another in the sphenoid sinus, but only the tumor in the sphenoid sinus had somatostatin receptor (SSTR) expression in 68-gallium 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid octreotate (Ga-68 DOTATATE) PET/CT. The sphenoid sinus tumor was proven to be a phosphaturic mesenchymal tumor (PMT), and the phosphate levels returned to normal after surgery. The literature review showed only 17 cases of TIOs that occurred in the sphenoid sinus, with an average age of 43.3 ± 13.7 years. Only three cases of TIOs in the sphenoid sinus did not invade the nasal cavity or other paranasal sinuses, which could be identified as isolated sphenoid sinus diseases. We compared the clinical features of sphenoid TIOs with those of non-sphenoid sinonasal TIOs, and it was found that the concentration of 1,25-dihydroxy vitamin D in the group with sphenoid TIOs was much higher than that in the group with non-sphenoid sinonasal TIOs. A total of 153 cases of TIOs in the sinonasal sinus were reviewed. The ethmoid sinus was found to be the major site (64.7%), followed by the nasal cavity (50.3%), maxillary sinus (19.0%), frontal sinus (16.4%), and sphenoid sinus (11.8%). There were 66 patients (43.1%) who showed tumors invading more than one sinus. Most of the tumors (69.3%) were diagnosed as PMTs by pathology, followed by hemangiopericytoma (14.3%). Immunostaining was beneficial in the differential diagnosis of these tumors; however, larger sample sizes are needed for better accuracy. CONCLUSION TIO in the sinonasal sinus, especially in the sphenoid sinus, is rare. Moreover, isolated sphenoid sinus disease can be easily misdiagnosed. When the clinical manifestation of osteomalacia is atypical, associating it with sphenoid sinus disease is even more difficult. Thus, TIO in the sphenoid sinus needs further exploration.
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Affiliation(s)
- Fen Wang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Wentao He
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Delin Ma
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Weijie Xu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Junhui Xie
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, China
- *Correspondence: Gang Yuan,
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Horng JC, Van Eperen E, Tutton S, Singh R, Shaker JL, Wooldridge AN. Persistent phosphaturic mesenchymal tumor causing tumor-induced osteomalacia treated with image-guided ablation. Osteoporos Int 2021; 32:1895-1898. [PMID: 33655402 DOI: 10.1007/s00198-020-05795-1] [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: 05/19/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
Phosphaturic mesenchymal tumors (PMTs) can present with vague symptoms of diffuse bone pain with pathologic fractures that often lead to a delayed diagnosis. We present a 60-year-old patient with a PMT that was persistently hypophosphatemic after resection, who was then successfully treated with cryoablation of the tumor. Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia characterized by vague symptoms of gradual muscle weakness and diffuse bone pain with pathologic fractures that often lead to a delayed diagnosis. This condition is usually caused by benign phosphaturic mesenchymal tumors (PMTs). Here, we present a case of persistent PMT after surgical resection treated with image-guided ablation. We present the patient's clinical examinations and laboratory findings (phosphorus, 1,25 (OH)2D, FGF-23, Intact PTH). Representative histologic images of a PMT are also presented. A 61-year-old male was evaluated for persistent hypophosphatemia and presumed osteomalacia. Six years earlier, he underwent surgical excision of a left ischial mass after presenting with TIO. The pathology was consistent with a PMT; however, hypophosphatemia persisted suggesting incomplete resection. He was treated with calcitriol and phosphate salts. A PET Ga68 dotatate scan of the patient revealed an avid left ischial mixed lytic and sclerotic lesions with marked amount of radiotracer uptake, suggesting persistent tumor. The patient was resistant to re-excision of the tumor due to the extended recovery period from his prior surgery and was treated instead with cryoablation of the tumor. His biochemical findings of hypophosphatemia and elevated FGF23 resolved after the ablation and have remained normal for 5 months after surgery. In patients with TIO, wide surgical excision is the treatment of choice. When this is not possible, image-guided ablation is an alternative therapeutic option.
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Affiliation(s)
- J C Horng
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Wauwatosa, WI, 53213, USA
| | - E Van Eperen
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Wauwatosa, WI, 53213, USA
| | - S Tutton
- Department of Vascular and Interventional Radiology, Medical College of Wisconsin, Wauwatosa, WI, 53213, USA
| | - R Singh
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J L Shaker
- Department of Medicine (Endocrinology), Medical College of Wisconsin, Milwaukee, WI, USA
| | - A N Wooldridge
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Wauwatosa, WI, 53213, USA.
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Wang P, Zhang S, Huo L, Jing H, Li F. Prognostic Value of Positive Presurgical FDG PET/CT in the Evaluation of Tumor-Induced Osteomalacia. Clin Nucl Med 2021; 46:214-219. [PMID: 33351512 DOI: 10.1097/rlu.0000000000003463] [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] [Indexed: 11/26/2022]
Abstract
METHODS Seventy-six patients who had surgically removed tumors that caused osteomalacia were included in this retrospective investigation. All patients underwent both 18F-FDG and 68Ga-DOTATATE PET/CT prior to surgery. The prognostic value of presurgical FDG PET/CT study was determined with 5-year follow-up. RESULTS In the presurgical evaluation, 68Ga-DOTATATE detected lesions in all 76 patients. However, FDG PET/CT was positive in only 25 among all 76 patients. Following surgical removal of the causative tumor, all 76 patients had symptomatic relief and normalization of the serum phosphate level initially. However, 15 of 76 cases (19.7%) had recurrent hypophosphatemia and became symptomatic again during the follow-up. Among these 15 patients with recurrence, 11 (73.3%) had recurrent lesions at the original location of the resected causative tumors, whereas 4 were in other locations due to malignant nature of the primary tumor. Interestingly, 14 of these 15 patients with recurrent disease had positive presurgical FDG PET/CT findings with an incident ratio of 56.0% (14 of 25). In contrast, only 1 patient with recurrent disease had negative presurgical FDG PET/CT scan with an incident ratio of 1.9% (1 of 51), significantly less than the positive presurgical FDG PET/CT group (P < 0.05). CONCLUSIONS A positive presurgical FDG PET/CT suggests increased likelihood for possible recurrence of TIO after surgical resection. In contrast, when a causative tumor detected by 68Ga-DOTATATE PET/CT does not have elevated activity on FDG PET/CT, the chance of recurrence is very small.
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Affiliation(s)
| | - Shu Zhang
- Department of Nuclear Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Abstract
RATIONALE Tumor-induced osteomalacia (TIO) is a highly unusual disease with enormous difficulties in clinical diagnosis and curative managements. The objective of this study is to report a very rare case who underwent surgical treatment of recurrent spinal phosphaturic mesenchymal tumor. The management of these unique cases has yet to be further elucidated. PATIENT CONCERNS A 52-year-old man presented with a 3-year history of back pain and 1-year history of continuous and progressive systemic bone pain. The patient, who had been diagnosed of TIO for 3 years, received surgical treatment of extended resection of spinal phosphaturic mesenchymal tumor at L5. Somatostatin receptor tomography revealed the expression of somatostatin in the spine increased significantly, with high suspicion of recurrent phosphaturic mesenchymal tumor. DIAGNOSIS Magnetic resonance imaging of spine and positron emission tomography-computed tomography showed the mass in L5, which was highly indicative of the recurrent pathogenic tumor. Postoperative pathology confirmed the diagnosis of phosphaturic mesenchymal tumor in the spinal region. INTERVENTIONS The patient underwent posterior L5 tumor resection, bone cement reconstruction, L4-S1 spinal canal decompression, and L3-S2 internal fixation. OUTCOMES The patient's symptoms improved significantly after the surgery, and we noticed that his hypophosphatemia was successfully corrected after the 2nd operation. Follow-up at 1 month after surgery revealed no recurrence, and the serum phosphorus level of the patient turned to be normal postoperatively. There were no complications associated with the operation during the follow-up period. LESSONS Taken together, the lesion's clinical features, imaging results, and pathologic characteristics are unique. Combined efforts of specialists from orthopedics, endocrinology, nuclear medicine, radiology, pathology, and medical oncology led to the successful diagnosis and management of this patient. TIO, although rare, should be part of the differential diagnosis when the patient has a history of hypophosphatemia and systemic multiple bone pain. We recommend surgical treatment of the phosphaturic mesenchymal tumor in the spinal region. Osteoplasty by bone cement may be a treatment option for patients with TIO who cannot undergo appropriate surgery or decline open surgery.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Zhen Huo
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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Abstract
Tumor-induced osteomalacia causing by phosphaturic mesenchymal tumor of the foot is exceedingly rare, thus may bring great challenges to the timely and proper diagnosis and treatment of clinicians. The only definitive management is removal of the phosphaturic mesenchymal tumor completely. The objective of this article is to report 2 unusual cases with tumor-induced osteomalacia causing by phosphaturic mesenchymal tumor of the foot.We describe 2 patients with phosphaturic mesenchymal tumor involving the foot who were successfully treated with tumor resection. On presentation to our institution, the patients both had signs of severe osteomalacia, and the patients' most outstanding complaints were diffuse bone pain, general weakness, and disabled walking. A 53-year-old female underwent surgical excision of pathogenic tumor on the sole of left foot. A 62-year-old female underwent complete excision of pathogenic tumor of right plantar. The patients showed appropriate destruction of the tumor, adequate pain relief, and the elevated blood phosphorus levels compared with the previous status.Surgical resection is the most effective treatment option for patients with tumor-induced osteomalacia who can undergo appropriate surgical treatment. This represents a safe and reasonable approach to sustainably relieve pain and other symptoms with tumor-induced osteomalacia in the foot.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Zhen Huo
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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Li Y, Li Y, Hui M, Liu Y, Liu X, Jin J, Gao P. Comparison of surgical treatments of tumor-induced osteomalacia in different locations in the lower limbs: A retrospective study. Medicine (Baltimore) 2019; 98:e14846. [PMID: 30882679 PMCID: PMC6426539 DOI: 10.1097/md.0000000000014846] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare disease that behaves benignly. Very few reports about the features of the responsible tumors according to anatomical locations have been presented.In this retrospective study of 53 patients with TIO-associated tumors in the foot/ankle, tibia and femur, we compared preoperative, postoperative, and follow-up courses, including alkaline phosphatase, phosphorus, and fibroblast growth factor 23, to compare the characteristics of TIO-associated tumors in these 3 locations (level of evidence: therapeutic level III).Patients in the foot/ankle group had longer disease courses and therefore a significantly higher complication rate (P < .001). All TIO-associated tumors in the foot/ankle group involved soft tissue (P = .021), whereas most lesions in the tibia group involved bone, and therefore had much higher concentrations of alkaline phosphatase (P = .020). Additionally, serum phosphorus took much longer to normalize after surgery in the foot/ankle group than that in the other 2 groups (P = .004). Consequently, symptom remission was much better in the tibia and femur groups (P = .008). Moreover, the Ki 67 index in TIO-associated tumors was significantly higher in the foot/ankle group (P < .001) and the recurrence rate in this group was markedly higher (P = .002).The TIO-associated tumors in the foot/ankle are characteristically of occult onset, more soft-tissue involvement, and more readily recurrence. More knowledge and examinations are necessary to enable early diagnosis, radical treatments, and minimize recurrence. New therapies are welcomed and needed.
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Affiliation(s)
- Ye Li
- Department of Orthopedics
| | | | - Min Hui
- Department of Internal Medicine
| | | | - Xiaoding Liu
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
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Dierselhuis EF, Overbosch J, Kwee TC, Suurmeijer AJH, Ploegmakers JJW, Stevens M, Jutte PC. Radiofrequency ablation in the treatment of atypical cartilaginous tumours in the long bones: lessons learned from our experience. Skeletal Radiol 2019; 48:881-887. [PMID: 30267104 PMCID: PMC6476835 DOI: 10.1007/s00256-018-3078-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 09/01/2018] [Accepted: 09/12/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of treatment of symptomatic cartilaginous neoplasms. We previously studied the application of radiofrequency ablation of atypical cartilaginous tumours in the long bones. The purpose of the present study was to investigate the additional effect of placing multiple needles and a longer procedure duration on the proportion of completely ablated tumours. Post-ablation MRI findings and the occurrence of complications were also assessed. METHODS We prospectively included 24 patients with atypical cartilaginous tumours in the long bones. Patients underwent CT-guided radiofrequency ablation followed by curettage with adjuvant phenolisation 3 months later, retrieving material assessed for viable tumour. Before curettage, gadolinium-enhanced MRI was performed to check for residual tumour. The occurrence of complications was noted. RESULTS Complete tumour ablation was achieved in 17 out of 24 patients (71%). Complete ablation was achieved in 5 of the 6 cases (83%) when multiple needles were used in tumours ≥30 mm. There was incomplete ablation in 8% of patients. Post-ablation gadolinium-enhanced MRI findings agreed with the histological results in 17 out of 23 cases and there was a negative predictive value of 83%. One patient suffered a fracture after radiofrequency ablation. CONCLUSION Radiofrequency ablation could be an alternative to curettage when treating atypical cartilaginous tumours in the long bones. It was shown that multiple needle placement in addition to longer duration of the ablation procedure is an effective measure in achieving complete ablation in tumours ≥30 mm. Gadolinium-enhanced MRI has a negative predictive value of 83% and could guide post-ablation follow-up.
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Affiliation(s)
- Edwin F Dierselhuis
- Department of Orthopaedics, Radboudumc, Postbus 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Jelle Overbosch
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Albert J H Suurmeijer
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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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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Łebek-Szatańska A, Papierska L, Marcinowska-Suchowierska E, Nowak KM, Zgliczyński W, Misiorowski W. Positive somatostatin receptor imaging does not predict somatostatin analogue efficacy in tumor-induced osteomalacia. Pol Arch Intern Med 2018; 128:554-555. [PMID: 30141426 DOI: 10.20452/pamw.4318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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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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Holst-Albrechtsen S, Juel J, Wagenblast ALH. [Atypical subcutaneous presentation of a basal cell carcinoma]. Ugeskr Laeger 2017; 179:V05170370. [PMID: 28874239] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Basal cell carcinoma (BCC) have many treatment options either by dermatologist, with excision or radiotherapy. A 78-year-old woman had a BCC removed surgically, and 18 years after she had a subcutaneously located tumour extirpated at the same location. The result of pathological examination was BCC located atypically in the subcutis. Iatrogenic seeding from primary excision or non-radical primary excision may explain this presentation. This is only the second report of subcutaneously located BCC.
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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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19
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Zhu W, Ma Q, Bian Y, Zhuang Q, Xia Z, Jin J, Weng X. Total hip/knee arthroplasty in the treatment of tumor-induced osteomalacia patients: More than 1 year follow-up. PLoS One 2017; 12:e0177835. [PMID: 28545150 PMCID: PMC5435341 DOI: 10.1371/journal.pone.0177835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
Background Tumor-induced osteomalacia (TIO) may result in a better prognosis after complete resection of the causative neoplasm. However, tumors located proximal to the articular surface of the metaphysis remain largely uninvestigated. Methods A retrospective study of sixteen patients was undertaken to evaluate treatment of tumors with joint arthroplasty and tumor resection. The bone metabolism index, hip/knee joint function, arthroplasty complications and symptoms were followed up for at least 12 months in each patient. Results All patients presented with neoplasms situated in the articular surface of the metaphysis, with 13 cases undergoing hip arthroplasty and 3 undergoing knee arthroplasty. Treatment of the tumors with joint arthroplasty and tumor resection significantly and rapidly ameliorate bone metabolism indexes in patients with TIO (p<0.01), with no identified tumor recurrence. The joint function evaluation score was improved in 15 patients (93.75%). Complications in these patients included post-operative pain, joint squeaking and secondary hyperparathyroidism. Conclusions Joint arthroplasty that includes tumor-expanding resection appears to be a safe and appropriate method for the treatment of TIO patients with a neoplasm located in the metaphysis proximal to the articular surface. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Wei Zhu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qi Ma
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanyan Bian
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qianyu Zhuang
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zenan Xia
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- * E-mail: (JJ); (XW)
| | - Xisheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- * E-mail: (JJ); (XW)
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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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21
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Gurich RW, Pappas ND. Lipoma of the Tendon Sheath in the Fourth Extensor Compartment of the Hand. Am J Orthop (Belle Mead NJ) 2015; 44:561-562. [PMID: 26665243] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Lipoma of an extensor tendon compartment is an exceedingly rare tumor of the hand. Although benign, it can often cause localized pain and finger stiffness, necessitating surgical excision. We report a case of a lipoma of the tendon sheath in the fourth dorsal compartment of the hand that was successfully treated with surgical excision.
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Affiliation(s)
- Richard W Gurich
- Department of Orthopaedic Surgery, Greenville Health System, Greenville, SC.
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22
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Shustik DA, Ng DCE, Sittampalam K. Phosphaturic mesenchymal tumour mixed connective tissue variant: report of three cases with unusual histological findings. Int J Clin Exp Pathol 2015; 8:7506-7517. [PMID: 26261662 PMCID: PMC4525996] [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] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/10/2015] [Indexed: 06/04/2023]
Abstract
Phosphaturic mesenchymal tumour mixed connective tissue variant (PMTMCT) is a rare tumour occurring in bone and soft tissue that usually behaves in a benign manner. Elaboration of biologically active substances by this tumour gives rise to a paraneoplastic syndrome known as oncogenic osteomalacia, manifesting clinically as bone pain, generalized weakness and pathological fractures. Recognition of PMTMCT and its associated syndrome is important, as resection of the tumour in most instances results in prompt resolution of symptoms. Previously reported cases of this tumour have emphasized the consistent presence of certain histological features that are considered prerequisite for making the diagnosis of PMTMCT. We describe three cases of PMTMCT, of which two first presented with progressive symptoms of osteomalacia and one remained clinically silent aside from the symptom of a palpable lump. Our cases highlight the wide-ranging histological patterns displayed by these tumours, and draw attention to certain microscopic findings that until now have been given little if any mention. Tentacular growth pattern and satellite nodules appear to be common findings in PMTMCTs, and can make complete surgical excision of these tumours challenging. The ability of this otherwise histologically benign tumour to permeate vascular spaces has to our knowledge never been described previously. One tumour lacked the characteristic calcifying matrix of PMTMCT, suggesting that in some tumours this defining feature may be focal if not entirely absent. PMTMCT shares features with and can resemble a variety of bone and soft tissue neoplasms, requiring the surgical pathologist to be familiar with this entity.
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Affiliation(s)
- David A Shustik
- Department of Pathology, Singapore General HospitalSingapore
| | - David CE Ng
- Department of Nuclear Medicine and PET, Singapore General HospitalSingapore
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23
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Jadhav S, Kasaliwal R, Shetty NS, Kulkarni S, Rathod K, Popat B, Kakade H, Bukan A, Khare S, Budyal S, Jagtap VS, Lila AR, Bandgar T, Shah NS. Radiofrequency ablation, an effective modality of treatment in tumor-induced osteomalacia: a case series of three patients. J Clin Endocrinol Metab 2014; 99:3049-54. [PMID: 24960541 DOI: 10.1210/jc.2013-4515] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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] [Indexed: 02/04/2023]
Abstract
CONTEXT Tumor-induced osteomalacia is curable if the tumors can be totally excised. However, when the tumors are present in locations that make surgery disproportionately risky, the need for less invasive strategies like radiofrequency ablation (RFA) is realized. PATIENTS AND METHODS We describe three patients with suspected tumor-induced osteomalacia who were treated in our department between 2006 and 2013 with tumors in surgically difficult locations and were subjected to single or multiple sessions of RFA. The response was documented in terms of symptomatic improvement, phosphorus normalization, and follow-up (99m)Technitium-labelled hydrazinonicotinyl-Tyr3-octreotide ((99m)Tc HYNIC TOC) scan. RESULTS Two of the three individuals, patient A (with a 1.5 × 1.2-cm lesion in the head of the right femur) and patient B (with a 1.3 × 1.2-cm lesion on the endosteal surface of the shaft of the left femur), achieved complete remission with single sessions of RFA. Three months after the procedure, (99m)Tc HYNIC TOC scans revealed the absence of uptake at the previous sites, corroborating with the clinical improvement and phosphorus normalization. Patient C had a large 5.6 × 6.5-cm complex lesion in the lower end of the left femur with irregular margins, loculations, and bone grafts placed in previous surgery. He failed to achieve remission after multiple sessions of RFA due to the complex nature of the lesion, although the tumor burden was reduced significantly as documented on serial (99m)Tc HYNIC TOC scans. CONCLUSIONS Although surgery remains the treatment of choice, RFA could be an effective, less invasive, and safe modality of treatment in judiciously selected patients.
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Affiliation(s)
- Swati Jadhav
- Department of Endocrinology (S.J., R.K.), Seth G. S. Medical College and King Edward Memorial Hospital, Parel, Mumbai, 400012, India; Department of Radiodiagnosis (N.S.She., S.Ku.), Tata Memorial Centre, Parel, Mumbai 400012, India; and Departments of Radiology (K.R., B.P.) and Endocrinology (H.K., A.B., S.Kh., S.B., V.S.J., A.R.L., T.B., N.S.Sha.), Seth G. S. Medical College and King Edward Memorial Hospital, Parel, Mumbai, 400012, India
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24
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Jadhav S, Kasaliwal R, Lele V, Rangarajan V, Chandra P, Shah H, Malhotra G, Jagtap VS, Budyal S, Lila AR, Bandgar T, Shah NS. Functional imaging in primary tumour-induced osteomalacia: relative performance of FDG PET/CT vs somatostatin receptor-based functional scans: a series of nine patients. Clin Endocrinol (Oxf) 2014; 81:31-7. [PMID: 24528172 DOI: 10.1111/cen.12426] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [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: 11/18/2013] [Revised: 12/07/2013] [Accepted: 01/27/2014] [Indexed: 02/04/2023]
Abstract
CONTEXT Localization of phosphatonin-producing mesenchymal tumours in patients with primary tumour-induced osteomalacia (pTIO) is challenging. Functional imaging plays an important role in the localization of these tumours. OBJECTIVE We studied the relative performance of different functional imaging modalities ((18) F-FDG PET/CT, (99) Tc-HYNIC-TOC SPECT/CT and (68) Ga-DOTATATE PET/CT) in tumour localization in cases of pTIO. DESIGN AND METHODS Retrospective chart evaluation of 16 patients with confirmed TIO treated from 2006 to 2013 was conducted in a tertiary care referral centre. RESULTS Of 16, nine patients had pTIO. In these nine, the positivity rates of different functional imaging modalities were 50% for (18) F-FDG PET/CT (four of eight patients), 100% for (99) Tc-HYNIC-TOC SPECT/CT (six of six patients) and 100% for (68) Ga-DOTATATE PET/CT (seven of seven patients). Of nine patients, six were subjected to both the (99) Tc-HYNIC-TOC SPECT/CT and (68) Ga-DOTATATE PET/CT and all of them showed coregistration on the two scans. CONCLUSIONS In patients with pTIO, the somatostatin receptor-based functional scans performed better than (18) F-FDG PET/CT in tumour localization. Amongst the somatostatin receptor-based scans, (99) Tc-HYNIC-TOC SPECT/CT and (68) Ga-DOTATATE PET/CT performed equally well for localization of tumours.
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Affiliation(s)
- Swati Jadhav
- Department of Endocrinology, KEM Hospital, Mumbai, India
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25
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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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26
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Lapa C, Genest F, Buck AK, Herrmann K, Kenn W, Rudert M, Jakob F, Seefried L. Diagnostic findings and treatment in a 51-year-old woman with oncogenic osteomalacia. J Clin Endocrinol Metab 2014; 99:385-6. [PMID: 24423314 DOI: 10.1210/jc.2013-3980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- C Lapa
- Department of Nuclear Medicine (C.L., A.K.B., K.H.), University Hospital Wuerzburg, D-97080 Wuerzburg, Germany; Orthopedic Department (F.G., M.R., F.J., L.S.), University of Wuerzburg, D-97074 Wuerzburg, Germany; and Institute of Radiology (W.K.), University Hospital Wuerzburg, D-97080 Wuerzburg, Germany
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27
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Piemonte S, Romagnoli E, Cipriani C, De Lucia F, Pilotto R, Diacinti D, Pepe J, Minisola S. Six-year follow-up of a characteristic osteolytic lesion in a patient with tumor-induced osteomalacia. Eur J Endocrinol 2014; 170:K1-4. [PMID: 24144968 DOI: 10.1530/eje-13-0581] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia is a rare paraneoplastic syndrome characterized by hypophosphatemia and inappropriately normal or low 1,25-dihydroxyvitamin D. CLINICAL CASE Here, we report a 6-year postoperative follow-up of a patient with oncogenic osteomalacia with a distinctive skeletal manifestation. The latter was characterized by an almost linear lytic lesion of a few millimeters with irregular borders, mainly involving the trabecular compartment but extending into cortical shell, located in the middle third of the right fibula. Six years after tumor resection, a sclerotic repair with a complete recovery was observed. Furthermore, we monitored a striking increase in bone mineral density throughout the observation period, reaching a peak of 73% over basal values at lumbar spine after 2 years; at total femur and radius, the peak was 47.5 and 4.6% respectively, after 4 years from tumor resection. CONCLUSIONS We report for the first time that an osteolytic lesion may be part of the skeletal involvement in tumor-induced osteomalacia.
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Affiliation(s)
- Sara Piemonte
- Departments ofInternal Medicine and Medical Disciplines
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28
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Kawano H. [Updates on rickets and osteomalacia: surgical treatment for rickets/osteomalacia]. Clin Calcium 2013; 23:1503-1509. [PMID: 24076650] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In general, surgical treatments are indicated for severe extremity deformities due to impaired bone growth and fractures due to bone fragility in rickets/osteomalacia patients. Corrective osteotomy and fixation with external fixators, Kirshner's wires, intramedullary nail, plates and casting including epiphysiodesis is performed. For tumor induced osteomalacia patients, excision of causative tumor is indispensable as definitive therapy. In this article, surgical treatments were updated especially for tumor induced osteomalacia.
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Affiliation(s)
- Hirotaka Kawano
- Department of Orthopaedic Surgery, Graduate School of Medicine, The University of Tokyo, Japan
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29
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Zabolotniĭ DI, Palamar OI, Guk AP, Zinchenko DA, Gorbach ON. [Bone and cartilaginous tumours in the sino-paranasal region with intracranial extension. Peculiarities of surgical treatment]. Vestn Otorinolaringol 2013:11-16. [PMID: 23715481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The objective of the present work was to study peculiarities of diagnostics of bone and cartilaginous tumours in the sino-paranasal region with intracranial extension, to substantiate the choice of the strategy and methods for the surgical intervention for the treatment of these neoplasms. The study included 19 patients with various bone and cartilaginous neoplasms in the craniofacial region. Diagnostics was based on computed tomography allowing for 3D reconstruction of the structures of interest, magnetic resonance imaging (with amplification whenever necessary), and angiography. It is proposed to use the microsurgical and pneumatic techniques to ensure the maximally complete removal of the tumours with a minimal injury to the surrounding tissues. The extension of fascial approach is recommended for the management of intracranially spreading tumours. This technique was used for the treatment of 9 patients (7 undergoing anterior craniofacial resection, 1 lateral craniofacial resection, and 1 subcranial resection) in combination with Moure and Denker rhinotomy. The transcranial approach was employed in 8 patients one of whom underwent transoral surgery and another transnasal intervention. Also, the histological structure of the tumours needs to be taken into consideration when planning the approach and the extent of the surgical intervention. It is concluded that preliminary courses of chemo and radiotherapy do not significantly improve the outcome of surgical treatment; in contrast, they promote the development of complications during the postoperative period. The results of this study indicate that for the management of benign tumours characterized by the slow growth rate (osteoma, chondroma, chordoma) the traditional ENT approaches can be supplemented by transcranial surgery. Extensive interventions (anterior craniofacial reseaction, lateral craniofacial resection) are needed for the management of aggressive malignant tumours (ostesarcoma, chondrosarcoma) without serious injury the healthy tissues; moreover, such approach increases the survival rate of the patients.
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30
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Papierska L, Ćwikła JB, Misiorowski W, Rabijewski M, Sikora K, Wanyura H. Unusual case of phosphaturic mesenchymal tumor. Pol Arch Med Wewn 2013; 123:255-256. [PMID: 23722193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Lucyna Papierska
- Department of Endocrinology, Medical Center for Postgraduate Education, Warszawa, Poland.
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31
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Shih YH, Chen HC, Liao SC, Tseng MCM, Lee MB. Psychotic disorder due to phosphaturic mesenchymal tumor with mixed connective tissue variant. Psychosomatics 2012; 53:96-7. [PMID: 22221727 DOI: 10.1016/j.psym.2011.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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32
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Falidas E, Ntasi A, Mathioulakis S, Vlachos K, Anyfantakis G, Boutzouvis S, Villias C. Multicystic nephroma in an elderly man. Case report. G Chir 2011; 32:483-486. [PMID: 22217377] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Multicystic nephroma is a relatively rare tumor of the kidney presenting unclear histological origin. Abdominal mass is a common onset sign in children while abdominal flank pain or abdominal discomfort, hematuria and recurrent urinary tract infections usually affect adults. Preoperative diagnosis is impossible especially in the adult variant of the tumor where clear cells carcinoma with cystic degeneration must always be suspected. We herein report a case of a 77 year old man complaining of flank abdominal pain and recurrent episodes of urinary tract infection due to a right-sided multicystic nephroma successfully treated with nephrectomy.
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Abstract
Tumour-induced (or oncogenic) osteomalacia is a paraneoplastic syndrome characterised by progressive fatigue, muscle weakness, bone pain, non-healing and recurrent fractures caused by mesenchymal tumours that secrete proteins that inhibit renal phosphate transport and 1α-hydroxylation of 25-OH-vitamin D. The potentially curative treatment of choice is complete surgical excision of the tumour.
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34
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Sandkull P, Seregard S. Malignant melanoma of soft parts arising from Tenon's capsule. Acta Ophthalmol 2009; 87:914-6. [PMID: 19154531 DOI: 10.1111/j.1755-3768.2008.01400.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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35
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Abstract
We describe a method for the preparation of amputated limbs to obtain a specimen for anatomical study of the arteries and the skeleton. The procedure is particularly applicable to hands, and prevents the destruction of a perfect hand that cannot be replanted.
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Affiliation(s)
- Martin Willian Stenekes
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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36
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Sampo M, Tarkkanen M, Huuhtanen R, Tukiainen E, Böhling T, Blomqvist C. Impact of the smallest surgical margin on local control in soft tissue sarcoma. Br J Surg 2008; 95:237-43. [PMID: 17703500 DOI: 10.1002/bjs.5906] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim was to review a single-institution experience of a prospective treatment protocol for soft tissue sarcoma of the extremity and trunk wall, with particular focus on the smallest surgical margin leading to local control. METHODS The study included 270 patients who had surgery for soft tissue sarcoma at Helsinki University Central Hospital between 1987 and 1997. Resection margins were measured prospectively from tumour specimens. Radiotherapy was administered if the smallest margin measured less than 2.5 cm, irrespective of tumour grade. RESULTS With a median follow-up of 6.6 years, the 5-year local control rate was 76.4 per cent. On multivariable analysis, the smallest surgical margin around the sarcoma (after radiotherapy) was prognostic for local control. A margin of at least 2.5 cm was associated with a local recurrence-free rate of 89.2 per cent at 5 years. Tumour size, depth or grade and patient's age had no independent prognostic effect on local control. CONCLUSION Surgical margin had independent prognostic value for local control. A surgical margin of 2-3 cm provided reasonable local control of soft tissue sarcoma, even without radiotherapy. Radiotherapy is recommended for smaller margins, irrespective of tumour grade.
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Affiliation(s)
- M Sampo
- Department of Pathology, HUSLAB and University of Helsinki, Helsinki, Finland.
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37
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Abstract
Leiomyomatosis peritonealis disseminata is an uncommon condition characterized by subperitoneal proliferation of benign nodules mainly composed of benign smooth muscle cells. This entity generally appears in premenopausal women and hormonal influences may play a role in its pathogenesis. The macroscopic appearance mimics peritoneal carcinomatosis. The characteristic clinical course is asymptomatic and diagnosis is only feasible after microscopic examination. To date, less than 100 cases have been reported in the literature. We report the case of a 40-year-old woman who underwent surgery in our department.
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Affiliation(s)
- Sandra Castro-Boix
- Servicio de Cirugía General. Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 08035 Barcelona, Spain.
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Abstract
We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated. The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221). The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°). At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery.
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Affiliation(s)
- H Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-Machi, Kanazawa, Japan.
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39
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Ramírez-Bárcena P, Rodríguez-Castellanos MA, Fajardo-Barajas D, Sandoval-Tress C. Cutaneous cartilaginous tumor. Dermatol Surg 2007; 32:1513-5. [PMID: 17199664 DOI: 10.1111/j.1524-4725.2006.32365.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patricia Ramírez-Bárcena
- Department of Dermatology, Instituto Dermatológico de Jalisco "Dr. José Barba Rubio," Secretaría de Salud Jalisco, Zapopan, Jalisco, México
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40
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van Zeeland YRA, Hernandez-Divers SJ, Blasier MW, Vila-Garcia G, Delong D, Stedman NL. Carpal myxosarcoma and forelimb amputation in a ferret (Mustela putorius furo). Vet Rec 2006; 159:782-5. [PMID: 17142629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Y R A van Zeeland
- Department of Small Animal Medicine, Faculty of Veterinary Medicine, University of Utrecht, Utrecht, The Netherlands
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41
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Abstract
Neoplasms of perivascular epithelioid cells (PEComas) have in common the coexpression of muscle and melanocytic immunohistochemical markers. Although this group includes entities with distinct clinical features, such as angiomyolipoma, clear cell sugar tumor of the lung, and lymphangioleiomyomatosis, similar tumors have been documented in an increasing diversity of locations. The term PEComa is now generally used in reference to these lesions that are not angiomyolipomas, clear cell sugar tumors, or lymphangioleiomyomatoses. While most reported PEComas have behaved in a benign fashion, malignant PEComas have occasionally been documented. We present a case of hepatic PEComa with benign histologic features, which nonetheless presented with metastases to multiple sites nearly 9 years later. This case represents the second documented malignant PEComa of the liver, as well as the longest follow-up of a surviving patient with a malignant PEComa, emphasizing both the need for criteria that more accurately predict the behavior of PEComas and the necessity of long-term follow-up of patients with PEComas.
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Affiliation(s)
- Jeremy R Parfitt
- Departments of Pathology, London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada.
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Abstract
BACKGROUND In a 28-year-old male who had suffered an olecranon fracture, delayed diagnosis was made of epithelioid sarcoma in the left upper extremity. Radical tumor resection was carried out which included removal of the entire elbow joint. MATERIAL AND METHODS The amputated hand with the distal one-third of the forearm was replanted at the upper arm. It was important to ensure that all tendinous structures of the forearm were attached to the three muscles of the upper arm and the nerves of the distal forearm with the nerves of the upper arm, which are incongruent in diameter with the former. Details of the operation are given below. RESULTS The anatomic peculiarities involved in this form of replantation, the early intensive therapy, reintegration of the replanted hand in the body scheme, and the usability of such a shortened extremity are described and the extremely good functional results documented in numbers and figures.
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Affiliation(s)
- H Piza-Katzer
- Klinik für Plastische- und Wiederherstellungschirurgie, Medizinische Universität Insbruck, Ludwig-Boltzmann-Institut für Qualitätssicherung in der Plastischen- und Wiederherstellungschirurgie, Innsbruck, Austria.
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Hodgson SF, Clarke BL, Tebben PJ, Mullan BP, Cooney WP, Shives TC. Oncogenic osteomalacia: localization of underlying peripheral mesenchymal tumors with use of Tc 99m sestamibi scintigraphy. Endocr Pract 2006; 12:35-42. [PMID: 16524861 DOI: 10.4158/ep.12.1.35] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To highlight a strategy for potential detection of mesenchymal tumors in oncogenic malacia, as illustrated by 3 cases. METHODS Three case reports are presented in which successful localization of the offending neoplasm was accomplished by using whole-body Tc 99m sestamibi scanning. Alternative localization techniques are also reviewed. RESULTS Oncogenic osteomalacia occurs infrequently and is caused by neoplasms that secrete phosphatonins, substances that interfere with proximal tubular resorption of phosphorus and can result in phosphaturia, hypophosphatemia, reduced 1,25-dihydroxyvitamin D concentration, and osteomalacia. Removal of the underlying neoplasm results in complete resolution of all biochemical, pathologic, and physical manifestations of this disorder, as shown in our 3 patients. Because the neoplasms are small and can occur in any tissue compartment, they are difficult to localize, a feature that often results in therapeutic failure. CONCLUSION We conclude that use of whole-body Tc 99m sestamibi scanning may be an appropriate and cost-effective initial strategy for the localization of peripheral phosphatonin-secreting tumors.
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Affiliation(s)
- Stephen F Hodgson
- Division of Endocrinology, Diabetes, Nutrition & Metabolism, Mayo Clinic Rochester, Rochester, Minnesota 55905, USA
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Jerbi M, Hidar S, Ziadi S, Khairi H. Benign multicystic peritoneal mesothelioma. Int J Gynaecol Obstet 2006; 93:267-8. [PMID: 16687143 DOI: 10.1016/j.ijgo.2006.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 03/08/2006] [Accepted: 03/08/2006] [Indexed: 10/24/2022]
Affiliation(s)
- M Jerbi
- Gynecologic and Obstetric Department, Farhat Hached Hospital, Sousse, Tunisia.
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Abstract
We report a rare case of fibroma of the tendon sheath in the knee. To our knowledge, only three previous cases of fibroma of the tendon sheath in the knee have been reported in the English literature. In our case, T1-weighted magnetic resonance imaging revealed a low intensity signal, T2-weighted magnetic resonance imaging showed a mixed area of high and low signal intensity, and gadolinium-diethylene triaminepentaacetic acid-enhanced magnetic resonance imaging showed faint enhancement at the periphery of the lesion. Magnetic resonance imaging therefore was valid for detection of this intraarticular lesion. The lesion, which was located between the posterior capsule of the left knee and the posterior cruciate ligament, was excised arthroscopically.
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Affiliation(s)
- Yuya Takakubo
- Department of Pathology, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata, Japan.
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Talwalkar S, Hayton M, Stilwell J, Temperley D, Freemont A. Tenosynovial haemangioma of the finger. Acta Orthop Belg 2005; 71:618-21. [PMID: 16305091] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Haemangiomas developing in the hand in relation to tendon and the tenosynovium (tendon sheath) are very rare. To our knowledge only three cases have been described arising in relation to the tenosynovium of the tendons of the hand, only one of which showed infiltration of the underlying tendon. We report the case of a 16-year-old right hand dominant student who presented to her family doctor with a swelling on her left little finger. An MRI scan was arranged which confirmed a soft tissue lesion between the flexor tendons and the proximal phalanx of the left little finger, with appearance similar to giant cell tumour of the tendon sheath. Surgical exploration demonstrated a dark red fleshy tumour that appeared to infiltrate the flexor digitorum sub-limis tendon, and extend around either side of the proximal phalanx. For complete excision of the lesion the infiltrated sublimis tendon and a part of the A2 pulley were sacrificed. There was no resultant bow-stringing of the profundus tendon. Histologically the tenosynovium was expanded by a vascular lesion consisting of dilated, thin-walled vascular channels within fibrous tissue; the appearances were consistent with those of a synovial haemangioma of the flexor tendons. Our case illustrates the pitfalls in diagnosis and the invasive potential of a synovial haemangioma. A complete surgical excision is critical to prevent recurrence.
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Nalbantoglu U, Aktas S, Peker KR. Chondromyxoid fibroma involving the entire metacarpal: a case report. J Hand Surg Am 2005; 30:1083-6. [PMID: 16182071 DOI: 10.1016/j.jhsa.2005.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [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: 10/28/2004] [Revised: 04/19/2005] [Accepted: 04/19/2005] [Indexed: 02/02/2023]
Abstract
The occurrence of chondromyxoid fibroma in the hand is rare. We report a case of chondromyxoid fibroma involving the whole fourth metacarpal that was treated by curettage and cancellous bone allograft.
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Affiliation(s)
- Ufuk Nalbantoglu
- Hand Surgery Service, Orthopedics and Traumatology Department, Acibadem Kadiköy Hospital and Patomed Pathology and Cytology Laboratory, Istanbul, Turkey.
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Dorai AA, Halim AS, Zulmi W. Versatility of the latissimus dorsi flap in upper limb salvage tumour surgery. Med J Malaysia 2004; 59 Suppl F:42-6. [PMID: 15941160] [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] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Reconstructive surgeons often encounter complex soft tissue and skeletal defects following oncological surgery. Soft tissue defects after wide resection in upper extremities posses a difficult challenge to find adequate tissue for reconstructing these defects. Paucity of local tissues dictates the requirement of loco-regional or distant flaps for these complex soft tissue defects which often exposes tendons, bones, nerves and joints. The latissimus dorsi muscle is a near ideal flap for the reconstruction because of the long neurovascular pedicle, ease of mobilization and its expendability. It can be rotated, with or without overlying skin, to cover soft tissue defects of the shoulder arm and elbow. Due to the large size of the muscle, it can be used to resurface the soft tissue defects and cover all major structures. Eleven consecutive cases were reviewed in which latissimus dorsi myocutaneous flap was used to reconstruct soft tissue defects of the upper limb following radical tumor resection. Flap survival was 100% with nominal donor site morbidity.
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Affiliation(s)
- A A Dorai
- Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan
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Siewert E, Tietze L, Maintz C, Geier A, Dietrich CG, Matern S, Gartung C. [Gastrointestinal stromal tumors: a broad clinical spectrum from incidental -discovery to acute gastrointestinal bleeding]. Z Gastroenterol 2004; 42:233-42. [PMID: 15022111 DOI: 10.1055/s-2004-812729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Three cases of gastrointestinal stromal tumors (GIST) are reported as typical examples of the broad clinical spectrum in which these rare tumors can be detected. The first case describes an 82-year-old patient with a hemorrhagic shock due to upper gastrointestinal bleeding from a GIST of the stomach. GIST most frequently present with either gastrointestinal bleeding, abdominal pain or a detectable mass on physical examination or by ultrasound imaging. Clinically asymptomatic tumor growth also occurs as demonstrated by the second case of a 44-year-old -woman with an incidental finding of GIST during surgery of the esophagus. The cases are used to discuss the consequences for therapy and prognosis resulting from the heterogeneity of this tumor entity; the relevant immunohistochemical markers used to distinguish between various tumor subtypes of gastrointestinal mesenchymal tumors (GIMT) are listed. Since gastrointestinal stromal tumors (GIST) represent the most common subgroup of GIMT, we focus on the clinicopathological prognostic factors of GIST. The third case of a 40-year-old patient with a malignant GIST recurrence after surgery and exhibiting secondary resistance after one year of successful therapy with the receptor tyrosine kinase inhibitor imatinib (Gleevec), antagonizing pathogenetically relevant constitutive c-KIT activation, illustrates the potential and limitations of the only effective drug treatment for advanced GIST.
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MESH Headings
- Abdominal Pain/etiology
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents/therapeutic use
- Benzamides
- Biomarkers, Tumor/analysis
- Cardia/pathology
- Cardia/surgery
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Diagnosis, Differential
- Dose-Response Relationship, Drug
- Drug Resistance, Neoplasm
- Esophageal Neoplasms/diagnosis
- Esophageal Neoplasms/drug therapy
- Esophageal Neoplasms/pathology
- Esophageal Neoplasms/surgery
- Esophagectomy
- Female
- Gastrectomy
- Gastric Mucosa/pathology
- Gastrointestinal Hemorrhage/etiology
- Gastrointestinal Hemorrhage/pathology
- Gastrointestinal Hemorrhage/surgery
- Gastroscopy
- Humans
- Imatinib Mesylate
- Incidental Findings
- Male
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/surgery
- Neoplasms, Connective Tissue/diagnosis
- Neoplasms, Connective Tissue/drug therapy
- Neoplasms, Connective Tissue/pathology
- Neoplasms, Connective Tissue/surgery
- Piperazines/therapeutic use
- Polyps/diagnosis
- Polyps/drug therapy
- Polyps/pathology
- Polyps/surgery
- Prognosis
- Proto-Oncogene Proteins c-kit/analysis
- Pyrimidines/therapeutic use
- Receptor Protein-Tyrosine Kinases/antagonists & inhibitors
- Shock, Hemorrhagic/etiology
- Stomach Neoplasms/diagnosis
- Stomach Neoplasms/drug therapy
- Stomach Neoplasms/pathology
- Stomach Neoplasms/surgery
- Stromal Cells/pathology
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- E Siewert
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Germany
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