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Kothandaraman S, Yadav V, Chandrasekhar NH, Sunil HV, Kumar SDG, Kannan S. Oncogenic Osteomalacia: Challenges in Diagnosis. Indian J Surg Oncol 2023; 14:583-588. [PMID: 37900640 PMCID: PMC10611642 DOI: 10.1007/s13193-021-01474-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
To report a case of osteomalacia induced by a mesenchymal tumour in the head and neck region, in view of its rarity and classical late diagnosis. To review the literature on the usage of fluorodeoxyglucose-positron emission tomography-computed tomography (FDG PET-CT) and octreotide scanning in the localisation of the culprit tumour. An elderly male presented with a 7-year history of chronic muscle pain and weakness, to the extent of functional disability. FDG PET-CT was done which showed uptake in the region of the right anterior ethmoids. Endoscopic excision of the mass was done. However, the patient did not improve significantly. Subsequently, a DOTA-1-NaI3-octreotide (DOTANOC) scan was done which revealed a tumour in the region of the right medial rectus, excision of which was done. This time, the patient improved clinically and biochemically. The histopathology was phosphaturic mesenchymal tumour. A steady but definitive symptomatic improvement was noted in the postoperative period along with reversal of the deranged biochemical parameters, confirming the diagnosis of oncogenic osteomalacia. Octreotide-based PET-CT seems to be the most sensitive imaging modality in localising the tumours that cause oncogenic osteomalacia. However, FDG-based PET-CT still would be a good choice in centres where SSTR-based imaging facilities are not available.
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Affiliation(s)
| | - Vishal Yadav
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Cancer Centre, Bengaluru, India
| | - Naveen H. Chandrasekhar
- Department of Head and Neck Surgical Oncology, Mazumdar Shaw Cancer Centre, Bengaluru, India
| | - H. V. Sunil
- Department of Nuclear Medicine, Mazumdar Shaw Cancer Centre, Bengaluru, India
| | | | - Subramanian Kannan
- Department of Endocrinology, Mazumdar Shaw Cancer Centre, Bengaluru, India
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Minisola S, Barlassina A, Vincent SA, Wood S, Williams A. A literature review to understand the burden of disease in people living with tumour-induced osteomalacia. Osteoporos Int 2022; 33:1845-1857. [PMID: 35643939 PMCID: PMC9463218 DOI: 10.1007/s00198-022-06432-9] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED This study reviews publications to describe the signs, symptoms and impact of tumour-induced osteomalacia (TIO) on patients' burden of disease. TIO is associated with a spectrum of signs and symptoms imposing a significant clinical burden, but the psychosocial impact of this rare disease has been poorly researched so far. INTRODUCTION To describe the signs, symptoms and impacts of tumour-induced osteomalacia (TIO) and summarise the state of research on the burden of disease of this ultra-rare condition. METHODS A targeted literature review was conducted in PubMed using pre-defined search terms. Relevant articles published between 1980 and 2021 were screened for inclusion. Seventy records were selected for analysis. Data were extracted and grouped into categories and sub-categories to identify recurrent signs, symptoms and impacts of TIO and describe the burden on patients. Chord diagrams were created to analyse the relationships between different TIO outcomes and characterise the presentation of TIO. RESULTS Although the number of articles on TIO published have been increasing over the past 20 years, most studies were case reports and case series (n = 65/70) and only few were studies with higher quality of evidence (n = 5/70). Most articles were based on data reported by clinicians (n = 67/70). Patients with TIO experienced a combination of outcomes including chronic pain, weakness, skeletal-related manifestations and limitations in mobility. Only a few studies (n = 2/70) analysed the burden of TIO on the emotional wellbeing and on the work life of the patient. CONCLUSION Patients with TIO present with a spectrum of signs and symptoms that impose a significant burden. The impact on the psychosocial wellbeing of patients should be further investigated, as this has been poorly researched so far. Studies with high quality of evidence should be designed to further the understanding of the burden of disease of TIO from the patient's perspective.
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Affiliation(s)
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, United Kingdom
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Tan TH, Chen EJ, Chew MT, Chye PC, Wong M. Extended Whole-body Ga-68 DOTATATE PET-CT in evaluating Tumour-Induced Osteomalacia: Case report and review of literature. Nucl Med Mol Imaging 2021; 55:130-5. [PMID: 34109008 DOI: 10.1007/s13139-021-00695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
Tumour-induced osteomalacia is a rare paraneoplastic syndrome that manifests as chronic hypophosphataemia, non-specific bone pain and muscle weakness. It is generally caused by phosphaturic mesenchymal tumour (PMT), which is uncommonly associated with synchronous tumours. However, diagnosis is often delayed for several years due to the rarity, indolent growing nature and non-specific symptoms of the disease, often resulting in an overlook by clinicians during assessments. The patient initially presented with hypophosphataemia and generalised skeletal pain with multiple atraumatic fractures. Blood tests revealed serum calcium levels at the upper limit and extremely low inorganic phosphate levels. Herein, we report a case where two synchronous PMTs from two different sites were detected by 'extended' whole-body Ga-68 DOTATATE PET-CT, leading to remission of the disease after complete surgical removal. Early detection and diagnosis of PMT neoplasm is crucial, as complete surgical resection of this tumour is the only definitive treatment currently known. Upon excision, this curable disease will result in complete resolution of symptoms and blood parameters, leading to remission of the disease which significantly improves the patient's quality of life. PMT often over-expresses somatostatin receptors (SSTR), predominantly subtype 2A, and Ga-68 DOTATATE PET-CT is a selective SSTR imaging that targets this characteristic over-expression in these tumours. The high diagnostic accuracy of Ga-68 DOTATATE PET-CT should be the primary imaging modality for full evaluation of this disease.
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Kumar S, Diamond T. Lessons learnt from delayed diagnosis of FGF-23-producing tumour-induced osteomalacia and post-operative hungry bone syndrome. Bone Rep 2020; 12:100276. [PMID: 32455150 DOI: 10.1016/j.bonr.2020.100276] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/04/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022] Open
Abstract
Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by a fibroblast growth-factor-23 (FGF-23)-secreting phosphaturic mesenchymal tumour (PMT) and is characterised by hypophosphataemic osteomalacia. We present a 36-year-old man initially presenting with diffuse bone and joint pain who was inappropriately treated for presumed ankylosing spondylitis for 2 years. Whole-body bone scan suggested metabolic bone disease, prompting referral to our endocrine institution. He was subsequently diagnosed with persistent hypophosphataemia, inappropriately high renal tubular phosphate excretion, 1,25-dihydroxyvitamin D3 suppression, severe osteoporosis and severe osteomalacia. FGF-23 concentrations (140 ng/L) were raised 3-fold above the upper limit of normal. Initial Gallium-68 (68Ga) DOTATATE positron emission tomography (PET)/CT scan missed an active lesion in the left fibular head as the field only included the mid-brain to the proximal femora. Histopathology results from tumour resection confirmed a PMT over-expressing FGF-23. Serum phosphate and FGF-23 normalised immediately post-operatively. He developed severe hypocalcaemia 3-weeks post-operatively (1.77 mmol/L) which normalised after 1 month of high-dose caltrate and calcitriol therapy. Osteomalacia, osteoporosis and associated symptoms resolved during medium-term follow-up with >100% improvement in his bone mineral density. This case report and discussion highlights the pitfalls contributing to delayed diagnosis of TIO and alerts clinicians to the potential complication of hungry bone syndrome post-tumour resection.
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Adnan Z, Nikomarov D, Weiler-Sagie M, Roguin Maor N. Phosphaturic mesenchymal tumors among elderly patients: a case report and review of literature. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM1801396. [PMID: 31051470 PMCID: PMC6499915 DOI: 10.1530/edm-18-01396] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/11/2019] [Indexed: 11/08/2022] Open
Abstract
Phosphaturic mesenchymal tumor (PMT) represents a rare cause of osteomalacia. The clinical signs and symptoms are vague and these lead to diagnosis delay. In the presence of hypophosphatemia and relatively high urine phosphate excretion, this entity should be taken into consideration in the deferential diagnosis of osteomalacia. In the present article, we report 81-year-old man presented to our clinic for evaluation due to osteopenia. His laboratory results disclosed hypophosphatemia, relatively increased urine phosphate excretion and increased level of intact fibroblast growth factor 23 (FGF23). A 68Gallium DOTATATE PET/CT revealed pathological uptake in the upper aspect of the left shoulder adjacent to the coracoid process. For suspected PMT a wide resection of the tumor was performed and pathological findings were consistent for PMT. Laboratory tests were normalized postoperatively. Reviewing the literature, we had identified 33 reported cases of PMTs among elderly patients age ≥70 years. Unlike previously reported data, where tumors predominantly localized in the lower extremities and pelvis, our search disclosed a high rate of tumor localization (10 cases - 33.3%) in the head with equal number of tumors (14 cases - 42.4%) localized in the head and upper extremity as well as in pelvis and lower extremity. The present case describes unique tumor localization in an elderly patient and our literature search demonstrated for the first time a high rate of tumor localization in the head among this group of patients. Learning points: PMTs represent a rare entity that should be considered in the differential diagnosis of elderly patients presented with persistent hypophosphatemia. Unlike previously reported data, head and neck tumor localization is frequent among elderly patients. 68Gallium-conjugated somatostatin peptide analogs, such as 68Ga-DOTATATE PET/CT demonstrated the greatest sensitivity and specificity for tumor localization in patients with phosphaturic mesenchymal tumors (PMTs). Wide tumor resection using intraoperative ultrasound is of major importance in order to ensure long-term cure.
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Affiliation(s)
- Zaina Adnan
- Endocrinology and Metabolism Department, Zvulon Medical Center, Clalit Medical Health Care Services, Haifa, Israel
| | - David Nikomarov
- Orthopedic Surgery Department, Nuclear Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | - Michal Weiler-Sagie
- Michal Weiler-Sagie, Nuclear Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | - Noga Roguin Maor
- Clalit Medical Health Care and the Clinical Research Unit, Haifa and Western Galilee, Haifa, Israel
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Savva C, Adhikaree J, Madhusudan S, Chokkalingam K. Oncogenic osteomalacia and metastatic breast cancer: a case report and review of the literature. J Diabetes Metab Disord 2019; 18:267-72. [PMID: 31275898 DOI: 10.1007/s40200-019-00398-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/14/2019] [Indexed: 12/16/2022]
Abstract
Objectives Oncogenic osteomalacia is a rare paraneoplastic metabolic syndrome that is characterised by severe hypophosphataemia, hyperphosphaturia and osteomalacia secondary to renal loss of phosphate. It is commonly caused by overproduction of fibroblast growth factor-23 (FGF23) from benign tumours of mesenchymal origin. Currently, there is no clear evidence on the management of oncogenic osteomalacia in patients with metastatic solid tumours. Methods We report a case of breast cancer-induced oncogenic osteomalacia and discuss its diagnosis and management. Results A 71-year-old woman with advanced breast cancer developed symptomatic oncogenic osteomalacia with raised FGF23, severe hypophosphataemia and hypocalcaemia. The electrolytic disturbances were exacerbated after the administration of bisphosphonates in the context of her oncological treatment. Systemic chemotherapy and maintenance endocrine treatment along with phosphate and calcium supplementation reduced the activity of oncogenic osteomalacia and resolved the electrolytic imbalances. Conclusions To our knowledge, this is the first reported case of oncogenic osteomalacia in a patient with breast cancer. Oncogenic osteomalacia constitutes a diagnostic and therapeutic challenge. Pre-clinical and clinical evidence suggest that a possible underlying mechanism is the presence of molecular alterations in the FGF/FGFR signalling pathway leading to overexpression of FGF23. In metastatic setting, anticancer treatment can potentially lead to the normalisation of the electrolytic disturbances and reduction of the activity of oncogenic osteomalacia. The use of antiresorptive therapy in patients with bone metastases can potentially trigger FGF23 overexpression. Its use should be guided by the patients' risk of skeletal-related events and electrolytic disturbances as well as the degree of activity of oncogenic osteomalacia.
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Schober HC, Kneitz C, Fieber F, Hesse K, Schroeder H. Selective blood sampling for FGF-23 in tumor-induced osteomalacia. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170006. [PMID: 29026610 PMCID: PMC5633052 DOI: 10.1530/edm-17-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/08/2017] [Indexed: 01/26/2023] Open
Abstract
Tumor-induced osteomalacia (TIO) is caused by the hormone fibroblast growth factor 23 (FGF-23). It is mainly produced in the tissue of mesenchymal tumors. Patients with TIO frequently suffer from a chronic decompensated pain syndrome and/or muscle weakness with postural deformity. Despite the severity of the disease, the diagnosis is frequently established late. In some cases, it takes several years to establish the condition. This case report concerning a 68-year old woman demonstrates the selective blood sampling for FGF-23 as path-breaking diagnostics to confirm the diagnosis of a neuroendocrine tumor. LEARNING POINTS Tumor-induced osteomalacia is a rare condition compared to other paraneoplastic syndromes.It causes complex symptoms such as progressive reduction of physical capacity, exhaustion, fatigue, a decompensated pain syndrome of the musculoskeletal system and fractures of several bones.Elevated serum levels of FGF-23 implicate massive phosphate elimination and resulting hypophosphatemia.The diagnosis is often established over a period of several years because the localization of small FGF-23-producing tumors is complicated.It is the combination of MRI and selective blood sampling for FGF-23 which permits reliable identification of tumors causing TIO and leads to accurate localization.In a patient with generalized pain and reduced physical capacity, osteological parameters such as phosphate, 25-OH vitamin D3 and 1,25-(OH)2D3, as well as bone-specific alkaline phosphatase levels in serum should be determined. Hypophosphatemia should always lead to further diagnostic investigations aiming at the detection of an FGF-23-producing tumor.
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Affiliation(s)
- Hans-Christof Schober
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Christian Kneitz
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Franziska Fieber
- Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Kathrin Hesse
- Departments of Internal Medicine.,Endocrinology, Rheumatology/Immunology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Henry Schroeder
- Department of Neurosurgery, Universitätsmedizin Greifswald, Greifswald, Germany
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Rodriguez-Velver KV, Zapata-Rivera MA, Montes-Villarreal J, Lavalle-Gonzâlez FJ, González-González JG, Villarreal-Pérez JZ, Rodríguez-Gutierrez R. Tumour-induced Osteomalacia Secondary to a Sarcoma. Eur Endocrinol 2016; 12:104-106. [PMID: 29632597 PMCID: PMC5813444 DOI: 10.17925/ee.2016.12.02.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/03/2016] [Indexed: 12/17/2022]
Abstract
Tumour-induced osteomalacia (TIO), is a rare paraneoplasatic syndrome found in >95% of benign tumours that secrete fibroblast growth factor 23 - a phosphaturic circulating hormone. A rare case of a TIO secondary to a sarcoma, in a 21-year old man with history of bone fractures and distinctive physical and biochemical characteristics is presented and discussed.
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Affiliation(s)
- Karla Victoria Rodriguez-Velver
- Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - María Azucena Zapata-Rivera
- Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Juan Montes-Villarreal
- Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Fernando Javier Lavalle-Gonzâlez
- Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | | | | | - Rene Rodríguez-Gutierrez
- Endocrinology Division, University Hospital "Dr. Jose E. Gonzalez", Medical School, Autonomous University of Nuevo Leon, Monterrey, Mexico.,Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota, US.,Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, US
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