Treatment and outcomes of tumor-induced osteomalacia associated with phosphaturic mesenchymal tumors: retrospective review of 12 patients

Abstract

Background: Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by severe hypophosphatemia and osteomalacia. Nonspecific symptoms make the diagnosis elusive. In addition, locating the responsible tumor(s) is challenging. The aim of this study was to investigate the clinical management and outcomes of TIO.

Methods: The clinical features, diagnostic procedures, treatment, and outcomes of 12 patients were reviewed retrospectively.

Results: The cohort comprised six men and six women (mean age 45.5 ± 9.9 years, range 23-61 years). The mean duration of disease was 3.7 ± 2.6 years. All patients manifested progressive bone pain, muscle weakness, and/or difficulty walking. Serum phosphorus concentrations were low in all patients (mean 0.42 ± 0.12 mmol/L). Technetium-99m octreotide scintigraphy was performed in 11 patients and showed lesions in the right distal femur, left femoral head, and right tibial plateau, respectively, in three patients. Magnetic resonance imaging (MRI) was negative for lesions in one patient. Two patients underwent biopsies that showed negative histopathology. Two patients, at 2 years and 8 months, respectively, after having negative technetium-99m octreotide studies, underwent ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (CT), which revealed lesions in the sacrum and soft tissue of the left palm, respectively. One tumor was detected by CT and MRI. Overall, lesion sites were the head (two patients, 16.7%), thoracic and lumbar region (two, 16.7%), pelvis (three, 25%), lower limbs (four, 33.3%), and upper limbs (one, 8.3%). All patients underwent surgery, and histopathology showed phosphaturic mesenchymal tumors in each. Postoperatively, serum phosphorus concentrations normalized within 2-7 days in 11 patients. With follow-ups of 1-41 months, surgery was effective in 10 patients. One patient developed local recurrence and another had metastases.

Conclusions: Locating tumors responsible for tumor-induced osteomalacia is often challenging. Although complete tumor resection confers a good prognosis in most patients, surveillance for recurrence and metastasis is necessary. Before surgery or when surgery is not indicated, oral phosphate can alleviate symptoms and metabolic imbalance.

Keywords: Fibroblast growth factor 23; Fractures; Hypophosphatemia; Oncogenic osteomalacia; Phosphaturic mesenchymal tumor; Spontaneous.

Fig. 1

Magnetic resonance imaging (MRI) and computed tomography (CT) of causative tumors. (a) Patient 5. Cranial MRI showed a soft mass (arrow) in the left nasal cavity and ethmoid, frontal, and maxillary sinuses. (b) Patient 2. MRI showed a tumor (arrow) in the sacral canal. (c) Patient 4. MRI showed a tumor (arrow) in the soft tissue of the left thigh. (d) Patient 10. CT showed a neoplasm (arrow) in the mons pubis. (e) Patient 3. CT showed a mass (arrow) in the right ilium. (f) Patient 12. CT showed a tumor (arrow) in the left fifth rib

Fig. 2

Patient 9. (a) A tumor was visible and palpable in the soft tissue of the left palm (arrow). (b) ¹⁸F–FDG PET/CT showed high ¹⁸F–FDG uptake in the tumor

Fig. 3

Patient 10. (a) ^99mTc-OCT showed strong expression of somatostatin receptors in the patient’s right mons pubis (arrow). (b) Recovery of serum phosphorus and alkaline phosphatase (ALP) in patient 10. The time of surgery is represented by the dashed line. Normal range of serum phosphorus was 0.84–1.65 mmol/L. Normal range of serum ALP was 40–150 U/L.

Fig. 4

Patient 11. Histological features of a phosphaturic mesenchymal tumor (PMT). Spindle mesenchymal cells are mildly atypical, with low mitotic activity and irregular vessels (H&E, original magnification ×20)