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      Bone scintigraphic patterns in patients of tumor induced osteomalacia

      case-report

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          Abstract

          Tumor induced osteomalacia (TIO) or oncogenic osteomalacia is a rare condition associated with small tumor that secretes one of the phosphaturic hormones, i.e., fibroblast growth factor 23, resulting in abnormal phosphate metabolism. Patients may present with non-specific symptoms leading to delay in the diagnosis. Extensive skeletal involvement is frequently seen due to delay in the diagnosis and treatment. The small sized tumor and unexpected location make the identification of tumor difficult even after diagnosis of osteogenic osteomalacia. The bone scan done for the skeletal involvement may show the presence of metabolic features and the scan findings are a sensitive indicator of metabolic bone disorders. We present the bone scan findings in three patients diagnosed to have TIO.

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          Tumor-induced osteomalacia.

          Tumor-induced osteomalacia (TIO) is a rare and fascinating paraneoplastic syndrome in which patients present with bone pain, fractures, and muscle weakness. The cause is high blood levels of the recently identified phosphate and vitamin D-regulating hormone, fibroblast growth factor 23 (FGF23). In TIO, FGF23 is secreted by mesenchymal tumors that are usually benign, but are typically very small and difficult to locate. FGF23 acts primarily at the renal tubule and impairs phosphate reabsorption and 1α-hydroxylation of 25-hydroxyvitamin D, leading to hypophosphatemia and low levels of 1,25-dihydroxy vitamin D. A step-wise approach utilizing functional imaging (F-18 fluorodeoxyglucose positron emission tomography and octreotide scintigraphy) followed by anatomical imaging (computed tomography and/or magnetic resonance imaging), and, if needed, selective venous sampling with measurement of FGF23 is usually successful in locating the tumors. For tumors that cannot be located, medical treatment with phosphate supplements and active vitamin D (calcitriol or alphacalcidiol) is usually successful; however, the medical regimen can be cumbersome and associated with complications. This review summarizes the current understanding of the pathophysiology of the disease and provides guidance in evaluating and treating these patients. Novel imaging modalities and medical treatments, which hold promise for the future, are also reviewed.
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            Oncogenic osteomalacia: diagnostic importance of fibroblast growth factor 23 and F-18 fluorodeoxyglucose PET/CT scan for the diagnosis and follow-up in one case.

            A case of oncogenic osteomalacia is reported in a 71-year-old man who presented with bone pain, muscle weakness, and severe hypophosphatemia. The tumor which was localized in the left lower mandible was not detected by tomodensitometry, resonance magnetic imaging, and (111)IN-octreotide scintigraphy, but was easily localized by F-18 fluorodeoxyglucose PET/CT SCAN (F-18 FDG PET/CT SCAN). To our knowledge, the value of this technique for detecting tumors in oncogenic osteomalacia has never been reported. Secondly, this case provided an opportunity for confirming the usefulness of serum fibroblast growth factor 23 (FGF23) measurement for the diagnosis and follow-up. We conclude that FGF23 measurements combined with F-18 FDG PET/CT SCAN were decisive tools in a case of oncogenic osteomalacia and are likely to be of considerable importance for facilitating early diagnosis and follow-up in the future.
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              Tumor-induced osteomalacia.

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                Author and article information

                Journal
                Indian J Nucl Med
                Indian J Nucl Med
                IJNM
                Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India
                Medknow Publications & Media Pvt Ltd (India )
                0972-3919
                0974-0244
                Jul-Sep 2013
                : 28
                : 3
                : 173-175
                Affiliations
                [1]Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
                [1 ]Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
                Author notes
                Address for correspondence: Dr. Ashwani Sood, Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: sood99@ 123456yahoo.com
                Article
                IJNM-28-173
                10.4103/0972-3919.119541
                3822419
                24250028
                cf18f61a-ca1f-4a3a-93a9-df35548d2d76
                Copyright: © Indian Journal of Nuclear Medicine

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Case Report

                Radiology & Imaging
                bone scan,fibroblast growth factor 23,hypophosphatemia,tumor induced osteomalacia

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