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Tumor-Induced Osteomalacia
A

Jill E. Vollbrecht, M.D.

D. Sudhaker Rao, M.B., B.S.
Henry Ford Health System
Detroit, MI 48202
tjvollbrecht@yahoo.com

n 87-year-old woman was referred to the endocrinology clinic

in 1979 for hypophosphatemia (serum phosphate level consistently <1.5 mg
perAUTHOR
deciliterVollbrecht
[0.48 mmol perRETAKE
liter]) causing
cramps and myalgia; tumor1st
ICM
induced
was
diagnosed.
A
radiograph
of
the hand showed a lytic lesion
2nd
REG Fosteomalacia
FIGURE
a&b
at theCASE
thirdTITLE
metacarpal bone (Panel A, Revised
arrow).3rdResults of a complete skeletal survey
4-C biopsy and tumor resection but agreed to receive
were EMail
negative. The patientLine
declined
SIZE
Enon
ARTIST:
mst
H/T calcitriol;
H/T
therapy
with
phosphate
and
there was some improvement in her serum
39p6
FILL
Combo
phosphate levels,AUTHOR,
although
normalization was never achieved. Although periodically
PLEASE NOTE:
lost to follow-up,
the
patient
remained
otherwise healthy, with no fractures and no
Figure has been
redrawn
and type
has been reset.
Please check carefully.
other, new conditions.
In 2006, a radiograph of the hand revealed complete destruction of
the third metacarpal bone,
with medial bowing of the second metacarpal
JOB: 35812
ISSUE: 3-20-08
bone (Panel B), presumably from tumor expansion. The hypophosphatemia in tumorinduced osteomalacia is mediated by increased tumor production of phosphatonin
fibroblast growth factor 23 (FGF-23), which results in hyperphosphaturia. Tumorinduced osteomalacia is typically associated with debilitating myalgias and weakness
from hypophosphatemia. However, as seen in this case, the condition may progress
over the course of two to three decades and result only in local bone destruction.
Copyright 2008 Massachusetts Medical Society.

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n engl j med 358;12 www.nejm.org march 20, 2008

The New England Journal of Medicine

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