Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

MUSCULOSKELETAL IMAGING
Year
: 2004  |  Volume : 14  |  Issue : 3  |  Page : 245--246

Tumoral calcinosis - a case report


K Hazarika, TR Borborah, HR Choudhury, M Sharma 
 Department of Radiology, Gauhati Medical College, Guwahati-781032, India

Correspondence Address:
K Hazarika
Department of Radiology, Gauhati Medical College, Guwahati-781032
India




How to cite this article:
Hazarika K, Borborah T R, Choudhury H R, Sharma M. Tumoral calcinosis - a case report.Indian J Radiol Imaging 2004;14:245-246


How to cite this URL:
Hazarika K, Borborah T R, Choudhury H R, Sharma M. Tumoral calcinosis - a case report. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Nov 13 ];14:245-246
Available from: http://www.ijri.org/text.asp?2004/14/3/245/28594


Full Text

 Introduction



Tumoral calcinosis is not a tumor in the neoplastic sense but is an encapsulated, saccular, multi-loculated calcific collection adjacent to a joint or bony prominence. This is a relatively uncommon disorder and its radiological diagnosis is vital for management. Here we present a case of tumoral calcinosis with typical radiographic features.

 Case Report



A 14 year old girl presented with a large swelling in the right lateral aspect of the thigh and a small lobulated swelling in the lateral aspect of left foot adjacent to the 5 th toe. The thigh swelling had appeared 1 '/2 years back immediately followed by the foot lesion. The swellings enlarged slowly attaining a large size in the thigh. History of ulceration with exudation of whitish material was also elucidated.

On examination, the swellings were non-tender, lobulated, and firmly attached to underlying muscle. A healed ulcer pit was seen in the foot swelling.

Radiographs revealed densely lobulated homogenous calcific masses with fluid-fluid levels, lying in the lateral aspect of the right hip and lateral aspect of 5th metatarsal left foot. Adjacent bones had normal density and were intact. The lobulated calcific masses showed intervening lucent septae giving a multi-loculated appearance.

Ultrasound revealed multi-loculated cystic lesions with densely echogenic debris showing layering in the dependent regions and movement with positional changes.

Serum calcium level was found to be normal, while the serum inorganic phosphate level was 6.5 mg / dl. ESR was raised to 60 mm AEFH.

Pathological examination of ultrasound-guided aspirated material showed multiple refractile crystalloids natural brown to black in color and occasional macrophages / multi-nucleated giant cells.

 Discussion



Also termed as lipocalcinogranulomatosis, calcifying endothelioma and calcareous granuloma, these are painless calcified masses in juxta-articular regions. Common sites are hips (near trochanter and buttocks), elbow, toes, wrists, ankles, shoulders, ribs, ischial spines and rarely, in the knees. It is usually seen in children, manifesting mostly in the 2nd decade [1]. The masses usually grow progressively; attain large sizes, 1 . 20cm, are largest around the hips and smallest around the toes, Sometimes the masses show surface ulceration and exude chalky, semi-liquid material containing calcium. Bones remain intact unless large juxta-articular masses cause restriction of joint functions or pressure bone erosion. It remains painless unless nerve compression occurs [2].

Familial tendency with an autosomal recessive inheritance has been suggested although evidence suggests that an autosomal dominant mode with varying penetrance also exists [3]. Majority of the cases have an inborn error of phostphate metabolism [3]. Hyperphosphatemia with normal GFR characterized by high ratio of phosphorous tubule maximum (TmP) to GFR [4]. Fluid-fluid levels are seen in metabolically active states [3],[5].

Fundoscopy may reveal retinal streaks and radionuclide scans show increased uptake over all areas of involvement [6].

These lesions can be easily differentiated from other soft tissue calcifications, renal osteodystrophy, chondrosarcoma and parosteal osteosarcomas.

Dietary restriction of calcium and phosphate together with phosphate binding antacids is the treatment of choice [3]. Our case showed some unique features of tumoral calcinosis. The lobulated, non-tender, masses showed fluid-fluid levels in ultrasonography and homogenous calcific loculated appearance with intact adjacent bones in radiography. The fluid-fluid levels with calcific density are seen in metabolically active states as is reflected by the inorganic phosphate levels.

References

1Bishop AF, Destonet JM, Murphy WA et al, Tumoral Calcinosis: Case report and Review. Skeletal Radiol 1982; 8: 269 - 274.
2Palmer PES, Tumoral Calcinosis. Br J Radiol 1966;39: 518-525.
3Grainger RG, Allison D, Adam A, Dixon AK: Diagnostic Radiology: A Textbook of Medical Imaging. 4th Ed; Churchill Livingstone, Philadelphia, 2001: Vol -3, p- 2085.
4Baldursson H, Evan EB, Dodge WF, Jackson WT, Tumoral Calcinosis with Hyperphosphatemia. A report of a family with incidence in 4 siblings. J Bone Joint Surg (Am) 1969; 51: 913 - 925.
5Hug I, Guncaga J, Tumoral Calcinosis with Sedimentation Sign. Br J Radiol 1974; 47: 734 - 736.
6Yaghmai I, Mirbod P, Tumoral Calcinosis Am J Roentgenol 1971; 111: 573 - 578.