330

Radiologic-Pathologic

Idiopathic Downloaded from www.ajronline.org by 117.29.136.246 on 10/30/15 from IP address 117.29.136.246. Copyright ARRS. For personal use only; all rights reserved

Felix S. Chew1

Conferences

Tumoral and William

of the Massachusetts

Calcinosis

B. Crenshaw

T2-weighted

A 22-year-old man had a recurrent mass in the sole of the right foot. Although he had been asymptomatic for approximately i5 years after a previous operation, he had noticed swelling

and tendemess

hyperphosphatemic,

alkaline normal.

for several but

renal

General Hospital

months.

The patient

and serum

function

phosphatase, and parathyroid Plain films of the foot showed

hormone

was

radionuclide

Idiopathic

calcium,

levels

MR images [1]. Because

metabolically, mulation.

tumoral

autosomal

were

a 7-cm, multiglobular, calcified soft-tissue mass on the planter aspect of the forefoot (Fig. 1). CT showed discrete, rounded, 2- to 20-mm CaICIfIC foci, some with homogeneous attenuation and some with sedimentation levels. The adjacent bones were normal. A local excision showed the lesion to consist of multiple calcific deposits surrounded by chronic foreign-body reaction and fibrosis. The calcareous material had the consistency of toothpaste. The final pathologic diagnosis was idiopathic tumoral calcinosis. Idiopathic tumoral calcinosis is thought to result from a heritable error in phosphorus metabolism that leads to extracellular deposition of calcium hydroxyapatite crystals [i 2]. These are seen most frequently in the form of periarticular

groups,

the most

show

are active

abnormal

is rare and appears

transmission

More

the deposits

scans

calcinosis

dominant

and symptoms.

bone

and

common

frequent

various

in blacks

than

accuto have

clinical

signs

in other

racial

age of presentation

is during

childhood or adolescence. The lesions enlarge slowly, may attain large size, and may become symptomatic by virtue of local mechanical effects. If incompletely resected, they may

recur. Other manifestations include elevated i ,25-dihydroxyvitamin D3 levels (not measured in this case), calcific myelitis, and dental abnormalities. Dietary restriction of phosphorus may be beneficial in some patients; surgical excision is reserved for symptomatic lesions. The radiologically indistinguishable condition of secondary tumoral calcinosis may occur in association

with

such disorders

as chronic

renal failure

or scleroderma.

,

REFERENCES 1 . Martinez 5. Vogler JB, Harrelson JM, Lyies KW. Imaging of tumoral calcinosis: new observations. Radiology i990;174:215-222 2. Aesnick D, Niwayama G. Diagnosis of bone and joint disorders, 2nd ed. Philadelphia: Saunders, 1988:4242-4245

soft-tissue masses. Suspended calcium salts may layer out within cystic structures. The surrounding granulomatous foreign-body response to the deposits results in bright signal on

/

I

,

A

A

B Fig. i.-Tumoral calcinosis. A, Radiograph shows multiglobular B, Axial CT scan shows multiple

calcific collections

mass

in planter

aspect

C

of forefoot.

of calcareous material, some with sedimentation C, Low-power photornicrograph of one collection shows calcified masses (straight arrows) (curved arrows). Note surrounding fibrosis (9. From the weekly

radiologic-pathologic

S. Chew, Daniel P. Barboriak, 1 Both authors: Department requests to F. S. Chew. AJR

158:330,

February

correlation

conferences

conducted

William E. Palmer, Daniel I. Aosenthal. of RadiOlOgy, Massachusetts General

1992 0361-803X/92/1582-0330

by Jack Wittenberg.

Hospital

C American Aoentgen

and Harvard

Ray Society

levels.

with foreign

Pathology Medical

editor:

School,

body inflammatory

Andrew

32 Fruit

reaction

E. Aosenberg.

St., Boston,

Radiology

and

giant

cells

editors:

Felix

MA 021 14. Address

reprint