Tumoral calcinosis: pearls, polemics, and alternative possibilities

Soft-tissue masses and masslike conditions: what does CT add to diagnosis and management?

OBJECTIVE

Although MRI is the technique of choice for evaluating most soft-tissue masses, CT often provides valuable complementary information. Specifically, there are distinguishing CT characteristics that can suggest a specific diagnosis, including the lesion's mineralization pattern, density, pattern of adjacent bone involvement, and degree and pattern of vascularity.

CONCLUSION

This article provides an overview of the CT evaluation of soft-tissue masses, emphasizing a differential diagnosis based on these CT features.

Bilateral dystrophic calcinosis circumscripta in a cynomolgus macaque (Macaca fascicularis)

The authors describe a case in which well-circumscribed, expansile, and nonencapsulated nodular masses with missing digits were detected on the right and left feet in a 6-year-old female cynomolgus macaque from a routine toxicology study. Grossly, these masses were composed of variably sized and firm nodules containing white, chalklike material in the subcutaneous tissue on cross section. Microscopically, the nodules were composed of irregular lobules containing amorphous to granular, light to dark basophilic material that was surrounded by macrophages and multinucleated giant cells and separated by fibrous connective tissue. The nodule's contents were von Kossa and Alizarin red S positive. Serum calcium and phosphorus levels of this monkey were within normal ranges. Based on the gross pathology, histopathology, serum chemistry, and histochemistry, a diagnosis of dystrophic calcinosis circumscripta was made. Dystrophic calcinosis circumscripta is an uncommon syndrome of mineralization that occurs following tissue damage, without abnormalities in calcium and phosphorus homeostasis, and it is characterized by deposition of calcium salts in soft tissues. To the best of the authors' knowledge, this is the first report of dystrophic calcinosis circumscripta in a cynomolgus macaque.

Calcific myonecrosis of the lower leg: diagnosis and options of treatment

INTRODUCTION

Calcific myonecrosis is a rare condition characterized by a calcified lesion. Because this lesion sometimes presents as a huge mass with unique radiographic characteristics, it can be confused with soft tissue sarcoma. The appropriate treatment is still controversial. We report here three cases diagnosed as calcific myonecrosis of the lower leg and discuss its clinical presentation, diagnosis and options for treatment.

PATIENTS AND METHODS

Three patients presented as expanding masses in the anterior or lateral compartment muscle and occurred more than 10 years after an initial injury. Plain radiographs showed a large soft tissue mass with extensive amorphous calcifications. Computed tomograms revealed a low-density tumor with scattered calcifications. Magnetic resonance imaging showed a bright, high-signal area on T2-weighted imaging consistent with fluid. Two patients underwent excisions for histopathological evaluation and one was treated conservatively because of the absence of disability.

RESULTS

Two operative patients had no complication and the returned to work without evidence of deterioration of the disease. In a patient treated conservatively, the mass was not enlarged and was still painless at 2-year follow-up.

CONCLUSION

The key points for diagnosis were (1) amorphous liner calcification, (2) anterior or lateral compartment, (3) previous injury (several decades) of the tibia or femur, and (4) compartment syndrome. Although calcific myonecrosis is not commonly encountered, it must be considered in the differential diagnosis of an expanding intramuscular mass. In asymptomatic masses where the diagnosis is recognized, observation may be possible and unnecessary aggressive surgical intervention should be avoided.

Tumoral calcinosis--or is it? A case report and review

Tumoral calcinosis is an uncommon lesion, composed of ectopic calcified tissue, most commonly seen in the large joints of the hips, shoulders, and elbows, but may involve the hand and wrist. Patients will often present with localized swelling and reduced mobility around the involved joints. Pain is inconsistent when presenting in the hands or wrists, but the lesions may interfere with daily activities. Multiple variations of the process have been described, ranging from those with no definable etiology (primary), to those associated with disorders (secondary) such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The original description of tumoral calcinosis, however, is the familial or hereditary type. Treatment of this process involves optimizing the underlying physiology and complete surgical excision for symptomatic cases.

Nonfamilial hyperphosphatemic tumoral calcinosis with ulnar neuropathy

We present a case of multiple large juxta-articular painless masses involving both the elbows and right hip in a 27-year old south Asian male who presented with ulnar neuropathy and constitutional symptoms. Radiology, blood investigations and biopsy confirmed it to be hyperphosphatemic tumoral calcinosis. Patient was also diagnosed with an extremely rare association, testicular microlithiasis. Complete surgical excision with low phosphate diet resulted in complete neurological recovery and no recurrence at 30 months. Tumoral calcinosis should be considered in the differential diagnosis of a case with multiple, symptomatic juxta-articular masses.

Tumour and tumour-like lesions of the intercondylar notch of the knee: a pictorial review

A variety of tumours and tumour-like lesions are found in the intercondylar notch of the knee. MR imaging is the technique of choice in evaluating these conditions. Correlation with radiographs is important to identify those lesions containing calcification. This review article discusses the imaging features of tumour and tumour-like lesions involving the intercondylar notch with an emphasis on MR imaging features that suggest a specific diagnosis.