Diffuse soft tissue calcification in tumoral calcinosis

Infantile tumoral calcinosis of the cervical spine presenting as torticollis

The computed tomography (CT) and MRI findings of infantile tumoral calcinosis and the utility of image-guided biopsy are demonstrated. A 5-month old presented with torticollis and a calcified cervical spinal mass. The radiologic appearance suggested a malignant neoplasm, prompting CT-guided biopsy, which diagnosed tumoral calcinosis. We hope to increase awareness of this entity and describe image-guided biopsy as a way to avoid morbidity associated with open biopsy.

Digital calcinosis circumscripta: case series and review of the literature

A series of three paediatric cases of digital calcinosis circumscripta is presented. Digital calcinosis circumscripta is an unusual form of calcinosis circumscripta occurring specifically in the digits. The condition is rare among the paediatric population. The cases serve to clarify the clinical and radiographic features of the condition and to discuss suggested treatment options.

Proposal for a pathogenesis-based classification of tumoral calcinosis

BACKGROUND

Deposition of calcium in skin is currently categorized into a group of disorders referred to as calcinosis cutis. Divisions between types and subtypes within this confusing classification are predominantly based on morphologic differences in the calcification and serve to obscure pathogenesis. This is especially evident in a subtype of calcinosis cutis, known as tumoral calcinosis. Calcifications in cases of tumoral calcinosis share the following characteristics, but without evidence of a common pathogenesis: large size, juxtaarticular location, progressive enlargement over time, a tendency to recur after surgical removal, and an ability to encase adjacent normal structures. The goal of this study was to formulate a pathogenesis-based classification for cases of tumoral calcinosis.

METHODS

In a literature review 121 cases of tumoral calcinosis were identified. These cases, along with a case evaluated in our clinic, were reviewed retrospectively, and their features compared.

RESULTS

Analysis suggests three pathogenetically distinct subtypes of tumoral calcinosis: (1) Primary normophosphatemic tumoral calcinosis: patients have normal serum phosphate, normal serum calcium, and no evidence of disorders previously associated with soft tissue calcification; (2) primary hyperphosphatemic tumoral calcinosis: patents have elevated serum phosphate, normal serum calcium, and no evidence of disorders previously associated with soft tissue calcification; and (3) secondary tumoral calcinosis: patients have a concurrent disease capable of causing soft tissue calcification. Justification for this classification is based on the presence or absence of disorders known to promote soft tissue calcification and statistically significant differences in family history, mean calcification number, mean serum phosphate level, and calcification recurrence after excision.

CONCLUSIONS

A classification for tumoral calcinosis is devised that outlines potential pathogenetic mechanisms and predicts response to therapy and prognosis. Analysis of other forms of calcinosis cutis may reveal definable pathogenetic differences that suggest a coherent classification for all cutaneous calcinoses.

Tumoral calcinosis: radiologic-pathologic correlation

OBJECTIVE

Tumoral calcinosis is a frequently misdiagnosed disorder. This study details the radiologic and pathologic characteristics of tumoral calcinosis that distinguish it from most other entities.

DESIGN

Radiologic and pathologic findings, and medical records of 12 patients with tumoral calcinosis were reviewed and compared with equivalent information about 5 patients with other calcified lesions.

PATIENTS

The 12 patients ranged in age from 15 months to 62 years. Six had idiopathic tumoral calcinosis and 6 had secondary tumoral calcinosis.

RESULTS AND CONCLUSIONS

A consistent radiologic finding for tumoral calcinosis was a dense calcified mass that was homogeneous except for a "chicken wire" pattern of lucencies, which correlated histologically with thin fibrous septae. Other characteristics of tumoral calcinosis included fluid-calcium levels, demonstrated in four patients, and smooth osseous erosions adjacent to the mass, demonstrated in three patients. Five cases of tumoral calcinosis were originally confused with other calcified lesions; however, the radiologic findings were characteristic of tumoral calcinosis in retrospect.

Soft tissue mineralization: roentgen analysis

Numerous, incompletely understood, and undetermined physiologic factors may exert further but unappreciated influences on the development of ectopic calcification and ossification. In the former instance, in addition to serum calcium and phosphorous ion concentrations, tissue pH, blood supply, hormones, i.e., vitamin D, vitamin A, and various enzymes (e.g., alkaline phosphatase and pyrophosphatase) may all play significant, ancillary, time-dependent, but as yet undetermined roles. Ossification, like calcification, may occur in association with many types of disorders and under a variety of circumstances, some of which, such as trauma, have been reduplicated in the laboratory. However, experimental conditions that produce ectopic bone, as well as the species that are predilected do not always coincide with clinical observations in man. Not only are there differences between species in regard to susceptibility to ectopic bone production under particular circumstances, i.e., rabbits are the most susceptible and mice the least to mechanical injury, but there are differences between individuals. Individual variability in susceptibility to soft tissue ossification suggests either a personal or familial predilection. If such liability is inherited, this would be an example of an ecogenetic condition, in which someone is susceptible to an environmental agent by virtue of genetic constitution. Histocompatibility (HLS) antigens have provided substantiation of this concept. In the case of soft tissue ossification, causative environmental agents could include trauma, burns, hip replacement, and immobility secondary to neurological insults. In the case of soft tissue calcification, trauma, infections, or repeated injections could constitute the triggering environmental event. Not only do individuals at risk develop bone, but those that do tend to do so in characteristic places. Therefore, there is an additional differential susceptibility at various sites in the same individual. In cases with neurological conditions, thigh muscles are more susceptible than paraspinal muscles. The underlying condition is a further moderator, i.e., in paraplegics, thigh muscles are most apt to be involved. Elbows are most commonly affected after burns regardless of the site of the burn. Ectopic ossification also has a further predilection for distribution. Not only are muscle groups unequal in risk in terms of site, but the type of muscle affected is relevant, since skeletal muscles are involved in these same conditions to the exclusion of smooth muscles.(ABSTRACT TRUNCATED AT 400 WORDS)