Tumoral calcinosis

The value of perforator flap reconstruction in painful soft tissue calcifications

Soft tissue calcifications frequently cause debilitating pain and functional impairments, considerably affecting patients' quality of life. As they are rare entities, evidence remains sparse, especially regarding treatment effectiveness and recurrence rates. While both pharmacological and surgical treatments may alleviate symptoms, complete resection is currently believed to prevent long-term recurrence of deposits. To improve understanding and raise awareness for soft tissue calcifications, the goal of this study was to review the current state of treatment and to compare benefits and possibilities of flap reconstruction versus simple excision in improving quality of life. Furthermore, we include a successful case report of complete resolution of symptoms following quadruple perforator flap reconstruction. By systematic literature review, studies published in MEDLINE between 1980 and 2024 reporting on surgical treatment and outcome of soft tissue calcifications were included, in addition to a detailed description of our case report. A total of 53 studies reporting on 197 patients with soft tissue calcifications were included. Simple surgical excision was the most commonly (85.9%) employed procedure, demonstrating a substantial recurrence rate of 13.3%. In contrast, no patients who underwent radical excision experienced recurrence. Dermal matrix grafts and flap reconstruction were successfully used in patients requiring substantial tissue coverage, highlighting their value in complex defect reconstruction following radical excision. The combination of complete surgical resection and flap reconstruction reduces recurrence rates and improves postoperative outcomes and quality of life of these patients, supporting early radical surgical intervention as the gold standard treatment for soft tissue calcifications.

Pathologic Fracture of Femoral Neck in a Patient with Tumoral Calcinosis

Tumoral calcinosis is a rare disease characterized by massive subcutaneous soft tissue deposits of calcium phosphate around large joints in patients with chronic kidney disease. Invasion of bone by tumoral calcinosis is rare. We experienced a case involving a femoral neck pathologic fracture due to bony invasion of tumoral calcinosis in a 46-year-old female with chronic kidney disease who had been on dialysis for 15 years. Successful outcomes were obtained by performance of total hip arthroplasty for treatment of the pathologic fracture of the femoral neck. Careful precaution is necessary to prevent pathologic fractures in patients with tumoral calcinosis around the hip joint.

Juxta-articular tumoral calcinosis associated with the temporomandibular joint: a case report and concise review

Background

Tumoral calcinosis is an uncommon clinicopathological condition which is characterized by the formation of calcium salt deposition in intra-articular or peri-articular soft tissues. It usually presents as a focal growth of hard tissue, either solitary or multiple, beneath the skin and connective tissue. Diagnostic techniques mainly include clinical and radiographic evaluation. The most commonly involved locations include the hip, elbow, shoulder and knee. Involvement of the head and neck regions are far less common. There have been 5 case reports of temporomandibular joint involvement in the literature so far.

Case presentation

We present a case report which describes the diagnosis and management of a 59 year old female patient with chronic right temporomandibular joint pain and localized bony hard swelling over the right pre-auricular region. Patient retained normal range of motion and mouth opening. Computed tomography taken showed a radio-opaque juxta-articular ovoid mass over the right pre-auricular region in close proximity but not fused to the mandibular condyle. Surgical excision was performed for this swelling via a pre-auricular approach under general anaesthesia. Histological examination performed confirmed the diagnosis of tumoral calcinosis. Pain at the right temporomandibular joint was resolved after the surgery. Serum calcium and phosphate levels were normal in this patient.

Conclusion

Surgical excision is the primary treatment modality for tumoral calcinosis. Tumoral calcinosis may be associated with elevated serum calcium and phosphate levels. In patients with elevated serum electrolytes, it is important to consider the overall systemic health in management of this condition. Management of serum electrolytes levels plays a role in reducing recurrence rates. This case report and review aims to discuss the diagnosis, treatment and overall systemic management of this rare condition.

Tumoral calcinosis--a pathogenetic overview: a histological and ultrastructural study with a report of two new cases, one in infancy

Tumoral calcinosis occurs as a well-defined pathologic entity in 3 heterologous groups of diseases--hyperphosphatemic familial tumoral calcinosis, normophosphatemic tumoral calcinosis, and secondary tumoral calcinosis. The histological lesion is stereotypic developing from the concurrence of a juxta-articular injury with an elevated calcium-phosphorus product. The reparative response to injury is histiocytic featuring synovial metaplasia forming bursa-like structures that create the characteristic compartmentalization of the lesion. Histiocytic-derived osteoclastogenesis occurs as a response to the calcifying process initiated in the mitochondria of necrotic histiocytes forming the bursa-like structures. These calcifications, propelled by a gamut of conditions elevating serum phosphorus, facilitate the further nucleation of hydroxyapatite in mitochondria, matrical lipidic debris located in the cytoplasm and lysosomes of osteoclasts and in the locular contents, and on collagen and other extracellular matrix materials. The lesions enlarge because of new locule formation and failure to reduce the calcified burden by the compartment lining histiocytes and dysmorphic osteoclasts that are unable to solubilize the hydroxyapatite. The histological landmarks of tumoral calcinosis may be lost when its development becomes quiescent. The classic calcifying classifications are inadequate for tumoral calcinosis requiring creation of a new category for this entity.

Tophaceous pseudogout of the ankle: case report

Level of Evidence: V, Expert Opinion

Familial tumoral calcinosis: a forty-year follow-up on one family

BACKGROUND

Familial tumoral calcinosis is a rare autosomal recessive disorder that was first described well in a report on four patients from one family in 1969. The disease leads to periarticular ectopic calcifications. The original report described patients from black, healthy, unrelated parents with sixteen children, seven of whom had the disease.

METHODS

On the basis of retrospective chart reviews and interviews with surviving family members, we describe the long-term follow-up of this one family, encompassing as long as forty years. Of the sixteen siblings, seven had tumoral calcinosis.

RESULTS

All seven affected children had hyperphosphatemia. There were two subsequent generations comprising thirteen children and seven grandchildren with no instances of tumoral calcinosis. The seven affected patients were followed for as many as forty years and underwent an average of twenty-one operations (range, four to thirty-six operations) for the treatment of calcified lesions. The genetic defect has been identified as the GALNT3 gene, thus leading to the hyperphosphatemic form of the disease. Although two of the patients had died by the time of the present study, the remaining five provided accounts of the disease course, the response to surgery and to medical therapy, and the effect of therapy on their lives. Some members had relatively few lesions and surgical procedures (as few as four), whereas others had an unrelenting course of lesions, recurrences, and surgical procedures (as many as thirty-six, with numerous other procedures). Three patients had multiyear periods with few symptoms--one for seven years, one for twelve years, and one for fifteen years. No effective medical therapy was found to control the lesions, and operations were associated with a high recurrence rate.

CONCLUSIONS

Familial tumoral calcinosis has a varied natural history; some patients have an unrelenting course, while others may experience quiescent periods. The GALNT3 gene is responsible for the hyperphosphatemic form as seen in this family. Molecular testing may be of benefit to members of affected families, and future studies may help to explain the phenotypic variability among affected individuals. No medical or surgical treatment plan seemed to be effective for controlling the lesions in this family.

Tumoral calcinosis of the gluteal region in a child: case report with overview of different soft-tissue calcifications

Tumoral calcinosis is a distinct clinical and histologic entity that is characterized by a large deposition of calcium that resembles a neoplasm and is found predominantly in adolescents and young adults in the periarticular tissues of large joints. The authors describe the clinical presentation of a 15-year-old boy admitted at our pediatric day-surgery center for surgical management of tumoral calcinosis of the left gluteal region. Complete surgical excision is the treatment of choice.

Tumoral calcinosis of the foot

Tumoral calcinosis is characterized by periarticular deposition of calcium phosphate, usually in the setting of normocalcemia and hyperphosphatemia. The term tumoral calcinosis can be used to describe lesions with periarticular deposition of calcium phosphate resulting either from a primary disorder or a secondary disorder, such as renal failure with associated secondary hyperparathyroidism. Treatment entails phosphate deprivation, control of any primary disease processes such as secondary hyperparathyroidism, and resection for recalcitrant symptoms. We present a case of tumoral calcinosis involving the foot which required resection and ultimately hyperparathyroidectomy.

Tumoral calcinosis in the premaxillary region

Tumoral calcinosis, an uncommon pathologic condition that manifests itself in many forms, has rarely been described in the craniofacial region. This report describes a case of tumoral calcinosis affecting the premaxillary region.

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.

Tumorous calcinosis: a disease of its own?

Tumorous calcinosis has been considered as a disease of its own. A survey of the literature shows that only its clinical and radiological appearances are universally agreed upon, while its epidemiology and etiology are still under discussion. A genetic disorder, recurrent soft-tissue microtrauma and terminal renal failure have been put forward as causes. All of them may lead to a localized or generalized disturbance of the calcium-phosphate metabolism, which in turn could produce tumorous calcinosis. Therefore, tumorous calcinosis should be regarded as a rare manifestation of a metabolic disorder rather than a disease of own.

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.

Nonfamilial tumoral calcinosis associated with chronic renal failure and secondary hyperparathyroidism: report of two cases with clinicopathological, immunohistochemical, and electron microscopic findings

The clinical and pathological findings, including those of immunohistochemical and ultrastructural studies, of two cases of tumoral calcinosis-like lesion (TCL) are described. Both cases were associated with chronic renal failure and hyperparathyroidism. One case presented as a rapidly growing 20-cm multiloculated, cystic, calcific gluteal mass on the sacrum, which was not clinically suspected to be related to hyperparathyroidism. The other case presented as a 2.5-cm calcific mass on the right foot that recurred after surgical excision as a 7-cm mass, which was clinically presumed to be related to secondary hyperparathyroidism. Light microscopic and immunohistochemical studies on both cases and ultrastructural studies on one case indicated that the calcifying process involved histiocytes and osteoclast-like giant cells of histiocytic origin lining the cystic cavities. Hydroxyapatite crystal formation and calcification appeared to develop predominantly from intracytoplasmic membrane bound vesicles and also from mitochondria. These findings are similar to those recently reported for familial tumoral calcinosis, which support its having a mechanism of calcification comparable with that of a TCL.

Tumoral calcinosis after thumb tip injury: case report

Tumoral calcinosis, developed in a 44-year-old male patient after a left thumb tip injury that was initially treated with a wraparound procedure, was excised. Five years after excision, there was no recurrence, and the thumb remained well-functioning.

Soft tissue calcification in children with terminal transverse defects of the upper limb--is it tumoral calcinosis?

We report five children with transverse defects of the upper limb who developed calcified deposits at the distal end of the limb. The lesions were excised from two children and had the typical histological appearance of tumoral calcinosis but on clinical grounds it is unlikely that this is the same condition as that previously described as tumoral calcinosis.

Tumoral calcinosis associated with congenital malformations of the hand

Two cases of tumoral calcinosis are reported in children with congenital hand malformations. After excision of large calcific masses, reconstruction was performed using a free phalangeal graft in one case and a free toe transfer in the other.

Uremic tumoral calcinosis: acute hand presentations mimicking infection

Tumoral calcinosis is an uncommon condition of the hand characterized by deposition of calcium salts in the soft tissues of the extremities. The condition may be hereditary or acquired. Acquired tumoral calcinosis, also called tumoral calcification, is a rare manifestation of renal osteodystrophy due to derangement in divalent ion metabolism. Two chronic dialysis patients with tumoral calcification of the hand are presented. These cases are unusual in their rapid onset of presentation, mimicking acute infection. Prompt recognition of the condition may allow early nonsurgical intervention to preserve function.

Tumoral calcium pyrophosphate deposition disease

A report of two patients in which a soft tissue mass, initially regarded as a malignant tumor, was shown to be the result of calcium pyrophosphate deposition disease. The first case, a woman aged 71 years, presented with a mass involving the right fifth finger. In the second case, also a woman aged 71 years, the lesion involved the tissues adjacent to the right hip. Each lesion consisted of a mass of highly cellular tissue containing deposits of calcium pyrophosphate dihydrate crystals. The clinical, radiological, and pathological features of the two cases are compared with those of seven similar cases reported in the literature.

Tumoral calcinosis in multiple digits: a case report

Tumoral calcinosis usually appears in the vicinity of large joints, and its appearance in the fingers must be quite rare since no reports of such an occurrence have been found. A case report of the presence of tumoral masses of hydroxyapatite in multiple digits is presented. No causative or related metabolic or collagen-vascular disease was identified, and the patient remains in good health.

Tumoral calcinosis: a case report and review of the literature

Tumoral calcinosis rarely occurs in the hand. It is an uncommon familial disease suggesting an autosomal recessive gene pattern, often with laboratory findings of hyperphosphatemia and normocalcemia. Our patient had bilateral hand involvement, including local calcinosis cutis of the skin and bone changes not previously reported in the literature. At a 2-year follow-up after two lesions were excised from her left hand, one lesion had completely resolved and the other recurred. Two large symptomatic lesions and one area of local calcinosis cutis in her right hand have recently been excised.