Clinical Picture
Tumoral calcinosis in chronic renal failure Shota Takashima, Takashi Sakamoto, Mitsuhito Ota Lancet Diabetes Endocrinol 2014; 2: 852 Department of Dermatology, Chitose City Hospital, Chitose, Japan (S Takashima MD, M Ota MD); and Chitose Cardiovascular Clinic, Chitose, Japan (T Sakamoto MD) Correspondence to: Dr Mitsuhito Ota, Department of Dermatology, Chitose City Hospital, Hokkou 2, Chitose 066–0033, Japan [email protected]
An 80-year-old woman was referred to the Chitose City Hospital (Chitose, Japan) with a 6 month history of a slowly increasing asymptomatic lumbar subcutaneous mass. She had been attending dialysis three-times a week for 10 years for chronic renal failure. A laboratory assessment showed the following abnormalities: serum calcium of 1·95 mmol/L (normal range 2·05–2·55), serum phosphorus of 3·3 mmol/L (0·74–1·52 mmol/L), serum intact parathyroid hormone of 142 ng/L (10–65 ng/L), and serum creatinine of 787 μmol/L (53–106 μmol/L). She was poorly compliant with taking phosphate-binding medications and dietary restrictions.
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Physical examination showed a firm, irregularly shaped, immobile subcutaneous nodule measuring 9 cm in the major axis on her right lumbar area (figure, A). CT scans showed a lobular calcified mass with fibrous capsules in the subcutis (figure, B, C). ⁶⁷Ga-scintigram showed an abnormal gallium accumulation corresponding to the right lumbar mass, with no other pathological uptake (figure, D). After a diagnosis of secondary tumoral calcinosis was made, the patient was managed by use of a phosphate-restricted diet, phosphate-binding medication, and an intensifying dialysis programme, which aimed to reduce the serum concentration of calcium–phosphorus products. Tumoral calcinosis manifests as an asymptomatic subcutaneous solid mass around major joints such as the hips, shoulders, elbows, and knees. It is characterised by a lobular calcified mass, and definitive diagnosis can frequently be made by the radiological features. Tumoral calcinosis is a severe complication in patients with chronic renal failure. Hyperphosphataemia and high serum calcium–phosphorus products that result from secondary hyperparathyroidism contribute to the development of this condition. In addition to the chemical precipitation, an inflammatory reaction is involved in this disorder; consequently, gallium accumulation has been extensively reported in tumoral calcinosis lesions. Management of tumoral calcinosis is difficult. Surgical excision is a treatment option, but the deposits can recur after surgery. Phosphate deprivation has met with some success and renal transplantation always leads to resolution. Contributors ST and MO did clinical assessment and investigation. TS was responsible for care of the patient. ST prepared the draft of the report, and MO reviewed and revised the report. All authors approved the final version. Written consent for publication was obtained from the patient. Declarations of interests We declare no competing interests.
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Figure: Clinical and radiological presentation of tumoral calcinosis (A) An irregularly shaped subcutaneous mass with normal surface on the right lumbar area. (B) CT transverse slice. (C) Three-dimensional CT showing lobular calcified mass with fibrous capsule in the subcutis. (D) ⁶⁷Ga-scintigram showing gallium uptake corresponding to the area of calcification in the right lumbar area.
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www.thelancet.com/diabetes-endocrinology Vol 2 October 2014
Tumoral calcinosis in chronic renal failure Shota Takashima, Takashi Sakamoto, Mitsuhito Ota Lancet Diabetes Endocrinol 2014; 2: 852 Department of Dermatology, Chitose City Hospital, Chitose, Japan (S Takashima MD, M Ota MD); and Chitose Cardiovascular Clinic, Chitose, Japan (T Sakamoto MD) Correspondence to: Dr Mitsuhito Ota, Department of Dermatology, Chitose City Hospital, Hokkou 2, Chitose 066–0033, Japan [email protected]
An 80-year-old woman was referred to the Chitose City Hospital (Chitose, Japan) with a 6 month history of a slowly increasing asymptomatic lumbar subcutaneous mass. She had been attending dialysis three-times a week for 10 years for chronic renal failure. A laboratory assessment showed the following abnormalities: serum calcium of 1·95 mmol/L (normal range 2·05–2·55), serum phosphorus of 3·3 mmol/L (0·74–1·52 mmol/L), serum intact parathyroid hormone of 142 ng/L (10–65 ng/L), and serum creatinine of 787 μmol/L (53–106 μmol/L). She was poorly compliant with taking phosphate-binding medications and dietary restrictions.
A
D
B
L
Physical examination showed a firm, irregularly shaped, immobile subcutaneous nodule measuring 9 cm in the major axis on her right lumbar area (figure, A). CT scans showed a lobular calcified mass with fibrous capsules in the subcutis (figure, B, C). ⁶⁷Ga-scintigram showed an abnormal gallium accumulation corresponding to the right lumbar mass, with no other pathological uptake (figure, D). After a diagnosis of secondary tumoral calcinosis was made, the patient was managed by use of a phosphate-restricted diet, phosphate-binding medication, and an intensifying dialysis programme, which aimed to reduce the serum concentration of calcium–phosphorus products. Tumoral calcinosis manifests as an asymptomatic subcutaneous solid mass around major joints such as the hips, shoulders, elbows, and knees. It is characterised by a lobular calcified mass, and definitive diagnosis can frequently be made by the radiological features. Tumoral calcinosis is a severe complication in patients with chronic renal failure. Hyperphosphataemia and high serum calcium–phosphorus products that result from secondary hyperparathyroidism contribute to the development of this condition. In addition to the chemical precipitation, an inflammatory reaction is involved in this disorder; consequently, gallium accumulation has been extensively reported in tumoral calcinosis lesions. Management of tumoral calcinosis is difficult. Surgical excision is a treatment option, but the deposits can recur after surgery. Phosphate deprivation has met with some success and renal transplantation always leads to resolution. Contributors ST and MO did clinical assessment and investigation. TS was responsible for care of the patient. ST prepared the draft of the report, and MO reviewed and revised the report. All authors approved the final version. Written consent for publication was obtained from the patient. Declarations of interests We declare no competing interests.
C
25·0 mm
Figure: Clinical and radiological presentation of tumoral calcinosis (A) An irregularly shaped subcutaneous mass with normal surface on the right lumbar area. (B) CT transverse slice. (C) Three-dimensional CT showing lobular calcified mass with fibrous capsule in the subcutis. (D) ⁶⁷Ga-scintigram showing gallium uptake corresponding to the area of calcification in the right lumbar area.
852
www.thelancet.com/diabetes-endocrinology Vol 2 October 2014
