Tumoral calcinosis. Controversies in the etiology and alternatives in the treatment
S. Tezelman, A. E. Siperstein, Q. Y. Duh and O. H. Clark
Surgical Services, Mount Zion Medical Center, San Francisco.
OBJECTIVE: To examine our experience and review the literature concerning
the diagnosis, origin, and treatment of tumoral calcinosis (TC).
DESIGN/SETTING: Case series based on patients with TC treated in University
of California-San Francisco hospitals from 1981 to 1992 and the review of
the patients described in the English-language literature. PATIENTS: The
study included a total of 17 patients: 10 women and seven men. MAIN OUTCOME
MEASURES: Sex, age, origin, symptoms, localization, treatment, and
morbidity. RESULTS: Seven men and six women, from 32 to 62 years of age,
had known disorders of calcium metabolism, and four women, from 37 to 84
years of age, did not. The main causes of the calcium metabolic disorder
were secondary hyperparathyroidism in 11 patients (85%) and primary
hyperparathyroidism in two patients. In three patients there was a history
of trauma at the involved site and in one patient the origin was unknown.
Swelling and pain are the most common presenting complaints. Generalized
pruritus was observed in 54% of the patients with metabolic disorders (P
< .001) but not in patients without metabolic disorders. Among our
patients with metabolic disorders, TC occurred most frequently at the
shoulder (46%) and elbow (31%). Eleven patients with secondary
hyperparathyroidism had received calcium carbonate to bind phosphate, a
high level of calcium in the dialysate, and calcitriol (1,25-vitamin D)
either orally, intravenously, or both, and three received epoetin alfa
(Epogen). Following parathyroidectomy, the patients with
hyperparathyroidism improved symptomatically, although calcifications did
not change in size. One patient had the calcifications resected and did
well, whereas another was treated by subtotal resection and had a
recurrence 3 years later. All four of our patients without a metabolic
disorder had complete resection of TC with no recurrence. CONCLUSION: We
believe TC is becoming more common in uremic patients with secondary
hyperparathyroidism because of recent changes in the medical treatment of
these patients. The increased use of calcium carbonate to bind phosphate as
well as calcitriol and calcium to suppress parathyroid function and
possibly epoetin alfa are causing more patients to develop TC.
