A 54-year-old man with chronic renal failure was admitted to a district general hospital with a three week history of left hip pain and reduced mobility of the joint. He had also noticed a bony lump growing over the sternal notch over the course of several months.
1) Plain radiograph pelvis: Revealed a large (10cm x 6.5cm) area of calcification adjacent to the left greater trochanter [Fig. A].
2) CT Pelvis: Demonstrates peri-articular multilobulated calcification anterolateral to the left greater trochanter. Multiple fluid calcium levels, demonstrating the sedimentation sign may be seen [Fig. B].
3) CT Thorax: Revealed a 3cm x 3cm calcification adjacent to the sternum. [Fig. C].
4) Nuclear medicine scan: demonstrated a focus of retained radiotracer in the region of the lower pole of right lobe of the thyroid gland suggestive of a parathyroid adenoma. [Fig. D].
Background:
Secondary tumoral calcinosis involves extensive calcification of periarticular tissues and is often associated with chronic renal failure, presenting as a palpable cutaneous mass that is usually found in the extensor aspects of the periarticular regions of hips, knees, elbows, shoulder, and more rarely the feet, hands and spine. [1, 2, 3] This is most frequently attributed to hyperparathyroidism and disturbances of calcium-phosphate metabolism. [2]
Primary tumoral calcinosis is a radiologically and histologically indistinguishable condition seen in patients without chronic renal failure, affecting a younger subgroup of patients, and is a hereditary condition [3]. In this condition, biochemical tests of calcium-phosphate metabolism and parathyroid hormones are often normal [4]
Clinical Perspective:
A 54-year-old male patient was admitted with a three week history of left-sided hip pain, which resulted in reduced mobility and the patient had an antalgic gait. In addition, he described hard prominence over the sternal notch. He had a coronary artery bypass procedure a year back. There was no known history of trauma to either the hip or the sternum. The sternal mass was recently biopsied at another hospital , having produced a few millilitres of a creamy aspirate.
Imaging Perspective:
Plain radiography of hip demonstrated a large area of calcification. Subsequent CT Pelvis demonstrated periarticular multilobulated calcification anterolateral to the greater trochanter. A previous CT Chest was reviewed and calcification was noted juxtaposed to the sternum (X-ray Chest was not available). The case was discussed in the multidisciplinary team meeting and as the Chest CT did not show any parathyroid mass. A nuclear medicine scan was performed which demonstrated a focus of retained radiotracer in the region of the lower pole of the right lobe of the thyroid gland suggestive of a parathyroid adenoma.
Outcome:
The patient subsequently underwent a total parathyroidectomy. An Ultrasound-guided steroidal injection into the left trochanteric region was performed and subsequent CT demonstrated complete resolution of calcification. The blood calcium levels also improved.
Teaching points:
• Soft-tissue calcification should be considered as a cause of joint pain or bony prominence in patients with renal failure together with a broad range of differential diagnoses that have similar radiological appearances. [5, 6, 7]
• Tumoral calcinosis is a rare condition present in only 0.5% - 1.2% of patients with renal failure and therefore may be misdiagnosed. [5]
• It is important to correlate radiological appearances with biochemical findings in patients who are known to have conditions causing metabolic abnormalities.
Written informed patient consent for the publication has been obtained.
Secondary tumoral calcinosis involving left hip and sternum
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Based on the provided X-ray and CT images, the following key findings are observed:
• A distinct multilobulated calcified soft tissue mass in the lateral anterior region of the left hip (greater trochanter area), appearing as clumps or nodules with relatively clear boundaries.
• A similar clump-like calcification is noted near the suprasternal notch (in front of or adjacent to the sternum).
• Radiologically, there is no obvious fracture line or severe joint destruction, but soft tissue calcification suggests deposits of calcium salts.
• Given the patient’s known chronic renal insufficiency and the imaging characteristics, abnormalities in calcium-phosphorus metabolism leading to soft tissue or peri-articular calcific lesions must be considered.
Based on the above imaging findings and the patient’s underlying medical history, the following diagnoses or differential diagnoses are proposed:
Taking into account the patient’s age (54 years), chronic renal insufficiency, imaging findings (multiple focal calcifications around joints and in soft tissue), abnormal parathyroid function in blood tests, and nuclear medicine imaging suggesting an adenoma in the lower pole of the parathyroid glands, the most likely diagnosis is: Secondary Tumoral Calcinosis, closely related to secondary hyperparathyroidism.
Postoperative imaging, after total parathyroidectomy and steroid injection therapy, showed significant reduction or resolution of calcifications, which further supports this diagnosis.
Treatment Strategies:
1) Parathyroid Surgical Intervention: Since the patient exhibits hyperparathyroidism and an adenoma, surgical intervention (such as parathyroidectomy) can correct the calcium-phosphorus imbalance and fundamentally control further calcium salt deposition.
2) Medication and Adjunct Therapies: Consider phosphate binders, calcium channel blockers, or, according to endocrinology advice, adjust calcium and vitamin D supplementation. Corticosteroid injections may be used locally if necessary to reduce inflammatory responses in affected areas.
3) Long-Term Monitoring: Regular follow-up of serum calcium, phosphorus, and PTH levels is recommended. Treatment plans for renal and endocrine management should be promptly adjusted based on these indicators.
Rehabilitation/Exercise Prescription:
Considering the patient’s history of chronic renal failure, past surgery, and recent hip joint pain, a gradual, individualized rehabilitation program should be used. The FITT-VP principle can be applied as follows:
• F (Frequency): Start with 3–4 sessions of low to moderate intensity rehabilitation per week; once the patient’s fitness improves, gradually increase to about 5 sessions weekly.
• I (Intensity): Begin with low-intensity exercises, such as walking at home or simple lower-limb resistance training using small resistance bands. Avoid high-impact or excessive weight-bearing activities. Progress the intensity based on joint pain and fatigue.
• T (Time): Initially, aim for 15–20 minutes per session, gradually extending to 30 minutes or more as tolerated by the patient.
• T (Type): Focus primarily on range of motion exercises, light resistance training, and low-impact aerobic activities. This may include walking on flat or controlled surfaces, stationary cycling, swimming, or water therapy.
• V (Volume): Keep overall exercise volume within tolerable limits to avoid triggering significant hip or other joint pain. Monitor and report subjective fatigue levels each week and adjust accordingly.
• P (Progression): Once symptoms are stable and serum calcium and phosphorus levels are well managed, gradually increase exercise intensity and duration. Continuously monitor muscle strength and joint range of motion. Seek immediate medical evaluation if any unfavorable symptoms arise (marked swelling, pain, or persistent fatigue).
During the rehabilitation process, special attention should be given to the patient’s renal function and bone health. Exercise methods, pacing, and load intensity should be adapted accordingly. Regular laboratory tests should be performed, and any anomalies should be promptly communicated to the nephrologist and endocrinologist to adjust the treatment and rehabilitation regimen.
This report is a reference-based medical analysis derived from the available information and does not replace clinical consultation or the advice of a professional physician. The patient should undergo further examinations and receive individualized treatment under professional medical guidance. In case of any questions or discomfort, immediate medical attention is advised.
Secondary tumoral calcinosis involving left hip and sternum
