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Tumoral Calcinosis: A Rare And Confusing Entity In The Spine 2014

Category General Spine Aswin Krishnamoorthy, MD Vinil Shah, MD Purpose LEARNING OBJECTIVES: Tumoral calcinosis is extremely rare in the spine, and therefore the lesion is often attributed to other more common spine pathologies including neoplasm, sequela of infection, and degenerative change. MR is often less helpful compared to CT. In particular, lack of an aggressive periosteal reaction and sedimentation phenomenon within the calcific lobules are better characterized on CT. There is some debate related to the term “tumoral calcinosis,” particularly whether the term refers to a specific disease or can be used to refer to a non-specific, essentially descriptive pattern of calcification. This can lead to additional confusion between radiologists and other clinicians. Materials & Methods An 83 year old female presents with back pain and was found to have a large (5 x 7 x 4 cm) multi-lobulated mass or conglomeration of masses centered about the L4/L5 facet joints. It also extended into the adjacent paraspinal regions and into the posterior extra-dural space within the spinal canal, causing severe spinal canal stenosis. The mass demonstrated T1 and T2 hypointensity and thin enhancement at its margins, but no associated soft tissue mass was present. CT showed a calcific lobulated mass with well-defined margins and sclerosis of the posterior elements of L4 and L5. No bone erosion was identified. Also, there was a suggestion of layering sediment within several of the lobules. Results A biopsy was performed and revealed amorphous, chalky material. Histological samples showed calcific deposits with surrounding fibrous reaction and scattered giant cells and histiocytes seen in tumoral calcinosis. The biopsy showed no evidence of malignancy or infection. Subsequent labs showed normal blood levels of calcium and phosphate in the patient. Conclusion Tumoral calcinosis due to its rarity in the spine is often misdiagnosed. Its imaging appearance and the debate regarding the proper use of the term are examined in this exhibit. References Durant DM et al. Tumoral calcinosis of the spine: a study of 21 cases. Spine 2001. 26(15) 1673-79. Jackson W et al. Unusual spinal manifestation in secondary hyperparathyroidism. Spine 2007. 32(19) 557-60. Olsen KM and Chew FS. Tumoral calcinosis: pearls, polemics, and alternative possibilities. Radiographics 2006. 26 871-85. Watanabe, A et al. Tumoral calcinosis of the lumbar meninges. Neurosurgery 2000. 47(1) 230-32.