Soft TissueCalcification andOssification

Types of Soft Tissue Calcification

•Dystrophic calcification

•Metastatic calcification

•Calcinosis

•Miscellaneous

•Dystrophiccalcification

Calcification indamaged ordegenerating tissue

No associatedmetabolic disorder

Calcified Hematoma

Dystrophic Calcification

Metastatic Calcification

•Metastaticcalcification

Calcification ofnormal tissue

Frequentlyassociatedmetabolicdisorder

Hypervitaminosis D

Calcinosis

•Calcinosis

Calcification of cutaneous,subcutaneous or deepconnective tissue

No consistent metabolicdisturbance

Inconstant association withcollagen-vascular disease

CalcinosisUniversalis

Three Types of Calcinosis

•Calcinosis circumscripta

•Calcinosis universalis

•Tumoral calcinosis

•Calcifications related to joints

•Calcifications within hands

•Diffuse calcification & ossification

•Vascular calcifications

•Myositis (Heterotopic ossification)

Outline

Outline

•Calcification or ossification related totumors

•Metastatic calcification

•Miscellaneous diseases

•Quiz

CalcificationRelated to Joints

Chondrocalcinosis

•Calcification of cartilage

Gout – calcium urate crystals

Pseudogout – calcium pyrophosphate

CPPD – calcium pyrophosphate

Ochronosis

Hyperparathyroidism (2° more common)

Diabetes

Degenerative disease

ChondrocalcinosisLocations

•Knees

•Symphysis pubis

•Hips

•Triangular fibrocartilage of ulna

•Shoulders

Chondrocalcinosis inPseudogout

Chondrocalcinosis in CPPD

Chondrocalcinosis

Terminology

•Chondrocalcinosis

Asymptomatic; 50% of adults > 85

•Pseudogout

Acute arthropathy with CPPD crystals

•CPPD Arthropathy

Osteoarthritis with CPPD

•Two types

Primary

Secondary

Tumoral CalcinosisCalcification Related to Joints

Tumoral CalcinosisPrimary Form

•Rare, familial, polyarticular, African-Americans

•Large, multiloculated, cystic collectionsof calcium in or near large joints

•Ca++ and P normal

•Usually asymptomatic

•May grow large enough to

Cause pain from nerve pressure

Ulcerate and become secondarily infected

Tumoral CalcinosisSecondary Form

•Chronic renal disease

•Monoarticular

•Calcium & phosphorous abnormal

Phosphorous increased

Tumoral CalcinosisCalcium hydroxyapatite/phosphate/carbonate insuspension

Tumoral Calcinosis

•Metaplasia of synovial connective tissue

Forms cartilage; though it may ossify

•Affects knee, hip and shoulder

•Tends to be mono-articular

•Cause of loose bodies

•Divided into 1° and 2° forms

Synovial ChondromatosisCalcification Related to Joints

Synovial ChondromatosisPrimary and Secondary

•1° form less common

More numerous; uniform in size

Adjacent joint is normal

•2° form more common

Associated with DJD

Fewer in number; varying sizes

1° Synovial  Osteochondromatosis

2° Synovial Osteochondromatosis

Calcific Tendinopathy/Bursitis Calcification Related to Joints

•Most commonly seen in shoulder

Long head of the biceps

Subacromial bursa

•May be associated with acute pain

Swelling, point tenderness

•Calcium hydroxyapatite crystals

Calcific Tendinopathy-Biceps tendon

Calcific Bursitis-Tronchanteric Bursitis

Gouty Tophi Calcification Related to Joints

•Deposits of monosodium urate crystalsin protein, lipid, polysaccharide

•Surrounded by giant cell FB reaction

•May occur in periarticular soft tissues,bursae, ligaments, tendons, eye, ear,nose, throat or skin

•Visible calcification ~50%

Gouty tophi – non-calcified

Gouty tophus - calcified

Calcification Within Hands

Calcinosis Circumscripta

•Cutaneous or subcutaneous

•Distinctive, sharply marginated,punctate appearance in fingers

•Almost always associated withscleroderma

•Associated with sclerodactyly

Calcinosis circumscripta-Scleroderma

Calcinosis circumscripta-Scleroderma

DiffuseCalcification andOssification

Calcinosis Universalis

•Unknown etiology

•Frequently associated withcollagen-vascular disease

Especially dermatomyositis

•Symptoms depend on organsinvolved

•Normal blood chemistry

Calcinosis Universalis

•Looks like heterotopic ossification

But, no true bone is formed

•Initially, superficial and nodular orplaque-like

•Later, deeper tissue, more sheet-like and peri-articular

Calcinosis universalis-Dermatomyositis

Calcinosis universalis-Dermatomyositis

Calcifications AssociatedWith Vascular Disease

Vascular CalcificationsTypes

•Arterial

Walls

•Venous

Small thrombi = phleboliths

Long thrombi

Soft tissue ossification 2° chronicvenous insufficiency

Arterial Calcification Vascular Calcifications

•In walls

Monckeberg’s Arteriosclerosis

Uniform wall calcification - media

Railroad-track appearance

Diabetics, uremics more prone

•Intimal atherosclerosis

Discontinuous, plaque-likecalcifications

Arterial Calcification-Monckeberg’s

Arterial Calcification-Atherosclerosis

Venous CalcificationsPhleboliths

•Within thrombi

Small thrombi

Phleboliths

•Characteristic central lucency

•Within long thrombi

Phleboliths

Calcified venous thrombus

Venous CalcificationsSecondary to Chronic Venous Disease

•Post-menopausal females

•Predilection for calves

•Subcutaneous

•Sheet-like

•Path: normal bone in subcutaneouslocation

Chronic Venous Insufficiency

MyositisHeterotopic Ossification

•Myositis Ossificans CongenitaProgressiva*

•Heterotopic ossification 2° totrauma

•Heterotopic ossification 2°immobility

*Fibrodysplasia Ossificans

Heterotopic OssificationTypes

Myositis OssificansFibrodysplasia Ossificans Progressiva

•Genetic dysplasia, autosomal dominant

•Starts in neck

•Proceeds slowly caudally

Back, then whole body

•Ossification in connective tissue, not muscle

•90% associated with microdactaly

Great toe, thumb, middle phalynx 5th finger

Myositis Ossificans ProgressivaFibrodysplasia Ossificans Progressiva

Heterotopic OssificationSecondary to Trauma

•Localized to site of injury

•Rapid in onset (4-6 weeks)

•Starts with cloud or veil of calcium

•Matures to bone

Trabeculae become evident

Axis tends to parallel muscle planes

•Not to be confused with osteosarcoma

Heterotopic Ossification 2° trauma

Week 2

Week 6

Week 12

Week 12

Parosteal OsteosarcomaVersus Heterotopic Ossification

•HO much more common

•Osteosarcoma extends from medullarycavity – attached to bone

•Osteosarcoma wraps around the bone

•Osteosarcoma more mature centrally thanperipherally

•HO more mature peripherally than centrally

Parosteal Osteosarcoma

Heterotopic OssificationSecondary to Immobility

•Cause not known

•Occurs in immobile patients

Paralysis, burn victims

•Around large joints

Hips, shoulders, knees

•Bone scan used for dating maturity

Heterotopic Ossification 2° Quadriplegia

Heterotopic Ossification 2° Quadriplegia

Calcification/OssificationRelated to Tumors

SynoviomaSynovial Sarcoma

•Malignant mesenchymal tumor

•Middle-aged/older adults

•Mostly lower extremities near joints

•Lobulated in shape; 30-40% calcify

•May cause erosion of adjacent bone

Synovial Sarcoma

Synovial Sarcoma

Osteosarcoma Ossification Related to Tumors

•Adolescents (median 17)

•Knee affected in 66%

•Sclerotic (25%), lytic (25%), mixed (50%)

•Soft tissue mass usually present

•New bone formation most irregular atperiphery of lesion

Osteosarcoma

Chondrosarcoma Calcification Related to Tumors

•Half as common as osteosarcoma

•Present in adulthood – 5th-6th decades

•Pelvis most often involved

•Large, soft tissue mass is common

•Rounded, granular, popcorn-ballappearance of cartilage calcification

Chondrosarcoma

Radiology Resource and Review

MetastaticCalcification

•Def: Calcification of normal tissue

•Most common in chronic renal dzon hemodialysis

•Usually upper lobes

Confused with pneumonia at first

•Bone scan  tracer in lungs

Metastatic Calcification

Metastatic Calcification in Lung 2°Chronic Renal Disease

Metastatic Calcification in Lung 2°Chronic Renal Disease

MiscellaneousCalcifications

Hemangioma

•Soft tissue mass

•Multiple phleboliths

Radiolucent centers

•May erode underlying bone

Hemangioma of Wrist

Calcified Pinna

•Addison’s disease

•Gout

•Hyperparathyroidism

Calcified pinna-Addison’s Disease

Ant

Post

Injection Cysts

•Cincona (Chincona) cysts-quinine

•Injection into fat instead of muscle

•May suppurate and may drain

•Bx shows fat necrosis and low gradeinflammation

Drug may be present in cysts for decades

Injection cysts

Ossification Within Scar

•Heterotopic ossification in

Skin, muscle or fat

•Almost all males

•Almost always vertical scar

•70% supra-, 30% infra-umbilical

Ossified Scar

1.Calcium urateCalcific tendinopathy

2.Calcium phosphatePseudogout

3.Calcium hydroxyapatiteGout

4.Calcium pyrophosphate Tumoral calcinosis

Match Crystal and Disease

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Match Crystal and Disease

Calcinosis Circumscripta - Scleroderma

Phleboliths

Myositis Ossificans (Heterotopic Ossification)

Chondrocalcinosis-CPPD

Arterial Calcification-Diabetic

Chronic Venous Insufficiency

Ossified Scar

Calcinosis Universalis-Dermatomyositis

Monckeberg’s Arteriosclerosis

Tumoral Calcinosis

Cincona cyst

Calcific Tendinopathy and Bursitis

Calcinosis Universalis –Dermatomyositis

R

L

ChondrocalcinosisCPPD Arthropathy

Calcific Tendinopathy

Calcinosis Circumscripta -Scleroderma

Synovial Osteochondromatosis

Heterotopic Ossification

Chondrocalcinosis

Calcified Venous Thrombus

Monckeberg’sArteriosclerosis

Chronic Venous Insufficiency

Osteosarcoma

Hemangioma

Tumoral Calcinosis

Calcification Associatedwith Parasites

Guinea WormDracunculus Medenensis

•Female Guinea Worm

•Burrows into connective tissuewith its larva

•May calcify

•30 cm long

Calcified Guinea Worms

Radiology Resource and Review

Cystercicosis

•Taenia solium,  pork tapeworm

•Eggs can form calcified cysts

In muscle

•Numerous, small, nodular calcifications

Cysticercosis

The End