Calcification in cystic renal masses: is it important in diagnosis?

PURPOSE: To determine whether the presence of calcifications in cystic renal masses is important in diagnosis and to suggest an approach to the management of calcified cystic renal masses. MATERIALS AND METHODS: Eighty-one cystic renal masses containing calcification in a wall or septum were evaluated by means of review of computed tomographic (CT) images (n = 81), follow-up CT images (n = 28), and results of pathologic examination (n = 40) by the authors in consensus. Images were evaluated for lesion size, amount and morphology of calcification, and any association of calcification with soft-tissue structures. Lesions were categorized according to the Bosniak cyst classification system; the amount of calcification was determined with a subjective grading system. Progression of calcification was qualitatively determined with available follow-up CT scans. RESULTS: Twenty-one lesions were Bosniak category II (benign) and showed small amounts and thin strands of calcification. Nineteen lesions containing more extensive calcification but no enhancing tissue were category IIF. Follow-up CT results available for 16 of these lesions (average follow-up length, 5 years 8 months) showed no substantial change. The three remaining lesions were proved benign at surgery. Twenty-five lesions were category III; surgical intervention was performed in 21 of these (benign, n = 12; malignant, n = 9). Sixteen lesions that contained obvious areas of enhancing soft tissue were category IV and proved malignant at surgery. CONCLUSION: Calcification in a cystic renal mass is not as important in diagnosis as is the presence of associated enhancing soft-tissue elements. This information should enable a reasonable approach to the management of calcium-containing renal cystic lesions.     

Breast tumors: composition of microcalcifications

The authors investigated the crystallographic patterns of calcifications in breast tissue from 31 patients, including eight calcified benign lesions, 17 calcified carcinomas, and six noncalcified control samples. Scanning electron microscopy, energy-dispersive x-ray analysis, and x-ray diffraction with the Guinier camera were employed and yielded information on the shape and composition of breast calcifications. Polyhedral crystals (with energy-dispersive x-ray analysis response to calcium) contained calcite, aragonite, or calcium oxalate, depending on the case. Calcium oxalate crystals were found only in malignant breast tissues. Spherical crystals (with energy-dispersive x-ray analysis response to calcium and phosphorus) contained apatite. Spherical crystals predominated in malignant processes, but all shapes and compositions were present in both benign and malignant processes. The relationship of the calcification to its surrounding tissue may account for differences in structure, but results are inconclusive and require further study.     

Calcified renal metastases: their etiology, pathogenesis, computed tomographic aspects and differential diagnosis

PURPOSE: To describe CT findings of calcified renal metastases focusing on differential diagnosis problems. MATERIAL AND METHODS: We retrospectively reviewed abdominal CT scans of 8000 patients with tumor, performed from 1984 to 1998. Among the 58 renal metastases, 9 showed a calcific component. We evaluated the location, morphostructural pattern, histology of the primary lesion, the synchronous or metachronous character and the type of treatment. All the lesions were pathologically proved. RESULTS: The primary histotype of the 9 metastases was as follows: 4 mucin-producing adenocarcinomas of the large bowel, 1 gastric mucinous adenocarcinoma, 1 chondrosarcoma, 1 osteosarcoma, 1 melanoma, 1 papillary thyroid carcinoma. In all the cases the renal metastasis was unilateral and unifocal. Granular multiple calcifications were demonstrated within the metastases of mucin-producing adenocarcinoma of the large bowel (3), within the metastasis of chondrosarcoma (1) and of melanoma (1). Diffuse "star-like" calcifications were demonstrated in renal metastases of mucin-producing adenocarcinoma of the large bowel and of gastric mucinous adenocarcinoma (1). Peripheral "egg-shell" calcifications were demonstrated in renal metastasis from papillary thyroid carcinoma (1). Completely calcified monofocal calcification was demonstrated in renal metastasis from osteosarcoma (1). DISCUSSION AND CONCLUSIONS: Calcified renal metastases are rare lesions related to specific oncotypes. The differential diagnosis (carcinoma with calcifications, osteosarcoma, chondrosarcoma, nephrocalcinosis, granulomatosis, hydatidosis etc.) is particularly difficult because of the aspecificity of the morphostructural pattern. Diagnosis is based on a history of specific oncotypes (papillary and mucin-secreting carcinomas, osteosarcoma and chondrosarcoma), but in most cases it requires pathologic confirmation.     

Calcified masses of the kidney. Apropos of 58 cases

Case reports were analyzed of patients with calcified renal masses observed in the department since 1968. Of the 65 radiologic reports reviewed, 7 were rejected since the course since diagnosis was unknown. Of the 58 case reports studied, 34 were of masses of certain diagnosis, 12 undetermined, 7 of masses in polycystic kidneys, 3 in tuberculous kidneys and 3 probably calcified hematomas. Analysis involved only those masses of proven diagnosis. Results confirmed the absence of specificity in favor of the cyst of peripheral character of calcifications: 33% of these masses were cancers. The existence of tissue calcification is synonymous of a solid mass, nearly always malignant (92% of cases). For peripherally calcified masses, arteriography was not sufficient to affirm benign nature of lesions, most of these masses having a particularly poorly vascularized or even avascular appearance. In these cases angiotensin was of special interest. Ultrasound imaging proved to be a reliable and perfectly sensitive examination. The presence of calcifications rarely interfered with study of tumoral contents. CT scan imaging and puncture biopsy were also perfectly sensitive and reliable examinations. Because of the high frequency of cancers in masses with peripheral calcification, all these masses should be surgically explored or at least punctured. Although a "benign" CT scan image appears sufficient to affirm the benign nature, this still requires more ample confirmation.     

Identification of calcification with MRI using susceptibility‐weighted imaging: A case study

Susceptibility weighted imaging (SWI) is a new MRI technique that can identify calcification by using phase images. We present a single case with a partially calcified oligodendroglioma, multiple calcified cysticercosis lesions, and multiple physiologic calcifications in the same patient. SWI phase images and computed tomography (CT) images are compared. SWI phase images showed the same calcified lesions as shown on CT and sometimes some new calcifications. Our conclusion is that SWI filtered phase images can identify calcifications as well as CT in this case. J. Magn. Reson. Imaging 2009;29:177–182. © 2008 Wiley‐Liss, Inc.     

CT and MRI findings of calcified spinal meningiomas: correlation with pathological findings

Objective

This study was designed to present characteristic CT and MR findings of calcified spinal meningiomas that correlate with pathological findings and to assess the efficacy of CT for the detection of calcifications within a mass in comparison to MRI.

Materials and methods

Between 1998 and 2009, 10 out of 11 patients who had pathologically confirmed psammomatous meningiomas showed gross calcifications on CT images and were included in this study. On CT scans of the 10 patients, the distribution pattern, morphology and number of calcifications within masses were evaluated. MRI was performed in seven patients and signal intensities of masses were assessed. The pathological results analyzed semi-quantitatively were compared with the density or the size of calcifications within a mass as seen on a CT scan.

Results

Seven of 10 masses were located at the thoracic spine level. Eight masses had intradural locations. The other two masses had extradural locations. Four masses were completely calcified based on standard radiographs and CT. Symptoms duration, the size of the mass and size or number of calcifications within a mass had no correlation. The location, size, and distribution pattern of calcifications within masses were variable. On MR images, signal intensity of calcified tumor varied on all imaging sequences. All the masses enhanced after injection of intravenous contrast material.

Conclusion

A calcified meningioma should be first suggested when extradural or intradural masses located in the spine contain calcifications regardless of the size or pattern as depicted on CT, especially in the presence of enhancement as seen on MR images.     

Problematic renal masses in ultrasonography and computed tomography

The diagnosis of renal masses is based upon the contribution of ultrasonography (US) and computed tomography (CT), which enable the recognition of these lesions with high diagnostic accuracy. However, a number of diagnostic difficulties exist in the definition of the nature of the mass, both for cystic and solid lesions, and to a lesser extent in the identification of the mass. "Complicated" cystic masses, such as calcified cysts, hemorrhagic cysts, inflammatory cysts, abscesses, and cystic tumors may be difficult to diagnose with US and sometimes with CT. CT is helpful in most of these cases because it enables the evaluation of the calcifications and the density of the fluid content. CT is also helpful in cases of cystic tumors because it shows the enhancement of septae within the masses. Problems with solid masses are the identification of small renal tumors and the definition of the benign or malignant nature of the mass. Although both techniques enable the recognition of most tumors, even if small in diameter, they are still limited in defining the pathological structure of the tumor.     

乳腺钙化的X线特征及其诊断乳腺疾病的价值

目的 :探讨X线影像对乳腺钙化在不同乳腺疾病中的诊断价值。材料和方法 :经手术、B超、穿刺活检或随访证实的 ,乳腺X线摄影确认的 15 0例钙化病例 ,回顾性分析其钙化形态、大小、密度、分布等特点。结果 :乳腺钙化可分成七型 ,即棍棒型、精盐型、沙石型、融合型、圆弧型、轨道型和圆孔型。棍棒型 3 0例 ,其中恶性 2 9例 (97% ) ;精盐型 40例 ,恶性 3 4例 (85 % ) ;沙石型 2 2例 ,良性 19例 (90 % ) ;融合型 2 5例 ,良性 2 3例 (92 % ) ;圆弧型、轨道型和圆孔型 ,均为乳腺良性病变。结论 :棍棒型及精盐型钙化是乳腺恶性病变钙化的主要类型 ;沙石型、融合型、圆弧型、轨道型和圆空型钙化是良性病变钙化的主要类型。乳腺钙化在诊断不同乳腺疾病及鉴别良恶性肿瘤中具有重要作用。     

Bright echogenic foci in early prostatic carcinoma: sonographic and pathologic correlation

One hundred sixty patients with biopsy-proved clinical stage A or B prostatic carcinoma were examined with high-resolution transrectal ultrasonography prior to radical prostatectomy. All tumors showed either a hypoechoic or isoechoic echo pattern. However, 11 patients demonstrated evidence of focal bright echogenic areas at the periphery or within the center of a hypoechoic tumor. Coarse echogenic foci seen in seven patients corresponded pathologically to calcified corpora amylacea in benign tumors of the prostate gland either at the edge of the tumor or scattered throughout the tumor. Seven patients showed a fine, stippled echogenic pattern within the lesion. On a pathologic level, this pattern represented high-grade tumors with extensive central comedonecrosis and calcifications in five patients and an unusual deposit of small intraluminal crystalloid deposits in two patients. Combinations of echo patterns were observed in three patients. This study demonstrates that echogenic foci can be seen within predominantly hypoechoic tumor nodules. Coarse bright echoes, usually at the periphery of the tumor, suggest calcifications in benign prostate glands. Tumor calcifications and intraluminal prostatic crystalloid deposits were located more centrally and had a finer stippled sonographic appearance.     

Fragmentation of calcified plaque after carotid artery stenting in heavily calcified circumferential stenosis

Introduction

We assessed the morphological change of calcified plaque after carotid artery stenting (CAS) in vessels with heavily calcified circumferential lesions and discuss the possible mechanisms of stent expansion in these lesions.

Methods

We performed 18 CAS procedures in 16 patients with severe carotid artery stenosis accompanied by plaque calcification involving more than 75% of the vessel circumference. All patients underwent multidetector-row computed tomography (MDCT) to evaluate lesion calcification before and within 3 months after intervention. The angiographic outcome immediately after CAS and follow-up angiographs obtained 6 months post-CAS were examined.

Results

The preoperative mean arc of the calcifications was 320.1?±?24.5° (range 278–360°). In all lesions, CAS procedures were successfully carried out; excellent dilation with residual stenosis ≤30% was achieved in all lesions. Post-CAS MDCT demonstrated multiple fragmentations of the calcifications in 17 of 18 lesions (94.4%), but only cracks in the calcified plaque without fragmentation in one (5.6%). Angiographic study performed approximately 6 months post-CAS detected severe restenosis in one lesion (5.6%) without fragmentation of calcified plaque.

Conclusions

Excellent stent expansion may be achieved and maintained in heavily calcified circumferential carotid lesions by disruption and fragmentation of the calcified plaques.     

The hypernephroma halo.

Most renal adenocarcinomas (hypernephromas) are characterized histologically by a dense, avascular, fibrous capsule. This capsule is rare or nonexistent in other benign or malignant renal tumors. The capsule was identified as a thin radiolucent stripe surrounding parts of the tumor periphery in 30 renal angiograms performed on a group of 70 patients with pathologically proven hypernephromas. Only one of 65 normal kidneys and 137 other benign or malignant renal tumors or pseudotumors exhibited angiographic evidence of this lucent stripe. This stripe is therefore referred to as the "hypernephroma halo." Its identification on an excretory urogram is occasionally possible; in five patients it was recognized prior to angiography suggesting the lesion causing it is a hypernephroma.     

Calcified suture material in the breast after radiation therapy.

Of 335 women who underwent lumpectomy and radiation therapy for breast cancer, 42 subsequently developed calcifications. Particles typical of calcified suture material were identified in 21 of the 42 women (50%). No obvious calcified suture material was found in approximately 1,140 women of 38,000 (3%) who had undergone mammography after they had previously undergone breast biopsy for a benign lesion and thus had not undergone radiation therapy. Calcified suture material rarely develops in the nonirradiated breast, but it is common after radiation therapy and should not be confused with recurrent breast cancer. These calcifications are likely the result of delayed resorption of catgut sutures, which provide a matrix on which calcium can precipitate in a suitable local environment.     

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

ObjectiveThe objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS).Materials and methodsWe retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 – December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign.Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified.ResultsOf 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05].ConclusionNew calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.     

Tomographic renal cortical scintigraphy: correlation with intravenous urography, computed tomography, ultrasonography, angiography, and nuclear magnetic resonance imaging

This study evaluates single-photon renal tomoscintigraphy (SPECT) in the evaluation of renal masses and correlates this modality, where indicated, with computed tomography (CT), ultrasonography (US), angiography (ANGIO) and nuclear magnetic resonance imaging (NMR). Eight patients with renal cortical lesions detected on intravenous urography (IVP) were evaluated by SPECT and planar nuclear imaging using Tc-99m glucoheptonate (GH). Three of these patients were felt particularly likely to have renal tumors and were additionally evaluated with US, CT, ANGIO and NMR. The five patients with nodules on IVP that were not particularly suggestive of malignancy had functioning, benign, renal tissue accounting for their IVP lesions. Four of five were found by planar-GH nuclear imaging, five/five by SPECT-GH. In addition, SPECT-GH allowed better "confidence" in the normal renal tissue diagnosis in three/five cases. Of the three renal lesions that were highly suggestive of malignancy, two were hypernephromas and one was hypertrophied functioning cortical tissue. All three were correctly identified prospectively on SPECT-GH; however, one hypernephroma was missed on planar-GH. NMR, CT, and ANGIO detected only one of two hypernephromas prospectively (US detected both); all four modalities incorrectly diagnosed the hypertrophied tissue suggestive of malignancy.     

Breast US in patients who had microcalcifications with low concern of malignancy on screening mammography

PURPOSE: To review ultrasound (US) findings in patients who have suspicious microcalcifications with low concern of malignancy (BI-RADS category 4A) on screening mammography and to evaluate helpful findings in differentiating benign and malignant lesions. MATERIALS AND METHODS: Between August 2005 and July 2006, 192 patients showed microcalcifications only, without mass or associated density, on screening mammography. Among them, we selected 82 patients who had microcalcifications with low concern of malignancy (category 4A) that were pathologically confirmed by surgical excision after wire localization (n=23) or biopsy (n=59). Breast US was performed in 37/82 cases and we analyzed the US findings for the calcification areas in these patients, evaluating the findings with benign or malignant pathological results. We correlated US findings with mammographic calcifications using mammography-guided 2D-localization for the calcifications before US examination. RESULTS: There were 12 malignant lesions (32.4%) including 3 invasive ductal carcinomas (IDC), one microinvasive ductal carcinoma (MIDC), 8 ductal carcinoma in situ (DCIS) and 25 benign lesions (67.6%) including 2 atypical ductal hyperplasias (ADH). IDC showed calcifications within heterogeneous hypoechoic parenchyma or calcifications within complex hypoechoic masses of taller-than-wide shape on US. One MIDC showed calcifications within heterogeneous hypoechoic parenchyma and six DCIS showed negative findings, or calcifications with a small nodule, or only calcifications on US. The most common positive US finding in benign lesions was cysts with calcifications. In 24/37 cases (64.8%) with negative US findings, 18 (75%) were benign lesions and 6 (25%) were DCIS. CONCLUSION: In patients with category 4A microcalcifications without associated findings on screening mammography, negative US findings had a high rate of benign results (18/24, 75%). Visible calcifications within heterogeneous hypoechoic parenchyma or mass on US increased the probability of malignancy.     

Nephroblastoma with egg-shell peripheral calcifications. Apropos of 3 cases

Three cases of nephroblastoma presented "egg-shell" peripheral calcifications of pseudocystic appearance of radiology. These peripheral lesions are compared with the more commonly reported central calcifications. Their pathology is unknown and they lack prognostic significance of any importance. As for all nephroblastomas the diagnosis is based on straight abdomen images, intravenous urography, ultrasound and computed tomography. Differential diagnosis is basically from renal adenocarcinoma in children, the latter often exhibiting similar calcifications, the distinction between the two types of tumor depending on age of onset. These calcified lesions are non-specific findings and various diagnoses are discussed.     

Cystic renal tumors: US and CT findings

Cystic renal tumors represent a variety of lesions in which both solid and liquid components coexist. These lesions may be either benign or malignant and include the multilocular cystic nephroma (MCN), the renal cell carcinoma (RCC), and the papillary adenocarcinoma (PAC). The MCN is a rare neoplasm formed of multiple loculated cystic masses divided by septa. The tumor is benign, although there are some rare reports of malignant cases. The RCC and the PAC may appear with cystic patterns. This is rather uncommon for the RCC, which inside has a unilocular or multilocular cystic appearance, if the necrotic component is large. PAC is an infrequent renal tumor, which has a greater tendency to appear as a large mass with a unilocular large cystic space. The ultrasonography (US) and computed tomographic (CT) features of 27 cystic tumors are presented. Both US and CT allowed the recognition of the cystic components, the septa, and the vegetations. The two imaging techniques made it possible to distinguish the tumors into “unilocular” and “multilocular” masses: the former correspond to RCC and PAC, the latter to MCN and RCC. CT added some information on calcified or partially calcified tumors. CT more than US enabled the differentiation between the malignant RCC and the benign MCN for which conservative surgery may be indicated. The two techniques did not allow the differentiation between RCC and PAC, which has different prognostic behavior.     

Computed tomography of internally calcified renal cysts

Three benign renal cysts containing nonperipheral calcifications on CT are presented. Renal cyst puncture and cytologic examination of the aspirate confirmed their benign nature. Calcification, either peripheral or within the mass, may occur in benign or malignant cystic lesions of the kidney. The demonstration of calcification is a definite indication for cyst puncture to avoid unnecessary surgery or overlooking a possible malignancy.     

MR imaging of calcified intracranial lesions

Fifty calcified intracranial lesions diagnosed with computed tomography (CT) were evaluated with magnetic resonance (MR) using a spin-echo sequence. MR images demonstrated 41 of 50 lesions seen as calcified on CT scans, among them 29 of 30 cerebral neoplasms and all ten arteriovenous malformations. The presence of calcification was suspected prospectively in about 60% of calcified lesions but was also suspected in 45% of uncalcified lesions (reviewed as control cases). No fine calcifications and only 25% of punctate calcifications were disclosed on MR images. In the nine lesions undetected by MR, calcification was the only abnormal CT finding. The findings of calcification on MR images were nonspecific, ranging from signal void or signal dampening on all sequences to no alteration of signal intensity. The most common finding of calcification was a focus of signal diminution, rather than signal void, as commonly reported.     

Tomographic renal cortical scintigraphy: Correlation with intravenous urography,computed tomography,ultrasonography, angiography,and nuclear magnetic resonance imaging

This study evaluates single-photon renal tomoscintigraphy (SPECT) in the evaluation of renal masses and correlates this modality, where indicated, with computed tomography (CT), ultrasonography (US), angiography (ANGIO) and nuclear magnetic resonance imaging (NMR). Eight patients with renal cortical lesions detected on intravenous urography (IVP) were evaluated by SPECT and planar nuclear imaging using Tc-99m glucoheptonate (GH). Three of these patients were felt particularly likely to have renal tumors and were additionally evaluated with US, CT, ANGIO and NMR. The five patients with nodules on IVP that were not particularly suggestive of malignancy had functioning, benign, renal tissue accounting for their IVP lesions. Four of five were found by planar-GH nuclear imaging, five/five by SPECT-GH. In addition, SPECT-GH allowed better confidence in the normal renal tissue diagnosis in three/five cases. Of the three renal lesions that were highly suggestive of malignancy, two were hypernephromas and one was hypertrophied functioning cortical tissue. All three were correctly identified prospectively on SPECT-GH; however, one hypernephroma was missed on planar-GH. NMR, CT, and ANGIO detected only one of two hypernephromas prospectively (US detected both); all four modalities incorrectly diagnosed the hypertrophied tissue suggestive of malignancy.