
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01018-6
10.1016/j.ijscr.2024.110237
110237
Case Report
Tumoral calcinosis in chronic renal failure: A case report and literature review
Andriandi
Husnul F.
Tirta C. Clement.tirta@yahoo.com
⁎
Orthopaedic and Traumatology Department, Faculty of Medicine, Universitas Sumatera Utara/Haji Adam Malik General Hospital, Medan, Indonesia
⁎ Corresponding author at: Haji Adam Malik General Hospital, Jl. Bunga Lau No.17, Kemenangan Tani, Kec. Medan Tuntungan, Kota Medan, Sumatera Utara 20136, Indonesia. Clement.tirta@yahoo.com
06 9 2024
10 2024
06 9 2024
123 11023715 5 2024
22 8 2024
31 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Tumor calcinosis is a rare and benign disorder characterized by calcified periarticular soft tissue masses. It may be idiopathic or caused by a condition known as hyperphosphatemia. There is still no definitive guideline for treating this disease, with excision being one of the primary treatment modalities.

Case presentation

2 patients with a history of longstanding diabetes and dialysis presented with a painless lump on their right buttock, measuring 18 × 30 cm in the right gluteal region. Laboratory examinations showed a high ureum, creatinine, and serum phosphate. A radiograph revealed opacity on the right hip joint, without involvement of the proximal femur bone. A biopsy confirmed the diagnosis of tumor calcinosis. Both patients were treated with calcium carbonate to control their high serum phosphate levels. Both patients showed excellent tumor control without progression.

Clinical discussion

Tumoral calcinosis (TC) is an extra-articular benign but aggressive tumor. The precise mechanism of TC remains unknown, which partly explains the lack of established treatment modality. We treat our patients with calcium carbonate to reduce the serum phosphate and treat the tumor without surgery. The treatment yielded a satisfactory clinical result.

Conclusion

This study showed that a secondary TC may be conservatively treated without any surgical excision if we address the underlying problem. But it may not result in a reduction of the tumor's size.

Highlights

• Tumoral calcinosis is a finding that can be encountered on tumors superimposed on chronic renal diseases.

• Tumoral calcinosis can cause significant comorbidity if left untreated.

• Surgical or medical treatments have been proposed for tumoral calcinosis.

• There is no consensus regarding the treatment guideline for tumoral calcinosis.

Keywords

Case report
Literature review
Tumoral calcinosis
Chronic renal disease
Clinical algorithm
==== Body
pmc1 Introduction

Tumor calcinosis is a benign disorder characterized by calcified periarticular soft tissue masses, usually made up of calcium salts, and it is commonly caused by hyperphosphatemia [1,2]. The hip, elbow, shoulder, foot, and wrist are the most commonly affected joints. Solitary or multiple swelling around the joints is the most common symptom, which is often accompanied by discomfort, pain, and/or limitations in joint movement. It was first reported by Giard and Duret in 1898 and 1899 in medical journals. Teutschlaender researched this disease process from 1930 to 1950, and it was known as Teutschlaender disease in European literature.3 Inclan et al. characterized this ailment in American literature in 1943 as a standard for diagnosing the disorder and created the term tumoral calcinosis [[3], [4], [5], [6]]. Although it is not a rare phenomenon, there has been no standard treatment method for tumoral calcinosis. The management of TC depends on the etiopathogenesis, site, size, symptoms, and relations to the other structures. Surgical excision of the lesion plays a pivotal role in the early management of TC. However, the rate of recurrence remains high and warrants repeated surgical excision. We present two patients who developed soft tissue calcifications with routine hemodialysis due to chronic renal failure, which are treated conservatively, along with a review of the literature for the treatment usually undertaken in tumoral calcinosis.

2 Case report

2.1 First case

A 53-year-old male with chronic uncontrolled type-2 diabetes and renal disease without any other notable medical history or family history of illness visited our outpatient clinic with a painless lump on his right buttock. He had undergone routine dialysis for 11 years, and the lump appeared 5 years ago. Initially, the lump appeared to be the size of a peanut, and it continuously grew larger. On physical examination, there was a mass measuring 18 × 30 cm on the right side of the gluteal region with a solid, smooth surface and an immobile, well-defined margin, and it decreased the range of motion of the right hip joint. Laboratory examinations showed a high ureum concentration (109 mg/dL), a high creatinine concentration (10.52 mg/dL), and a high serum phosphate concentration (7.4 mg/dL). Normal serum calcium concentration (9.7 mg/dL), alkaline phosphatase (64 IU/L), and vitamin D3 (43 ng/mL) concentration were also noted. A conventional radiograph showed opacity on the right hip joint without involvement of the proximal femur bone, and it was suggested as a soft tissue tumor on the right inguinal region. Magnetic Resonance Imaging showed a change in signal intensity in size of 6 cm × 9 cm × 11 cm on the right gluteal area, which involves the quadratus femoris muscle, inner side of the gluteus maximus muscle, obturator internus muscle, and obturator externus muscle, and it attached to the ischium bone and posterior side of the proximal femur bone without any apparent destruction or tumor infiltration. A biopsy confirmed the diagnosis of tumor calcinosis. The patient was treated with calcium carbonate to decrease his serum phosphate concentration. On the last follow-up 6 months after diagnosis and treatment, there was no worsening of the patient's general condition, and the calcification did not grow larger (Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6, Fig. 7).Fig. 1 Pelvis AP x-ray showing the calcified mass of the right hip.

Fig. 1

Fig. 2 MRI showing extension of the tumor in the HP region and femur.

Fig. 2

Fig. 3 Histopathology shows tumoral calcinosis as a calcified tumor matrix.

Fig. 3

Fig. 4 AP x-ray showing the calcified mass of the right hip.

Fig. 4

Fig. 5 Showing the extension of the tumor in MRI.

Fig. 5

Fig. 6 Histopatology showing a calcified tumor matrix confirming the diagnosis of tumoral calcinosis.

Fig. 6

Fig. 7 Algorithm for tumoral calcinosis.

Fig. 7

2.2 Second case

A 42-year-old male who was also an uncontrolled type-2 diabetic with chronic kidney disease visited our outpatient clinic with pain and a lump on his right buttock. The patient denies any other history of disease or any family illness. He had undergone routine dialysis for 4 years, and the lump had appeared a year previously. The lump starts off small and gradually grew larger. On physical examination, there was a mass measuring 10 × 10 cm on the right side of the gluteal region with a solid, smooth surface and an immobile, well-defined margin that restricted the range of motion of the right hip joint. Laboratory examinations showed a high ureum concentration (137 mg/dL) and a high creatinine concentration (13.73 mg/dL). Normal ALP (53 IU/L) and vitamin D3 levels (46 ng/mL) conventional radiograph showed opacity on the lateral side of the right hip joint without involvement of the proximal femur bone, and it was suggested as a soft tissue tumor on the right gluteal region. Magnetic resonance imaging showed a heterogeneous mass of approximately 6 × 13 × 16 cm on the lateral side of the right proximal femur bone without bone destruction, vascular involvement, or tumor infiltration. A biopsy confirmed the diagnosis of tumor calcinosis. The patient was treated with calcium carbonate. After 1 year of follow-up, the general condition of the patient did not deteriorate, and the overall general condition of the patient was not found to be different. There was no improvement in tumor size, and the patient had no other symptoms. The cases are treated by the same surgeon, and the cases have been reported in line with the SCARE criteria [36].

3 Discussion

Tumoral calcinosis (TC) is an extra-articular aggressive benign tumor presenting with growing mass and is characterized by the deposition of calcium phosphate. This is evident in both of our patients, where the presenting symptoms are a painless mass with calcification components on the plain x-ray. Following the usual predilection of the major joints such as the hip, elbow, and shoulder, our cases both have tumoral calcinosis in the right buttocks. Several etiopathogeneses have been proposed in tumoral calcinoses, such as primary normal-phosphatic TC, primary hyperphosphatemicTC, and secondary TC. The precise mechanism of TC remains unknown. It is thought to be repetitive trauma that leads to microhemorrhage in peri-articular tissue, initiating a foamy histiocytic response. Trauma has been reported to be the preceding condition in the normal-phosphatic variety of TC [1].

There are 3 types of tumor calcinosis: (1) idiopathic calcinosis, the most prevalent type with a 30 % chance of having a family history; (2) dystrophic calcification, which is caused by injured tissue; and (3) secondary tumor calcinosis, which can occur due to underlying diseases, including primary or secondary hyperparathyroidism, vitamin D overdose, scleroderma, and chronic renal failure. [1] Inadequate glomerular filtration rate produces an inability to eliminate daily nutritional phosphate load as well as a reduction in the levels of the 1α-Hydroxylase enzyme. Hyperphosphatemia and calcitriol insufficiency result in secondary hyperparathyroidism, also known as renal osteodystrophy. Uremic bone mineral metabolism disturbances result in extraosseous calcification and calciphylaxis [[7], [8], [9]]. A reparative process is started, and friction forces combined with this cause neobursae to develop. Functional bursae and bone formation are nonetheless prevented by an interaction between the multifactorial calcification process and collagenolysis brought on by proteolytic enzymes made by dissolving histiocytes. As a result, the typical TC lesions form, marking the process's active stage. Genetics may also explain the development of hyperphosphatemia in TC. Mutations in the FGF23, GALNT3, or KLOTHO genes result in the inactivation of the phosphaturic protein FGF23 in the primary hyperphosphatemic variety. In both of our patients, we suspected that the calcinosis was caused by a tumoral calcinosis due to renal osteodystrophy, as proven by the high phospate and kidney function test results, along with the history of chronic kidney disease. TC lesions show a cystic nature with white and yellow chalky material formed by calcium hydroxyapatite crystals, calcium carbonate, and calcium phosphate [4]. Hence, the treatment of TC remains debatable. There were no clear guidelines for whether conservative or surgical management should be performed. A scoping review was done by all the authors to find out about the management of TC. The scoping review was carried out using PubMed search engines with the search keywords “Tumor Calcinosis.” The result showed 27 reported cases in English (Table 1), with a total of 32 articles published. Table 1 lists all of the reported cases, with the earliest publication year being 1982. From the scoping review, most cases of tumor calcinosis are reported in males (16/27 cases, 59,2 %), with a median age of 45 years old (3–80 years old). Most of the underlying causes are end-stage renal disease (14 cases), idiopathic (9 cases), psoriatic arthritis (1 case), and two cases were not described by the author. The common anatomic location is on the shoulder joint and hip joint.Table 1 List of all cases in reported cases.

Table 1Author	Underlying causes	Symptoms	Location	Age	Imaging	Size (cm)	Treatment	Improvement/recurrence	
Alkhatib et al. [10] 2014	N/A	Limitation of movement	Bilateral subscapular		Chest x-ray
• CT-Scan

	10.5	Surgical tumor removal	Yes, following surgical tumor removal	
Al-Rumaih et al. [11] (2020)	N/A	Pain and swelling	Hip	6	X-ray
MRI	4.1 × 8 × 10.8	Medical treatment	N/A	
Al-Sukaini et al. [12] 2016	Idiopathic	Recurrent fall	Cervical	57	CT-Scan
MRI
Biopsy	N/A	Surgical	Resolution	
Sean et al. [13] 2017	ESRD	Pain and swelling	Shoulder	19	MRI	N/A	Hemodialysis with low-calcium dialysate	N/A	
Loya et al. [14] 2017	ESRD with secondary hypoparathyroidism	Hip and shoulder pain and swelling	Right shoulder and hip	45	USG
X-ray
CT-Scan	N/A	N/A	N/A	
Samia et al. [15] 2019	ESRD	Pain and swelling	Right shoulder	58	X-ray
MRI	N/A	Low calcium diet
Hemodialysis	No improvement	
Eisenberg et al. [16] 1990	ESRD without hyperparathyroidism	Pain, swelling, severe restriction of movement	Shoulder, hip, knee, wrist, and digits	58	X-ray
Bone scintigraphy
BIopsy		Lowering dialysate calcium concentration	No improvement	
Kim et al. [17] 2002	ESRD	Tenderness, ulceration, and cellulitis	Hand, feet, and shoulder	44	X-ray
Bone scan	N/A	Daily Nocturnanl Hemodialysis	Resolution	
Maioli et al. [18] 2017	ESRD	Swelling and pain	Hand	22	X-ray	N/A	Hemodialysis	Resolution	
Takashima et al. [19] 2014	ESRD	Asymptomatic	Hip	80	X-ray
CT-Scan
Bone scintigraphy	N/A	Phosphate-restricted diet
Phosphate-binding medication
Dialysis	Resolution	
Lin et al. [20] 2014	ESRD	N/A	Shoulder and hip	60	X-ray	N/A	Dialysis
Lowering serum calcium phosphorus products
Vitamin D analogs	No improvement	
Altaf et al. [21] 2020	ESRD	Difficulty to walk	Buttock	55	X-ray
MRI	30 × 20 cm	Surgical excision
Calcium, phosphorus, and PTH control	No recurrences	
Ibrahim et al. [22] 2017	ESRD	Pain	Wrist	26	X-ray
CT-Scan	N/A	Dialysis
Parathyroidectomy	Resolution and no recurrence at 26 months	
Ibrahim et al. [22] 2017	ESRD	Pain, restriction of movement	Shoulder and knee	56	X-ray
Bone scan	N/A	Dialysis
Parathyroidectomy	Resolution and no recurrence at 12 months	
Jones et al. [23] 2003	ESRD	Swelling, ulceration, pain, and restriction of movement	Shoulder and hand	49	X-ray
Biopsy	N/A	Dialysis	No improvement	
Lawrence et al. [24] 1994	ESRD	Swelling	Hands, elbow, shoulder, and neck	45	X-ray	Neck 4 × 4 cm
Elbow 5x5cm
Shoulder 5 × 6 cm	Subtotal parathyroidectomy	Improvement	
Straten et al. [25] 2005	N/A	Pain, swelling	Sternoclavicular	30	X-ray
CT-Scan	5 cm in diameter	Partial parathyroidectomy
CAPD
Low protein diet
Non-calcium-based-phosphate binder	Worsen	
Amadei et al. [26] 1998	Idiopathic	Swelling with hypoplasia of the second phalanx of the thumb and agenesis of the long fingers of the left hand	Hand	3	X-ray
MRI	N/A	Surgical excision	No recurrence	
Ansaloni et al. [27] 2001	Idiopathic	Painless mass	Hip	75	X-ray
Biopsy	5 cm in diameter	Surgical excision	No recurrences	
Azami et al. [28] 2020	Psoriatic arthritis	Dermal lesion, pruritus, pain, and swelling	Hand, wrist, and shoulder	67	X-ray
Biopsy	N/A	Eternacept	Resolution	
Banshelkikar et al. [29] 2014	Idiopathic	Painful swelling lesion	Middle finger and heel	13	X-ray	Hand 1.5 × 3 cm
Heel 2 × 3 cm	Surgical excision	No recurrence	
Bishop et al. [30] 1982	Idiopathic	Dull pain	Shoulder and hip	50	X-ray
Biopsy	N/A	N/A	N/A	
Bittmann et al. [31] 2003	Idiopathic	Pain	Buttock	15	X-ray
Biopsy	1.5 cm	Surgical excision	N/A	
Bogumill et al. [32] 1985	Idiopathic	Asymptomatic	Fingers	50	X-ray
Biopsy	N/A	Surgical excision	N/A	
Cavit et al. [33] 2021	Idiopathic	Restriction of movement, Numbness	Elbow	58	X-ray
CT-Scan
• MRI

• Biopsy

	8.5 × 5.5 × 2.5 cm	Surgical excision	No recurrence	
Croock et al. [34] 1987	Idiopathic	Pain	Shoulder and arm	76	X-ray
Biopsy	N/A	Refuse to receive surgical treatment	Minimal improvement	
Fatehi et al. [35] 2016	ESRD	Painful mass	Cervical spine	73	USG
CT-Scan
Bone scan	2.9 × 2.3 × 2.2 cm	Hemodialysis	Improvement	

The most common investigation used in several literature are plain radiographs, MRI, and biopsy. CT- scans and bone scans were utilized to assess the TC in several studies.

Various treatments have been performed in several studies, ranging from conservative to surgical excision. However, the pivotal role in TC management is maintaining the serum phosphate level at a normal level. Surgical excision may be performed if TC develops symptoms such as deformity, nerve pain, deformity, ulceration, and affected joint function. However, surgical excision is not spared from several complications, such as prolonged drainage that delays and promotes sinus tract formation. Incomplete surgical excision also leads to faster growth of the TC [6]. Phosphate-binding chelating agent or acetazolamide has been proven to reduce the recurrence rate of TC in normal- and hyperphosphatemic TC. Parathyroidectomy and renal transplantation may also be performed in uncontrolled phosphate serum. Based on the literature review and our clinical expert opinion about tumor calcinosis, we propose an algorithm to guide the management. In conclusion, tumoral calcinosis can be controlled by addressing the underlying problem, such as maintaining adequate phosphate levels.

Surgical treatment is reserved for tumors that cause severe deformity and disturbance of daily activity, but up until now, there has been no definitive indication for surgery. Even though in our algorithm we proposed that tumors <10 cm should be treated conservatively, this does not mean that we encourage all tumors >10 cm to be surgically excised. In our case, even though one of the cases presents with a tumor that is >10 cm, we still choose conservative treatment without surgical excision because the tumor size itself does not cause significant disturbance to the patient's day-to-day living.

4 Conclusions

This study showed that a secondary TC may be treated conservatively without any surgical excision. However, the size did not get any smaller during conservative treatment. Addressing the etiopathogenesis of TC plays a pivotal role in controlling the symptoms and preventing the recurrence of TC.

Informed consent

Informed consent regarding the case series were informed to the patient at the last follow up.

Funding source

There is no external funding source for this case series.

Ethical approval

Because this is not an experimental intervention study, and it is not a first in man study, no ethical approval were asked by the ethical committee.

Author's declaration

All the authors listed declared to have read and contributed significantly to the manuscript.

Author's Artificial Intelligence (AI) declaration

AI such as quilbot have been used as a tool to help checked the grammar of the manuscript with rigorous checking and rewording by the authors of anything that are produced by AI.

Guarantor

Andriandi, Sp.OT (first author) is the guarantor of this paper.

Conflict of interest statement

All author declares that there is no conflict of interest associated with this case series.
==== Refs
References

1 Cofan F. García S. Combalia A. Campistol J.M. Oppenheimer F. Ramón R. Uremic tumoral calcinosis in patients receiving longterm hemodialysis therapy J. Rheumatol. 26 2 1999 379 385 9972973
2 Tezelman S. Siperstein A.E. Duh Q.Y. Clark O.H. Tumoral calcinosis. Controversies in the etiology and alternatives in the treatment Arch. Surg. 128 1993 737 745 8317954
3 Oslen K.M. Chew F.S. Tumoral calcinosis: pearls, polemics, and alternative possibilities RadioGraphics 26 2006 871 885 16702460
4 Altaf J. Rashid T. Husain M. Arif M. Ahmad M. Tumoral calcinosis, a diagnostic dilemma: a case report Int. J. Adv. Med. 7 8 2020 1286
5 Samia M. Soufiane E. Maarfi A. el Hanane B. Mounia B. Douhi Z. Multiple Tumoral calcinosis in a hemodialysis patient Urol. Androl. Open J. 4 1 2020 1 3
6 Byiringiro Mugabe F. Rugwizangoga B. Tumoral calcinosis of bilateral hip joint in an adult female: a case report Rwanda Med. J. 76 4 2019 1 2
7 Kim S.J. Goldstein M. Szabo T. Pierratos A. Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis Am. J. Kidney Dis. 41 3 2003 1 7 12500213
8 Ke G. Li S. Cui Y. Chen X. Che H. Dou C. Treatment of uremic Tumoral calcinosis in maintenance hemodialysis patients Blood Purif. 49 6 2020 658 664 32289781
9 Binnani P. Aggarwal V. Bahadur M.M. Fulara N. Case report Tumoral calcinosis (Teutschlanderdisease) in a dialysis patient Indian J. Nephrol. 18 3 2008 122 124 20142918
10 Alkhatib A. Burton L.E. Carachi R. Familial tumoral calcinosis Scott. Med. J. 59 4 2014 Nov e17 e20 25351424
11 Al-Rumaih M.H. Al-Otaibi M.A. Alshammari A.N. Tumoral Calcinosis Presentation in Operated Developmental Dysplasia of the Hip: A Case Report and Review of Litera- ture. 12 Cureus 2020 e9948
12 Al-Sukaini A. Paulino Pereira N.R. Yu E.W. Chebib I. Bredella M.A. Schwab J. Idiopathic tumoral calcinosis-like lesion in the lower cervical spine causing acute central cord syndrome: case report J. Neurosurg. Spine 26 1 2017 Jan 97 102 27611507
13 Verma S. Bassily E. Jarmi T. An extreme case of tumoral calcinosis in an end-stage renal disease patient Kidney Int. [Internet] 91 4 2017 Apr 991 28314585
14 Loya R. Beavers K. Scherer K. Multimodality imaging of calcinosis of chronic renal failure Cureus [Internet] 2017 Mar 24
15 Samia M. Soufiane E. El Maarfi A. Hanane B. Mounia B. Douhi Z. Multiple Tumoral calcinosis in a hemodialysis patient Urol. Androl. Open J. [Internet] 4 1 2020 May 4 1 3
16 Eisenberg B. Tzamaloukas A.H. Hartshorne M.F. Listrom M.B. Arrington E.R. Sherrard D.J. Periarticular tumoral calcinosis and hypercalcemia in a hemodialysis patient without hyperparathyroidism: a case report J. Nucl. Med. [Internet] 31 6 1990 Jun 1099 1103 2348239
17 Kim S.J. Goldstein M. Szabo T. Pierratos A. Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis Am. J. Kidney Dis. [Internet] 41 3 2003 Mar e12.1-e12.7
18 Maioli M.E. Delfino V.D.A. Guerra A.C.D.Z. Kunii L.F. Frange R.F.N. Reversal of uremic tumoral calcinosis by optimization of clinical treatment of bone and mineral metabo- lism disorder J. Bras. Nefrol. [Internet] 39 2 2017
19 Takashima S. Sakamoto T. Ota M. Tumoral calcinosis in chronic renal failure Lancet Diab. Endocrinol. [Internet] 2 10 2014 Oct 852
20 Lin W.-T. Chao C.-M. Tumoral calcinosis in renal failure QJM [Internet] 107 5 2014 May 1 387 23904519
21 Altaf J. Rashid T. Husain M. Arif M. Ahmad M. Tumoral calcinosis, a diagnostic dilemma: a case report Int. J. Adv. Med. [Internet] 7 8 2020 Jul 21 1286
22 Ibrahim Montasser D. Issouani J. Hassani M. Kabbaj D. Tumoral calcinosis: diffuse multifocal form in hemodialysis patients. Two case reports Orthop. Traumatol. Surg. Res. [Internet] 103 5 2017 Sep 815 820 28576700
23 Jones G. Kingdon E. Sweny P. Davenport A. Tumoral calcinosis and calciphylaxis presenting in a dialysis patient Nephrol. Dial. Transplant. [Internet] 18 12 2003 Dec 1 2668 2670 14605296
24 Lawrence R.A. Özener Ç. Kılıç S. Akoglu E. Tumoral calcinosis in chronic renal failure: two case reports Med. J. Islam World Acad. Sci. [Internet] 7 2 1994 106 110
25 Van Straten A. Hoogeveen E.K. Khan S.H.M. De Schepper A.M. Unusual presentation of tumoral calcinosis in chronic renal failure : A case report Unusual presentation of tumoral calcinosis in chronic renal failure : a case report. 2005 July 2018
26 Amadei F. Petrolati M. Idiopathic tumoral calcinosis associated with congenital malformation of the hand. Case report. Ann Chir la main du Memb Super organe Off des Soc Chir la main = Ann hand Up limb Surg. 17 1 1998 59 62
27 Ansaloni L. Falaschi F. Pazè E. Tumoral calcinosis: case report East Afr. Med. J. 78 3 2001 Mar 165 166 12002060
28 Azami A. Mohebbipour Loron A. Anari H. Matin S. Case report: a report of a rare case tumoral calcinosis syndrome in a patient afflicted with psoriatic arthritis Arch. Osteoporos. 15 1 2020 Jul 106 32700242
29 Banshelkikar S.N. Argekar H. Bhoir A. Idiopathic Tumoral calcinosis with unusual presentation-case report with review of literature J. Orthopaed. Case Rep. 4 2014 59 62
30 Bishop A.F. Destouet J.M. Murphy W.A. Gilula L.A. Tumoral calcinosis: case report and review Skeletal Radiol. 8 4 1982 269 274 6755712
31 Bittmann S. Günther M.W. Ulus H. Tumoral calcinosis of the gluteal region in a child: case report with overview of different soft-tissue calcifications J. Pediatr. Surg. 38 8 2003 Aug E4 E7
32 Bogumill G.P. Lloyd R.J. Tumoral calcinosis in multiple digits: a case report J. Hand Surg. Am. 10 5 1985 Sep 739 743 4045163
33 Cavit A. Çapkın S. Yılmaz K. Kaleli T. Bilateral brachial artery infiltration by tumoral calcinosis: a case report Acta Orthop. Traumatol. Turc. 55 3 2021 May 281 284 34100372
34 Croock A.D. Silver R.M. Tumoral calcinosis presenting as adhesive capsulitis: case report and literature review Arthritis Rheum. 30 4 1987 Apr 455 459 3580013
35 Fatehi M. Ahuja C.S. Wang S. Ginsberg H.J. Uremic tumoral calcinosis in the cervical spine: case report J. Neurosurg. Spine 25 1 2016 Jul 26 30 26943247
36 Sohrabi C. Mathew G. Maria N. Kerwan A. Franchi T. Agha R.A. The SCARE 2023 guideline: updating consensus surgical CAse REport (SCARE) guidelines Int. J. Surg. Lond. Engl. 109 5 2023 1136
