Discuss the radiological

differential diagnosis of soft

tissue calcification
By
Dr Kator Iorpagher
Dept of Radiology
BSUTH Makurdi

01/22/2024
Outline
• Introduction
• Classification
• Imaging modalities
• Differential diagnosis on imaging modalities
• Conclusion
• References

01/22/2024
Introduction
 Radiological appearance soft tissue calcification aid in the diagnosis
and treatment of certain systemic disorders.
Elevated serum ca2+ and P3+- metastatic STC
In altered, necrotic or dead tissue- dystrophic STC
Evaluation is based on distribution pattern, lab and clinical evaluation
 It is diffentiated from ossification by the disordered
accumulation/deposition of calcium
Not controlled by genes

01/22/2024
Classification of soft tissue calcification
• Based on causes
1. calcium/phosphate metabolism- dystrophic, metastatic and
calcinosis
2. Pattern of lesions- popcorn, rimlike, amorphous, tram track
3. Distribution- localised and generalised
4. Location of lesions- joints. Lymph nodes, bursae, muscles, tendons,
ligaments, arteries, nerves, cartilage, etc. also called compartmental
approach.

01/22/2024
Imaging methods
• Conventional radiography
• Ultrasonography
• Computed tomography
• Magnetic resonance imaging
• Scintigraphy

Radio opaque on radiographs, hyperdense on CT and echogenic on US.

The appearance on MRI is variable but predominantly hypointense

01/22/2024
Image evaluation
• Location of the lesion
• Pattern of calcification
• Distribution
• Clinical history
• laboratory studies of Ca2+, P+

01/22/2024
 Classification of soft tissue calcification
• Based on calcium/phosphate metabolism

Type of calcification Typical appearance Prevalence

Dystrophic Small to large amorphous calcification 95-98%

in damaged tissues. May progress to
ossification

Metastatic/metabolic Fine speckled calcification through out 1-2%

tissue
Calcinosis Multilobulated lesions usually near <1%
joints
01/22/2024
Classification based on pattern.
• Rim- like – as seen in the walls of hollow organs. E.g gallbladder,
urinary bladder
• linear/tram like/track like- as seen in wall of tubular structures. E.g
arteries, ureters, fallopian tubes.
• Lamella/laminar- formed around the nidus in a hollow lumen E.G
lamellated calculus in the urinary bladder
• Cloud like/amorphous/ pop corn- within a solid organ or tumour. E.g
thyroid, lymph nodes, fibroids.

01/22/2024
 Dystrophic calcification
• Seen in damaged/devitalised/degenerating/inflamed/injured/necrotic
tissues
• No associated metabolic disorder
• Accounts for over 95% of STC in radiology
• In damaged soft tissues it appear as small to large amorphous
calcification.
• Causes include- vascular, infection/infestations, neoplasms,
congenital, inflammatory, autoimmune/CT disorders, degenerative,
trauma, metabolic without hypercalcemia

01/22/2024
 Vascular calcification
Arterial calcification-
Artheroma/Atherosclerosis - irregular plaques
Medial sclerosis- ring like or crescentic calcifications
Commonly seen in popliteal/femoral arteries
Diabetic patients are most susceptible
Tunica media arteriosclerosis (Mönckeberg’s arteriosclerosis)
Curvilinear calcification in aneurysm/aortic arch
Tissue infarction e.g. myocardial infarction

01/22/2024
Figure 1: Lateral radiograph of the ankle
shows metabolic vascular calcifications

01/22/2024
Figure 2: Lateral Knee radiograph shows extensive calcification
of femoral/popliteal arteries with railroad track pattern.

 Monckeberg’s arteriosclerosis
 70yr old man with hx of fall and
knee pain

01/22/2024
Figure 3: Colour/duplex/triphasic images of
the carotid vessels

01/22/2024
 Venous calcification
Commonly in thrombosed vein
Called Phleboliths
Appear as round-oval opacities with lucent centres
Seen commonly in pelvic veins (uterine & prostatic), calf
veins, spleen, ankle, orbits.
Where they don’t commonly occur → AVM
May be seen in haemangiomas

01/22/2024
Figure 4: Cone view of pelvic radiograph-
multiple bilateral oval shaped phleboliths

01/22/2024
Figure 5:Lateral radiograph of the right leg shows a
hard soft tissue mass with pain during walking.

 Calcification over posterior aspect

of mass

 Venous malformation

01/22/2024
Figure 6: Lateral radiograph and Axial T2 weighted
fat supressed MRI of left elbow joint

01/22/2024
 Infections/infestations/inflammation

Cysticercosis
Dracunculiasis (guinea worm)
Schistosomiasis
Loa loa (microfiliria)
Armillifer armillatus
Pancreatitis (fat necrosis)

01/22/2024
Figure 7: AP knee radiographs shows bilateral peri-articular multiple
elongated rice grain calcification with orientation along the muscle
fibres

01/22/2024
Figure 8:NCECT scan of the abdomen and CXR- multiple
horse-shoe, c-shaped calcification less than 1cm in
endothelium of chest and abdomen- armillifer armillatus

01/22/2024
Figure 9: AP radiograph of the knee shows multiple linear
calcifications in the medial and lateral soft tissues- dracunculiasis

01/22/2024
Figure 10: plane abdominal radiograph demonstrates
Multiple foci of calcification superimposed bilaterally
over buttocks.

 Injection granulomas

01/22/2024
 Neoplasms

Thyroid (goitre/medullary carcinoma of thyroid)

Lipoma
Haemangioma
Leiomyoma/leiomyosarcoma
Osteosarcoma
Synovial sarcoma
Chondrosarcoma
Necrotic tumour (following chemotherapy/radiation therapy)

01/22/2024
Figure 11: Plain knee radiograph shows large soft tissue
mass with sunburst periosteal reaction and specks of
calcification- osteosarcoma

01/22/2024
Figure 12: Lateral/AP forearm radiograph shows
diffuse soft tissue swelling with multiple phleboliths

 Haemangioma

01/22/2024
Figure 13: Lateral and AP neck radiograph shows
dense focal calcified goiter

01/22/2024
Figure 14: Plane right foot radiograph/T1 weighted CE MRI
images with fat suppression. Signal voids indicate calcification

Soft tissue sarcoma

01/22/2024
 Degenerative Diseases/Trauma
Calcium pyrophosphate deposition disease (CPPD)
Calcific tendinitis
Calcific bursitis
Pellegrini-Stieda lesion

Heterotopic ossification/myositis ossificans

Injection granulomas
Haematoma
Thermal injuries (burns and frost-bite)
01/22/2024
Figure 15: AP radiograph of the right knee- linear calcification
abutting medial femoral condyles. T2 weighted MRI confirms
lesion in region of proximal attachment of medial collateral
ligament.

 Pelligrini-stieda lesion.

01/22/2024
Figure 16: AP radiograph of the shoulder- globs of
amorphous calcification at supraspinatus tendon

 Calcific tendinitis

01/22/2024
Figure 17: Lateral knee radiograph showing
post traumatic bursitis

01/22/2024
Figure 18: AP left hip radiograph and T1
weighted MRI-Trochanteric bursitis

01/22/2024
Figure 19:Lateral ankle radiograph showing
dystrophic calcification in Achilles tendon

01/22/2024
 Connective tissue/autoimmune disorders
Scleroderma (progressive systemic sclerosis)
Autoimmune inflammatory myositis (dermatomyositis &
polymyositis)
Systemic lupus erythematosus (SLE)
CREST syndrome [Calcinosis cutis (usually seen under the skin of the
hands or wrists), Raynaud's phenomenon, Esophageal disorders,
Sclerodactyly, and Telangiectasia].

01/22/2024
Figure 20: AP/lateral knee radiographs- sheet like
calcifications along fascial planes, subcutaneous tissue,
soft tissue atrophy and osteoporosis

 Demotomyositis

01/22/2024
Figure 21: AP radiograph of the hand – multiple dense
and well defined calcified nodules.

 Scleroderma

01/22/2024
 Metabolic/metastatic calcifications
• Refers to deposition of calcium salts in previously normal tissue
resulting due to abnormal calcium metabolism
• Any process that elevates calcium-phosphorus product eg renal failure,
sarcoidosis, hyperparathyroidism
• Accounts for 1-2% of all STC seen in radiology
• Most are generally diffuse
• Common sites are alveoli, bronchial walls, kidneys, gastric mucosa,
heart
• Mechanisms are skeletal deossification, massive bone destruction,
hypercalcaemia, increased intestinal absorptiom.
01/22/2024
 Metabolic disorders

Renal osteodystrophy with 2o hyperparathyroidism

Hypoparathyroidism
Gout
Pseudogout (chondrocalcinosis)
Alkaptonuria)
Diabetes mellitus

01/22/2024
 Figure 22: AP radiograph of right hand -subperiosteal bone
resorption, lobulated calcified mass abutting ulna styloid process.
Magnified images-bone erosions of middle phalanges/acroosteolysis

 Hyperparathyroidism

01/22/2024
Figure 23: AP radiograph of foot- calcified soft tissue
swelling/juxta articular erosion at 1st metatarsophalangeal
joint.

 Gout
 Joint and bone density are normal
 No intra articular debris

01/22/2024
 Calcinosis
Calcium deposition in skin, subcutaneous, or deep connective tissues
in the presence of normal calcium metabolism.
Account for less than 1% of STC seen in Radiology.
Commonly seen related to joints associated with pain and reduced
joint mobility especially in tumoural calcinosis.
Three types of calcinosis:
1. Calcinosis circumscripta
2. Calcinosis universalis
3. Tumoural calcinosis –primary & secondary
01/22/2024
 Calcinosis circumscripta
Cutaneous or subcutaneous.
Distinctive, sharply marginated, punctate appearance in fingers.
Almost always associated with scleroderma.
Associated with sclerodactyly.
Referred to figure 21 above.

01/22/2024
 Calcinosis universalis
Unknown aetiology.
Calcification is usually diffuse.
Frequently associated with collagen vascular disease especially
dermatomyositis (figure 20 above)
Symptoms depends on organs involved.
Normal blood chemistry.
Looks like heterotopic ossification.
Initially, superficial and nodular or plaque-like.
Later, deeper tissues, more sheet-like and peri-articular.
01/22/2024
 Primary tumoural calcinosis
Primary tumoural calcinosis
Rare, familial, polyarticular, African-Americans
Large, multiloculated, cystic collections of Ca++ in/near large joints
Ca++ and phosphates serum levels are normal
Usually asymptomatic
May grow large enough to:
Cause pain from nerve pressure
Ulcerate and become secondarily infected
01/22/2024
 Secondary tumoural calcinosis
Secondary tumoural calcinosis
Chronic renal disease –50% of patients may have some associated
abnormalities in their renal lab work.
Abnormal serum phosphates levels(increased)
Monoarticular
The calcifications are usually large, globular, and located in the soft
tissues over joints.

01/22/2024
Figure 24: AP radiographs of elbow and oblique/lat. views of
hand- Uremic tumoral calcinosis

01/22/2024
Figure 25: Axial CT scan reveals multilobulated mixed
calcified/cystic lesions with sedimentation at greater
trochanteric bursae bilaterally- primary tumoral calcinosis

01/22/2024
 Miscellaneous/congenital causes
Breast calcifications
Nerve calcifications
Lymph nodes calcifications
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Ankylosing spondylitis
Tattoo marks
Foreign body (20surgery/other injuries)
Congenital
Ehlers-Danlos syndrome
Fibrodysplasia ossificans progressive (previously called myositis ossificans congenita
progressive)
01/22/2024
Pseudoxanthoma elasticum
Figure 26: Axial CECT scan of the abdomen-
calcification in wall of the gall bladder

01/22/2024
Figure 27: Axial NCECT scan of the orbits-
bilateral foci calcific lesions at optic discs

01/22/2024
Figure 28: Chest radiograph showing bilateral egg
shell nodal calcification

Egg shell calcification

 Silicosis
 Sarcoidosis
 Post radiotheraphy lymphoma

01/22/2024
Figure 29: Breast mammographic images showing
amorphous and linear calcification

01/22/2024
 Conclusion
Soft tissue calcifications can be due to diverse causes which can be
broadly grouped into dystrophic, metastatic (metabolic), and calcinosis.
Conventional radiography/x-rays remains vital in the initial assessment
of most cases of STC, given their inexpensive cost and widespread
availability.
While MR imaging has become the imaging technique of choice in the
evaluation of soft-tissue lesions, it can grossly underestimate
calcification which can have variable appearance depending upon the
amount of calcium.
Ultrasound and CT may be used for precise localization of STC and to
assess the noncalcified component of tissues.
Clinical history and laboratory investigations are vital in the radiological
management of patients with STC.
01/22/2024
 References
Banks KP, Bui-Mansfield LT, Chew FS et-al. A compartmental approach to
the radiographic evaluation of soft-tissue calcifications. Semin Roentgenol.
2005;40 (4): 391-407.
Dähnert W (2007). Radiology Review Manual. Lippincott Williams & Wilkins
Philadelphia. Pp 26-27.
Grainger R, Andy A, Adrian D, Jonathan G, Cornelia SP (2014). Grainger &
Allison's Diagnostic Radiology. 6thedition. Churchill Livingstone. Pp 957-962.
Herring W (2007). Learning Radiology: Recognizing the Basics. 1st edition.
Mosby Elsevier Philadelphia. Pp 173-180.
Calcification in soft tissues V L stewart et al. JAMA 1983
Imaging features of soft tissue calcifications and related disease: a
systematic approach. Zhen- An Hwang et al. Korean J Radiol. Nov- Dec 2018.
01/22/2024
 References cont.
http://learningradiology.com/lectures/bonelectures/
softtissuecalc2012/Soft%20Tissue%20Calcifications/Soft%20Tissue
%20Calcifications.html
http://learningradiology.com/archives05/COW%20163-
Nephrocalcinosis/nephrocalcinosiscorrect.htm
https://radiopaedia.org/articles/soft-tissue-calcification-2
https://rad.washington.edu/about-us/academic-sections/
musculoskeletal-radiology/teaching-materials/online-
musculoskeletal-radiology-book/soft-tissue-calcifications/

01/22/2024