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Tumor calcification after radiotherapy demonstrated by computed tomography
b. Kreel, M.D., F.A.C.P., F.R.C.R. Q. Bydder, F.R.A.C.B.
An EMI CTSWS whole-body scrmner was used to obtain 20.set scnne in Ihc abdomen and 65.~~ scansin the head and pelvis.
Division of RadIology, Cllnlcsl Research Centre and Northwick Park Hospital, Harrow, Middlesex
CASti
REPORTS
Cnse 1
Ossification or calcification in soft tissue tumors following radiotherapy archcmothcmpy may bedemonrtratcd by cosventioti radiological methods (l-7). Computed tonwgraphy (CT), with its hiph scnaitivity in the detcstion of calcium, offers an additional technkw for the recognition of this phenomenon and can distinguish between ossification, where cortex and medulla are shown. and calcification, which appears amorphous. Three eaves diagnosed by CC are described, one of which clearly showed ossification, while the other two casesdisplayed amarphour calcification.
Patients requirbw body scans were oreoared with a low-residue~diet &d &al calcium phoipbate for 2 days, followed by 6Qa-jMo ml of 2.5% @rtrografin (mcglumine and sodium diatrizoate) orally lo-20 min prior to the examination. lnlravcoous $Iucagon (0.25 mn) was used and repcared as nece8s8ry to W.W.Z bowel paresis. No specific preparation WBSused for the head ~cano.
A 55-yeardld man presentedwith a I-year history of back pain 10 year5 after an abdominal-perineal resetdon for carcinoma of the rectum. On examination there was a palpable maas over the left posterior s8cnml. The initial CTscau showed a 6x4cm soft iissue i.;.us in the left preracral region inliltrating the pyriformir muscle and the adjacent ELIC.~UIII (Figure I). A full course of radiotherapy was administered with symptomatic improvement but some fullnasmmained over the left buttock on palpad;... The follow-up CT sum I months later showed the mass bad decreasedin size to 5 x 2.5 cm and had developed coarse, irmgular upacification (Figure 2) with a clearly defixd cortex and medulla, indicating ossification (Figare 3). Histograms of attenuation values of the tumor’showcd an increasein mean wlue
from Il.7 10 63.9 EMI units and nn incrcev In rouphncss(Figure 4). Cnt 2 A 37.year-cnldman prewnted with intraclable vomiting. Al !aParotomy a large inlra-abdomiccd mm1 wits To .nd and biopy of thir lesion revealed a malignant lymphnma. Afftr a 3.week course of radiahcrapy of
Irfwrncy
aa%d in size lo 7 X 7 an and dcvdopad marked ITrc~ulnr crkirrrtion (Fisurc 6). A Ihird CT wmirutioa 2month5 later ahoweddnochmsin the sizeof I~C orl&~I mass bul lers c1)cificatio. (Fiiurc 7). How. mars YIU now interposed. and there wu incrcuc in lbccizeof ther*ulhllrrlym~opathywithmare obvbu bydmtwphrtis. A p&in abdomir4 mm *It SI tbir IinM but prior to the Bdmbllstra~ of &=tm#nfb~ showed COWS akilM&n (F&we 8).
A 62-yarold WOIIUSIwith biopsy-prove carcinoma of the wopfwvu and lymphrdewprthy in the neck wm trated dab radiotterapy. She presented 3 yew
later with persisten occipital pain. A CT scanshowed an area of clllriticatidn lying immediatety anterior to ihe margin of the f&amen magnum and below the clivus II the she of rhe previous biopsy (Figure 9).
DISCUSSION
In threedifferent typc~ of tumor, auificationorcelcitiution following radiihcmpy WLE readily detectable on CT. I1 was .%ociaal with a favorabk local rcqxmsc in all thrcr CSCYbut adjumt rnurr~~~ in case 2. The incidence of this phenomenon is difficult to estimate from the wvcral SMU series and spxadn’
V&n aclcnrly delinedconex~o~crviribleon CT in Ihr area of calcium &position, [be appcxancc indicarcs actual ouifkution nthe, Finn cnlcificaion. but this dinlinclion mlty nM be visibtc on rhe plain litm. Wbil: hii,Oloscat orstffcntion may bc presentin the tomu, showing calcium depo& radiologically. osriffcat!on an ool* be diinoxd whm there are fea-
ACILNOWLEDCMrXTS We are grateful to the Dcpanment of Health and Social Sxurity. whose farsighted made this study pasibtc. Thanks OTCalso due IO Mrs. Jane1 Thomtxm. wh.3 pepnred Ihe manuscript.
support
and Johnson (4) ,eluwwJ a posmdivc seriesof 164 pnitals wilh Hcxigkir~‘s daeaw uno received radia. #IO” to the n.?disuinum. four ot whom developed wde cakiflcaoon a, interaIr of I-J yrars afrer treat. men,. Thor ,ar rnzy welt rmy wilh :h< type of tumor. rndinuon dwc. aud ~nclbodof dcle.tionofthccnlcif~carion
The ~mwcw,desy,rad orcof CI will undoubtedly lca.i to blcrcaat rccognirion 01 ttnt phenomenon, xtrlrough thcl c are some ddftcutws in inlerprekaion. The fmrwl volunre :ffcct m7.y ksd IO rhe e,,oneO”s tmpression uf cntcdca,i;,u in sol: ,iswc adj;cc,d to bone. but xxu,a,e inlcrpretation can oamtl) be achieved by craminstion of slicer pdjncent fo Ihe itice cl inrerat. The ,o,,,rti “ye of oral con,,asf agmtr of tqh r:.dlotogicnt dcns~ly 10 identify bowel may create D. probks i? interpretation. sixc i, may appear thal bowel has hccn %ccln,~cd adjawnt to thctumo, rarhc, ~hfmtha?
COl41 lWJ3tiG hFL?R
MEIHCAL
RAMOTHELUPY
LDUCATEOOH QUESTtONS DBL3fONSTllAlEXl
(TUMOR
BY COMPUT3l
CA LCIFXAIXIN WCMOG4AS’H;‘~
Tree or Fdxc:
Ifrom
I.
Radmlogical
2.
medullary compoacol,. The partial vuiume cffccl may give the erran )ous imprez #ion of calcilicarion
ossification
in sol1 tiw_c may be dirrir guishe
cnlcifics
ion b) the presence oicartictd
in soft tissue lesions adjacent to
‘,OW. 3.
Leccnr
5.
Contract-:antaining
hw~orrhagc
canoal bowl
he diffcrcniixted adjacenl
from ca’cificaticn
to lumor may ‘A Grakcn
and
by rhc me of dua! energy GIN. for soft tissue calcification.
An EMI CTSWS whole-body scrmner was used to obtain 20.set scnne in Ihc abdomen and 65.~~ scansin the head and pelvis.
Division of RadIology, Cllnlcsl Research Centre and Northwick Park Hospital, Harrow, Middlesex
CASti
REPORTS
Cnse 1
Ossification or calcification in soft tissue tumors following radiotherapy archcmothcmpy may bedemonrtratcd by cosventioti radiological methods (l-7). Computed tonwgraphy (CT), with its hiph scnaitivity in the detcstion of calcium, offers an additional technkw for the recognition of this phenomenon and can distinguish between ossification, where cortex and medulla are shown. and calcification, which appears amorphous. Three eaves diagnosed by CC are described, one of which clearly showed ossification, while the other two casesdisplayed amarphour calcification.
Patients requirbw body scans were oreoared with a low-residue~diet &d &al calcium phoipbate for 2 days, followed by 6Qa-jMo ml of 2.5% @rtrografin (mcglumine and sodium diatrizoate) orally lo-20 min prior to the examination. lnlravcoous $Iucagon (0.25 mn) was used and repcared as nece8s8ry to W.W.Z bowel paresis. No specific preparation WBSused for the head ~cano.
A 55-yeardld man presentedwith a I-year history of back pain 10 year5 after an abdominal-perineal resetdon for carcinoma of the rectum. On examination there was a palpable maas over the left posterior s8cnml. The initial CTscau showed a 6x4cm soft iissue i.;.us in the left preracral region inliltrating the pyriformir muscle and the adjacent ELIC.~UIII (Figure I). A full course of radiotherapy was administered with symptomatic improvement but some fullnasmmained over the left buttock on palpad;... The follow-up CT sum I months later showed the mass bad decreasedin size to 5 x 2.5 cm and had developed coarse, irmgular upacification (Figure 2) with a clearly defixd cortex and medulla, indicating ossification (Figare 3). Histograms of attenuation values of the tumor’showcd an increasein mean wlue
from Il.7 10 63.9 EMI units and nn incrcev In rouphncss(Figure 4). Cnt 2 A 37.year-cnldman prewnted with intraclable vomiting. Al !aParotomy a large inlra-abdomiccd mm1 wits To .nd and biopy of thir lesion revealed a malignant lymphnma. Afftr a 3.week course of radiahcrapy of
Irfwrncy
aa%d in size lo 7 X 7 an and dcvdopad marked ITrc~ulnr crkirrrtion (Fisurc 6). A Ihird CT wmirutioa 2month5 later ahoweddnochmsin the sizeof I~C orl&~I mass bul lers c1)cificatio. (Fiiurc 7). How. mars YIU now interposed. and there wu incrcuc in lbccizeof ther*ulhllrrlym~opathywithmare obvbu bydmtwphrtis. A p&in abdomir4 mm *It SI tbir IinM but prior to the Bdmbllstra~ of &=tm#nfb~ showed COWS akilM&n (F&we 8).
A 62-yarold WOIIUSIwith biopsy-prove carcinoma of the wopfwvu and lymphrdewprthy in the neck wm trated dab radiotterapy. She presented 3 yew
later with persisten occipital pain. A CT scanshowed an area of clllriticatidn lying immediatety anterior to ihe margin of the f&amen magnum and below the clivus II the she of rhe previous biopsy (Figure 9).
DISCUSSION
In threedifferent typc~ of tumor, auificationorcelcitiution following radiihcmpy WLE readily detectable on CT. I1 was .%ociaal with a favorabk local rcqxmsc in all thrcr CSCYbut adjumt rnurr~~~ in case 2. The incidence of this phenomenon is difficult to estimate from the wvcral SMU series and spxadn’
V&n aclcnrly delinedconex~o~crviribleon CT in Ihr area of calcium &position, [be appcxancc indicarcs actual ouifkution nthe, Finn cnlcificaion. but this dinlinclion mlty nM be visibtc on rhe plain litm. Wbil: hii,Oloscat orstffcntion may bc presentin the tomu, showing calcium depo& radiologically. osriffcat!on an ool* be diinoxd whm there are fea-
ACILNOWLEDCMrXTS We are grateful to the Dcpanment of Health and Social Sxurity. whose farsighted made this study pasibtc. Thanks OTCalso due IO Mrs. Jane1 Thomtxm. wh.3 pepnred Ihe manuscript.
support
and Johnson (4) ,eluwwJ a posmdivc seriesof 164 pnitals wilh Hcxigkir~‘s daeaw uno received radia. #IO” to the n.?disuinum. four ot whom developed wde cakiflcaoon a, interaIr of I-J yrars afrer treat. men,. Thor ,ar rnzy welt rmy wilh :h< type of tumor. rndinuon dwc. aud ~nclbodof dcle.tionofthccnlcif~carion
The ~mwcw,desy,rad orcof CI will undoubtedly lca.i to blcrcaat rccognirion 01 ttnt phenomenon, xtrlrough thcl c are some ddftcutws in inlerprekaion. The fmrwl volunre :ffcct m7.y ksd IO rhe e,,oneO”s tmpression uf cntcdca,i;,u in sol: ,iswc adj;cc,d to bone. but xxu,a,e inlcrpretation can oamtl) be achieved by craminstion of slicer pdjncent fo Ihe itice cl inrerat. The ,o,,,rti “ye of oral con,,asf agmtr of tqh r:.dlotogicnt dcns~ly 10 identify bowel may create D. probks i? interpretation. sixc i, may appear thal bowel has hccn %ccln,~cd adjawnt to thctumo, rarhc, ~hfmtha?
COl41 lWJ3tiG hFL?R
MEIHCAL
RAMOTHELUPY
LDUCATEOOH QUESTtONS DBL3fONSTllAlEXl
(TUMOR
BY COMPUT3l
CA LCIFXAIXIN WCMOG4AS’H;‘~
Tree or Fdxc:
Ifrom
I.
Radmlogical
2.
medullary compoacol,. The partial vuiume cffccl may give the erran )ous imprez #ion of calcilicarion
ossification
in sol1 tiw_c may be dirrir guishe
cnlcifics
ion b) the presence oicartictd
in soft tissue lesions adjacent to
‘,OW. 3.
Leccnr
5.
Contract-:antaining
hw~orrhagc
canoal bowl
he diffcrcniixted adjacenl
from ca’cificaticn
to lumor may ‘A Grakcn
and
by rhc me of dua! energy GIN. for soft tissue calcification.