Calcifying tendinitis of the rotator cuff with cortical erosion and intraosseus migration: the importance of its recognition.

Transcription

1 Calcifying tendinitis of the rotator cuff with cortical erosion and intraosseus migration: the importance of its recognition. Poster No.: P-0048 Congress: ESSR 2015 Type: Scientific Poster Authors: J. Martel Villagrán, M. C. Pardo Souto, Á. Bueno Horcajadas, S. Martin Martin, M. Gil ; Madrid/ES, Ferrol/ES, Alcorcon/ES, 4 5 Palma de Mallorca/ES, Lérida/ES Keywords: Diagnostic procedure, MR, CT, Conventional radiography, Musculoskeletal system, Calcifications / Calculi DOI: /essr2015/P-0048 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 25

2 Purpose The aim of the present work is to show the imaging findings of calcifying tendinosis with cortical erosion and intraosseous migration (CTCEIM) affecting to the shoulder. Calcifying tendinosis is a common disorder of unclear etiology characterized by the formation of calcium hydroxyapatite crystals within a tendon, mostly involving the rotator cuff, mainly the supraspinatus tendon, and less frequently other tendons in virtually any location. In rare cases -there are a few cases of CTCEIM previously described in the literature- calcium located into the tendon can induce bone erosion and then it can suffer intraosseous migration. The causes of CTCEIM are unknown. Hypotheses of the bone erosion include active inflammation and local hypervascularization at the tendon insertion or mechanical effects of muscle traction. The radiological manifestations of shoulder CTCEIM depends both on the location of calcium deposits and on the phase of the process. Stages of CTCEIM Fig. 1 on page 4 : A. Silent phase: subclinical calcium deposition occurs in the rotator cuff tendons. B. Mechanical phase: B.1. Elevation of the floor of the bursa. Due to the increase of crystals deposition, the floor pushes upwards the subacromial (subdeltoid) bursa. B.2. Breakage and spreading of calcium collections below the floor of the bursa. B.3. intrabursal breakage. The crystals are expelled into the bursa. C. Adhesive periarthritis phase Sometimes, we can find shoulder adduction because of adhesive bursitis. D. Intraosseous loculation: Calcium deposits spreads into the bone. E. "Hourglass" loculation (rarely evidenced): a bilobed reservoir secondary to pressure from the adjacent coracoacromial ligament. CTCEIM differential diagnosis. CTCEIM can be a difficult diagnosis. Plain films, ultrasound, CT and MRI studies can be needed. CTCEIM is an important entity to recognize because it can often lead to confusion with other processes such as infectious or malignant diseases, resulting in unnecessary biopsies or interventions. The CTCEIM differential diagnosis is wide, including Page 2 of 25

3 osteoma, osteoid osteoma, osteoblastoma, chondroblastoma, osteoblastic metastases, osteonecrosis, erosion from synovial diseases or even soft tissue sarcoma with secondary bone infiltration. Page 3 of 25

4 Images for this section: Fig. 1: Different stages of calcifying tendinitis: calcium deposit in the tendon (A), elevation of the floor of the subacromial bursa (B), breakage of the bursa and the calcium is expelled into the bursa (C), calcium deposit extends to the bone (intraosseous migration) (D). (Illustration adapted from Resnick and Kransdorf: Bone and Joint Imaging. 3td; Ed. Elsevier Spain, 2006). Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 4 of 25

5 Methods and Materials We reviewed the imaging (plain film, ultrasound, multidetector computed tomography and magnetic resonance imaging) findings of 7 shoulder patients with CTCEIM (2 male and 5 female), years old. All patients presented with a history of pain with exacerbation and loss of function of the shoulder, in whom migration of calcium located in the rotator cuff tendons into the humeral head was demonstrated by imaging. Three cases were related to subscapular tendon, two to the supraspinatus tendon and the other two were originated in the infraspinatus tendon. Sex Age Location Biopsy Surgery Case nº1 Female 30 Supraspinatu No Yes Case nº2 Male 42 SupraspinatusNo No Case nº3 Female 54 SubescapularisYes No Case nº4 Female 41 Infraspinatus No No Case nº5 Male 48 Infraspinatus No No Case nº6 Female 28 Subscapularis No No Case nº7 Female 50 Subscapularis No No Page 5 of 25

6 Results CTCEIM imaging approach: In patients with a painful shoulder, if an imaging study is considered necessary after anamnesis, the first technique of choice is conventional Xray, recommending at least two projections. Although X-ray sometimes is not enough to achieve a definitive diagnosis of CTCEIM, we must keep this entity in mind if we find calcifications in the pathway of a tendon, have the typical "comet tail" arrangement or if bone erosion is found in the tendinous insertion point. Ultrasound is a complementary technique to conventional radiology, being very reliable in the diagnosis of calcifying tendinosis, and allowing acurate assessment of calcifications and the study of the possibly associated tendon ruptures. It can also detect cortical erosions, but its main disadvantage is that it cannot evaluate the bone medullary cavity. MRI is a second line choice, being a very accurate technique to the rotator cuff disease diagnosis, adding the ability to visualize both the cortical and spongy bone lesions. MRI may overestimate CTCEIM due to the bone and soft tissue edema associated with the inflammatory component of calcifying tendinosis; it also has a very limited usefulness to the study of calcifications. MDCT is reserved to cases where there is any doubt about bone injury. MDCT nicely depicts the cortical disruption, showing the relationship with the tendon and the "comet tail" appearance of calcifications. Plain films demonstrated a lytic lesion with calcifications in 2 cases, a sclerotic lesion in 3 cases and a single lytic lesion in 2 cases. Similar findings were described at MDCT, when MR findings were confusing because of an extensive pattern of bone marrow edema. In three cases patients were misdiagnosed and an open biopsy was performed. Conservative treatment was useful in all the cases but one, in which surgery was performed to remove the calcium. We show images of five of the seven cases. Case 1: Page 6 of 25

7 A 30-year-old woman complaining of pain and functional limitation of the left shoulder for months. She underwent a shoulder X-ray which showed a sclerotic lesion with radiolucent halo in the humeral head Fig. 2 on page 10. MRI showed a lytic lesion with low SI content in all sequences and perilesional edema Fig. 3 on page 10. The rotator cuff was not injured. A previous plain radiograph of the left shoulder taken 7 months earlier showed calcifying tendinosis in the supraspinatus tendon Fig. 4 on page 11. Surgery of the lytic humeral lesion was performed. The intraoperative pathological finding was a cystic intraosseous cavity with small foci of calcium Fig. 5 on page 12. Further study of the pathological specimen showed fragments of bone tissue with foci of dystrophic calcification, findings compatible with calcium intraosseous migration, and a CTCEIM diagnosis was confirmed. Case 2: A 42-year-old male with pain in left shoulder for two months that did not improve after treatment. A radiograph of the left shoulder showed a calcification in the distal region of the supraspinatus tendon and a small sclerotic lesion in the humeral head Fig. 6 on page 13. A MRI was performed which demostrated a cystic lesion with an internal hypointense image suggestive of calcifying tendinitis with intraosseous migration Fig. 7 on page 14. Afterwards, he underwent a MDCT to confirm the CTCEIM suspected diagnosis, showing a calcium deposit within the lytic lesion as well as a cortical erosion Fig. 8 on page 14 Case 3: A 54-year-old woman with a history of successfully treated breast cancer, with no evidence of recurrence or distant metastatic disease after two years, presented with right shoulder pain for months. The initial MRI study, performed in another center, showed humeral head edema Fig. 9 on page 15. A metastatic lesion was suspected and a biopsy of the lesion was performed, which was negative for malignancy. Page 7 of 25

8 Afterwards, the patient underwent an X-ray, a MRI and a MDCT of the shoulder in our center. MRI post-biopsy images show a cystic lesion with perilesional edema Fig. 10 on page 16. MDCT images revealed a lytic lesion with cortical erosion in the anterior region of the humeral head. In addition, MDCT showed a small extraosseous calcification, adjacent to the lytic lesion, in the distal region of the subscapularis tendon Fig. 11 on page 17. All these findings were considered suggestive of CTCEIM of the subscapularis tendon. Two months after the biopsy, a MRI scan revealed disappearance of the bone edema Fig. 12 on page 18, consisting with a CTCEIM diagnosis. Case 4: A 41-year-old woman with no relevant medical history suffering left shoulder pain for months. A plain radiograph and a shoulder ultrasound study showed calcifying tendinosis of the infraspinatus tendon, with minimal erosion of the cortical bone. The patient pain did not improve despite medical treatment, and a MDCT study was performed showing a sclerotic lesion in the posterior region of the humeral head associated with a minimal cortical erosion. There were also yuxtacortical calcifications with a "comet tail" linear arrangement located within the infraspinatus tendon Fig. 13 on page 19 Subsequently, the patient underwent a MRI which showed a lesion with sclerotic borders and a cortical erosion associated with significant perilesional edema and a small calcium deposit inside the lesion. The infraspinatus tendon calcifications were also visualized Fig. 14 on page 20 A tentative diagnosis of CTCEIM of the infraspinatus tendon was done. The clinical and radiological outcome confirmed this diagnosis. Case 5: A 48-year-old male suffering left shoulder pain for weeks. A shoulder X-Ray (with both anteroposterior and oblique projections) was considered normal Fig. 15 on page 21 Page 8 of 25

9 The patient had pain despite medical treatment, so he underwent a MDCT which showed a lytic lesion containing punctate calcifications in the posterior region of the humeral head associated with cortical erosion Fig. 16 on page 21. All these findings are consistent with CTCEIM of the infraspinatus tendon. An US study was later performed to check the infraspinatus tendon condition, which shows cortical erosion and migration intrasubstance, but fibrillar pattern of the tendon does not have significant alterations Fig. 17 on page 21 Page 9 of 25

10 Images for this section: Fig. 2: Anteroposterior plain radiograph of the left shoulder reveals a sclerotic lesion with radiolucent halo in the greater tuberosity (arrow). Diagnóstico por Imagen, Hospital Son Llatzer - Palma de Mallorca/ES Page 10 of 25

11 Fig. 3: Coronal and axial DP (A,B) and coronal and axial DP FAT SAT MRI (C,D). A lytic lesion is observed in the greater tuberosity with a content that shows low signal intensity in all sequences, corresponding to the sclerotic lesion observed on the plain radiograph. In addition, there is extensive perilesional edema. Diagnóstico por Imagen, Hospital Son Llatzer - Palma de Mallorca/ES Page 11 of 25

12 Fig. 4: Anteroposterior plain radiograph of the left shoulder taken 7 months before shows calcifying tendinosis in the thickness of the supraspinatus tendon. Diagnóstico por Imagen, Hospital Son Llatzer - Palma de Mallorca/ES Page 12 of 25

13 Fig. 5: Anteroposterior plain radiograph performed a few months after surgical intervention shows the disappearance of both the calcium deposits and the sclerotic lesion. Diagnóstico por Imagen, Hospital Son Llatzer - Palma de Mallorca/ES Page 13 of 25

14 Fig. 6: Anteroposterior plain radiograph shows a calcification in the distal region of the supraspinatus tendon and a small sclerotic lesion in the humeral head (arrow). IDI. Hospital Arnau i Vilanova - Lérida/ES Fig. 7: Coronal SPIR T2 and coronal DP MRI images demostrate a cystic lesion with a hypointense image inside suggestive of calcifying tendinitis with intraosseous migration. IDI. Hospital Arnau i Vilanova - Lérida/ES Page 14 of 25

15 Fig. 8: Coronal and sagittal CT images confirm the suspected diagnosis, showing a calcium deposit within the lytic lesion and erosion of the cortical. IDI. Hospital Arnau i Vilanova - Lérida/ES Page 15 of 25

16 Fig. 9: Coronal T2 image show significant edema in humeral head that it is suspected to be a metastatic lesion because the patient had a history of breast cancer. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 16 of 25

17 Fig. 10: Coronal T1 and coronal SPAIR T2. The MRI post-biopsy images show a cistyc lesion with perilesional edema. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 17 of 25

18 Fig. 11: Axial and coronal computed tomography images reveale a lytic lesion with cortical erosion in the anterior region of the humeral head. Adjacent to this lesion, in the distal region of the subscapularis tendon, it showes a small extraosseous calcification (arrows). Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 18 of 25

19 Fig. 12: MRI reveals disappearance of edema of the humeral head two months after the biopsy. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 19 of 25

20 Fig. 13: Axial computed tomography images shows a sclerotic lesion in the posterior region of the humeral head with minimal cortical erosion. Also, there are yuxtacortical calcifications with a "comet tail" linear arrangement located within the infraspinatus tendon. IDI. Hospital Arnau i Vilanova - Lérida/ES Page 20 of 25

21 Fig. 14: Axial and coronal STIR. MRI shows a lesion with sclerotic borders and cortical erosion with important perilesional edema and a small calcium deposit inside of the lesion (black arrows). The infraspinatus tendon calcifications also visualized (white arrow). IDI. Hospital Arnau i Vilanova - Lérida/ES Fig. 15: The shoulder X-ray is normal in both anteroposterior and oblique projections. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Fig. 16: Axial and coronal computed tomography images shows a lytic lesion in the posterior region of the humeral head with cortical erosion and punctate calcifications inside. All these findings are consistent with calcifying tendinitis of the infraspinatus tendon with cortical erosion and intraosseous migration. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 21 of 25

22 Fig. 17: An US study shows cortical erosion and migration intrasubstance (arrow), but fibrillar pattern of the tendon does not have significant alterations. Note the powerful musculature had this patient. Diagnóstico por Imagen, Hospital Universitario Fundación de Alcorcón - Madrid/ES Page 22 of 25

23 Conclusion CTCEIM is a rare entity which diagnosis can be difficult. We must keep in mind the imaging findings of this entity in order to avoid aggressive procedures and unnecessary surgery. Page 23 of 25

24 References 1. Morán L.M, González M. Tendinosis calcificante del pectoral mayor con migración intraósea. Radiología, 2011; 53 (4): Resnick D, Kransdorf J. Bone and Joint Imaging. 3td. Elsevier Spain; Martin S, Rapariz J.M. Intraosseous calcium migration in calcifying tendinitis: a rare cause of single sclerotic injury in the humeral head. Eur Radiology, 2010; 20: Chan R, Kim D, Millett P, Weissman B. Calcifying tendinitis of the rotator cuff with cortical bone erosion. Skeletal Radiology, 2004; 33: JJ, Kransdorf MJ. Osseous involvement in calcific tendinitis: A retrospective review of 50 cases. AJR Am J Roentgenol. 2003;181: Cahir J, Saifuddin A. Calcific tendonitis of pectoralis major: CT and MRI findings. Skeletal Radiol. 2005;34: Kraemer EJ, El-Khoury G. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol. 2000;29: Seyahi A, Demirham M. Arthroscopic Removal of Intraosseous and Intratendinous Deposits in Calcifying Tendinitis of the Rotator Cuff. Arthroscopy, 2009; 25: Curtis et al. Calcium hidroxiapatite deposition disease. Radiographics 1990; 10: Page 24 of 25

25 Personal Information (first author): Page 25 of 25