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The Journal of Clinical Endocrinology & Metabolism Vol. 93, No. 4 1121-1122
Copyright © 2008 by The Endocrine Society

IMAGE IN ENDOCRINOLOGY

Massive Soft Tissue Calcifications and Cinacalcet

Simona Zerbi, Pio Ruggiero and Luciano A. Pedrini

Nephrology and Dialysis Unit, Bolognini Hospital, 24068 Seriate, Italy

Address all correspondence and requests for reprints to: Simona Zerbi, M.D., Nephrology and Dialysis Unit, Bolognini Hospital, Via Paderno 21, 24068 Seriate (Bergamo), Italy. E-mail: simona.zerbi{at}tiscali.it.

A 37-yr-old man on long-term hemodialysis developed a relapse of secondary hyperparathyroidism after subtotal parathyroidectomy. Dialysis treatment adjustment and conventional medical therapies, involving noncalcium phosphate binders and active vitamin D sterols, proved ineffective. Painful and rapidly increasing tumor-like masses appeared over the second finger and the back of his right hand. Laboratory studies showed persistent serum levels of intact PTH of more than 1500 pg/ml and calcium-phosphate product of more than 100 mg2/dl2 [recommended levels in dialysis patients, 150–300 pg/ml (16.5–33 pmol/liter) and <55 mg2/dl2, respectively] (1). A radiograph of the right hand revealed massive soft tissue swelling and calcifications (Fig. 1Go).


Figure 1
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  		FIG. 1. Plain film of the right hand showing massive soft tissue swelling and huge calcifications around the ungual and middle phalanx of the second finger and over the carpus-metacarpus area.

 
Due to the patient’s disinclination for further surgical treatment, we decided to administer cinacalcet (2, 3), a calcimimetic agent, at doses of 30–60 mg/d, achieving a significant suppression of intact PTH (350 pg/ml) and calcium-phosphate product (60 mg2/dl2). After correction of the calcium-phosphate product, oral calcitriol and calcium acetate were administered. Six months later, a radiographic control showed the disappearance of the calcifications (Fig. 2Go).


Figure 2
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  		FIG. 2. Radiographic control showing the complete disappearance of the calcifications.

 
Massive soft tissue calcification is a feature of severe renal hyperparathyroidism and is due to chronic elevation of calcium-phosphate product, resulting in the precipitation of calcium phosphate. The calcified masses should not be misdiagnosed as tumors and surgically excised, because they will recur unless the biochemical abnormalities are corrected (4). High serum calcium and phosphate levels may also cause disseminated calcification in the skin, joints, viscera, and arteries (calciphylaxis) resulting in painful ischemic necrosis of skin and gangrene, cardiac arrhythmias, and pulmonary failure. Uncontrolled hyperphosphatemia and progressive metastatic calcifications have always been indications for surgical parathyroidectomy (5). When conventional therapies have been exhausted, cinacalcet represents an exceptional therapeutic opportunity particularly for patients exposed to technical difficulties linked to a neck re-operation (3).


   Footnotes
 
Conflict of Interest Statement: The authors declare no conflict of interest.

Received October 3, 2007.

Accepted January 24, 2008.


   References
Top
 References
 

  1. National Kidney Foundation 2003 K-DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 42:S1–S201
  2. Block GA, Martin KJ, de Francisco AL, Turner SA, Avram MM, Suranyi MG, Hercz G, Cunningham J, Abu-Alfa AK, Messa P, Coyne DW, Locatelli F, Cohen RM, Evenepoel P, Moe SM, Fournier A, Braun J, McCary LC, Zani VJ, Olson KA, Drueke TB, Goodman WG 2004 Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med 350:1516–1525[Abstract/Free Full Text]
  3. Lomonte C, Antonelli M, Losurdo N, Marchio G, Giammaria B, Basile C 2007 Cinacalcet is effective in relapses of secondary hyperparathyroidism after parathyroidectomy. Nephrol Dial Transplant 22:2056–2062[Abstract/Free Full Text]
  4. Adams JE 2002 Dialysis bone disease. Semin Dial 15:277–289[CrossRef][Medline]
  5. Ureña P, Basile C, Grateau G, Lacour B, Vassault A, Bordeau A, Bourdon R, Dubost C, Zingraff J, Druëke T 1989 Short-term effects of parathyroidectomy on plasma biochemistry in chronic uremia. Kidney Int 36:120–126[Medline]



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