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Case report
TUMORAL CALCINOSIS-LIKE LESION IN THE NASALSEPTUM IN END-STAGE RENAL DISEASE
M!"# P$%$' I"()# M*$ V$**#1 ' C* S+2' P#,* R.$)3' O* L.#%"#'
C*$+" L#)-C*"$45
Department of Otorhinolaryngology, Department of Pathology, Department of Radiology
Department of Nephrology.
Puerta de Hierro University Hospital, Madrid Spain
I%"*,.6"$%
A tumoral alinosis!li"e
lesion or metastati
alifiation is a pathologi
ondition harateri#ed $y
deposits of alium%
phosphate rystals &ithin
other&ise normal soft tissue
as a result of hyperphosphatemia &ith or
&ithout onurrent
hyperalemia. 'here is a
hereditary and an a(uired
possi$le etiology )*+
Metastati alifiation is a
&ell "no& ompliation of
end%stage renal disease,
ho&ever the presene of
these deposits presented
linially as a nasal lesion is
etremely rare )-, +
C+# R#*"
A /0!year%old male &ith
end%stage renal disease, ahistory of hroni renal
failure and aute myoardial
infartion 1&ith stent
implantation2, presented
himself &ith a s&elling of
the anterior nasal septum.
Sine May -333 he &as
treated &ith hemodialysis.
'he hemodilutor that is used
during these proedures is
fragmented heparin. During
Cite: Mayte P, Ithzel M, Clara S, Pedro R, Omar L, Cristobal LC, Tumoral calcinosis like lesin
in the nasal septum in end sta!e renal disease, "ournal o# $ead and %eck physicians and
sur!eons, &'()*(+(:(-.&/
19
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4uly -33*, the patient slo&ly
developed a painless
s&elling in the nasal septumthat progressed more rapidly
over the last day of that
month. On eamination, the
s&elling &as a round lesion
of approimately - m in
diameter and affeted the
artilaginous anterior septum
in $oth sides. 'he remaining
nasal septum did not sho&
any a$normalities. On the
surfae the lesion had &hite
points and &as slightly
flutuant upon palpation.
Although the patient did not
have fever, a nasal a$sess
&as suspeted and the lesion
&as eplored under loal
anesthesia 1lidoaine -5
adrenaline *6*333.3332. Aaseous material &as
evauated from multiloular
tissue. 7ultures of this
material remained sterile.
Radiologi studies &ith 7'
san revealed a foal lesion
in the anterior nasal septum
&ith multiple, rounded
opaities separated $y
radioluent lines in a laminar
pattern. 18igure *a2
'he tissue from the $iopsy
sho&ed a entral mass of
amorphous and alifiedmaterial inside a dense
fi$rous tissue and $ordered
$y a nodular proliferation of
marophages and
multinulear ells. 18igure
*$2
9a$oratory findings
presented a severe seondary
hyperparathyroidism &ithhyperphosphatemia $ut no
evidene of inreased
alium levels: a
'ehnetium%;; parathyroid
san sho&ed a hyperplasia of
$oth inferior parathyroid
glands.
Radiologial imaging of
large $ones revealed noevidene of alinosis
involving either their soft or
periartiular tissues.
'he patient had a (ui"
reovery after the operation
and intravenous vitamin D
&as administered to ontrol
hyperparathyroidism and
later on a parathyroidetomy&as performed. During
Cite: Mayte P, Ithzel M, Clara S, Pedro R, Omar L, Cristobal LC, Tumoral calcinosis like lesin
in the nasal septum in end sta!e renal disease, "ournal o# $ead and %eck physicians and
sur!eons, &'()*(+(:(-.&/
20
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follo&%up one year later, the
patient presented a minimal
lesion &ithout any signs ofne& deposits in the septal
area. At present the patient is
alive &ithout nasal
symptoms.
D$+6.++$%
'umoral alinosis is a
ongenital or a(uired defet
in alium meta$olism thatin the first ase is inherited
aording to a dominant or
reessive pattern.
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hyperphosphatemia and an
inappropriate alium load
);+.
'reatment must $e aimed on
reduing the 7a P produt.
One option inludes the use
of lo&%alium dialysate to
help learing the alifi
deposits, $ut this measure
may eaer$ate the
seondary
hyperparathyroidism if largeamounts of alium are lost
over long periods. A lo&%
phosphate diet, stopping the
vitamin D, and alium
supplements may also have
some positive results )0,*3+.
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the hypothesis of its mode of
ation is that its molar
solu$ility $eing more thanthat of alium phosphate
may potenially interrumpt
alium phosphate
preipitaion in to soft tissue.
Nevertheless, its mode of
ation and optimal
administration route are still
$eing studied.
7alimimetis ontrol
suessfully seondary
hyperparathyroidism in
patients &ith end stage renal
disease and also lo&er serum
levels of $oth phosphate and
alium. Still there are
studies $eing held on to
prove &hether alimimetis
are assoiated &ith
improvement of meaningfulpatient outomes. Strategies
to regress or stop the
progress of etraosseous
alifiation are &arranted.
9oading the system &ith
alium and phosphate may
have very negative outomes
and $e of real danger, so the
ation of novel drugs and
other interventions that target
learane mehanisms must
$e profoundly analy#ed and
studied );+.
Although our patient has a
high ris" of developing
metastati alium deposits,
the presene of this
alinosis in the nasal
septum &as a surprise. An
early and ade(uate diagnosis
$y radiology and eploration
an avoid unneessary
anti$ioti treatment andhospitali#ation. Some
ompliations may inlude
fistula formation and
infetion, &hih may
produe systemi symptoms.
SUMMARY
Ftraosseous tissue
alifiation in patients &ithadvaned hroni "idney
disease undergoing dialysis
is a omple, highly
prevalent proess.
Pathologial alifiation
sites may vary, $ut the
loali#ation in the nasal
septum is very rare.
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alifiation. Radiologi
imaging help onfirm this
ondition. Ade(uate ontrolof serum alium%phosphate
levels &ill diminish the ris"
of formation or reurrent
deposits in these patients.
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Cite: Mayte P, Ithzel M, Clara S, Pedro R, Omar L, Cristobal LC, Tumoral calcinosis like lesin
in the nasal septum in end sta!e renal disease, "ournal o# $ead and %eck physicians and
sur!eons, &'()*(+(:(-.&/
26
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uremi tumoral alinosis.?one. 8e$: >-1-2, -3*,
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Cite: Mayte P, Ithzel M, Clara S, Pedro R, Omar L, Cristobal LC, Tumoral calcinosis like lesin
in the nasal septum in end sta!e renal disease, "ournal o# $ead and %eck physicians and
sur!eons, &'()*(+(:(-.&/
28
1 1
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F$7.*# 18Soft tissue mass &ith etensive areas of alifiation
that affets the anterior septal artilage 1Aial 7' san2
F$7.*# 18 Histopathologi eamination &ith a tumoral
alinosis in ative phase 1hematoylin and eosin stain -332
C%$6" $%"#*#+" 9 N$
A6:%;#,7##%"+- N$
S.*"- N$
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