PMC4861886_01
AP radiograph of the left shoulder demonstrates a comminuted fracture of the left proximal humerus with medial displacement. This was the patient's original injury.
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He presented to the emergency department with a comminuted fracture of his left proximal humerus after falling at his workplace (Fig. 1).
Four years following the initial injury, the patient presented to his primary care clinician with complaints of a firm left shoulder mass. (A) AP radiograph shows large amorphous calcification surrounding the fracture nonunion of the left proximal humerus. Notice the layering fluid level (arrow). The worrisome finding was the appearance of permeative destruction of the proximal humeral diaphysis (arrowhead). (B) AP wrist radiograph reveals amorphous calcification along the distal ulna (arrow) and extensive vascular calcifications.
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Radiographs demonstrated amorphous calcifications at the extensor surface of his right wrist and in the soft tissues adjacent to the left shoulder (Fig. 2).
(A) Coronal T1-weighted (TR533/TE17), (B) coronal T2-weighted (TR2500/TE70), and (C) axial T2-weighted with fat saturation (TR3186/TE70) sequences (b) of the left shoulder demonstrate a large mass with low T1 and T2 signal (arrows) corresponding to mineralized areas on the prior radiograph. A large joint effusion with proliferative synovitis is also present (arrowheads).
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He was referred to an orthopedic oncologist, who ordered magnetic resonance imaging (MRI) of the shoulder (Fig. 3).
(A) Anterior projection from the PET maximum-intensity projection (MIP) image reveals intense FDG avidity of the mineralized foci at the left shoulder and right hip (arrows). Also present is a right hilar small-cell lung carcinoma (arrowhead). (B) Axial CT image demonstrates the amorphous calcifications at the left shoulder distal to the fracture nonunion. (C) Axial fused image from an F18-FDG PET CT demonstrates avid FDG uptake within the mineralized component. Axial CT (D) and fused image (E) at the right hip shos a mineralized focus at the right lesser trochanter with intense FDG avidity (arrows).
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During the workup for this malignancy, PET/CT revealed intense F-18 fluorodeoxyglucose (FDG) uptake within the extensive calcification surrounding the fracture nonunion of the left shoulder (Figs. 4A-C). The CT (Fig. 4B) also revealed an amorphous, cystic, and multilobulated calcified mass at the shoulder, which was determined to be a focus of secondary tumoral calcinosis related to the patient's chronic renal disease. In addition, an FDG-avid focus of tumoral calcinosis was noted adjacent to the right lesser trochanter (Figs. 4D, E).