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Fluoroscopy-induced chronic radiation skin injury: a disease perhaps
often overlooked.
Arch
Dermatol. 2007 May;143(5):637-40.
BACKGROUND: Fluoroscopy-induced
chronic radiation dermatitis (FICRD) resulting from prolonged exposure
to ionizing radiation during interventional procedures has been
documented in the radiology and cardiology literature. However, the
phenomenon has been rarely reported in the dermatologic literature.
Since patients with FICRD often see a dermatologist or a primary care
physician to treat their injuries, the diagnosis of FICRD is perhaps
often overlooked. OBSERVATIONS: A 62-year-old man with type 2 diabetes
mellitus and severe coronary artery disease was seen with a 2-year
history of a pruritic, tender, telangiectatic patch lesion over his
left scapula. Over the next 2 years, the lesion became indurated and
eventually ulcerated. A skin biopsy specimen demonstrated changes
consistent with a chronic radiation dermatitis. The patient was
unaware of radiation exposure, but persistent questioning from his
dermatologists revealed that he had undergone multiple
fluoroscopy-guided cardiac procedures. This was confirmed by a review
of his medical records. Conclusion The diagnosis of FICRD should be
considered for any patient who is seen with an acquired vascular
lesion, a morphealike lesion, or an unexplained ulcer localized over
the scapula, the back, or lateral trunk below the axilla.
Post-radiotherapy vascular proliferations in mammary
skin: a clinicopathologic study of 11 cases.J
Am Acad Dermatol. 2007 Jul;57(1):126-33.
BACKGROUND: Post-radiotherapy atypical vascular lesions
(AVL) in mammary skin show significant clinical and histopathologic
overlap with well-differentiated angiosarcoma (AS) and pose a
considerable diagnostic and managerial challenge when encountered.
OBJECTIVE: We review Stanford's experience with diagnosing AVL and
formulate a clinicopathologic approach to these lesions. METHODS: We
performed a clinicopathologic study on 11 cases that were initially
diagnosed as AVL and examined whether there are specific clinical or
histopathologic features that delineate AVLs from well-differentiated
AS. RESULTS: Clinically, all patients were women with a mean age of
68.1 years, had a history of infiltrating breast carcinoma, and were
treated by excision with postoperative radiation therapy. All lesions
were located in mammary skin within the prior radiation field. The
clinical presentation included erythema, telangiectasias, papules,
plaques, and nodules. All patients were diagnosed with AVL on initial
biopsy. Six patients showed no recurrence or progression of disease
following incomplete excision with no further therapy (3/6) or
re-excision with negative margins (3/6). The remaining 5 patients were
shown to have AS in the re-excision specimen. The patients diagnosed
with AS were older and had a shorter interval from radiation as
compared to those who did not experience an adverse outcome.
Histologically, all initial biopsy specimens were transected and were
characterized by complex, anastomosing vascular proliferations with
dilated spaces. Each case was morphologically evaluated according to
the AVL criteria of Fineberg and Rosen. Three cases met all of the
criteria for AVL, and these patients showed no progression of disease.
The remaining cases met most but not all diagnostic criteria for AVL
and showed some features of AS, but fell short of a definitive
diagnosis of AS, including the 5 cases that were subsequently
diagnosed as angiosarcoma. LIMITATIONS: This retrospective study
utilized a small number of cases from a single consultation service;
therefore, some inherent selection bias may exist. CONCLUSION: We
could not identify unequivocal clinical or histologic criteria that
allows for a sharp separation between AVL and AS. Dermatologists and
pathologists need to be aware of the overlap between AVL and
well-differentiated AS and all patients who receive a diagnosis of AVL
should undergo complete excision with close clinical follow-up and
biopsy of any new lesions.
Vascular proliferations of the skin after radiation therapy for breast
cancer: clinicopathologic analysis of a series in favor of a benign
process: a study from the French Sarcoma Group.Cancer.
2007 Apr 15;109(8):1584-98.
BACKGROUND:
Cutaneous vascular proliferations that occur in the field of prior
radiotherapy include angiosarcoma and small, cutaneous lesions with a
pseudosarcomatous pattern that previously were reported as atypical
vascular lesions or benign lymphangiomatous papules. METHODS: The
objective of this study was to investigate the clinicopathologic
features and outcomes of 56 radiation-induced vascular proliferations
that occurred in 36 patients who received previous treatment for
breast carcinoma. Data from all patients were retrieved from the files
of the French Sarcoma Group. Immunostaining with D2.40 antibody was
performed in 24 lesions. RESULTS: All patients (median age, 52 years)
had received external radiotherapy. Small papules developed within the
field of prior radiotherapy (median latency interval, 66 months).
Microscopically, the lesions were relatively well circumscribed, and
they were located mostly in the superficial/middermis. They were
composed of dilated or irregular-jagged vascular channels that were
lined by a single layer of bland endothelial cells, and they
demonstrated either a predominately lymphangioendothelioma-like or
lymphangioma/lymphangioma circumscriptum-like growth pattern.
Micropapillary tufts were common findings. Ten lesions showed
additional cytologic and/or architectural atypia. Twenty of 24 lesions
showed D2.40 positivity. Follow-up information was available for 31
patients (median follow-up, 48 months): Five women developed new
cutaneous lesions, and 1 woman had spontaneous regression of her
lesions. None of the patients developed cutaneous angiosarcoma. Five
patients were lost to follow-up. CONCLUSIONS: Although vascular
proliferations in irradiated skin may mimic angiosarcoma
morphologically, the large majority of these lesions showed a benign
clinical outcome. Despite relatively limited follow-up, the current
results indicate the benign nature of these vascular proliferations.
Radiation-associated cutaneous atypical vascular lesions and
angiosarcoma: clinicopathologic analysis of 42 cases.Am
J Surg Pathol. 2005 Aug;29(8):983-96.
Cutaneous
angiosarcoma is a rare but well-recognized complication after
radiation therapy. Atypical post-radiation vascular lesions (AVLs)
with a benign course have been described recently, but few cases with
limited follow-up have been studied so far. A total of 42 cases
diagnosed as either radiation-associated cutaneous vascular lesions or
angiosarcoma were retrieved from departmental and consultation files
from 1995 to 2003. Hematoxylin and eosin-stained sections and clinical
as well as follow-up data were evaluated. All patients were female
with a median age of 59 years (range, 36-90 years). Presentation
ranged from small erythematous/violaceous papules or nodules to large
plaques with discoloration located on the chest wall (35), abdomen
(2), shoulder, groin, flank, axilla, and lower leg (1 each). Reasons
for radiation included breast carcinoma (35 cases) and a variety of
other lesions (mainly malignant disease). Size range was 0.1 to 20 cm.
Angiosarcomas presented as larger lesions (median, 7.5 cm) compared
with AVLs (median, 0.5 cm). The time interval from radiation was
significantly shorter for the development of AVL (median, 3.5 years)
compared with cutaneous angiosarcoma (median, 6 years). Histologic
evaluation revealed 26 lesions meeting criteria for angiosarcoma,
ranging from morphologically low-grade to high-grade; 16 cases were
classified as AVLs. These were fairly well-circumscribed lesions
confined within superficial to mid dermis and composed of complex
anastomosing and focally dilated vascular spaces. Some showed
prominent hyperchromatic endothelial cells, while others were
characterized by areas with a dissecting growth pattern within dermal
collagen. Endothelial multilayering was absent. Clinical follow-up,
available for 36 patients (range, 2-84 months; median, 17 months),
revealed 4 patients who died of disease, 4 patients had systemic
metastasis, and 12 patients with local recurrence. All patients with
systemic relapse had an initial diagnosis of angiosarcoma. One patient
with an AVL had a recurrence at the same site, 3 patients developed
additional new lesions, and 1 patient developed multiple small papules
on the chest wall, which progressed from an AVL to angiosarcoma. This
study outlines the morphologic spectrum of radiation-associated
cutaneous AVLs. No adverse outcome has been observed so far in this
more benign subset of cases, but longer-term follow-up is necessary.
Radiation recall
dermatitis, panniculitis, and myositis following cyclophosphamide
therapy: histopathologic findings of a patient affected by multiple
myeloma.Am J Dermatopathol. 2004 Jun;26(3):213-6.
Radiation
recall dermatitis is one of the skin sequelae that may affect oncology
patients. It occurs in a previously irradiated field, when subsequent
chemotherapy is given. The eruption may be elicited by chemotherapy,
even several months after radiotherapy. Its mechanism is poorly
understood, and the histopathologic findings have received, to date,
only sketchy descriptions. A 55-year-old male affected by multiple
myeloma received radiation therapy both on his left coxofemoral area,
and lumbar region (D11-L1). After cyclophosphamide administration, he
developed 2 well defined square-shaped, infiltrated
erythematoviolaceous plaques in the prior irradiated fields.
Histopathologic findings revealed a diffusely fibrosclerosing process,
involving deep dermis, hypodermis, as well as the underlying muscle,
while sparing the epidermis and superficial-mid dermis. Histopathology
was indistinguishable from deep radio-dermatitis, panniculitis, and
myositis.
This is the first case providing clear evidence of the causative role
of cyclophosphamide in inducing a cutaneous and subcutaneous radiation
recall reaction.
Radiation-induced skin reactions (except malignant tumors).Bull
Cancer. 2003 Apr;90(4) :319-25.
The aim of
this work, synthesized from personal case reports and a review of
literature is to describe cutaneous complications of radiation therapy
(except radiation-induced cancers): known and frequent such as
radiation dermatitis or less frequent, beginning or strictly limited
on irradiated skin areas: acne, infectious diseases, dyskeratosis,
Grover's disease, sub-cutaneous pustulosis, cutaneous lichen, morphea,
autoimmune bullous dermatosis, subacute cutaneous lupus erythematosus.
Furthermore, we try to precise the physiopathogenic mechanisms of
these dermatosis and we want to draw the attention on these dermatoses
which sometimes need a multidisciplinary approach.
Delayed effects
of accidental cutaneous radiation exposure: fifteen years of follow-up
after the Chernobyl accident. J Am Acad Dermatol. 2003
Sep;49(3):417-23.
BACKGROUND:
During the Chernobyl accident in 1986, 237 individuals were identified
as having the most severe exposure to ionizing radiation. In the
period between 1998 and 2000, 99 long term survivors out of this group
were reassessed for radiation-induced cutaneous lesions.
OBJECTIVE: To identify sequelae of accidental cutaneous irradiation.
METHODS: Detailed dermatologic examinations, including biopsies of
suspicious cutaneous lesions for histopathologic examination and 20
MHz sonography, were performed in all patients.
RESULTS: Twenty-two of the 99 patients displayed radiation-induced
cutaneous lesions. Epidermal atrophy, telangiectases, and pigment
alterations were present in all these individuals. Keratotic lesions
were found in 14 patients. Cutaneous fibrosis was documented in 8
individuals by the use of 20 MHz sonography, while a radiation ulcer
was found in 5. In one patient, two basal cell carcinomas were found.
CONCLUSION: The life-long follow-up of irradiated persons is of great
importance in order to identify cutaneous neoplasms at an early
treatable stage.
Benign Vascular
Proliferations in Irradiated Skin. Am J Surg Pathol 2002;26:328-337
Several types
of cutaneous vascular proliferations have been described in areas of
irradiated skin, including both benign lesions, such as benign
lymphangiomatous papules, atypical vascular lesions, or benign
lymphangioendothelioma, and malignant neoplasms such as high-grade
angiosarcomas.
This report
describes the clinicopathologic features of 15 cases of different
types of benign cutaneous vascular proliferations arisen within
irradiated skin. All patients were female ranging in age from 33 to 72
years, and they had received postoperative external radiotherapy for
treatment of breast carcinoma (14 cases) or ovarian carcinoma (one
case). In those cases in which the latency interval period between
radiotherapy and the development of the vascular lesion was known from
the clinical records, the latency interval period elapsed between
radiotherapy and diagnosis of the vascular lesion ranged from 3 to 20
years. The most common clinical presentation of the cutaneous lesions
consisted of papules, small vesicles, or erythematous plaques on the
irradiated field.
Histopathologically, most lesions consisted of irregular dilated
vascular spaces, with a branching and anastomosing pattern, thin
walls, and lymphatic appearance involving the superficial dermis. A
discontinuous single layer of endothelial cells with flattened nuclei
lined these vascular channels, and numerous small stromal papillary
formations also lined by endothelial cells projected into the lumina
of the dilated lymphatic vessels. These cases were classified as
benign lymphangiomatous papules or plaques. Two cases showed different
histopathologic findings because they consisted of poorly
circumscribed and focally infiltrating irregular jagged vascular
spaces involving the entire dermis and lined by inconspicuous
endothelial cells. In some areas these irregular slit-like vascular
spaces dissected collagen bundles of the dermis. These cases were
classified as atypical vascular proliferations mimicking benign
lymphangioendothelioma or patch-stage Kaposi's sarcoma. All cases
showed similar immunohistochemical findings and the endothelial cells
lining the vascular spaces expressed immunoreactivity for CD31, but
they stained only focally positive for CD34 or were negative for this
marker. Immunohistochemical investigations for -smooth muscle actin
failed to demonstrate a complete peripheral ring of actin-positive
pericytes in most of the neoformed vascular structures.
This
immunohistochemical profile also supported the lymphatic nature of
these vascular proliferations developed in irradiated skin. Although
some of these lesions may mimic histopathologically patch-stage
Kaposi's sarcoma or well-differentiated angiosarcoma, the follow-up of
the patients of this series demonstrated that the vascular
proliferations arisen in irradiated skin invariably showed a benign
biologic behavior.
Postirradiation
Pseudosclerodermatous Panniculitis. Am J Dermatopathol
2001;23:283-287.
Pseudosclerodermatous panniculitis is an unusual variant of
panniculitis that results as a complication of megavoltage
radiotherapy. Four women developed this unusual entity on the anterior
chest and abdominal skin after receiving megavoltage therapy for
either breast carcinoma or painful bone metastases from breast
carcinoma.
Histopathologically, the epidermis and dermis of the involved area
showed little or no evidence of radiodermatitis. The main findings
were confined to the subcutaneous tissue and consisted of thickened,
sclerotic septa composed of both thick and thin collagen bundles, and
a lobular panniculitis characterized by lipophagic granulomas and
scattered lymphocytes and plasma cells. Additionally, one of the cases
showed markedly dilated vascular spaces with the appearance of
lymphatics in the upper part of the dermis.
Pseudosclerodermatous panniculitis after irradiation is an unusual
cutaneous complication of megavoltage radiotherapy that should be
distinguished from subcutaneous metastatic disease, cellulitis, or
connective tissue diseases involving the subcutaneous fat. The
differential diagnosis can be established on the basis of the
characteristic histopathologic features of postirradiation
pseudosclerodermatous panniculitis.
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