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Finnegan P, Kiely L, Gallagher C, Mhaolcatha SN, Feeley L, Fitzgibbon J, White J, Bourke J, Murphy LA. Radiation-induced morphea of the breast-A case series. SKIN HEALTH AND DISEASE 2023; 3:e148. [PMID: 36751336 PMCID: PMC9892419 DOI: 10.1002/ski2.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022]
Abstract
Radiation-induced morphea (RIM) is a rare but recognized late complication of radiotherapy. It was first described in 1905, not long after the initial discovery of X-rays by Roentgen. Characterized by the deposition of excess collagen in the dermis, it results in thickening of the skin. Its frequency is approximately 2 in 1000. We present a series of three cases involving patients receiving radiotherapy treatment for breast cancer, each of which subsequently developed RIM. Because of its rarity, RIM is often misdiagnosed as infection or metastatic disease. This can lead to delayed diagnosis and treatment, leading to poorer outcomes such as chronic pain issues. Early dermatological involvement and tissue sampling to examine histopathological features can avoid this, leading to better care and improved results. A variety of treatment options are available, ranging from topical to systemic, with early induction more likely to result in a positive response.
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Affiliation(s)
- Paula Finnegan
- Department of DermatologyUniversity Hospital LimerickDooradoyleLimerickIreland
| | - Lisa Kiely
- Department of DermatologySouth Infirmary VictoriaUniversity HospitalCorkIreland
| | - Catriona Gallagher
- Department of DermatologySouth Infirmary VictoriaUniversity HospitalCorkIreland
| | | | - Linda Feeley
- Department of HistopathologyCork University HospitalWilton, CorkIreland
| | - Jim Fitzgibbon
- Department of HistopathologyCork University HospitalWilton, CorkIreland
| | - Jessica White
- Department of HistopathologyCork University HospitalWilton, CorkIreland
| | - John Bourke
- Department of DermatologySouth Infirmary VictoriaUniversity HospitalCorkIreland
| | - Lesley Ann Murphy
- Department of DermatologySouth Infirmary VictoriaUniversity HospitalCorkIreland
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Milam EC, Rangel LK, Pomeranz MK. Dermatologic sequelae of breast cancer: From disease, surgery, and radiation. Int J Dermatol 2020; 60:394-406. [PMID: 33226140 DOI: 10.1111/ijd.15303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 01/24/2023]
Abstract
The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.
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Affiliation(s)
- Emily C Milam
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Lauren K Rangel
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Miriam K Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
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3
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Reply to: “Skin diseases of the breast and nipple”. J Am Acad Dermatol 2020; 82:e159. [DOI: 10.1016/j.jaad.2019.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 11/17/2022]
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Partl R, Regitnig P, Lukasiak K, Winkler P, Kapp KS. Incidence of Morphea following Adjuvant Irradiation of the Breast in 2,268 Patients. Breast Care (Basel) 2019; 15:246-252. [PMID: 32774218 DOI: 10.1159/000502030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/09/2019] [Indexed: 12/25/2022] Open
Abstract
Background Morphea of the breast is an autoimmune reaction of the subcutaneous connective tissue which can be triggered by exposure to ionizing radiation. The literature suggests incidence rates of 1:500 to 1:3,000 which, however, do not seem to match the very small number of cases reported. Objectives The aim of the present study was to determine the incidence of morphea following irradiation of the breast in order to generate more evidence about the frequency of this serious and mutilating complication. Method Retrospective analysis of patient data who underwent adjuvant radiotherapy in the period 2009-2018 following breast-conserving surgery and who made use of the recommended radiooncology follow-up examinations in 2018. Analysis was done by descriptive statistics. Results Of a total of 5,129 patients who had undergone radiotherapy over a 10-year period, follow-up data were available in 2,268 patients. In 2,236 patients (98.6%) the breast had been irradiated using conventional fractionation schemes with a total dose of 50-50.4 Gy; 32 (1.4%) were given a total dose of 40.05 Gy in 15 fractions. During the observation period, 6 patients were diagnosed with morphea (4 unilateral and 2 bilateral) by punch biopsies resulting in a cumulative incidence proportion of 0.26% (95% CI: 0.24-0.28), translating into 1 case for every 378 irradiated patients. Conclusions In the case studies reported to date, morphea is described as a very rare complication. In contrast, our data suggest a cumulative incidence of 1:378, which is higher than other authors have estimated. This leads us to suspect that in a large number of patients, morphea is incorrectly diagnosed as an infection (in the early stages) and radiation-induced fibrosis (in later stages).
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Affiliation(s)
- Richard Partl
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Graz, Austria
| | - Peter Regitnig
- Institute of Pathology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Graz, Austria
| | - Katarzyna Lukasiak
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Graz, Austria
| | - Peter Winkler
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Graz, Austria
| | - Karin Sigrid Kapp
- Department of Therapeutic Radiology and Oncology, Medical University of Graz, Comprehensive Cancer Center Graz (CCC), Graz, Austria
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Postirradiation Morphea in Patients With Breast Cancer: Possible Association With Other Autoimmune Diseases. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Diago A, Llombart B, Requena C, Sanmartín O, Guillén C. Postirradiation Morphea in Patients With Breast Cancer: Possible Association With Other Autoimmune Diseases. ACTAS DERMO-SIFILIOGRAFICAS 2018; 110:153-159. [PMID: 30389122 DOI: 10.1016/j.ad.2017.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/01/2017] [Accepted: 10/04/2017] [Indexed: 10/28/2022] Open
Abstract
Postirradiation morphea is an uncommon entity that has been mostly described in women with breast cancer. The increasing use of radiotherapy to treat breast cancer and the clinical similarities between morphea and other conditions, such as radiodermatitis, postirradiation fibrosis, and tumor recurrence, highlights the need for dermatologists to be familiar with this entity. We present a series of 6 women with a mean age of 64.2 years and a mean latency of 9.5 years between radiotherapy for breast cancer and onset of morphea. Four of the patients had a history of autoimmune disease: rheumatoid arthritis, Sjögren syndrome, vitiligo, and Crohn disease. No specific risk factors for postirradiation morphea have been identified to date, although it would appear that a history of autoimmune disease could be associated with an increased risk of morphea in patients treated with radiation therapy.
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Affiliation(s)
- A Diago
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España.
| | - B Llombart
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
| | - C Requena
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
| | - O Sanmartín
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
| | - C Guillén
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
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Partl R, Regitnig P, Tauber G, Pötscher M, Bjelic-Radisic V, Kapp KS. Radiation-induced morphea-a rare but severe late effect of adjuvant breast irradiation : Case report and review of the literature. Strahlenther Onkol 2018; 194:1060-1065. [PMID: 30014236 PMCID: PMC6208943 DOI: 10.1007/s00066-018-1336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/04/2018] [Indexed: 02/05/2023]
Abstract
Background Radiation-induced morphea (RIM) is a circumscribed localized scleroderma that occurs most often in the breast. After an asymptomatic period of one month to several years, the symptoms (circumscribed inflammation, edema, sclerosis) often arise suddenly and cannot be clinically distinguished from a local recurrence in the form of inflammatory carcinoma. Case We present a case of a 74-year-old woman who developed this rare and serious local side-effect in connective tissue following neoadjuvant CDK 4/6 inhibitor abemaciclib (Verzenio®) and aromatase inhibitor anastrozole (Arimidex®) therapy and subsequent radiation therapy of the breast. Conclusions Little is known about risk factors and pathogenesis of RIM. Here we describe the first case of RIM following immunotherapy. The diagnosis is based on clinical appearance and histopathological examination. Treatment should be initiated in the inflammatory stage in order to prevent or delay irreversible fibrosis and atrophy of the breast.
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Affiliation(s)
- Richard Partl
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Peter Regitnig
- Institute of Pathology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 25, 8036, Graz, Austria
| | - Gerlinde Tauber
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Michaela Pötscher
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Vesna Bjelic-Radisic
- Division of Gynecology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 14, 8036, Graz, Austria
| | - Karin S Kapp
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria.
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Underdiagnosed and disfiguring - Radiation-induced morphea following breast cancer treatment. Breast 2018; 39:97-100. [DOI: 10.1016/j.breast.2018.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/10/2018] [Accepted: 04/05/2018] [Indexed: 11/23/2022] Open
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Moretti A, Bianchi F, Abbate IV, Gherardi G, Bonavita M, Passoni E, Nazzaro G, Bramati A, Dazzani MC, Piva S, Paternò E, Frungillo N, Farina G, La Verde N. Localized morphea after breast implant for breast cancer: A case report. TUMORI JOURNAL 2018; 104:NP25-NP28. [PMID: 29714655 DOI: 10.1177/0300891618763209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Early breast cancer follow-up guidelines for patients who underwent surgery suggest a regular and accurate clinical examination of the breast area, for an early identification of cutaneous or subcutaneous breast cancer relapse. Nonetheless, breast skin lesions arising in patients treated with mastectomy for breast cancer can be caused by several diseases. A series of diagnostic hypotheses should be considered, not only focusing on cutaneous metastasis, but also on dermatologic and systemic diseases. CASE REPORT In February 2015, a 37-year-old patient underwent a right subcutaneous mastectomy for stage IIA breast cancer. Five months after beginning adjuvant chemotherapy, she noted hyperpigmentation and thickening of the skin on the right breast. Differential diagnosis included local relapse, skin infection, lymphoma, or primary cutaneous disease, and a skin biopsy was performed. The histopathologic specimen showed full-thickness sclerosis, with features of localized morphea. Therapy with clobetasol was prescribed, with progressive resolution of the thickness. The collaboration between many professionals in a multidisciplinary team (oncologist, dermatologist, plastic surgeon, and pathologist) was crucial to achieving the diagnosis. CONCLUSION In the literature, some articles describe correlation between connective tissue diseases and silicone breast implants, but the pathogenetic mechanisms are unknown. We report a rare case of breast morphea after positioning a silicone implant in a patient who had undergone mastectomy. This clinical report represents an interesting model of multidisciplinary management of a patient with breast cancer who developed an uncommon dermatologic disease. Further studies are needed to clarify the association between silicone implants and breast morphea.
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Affiliation(s)
- A Moretti
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - F Bianchi
- 2 Department of Pathology, ASST Fatebenefratelli & Sacco, Milan, Italy
| | - I V Abbate
- 3 Department of Dermatology, Umberto I Hospital Lugo, (Ravenna), Italy
| | - G Gherardi
- 2 Department of Pathology, ASST Fatebenefratelli & Sacco, Milan, Italy
| | - M Bonavita
- 4 Department of Plastic Surgery, Fatebenefratelli, ASST Fatebenefratelli & Sacco, Milan, Italy
| | - E Passoni
- 5 Department of Dermatology, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Nazzaro
- 6 Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Italy
| | - A Bramati
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - M C Dazzani
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - S Piva
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - E Paternò
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - N Frungillo
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - G Farina
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
| | - N La Verde
- 1 Department of Oncology Fatebenefratelli, ASST Fatebenefratelli Sacco, Milan, Italy
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A case of radiation-induced bullous morphea/lichen sclerosus overlap in a breast cancer patient. Rep Pract Oncol Radiother 2017; 23:47-49. [PMID: 29872368 DOI: 10.1016/j.rpor.2017.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/06/2017] [Accepted: 11/26/2017] [Indexed: 11/23/2022] Open
Abstract
Radiation induced morphea (RIM) is an increasingly common complication of radiation treatment for malignancy as early detection has made more patients eligible for non-surgical treatment options. In many cases, the radiation oncologist is the first person to learn of the initial skin changes, often months before a dermatologist sees them. In this paper we present a breast cancer patient who developed a rare bullous variant of RIM, which delayed her diagnosis and subsequent treatment. It is imperative to diagnose RIM early as it carries significant morbidity and permanent deformity if left untreated. The lesions typically present within 1 year of radiation therapy and extend beyond the radiated field. RIM is often mistaken for radiation dermatitis or cellulitis. Bullae, when present, are often hemorrhagic in appearance, which can serve as another clinical clue. It is important to refer these patients for a full gynecologic exam as there can be concurrent anogenital lichen sclerosus et atrophicus which is both debilitating and carries a long term risk for squamous cell carcinoma. Treatment with systemic agents is often necessary, and can be managed by a dermatologist. The most proven regimen in the literature appears to be methotrexate, with our without concurrent narrow band UVB phototherapy.
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Gonzalez-Ericsson PI, Estrada MV, Al-Rohil R, Sanders ME. Post-irradiation morphoea of the breast: a case report and review of the literature. Histopathology 2017; 72:342-350. [DOI: 10.1111/his.13343] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Paula I Gonzalez-Ericsson
- Breast Cancer Research Program; Vanderbilt-Ingram Cancer Center; Vanderbilt University Medical Center; Nashville TN USA
| | - Monica V Estrada
- Department of Pathology; School of Medicine; University of California; San Diego CA USA
| | - Rami Al-Rohil
- Department of Pathology; Vanderbilt University Medical Center; Nashville TN USA
| | - Melinda E Sanders
- Breast Cancer Research Program; Vanderbilt-Ingram Cancer Center; Vanderbilt University Medical Center; Nashville TN USA
- Department of Pathology; Vanderbilt University Medical Center; Nashville TN USA
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