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Künzel SR, Günther C. [Radiation-induced morphea-an overview]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:214-217. [PMID: 38240813 DOI: 10.1007/s00105-023-05292-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Radiation-induced morphea is a fibro-inflammatory remodelling process of the subcutaneous connective tissue caused by ionising radiation, most commonly in the context of breast cancer treatment. The underlying pathomechanisms and putative risk factors are unknown. Therefore, misdiagnosis and inappropriate treatment pose a significant problem in the care of those patients. OBJECTIVES The aim of the study was to provide an overview as well as guidance for the diagnosis and treatment of radiation-induced morphea based on current case reports and review articles. RESULTS AND CONCLUSIONS Radiation-induced morphea is a rare condition that represents an interdisciplinary challenge for (gynaecological) oncology, radiotherapy and dermatology. Frequent misdiagnoses include infection (erysipelas), cancer recurrence or radiation dermatitis. Early histological diagnosis and the initiation of anti-inflammatory therapy using topical glucocorticoids or calcineurin inhibitors in combination with phototherapy and/or methotrexate are the most relevant success factors for an adequate clinical response.
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Affiliation(s)
- Stephan R Künzel
- Klinik und Poliklinik für Dermatologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, Dresden, Deutschland.
- Institut für Transfusionsmedizin, Medizinische Fakultät Carl Gustav Carus, Blasewitzerstr. 68/70, 01307, Dresden, Deutschland.
- DRK Blutspendedienst Nord-Ost gGmbH, Dresden, Deutschland.
| | - Claudia Günther
- Klinik und Poliklinik für Dermatologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, Dresden, Deutschland
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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 2022; 3:e148. [PMID: 36751336 PMCID: PMC9892419 DOI: 10.1002/ski2.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 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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Limninart N, Harvey JA, Schultz KJ, Mills AM, Noland MMB, Schroen AT, Rochman CM. "What Do You Mean It's Not Cancer?" A Review of Autoimmune and Systemic Inflammatory Diseases Involving the Breast. JOURNAL OF BREAST IMAGING 2021; 3:612-625. [PMID: 38424941 DOI: 10.1093/jbi/wbab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Indexed: 03/02/2024]
Abstract
Autoimmune and systemic inflammatory diseases represent a heterogeneous group of immune-mediated conditions with a wide range of clinical presentations and various affected organs. Autoimmune diseases can present in the breast as localized disease or as part of systemic involvement. Although breast involvement is uncommon, the spectrum of imaging findings can include breast masses, axillary adenopathy, calcifications, and skin changes, the appearance of which can mimic breast cancer. Common etiologies include diabetic mastopathy, systemic lupus erythematosus, scleroderma, rheumatoid arthritis, idiopathic granulomatous mastitis, sarcoidosis, and Immunoglobulin-G4 related mastopathy. This educational review will present multimodality imaging findings of breast manifestations of systemic inflammatory and autoimmune diseases and coexisting complications. It will also review how these disorders may affect breast cancer risk and breast cancer treatment options, including radiation therapy.
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Affiliation(s)
- Narisara Limninart
- King Chulalongkorn Memorial Hospital, Department of Radiology, Bangkok, Thailand
| | - Jennifer A Harvey
- University of Rochester, Department of Medicine Imaging Sciences, Rochester, NY, USA
| | - Katherine J Schultz
- Cincinnati Children's Hospital, Department of Pediatric Rheumatology, Cincinnati, OH, USA
| | - Anne M Mills
- University of Virginia, Department of Pathology, Charlottesville, VA, USA
| | | | - Anneke T Schroen
- University of Virginia, Department of Surgery, Charlottesville, VA, USA
| | - Carrie M Rochman
- University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, VA, USA
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Sink JR, Chiu YE. Pediatric morphea state-of-the-art literature review: Reframing morphea as a systemic disease. Pediatr Dermatol 2021; 38:1020-1031. [PMID: 34272748 DOI: 10.1111/pde.14688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric morphea is an inflammatory, fibrosing dermatologic disorder. Although morphea may be localized to the skin and subcutaneous tissues, differentiating it from systemic sclerosis, there is increasing evidence that morphea is a manifestation of a systemic inflammatory process, with the potential to involve many organ systems. Given the potential risk for irreversible sequelae, pediatric morphea should be treated early and aggressively. Long-term disease monitoring is essential.
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Affiliation(s)
- Jacquelyn R Sink
- Department of Dermatology, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Yvonne E Chiu
- Departments of Dermatology (Section of Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Liao JB, Chen W, Lee HS, Wu SR, Wei KC. Histopathology of fluoroscopy-induced radiation ulcer: a case series study in comparison with morphea. J Dtsch Dermatol Ges 2021; 18:447-454. [PMID: 32413216 DOI: 10.1111/ddg.14092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/03/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Histopathologic diagnosis of fluoroscopy-induced radiation ulcer (FIRU) can be challenging if the past history of radiation exposure is unknown. Morphea is the most important differential diagnosis. This study was intended to identify clinical and pathologic features that can be used to distinguish FIRU from morphea. PATIENTS AND METHODS We performed a retrospective study on 25 specimens from 15 patients with FIRU and 21 specimens from 21 patients with morphea. Clinical findings and pathological features were analyzed. RESULTS Thirteen of 15 patients (86.7 %) with FIRU underwent angioplasty for coronary artery disease, and eleven patients had lesions in the right subscapular area. Compared with morphea, FIRU patients were more likely to display non-inflammatory infiltrates (28 %), bizarre fibroblasts (100 %), sclerosis (48 %), telangiectasia (96 %), vascular damage (64 %), and loss of skin appendages (100 %). In morphea, bizarre fibroblasts were rare (14 %), while telangiectasia (62 %) and loss of skin appendages (62 %) were variable. Loss of CD34+ cells and compression of elastic fibers could not be used to distinguish between FIRU and morphea. CONCLUSIONS Skin lesion in the right subscapular area with presence of bizarre fibroblasts, sclerosis, telangiectasia, and loss of cutaneous appendages as seen with histology are highly characteristic of the radiation damage associated with fluoroscopic angiography.
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Affiliation(s)
- Jia-Bin Liao
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Shu Zen Junior College of Medicine and Management, Kaohsiung, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany.,Department of Dermatology, Pingtung Hospital, Ministry of Health and Welfare, Taiwan
| | - Herng-Sheng Lee
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shiou-Rong Wu
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kai-Che Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Faculty of Yuh-Ing Junior College of Health Care and Management, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Liao JB, Chen W, Lee HS, Wu SR, Wei KC. Histopathologie des Röntgenulkus: Fallserie mit Vergleich zur zirkumskripten Sklerodermie. J Dtsch Dermatol Ges 2020; 18:447-455. [PMID: 32413233 DOI: 10.1111/ddg.14092_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/03/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Jia-Bin Liao
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Shu Zen Junior College of Medicine and Management, Kaohsiung, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany.,Department of Dermatology, Pingtung Hospital, Ministry of Health and Welfare, Taiwan
| | - Herng-Sheng Lee
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shiou-Rong Wu
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kai-Che Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Faculty of Yuh-Ing Junior College of Health Care and Management, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Logunova V, Bridges AG. Subcutaneous mixed lobular and septal panniculitis with numerous eosinophils associated with autologous fat grafting: Expanding the differential diagnosis of eosinophilic panniculitis. J Cutan Pathol 2019; 47:305-307. [PMID: 31774571 DOI: 10.1111/cup.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/29/2019] [Accepted: 11/10/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Valentina Logunova
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Alina G Bridges
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota.,Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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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: 3] [Impact Index Per Article: 0.6] [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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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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