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  Table of Contents    
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Year : 2018  |  Volume : 61  |  Issue : 3  |  Page : 393-396
Fluoroscopy-induced chronic radiation dermatitis masquerading as morphea: A diagnostic pitfall


1 Delhi Dermpath Laboratory, Delhi Dermatology Group, New Delhi, India
2 Sundharam's Dermatology and Pediatric Centre, New Delhi, India

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Date of Web Publication13-Jul-2018
 

   Abstract 


Chronic radiodermatitis is a rare complication of fluoroscopy-guided procedures. The diagnosis of fluoroscopy-induced chronic radiation dermatitis is challenging because of its rarity, late insidious onset, and close clinicopathological resemblance to morphea. We report two cases of fluoroscopy-induced chronic radiodermatitis following cardiac procedures to highlight the clinicopathological features. The diagnosis relies on recognizing the characteristic clinical presentation of well-demarcated, rectangular- or square-shaped indurated plaque with depigmentation, telangiectasia, and ulceration located on the scapula, back, or axilla; supported by the histological identification of radiation fibroblasts in a sclerotic dermis.

Keywords: Fluoroscopy, radiation dermatitis, radiodermatitis

How to cite this article:
Batrani M, Kubba A, Sundharam J. Fluoroscopy-induced chronic radiation dermatitis masquerading as morphea: A diagnostic pitfall. Indian J Pathol Microbiol 2018;61:393-6

How to cite this URL:
Batrani M, Kubba A, Sundharam J. Fluoroscopy-induced chronic radiation dermatitis masquerading as morphea: A diagnostic pitfall. Indian J Pathol Microbiol [serial online] 2018 [cited 2019 Dec 7];61:393-6. Available from: http://www.ijpmonline.org/text.asp?2018/61/3/393/236617





   Introduction Top


Radiodermatitis is a well-known complication of radiotherapy occurring in about 95% of patients.[1],[2] It may also occur due to accidental overexposure to ionizing radiation. Fluoroscopic-induced radiation dermatitis (FIRD) has increasingly been reported coinciding with the rising trend of fluoroscopic-guided diagnostic and therapeutic procedures. The incidence of FIRD is very low and has been estimated to be between 0.01% and 0.001% per procedure, but in a recent report, the incidence was documented as 0.34% per procedure and 0.42% per patient.[3],[4] Radiodermatitis is categorized as acute, subacute, and chronic.

The diagnosis of fluoroscopy-induced chronic radiation dermatitis (FICRD) is often overlooked because of its rarity, late insidious onset, and clinicopathological resemblance to morphea.

We present two cases of FICRD emphasizing the importance of recognizing this entity and highlighting the clinicohistopathological features to avoid misdiagnosis.


   Case Reports Top


Case 1

A 67-year-old, diabetic, male presented with a 12 cm × 15 cm painful, indurated plaque on the left scapular region. It manifested depigmentation and telangiectasia in the center with a small crusted erosion while the periphery was erythematous and hyperpigmented [Figure 1]. The initial dermatologist raised the possibility of morphea and scrofuloderma. However, another dermatologist suspected it to be related to a fluoroscopic procedure. An angioplasty with stent insertion was performed 2.5 years earlier. The procedure was complicated and prolonged. The patient recalled that the stent insertion failed at one hospital and he had to be shifted to another hospital, where only two of the three planned stents could be inserted. One week after the procedure, he experienced pruritus on the back. Two weeks later, it was followed by peeling of skin with redness and discoloration. These initial symptoms almost completely resolved within 6 months. Subsequently, the area acquired a firm texture and ulcerated. The ulcer did not heal over next 2 years despite multiple treatments with antibiotics, topical steroids, and phototherapy. The histopathology revealed a flat epidermis, papillary and reticular dermal sclerosis, loss of appendages, and telangiectatic vessels [Figure 2]a. Scattered stellate fibroblasts with large hyperchromatic nuclei were noticeable [Figure 2]b. A diagnosis of FICRD was made. The patient had a satisfactory resolution with a skin graft.
Figure 1: Case 1 – Depigmented indurated plaque with telangiectasia and erosion surrounded by erythematous hyperpigmented rim on the left scapular region

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Figure 2: (a) Flattened epidermis with dermal sclerosis, loss of appendages, and telangiectatic vessels (H and E, ×40). (b) Scattered stellate radiation fibroblasts with large hyperchromatic nuclei (H and E, ×400)

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Case 2

A 58-year-old female presented with a 3-year history of 9” × 3” painful, depigmented-erythematous, indurated, telangiectatic plaque over the right scapular region. A depressed area corresponding to skin grafting done 7 months prior for nonhealing ulcer was seen within the plaque [Figure 3]. The clinical differential diagnoses considered were morphea and dermatofibrosarcoma. Two biopsies were performed and showed similar features as described above for case 1. For 1.5 years, this case remained misdiagnosed as morphea. Although the history of fluoroscopy-guided pacemaker insertion few months before the onset of lesion was known, the significance of this history was missed by dermatologist and pathologist. The clinical photographs and biopsies were re-evaluated, and in view of similarity to case 1, the diagnosis was revised to FICRD.
Figure 3: Case 2 – Depigmented, erythematous, indurated plaque with telangiectasia on the right scapular area

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   Discussion Top


The risk of developing radiodermatitis is proportional to radiation dose, duration of exposure, time interval between exposures, technique, size, and location of the exposed area. The susceptibility also depends on host factors such as light skin color; smoking; body constitution; obesity, overlapping skin folds, and compromised skin integrity; poor nutritional status; autoimmune diseases including connective tissue diseases, diabetes mellitus, and hyperthyroidism; defects in DNA repair genes; and chemotherapeutic agents.[1],[2],[5]

Modestly fractioned radiation doses used in conventional radiotherapy are designed to spare the skin, whereas fluoroscopic procedures have no skin-sparing quality, and a high fraction radiation dose may get delivered during a single procedure or as cumulative fractions in repeated procedures.[5],[6] The radiation dose and exposure time depend on the type and complexity of the procedure, with interventional cardiology and neuroradiology procedures being particularly associated with a high dose. In 2005, the Joint Commission defined a fluoroscopic sentinel event as prolonged fluoroscopy resulting in a cumulative peak skin dose of ≥15 Gy to a single field, which may be accumulated through multiple procedures during a period from 6 months to 1 year.[7]

Although over two million fluoroscopic procedures are performed yearly, the incidence of FIRD is very low,[8] possibly owing to radiation doses delivered in majority of the procedures being lower than the threshold for skin injury.[9],[10] However, many cases remain unrecognized or unreported, and thus, the true incidence remains underestimated.[3]

Radiodermatitis is classified into acute, subacute, and chronic. An episode of acute radiodermatitis increases the risk of developing chronic radiodermatitis. However, not all cases of acute reaction are followed by chronic injury. Likewise, chronic radiodermatitis may or may not be preceded by an acute phase.[1],[2],[4],[6],[9],[10] Frazier et al. reviewed 42 cases of FIRD reported in dermatology literature till 2007, of which 31 were of chronic, 3 were of subacute, and 9 were of acute FIRD.[6] The reason for low number of published cases of acute FIRD is more likely to be its mild self-limited course and is probable that only the severe cases of FIRD are reported.

Acute radiodermatitis occurs within 90 days of radiation exposure.[1],[2] The reaction simulating a burn injury varies from erythema, dry to moist desquamation, blistering, ulceration, and necrosis.[1],[2],[11] Most cases are mild and are likely to heal.[1],[3] Histology resembles a phototoxic reaction characterized by pyknotic keratinocytes and intracellular epidermal edema. Dermal changes include edema, vascular dilation, hemorrhage, thrombi, and sparse inflammation.[11],[12],[13] Severe reactions show epidermal and dermal necrosis, blistering, and desquamation.[11]

Subacute radiodermatitis occurs weeks to months after exposure and shows features overlapping with acute and chronic radiodermatitis. Clinically, it may mimic contact dermatitis, fixed drug eruption, dermatomyositis, morphea, and subacute cutaneous lupus erythematosus.[11] Histologically, an interface dermatitis with basal layer vacuolization and prominent apoptotic and some cytologically atypical keratinocytes are seen. A variably dense perivascular lymphohistiocytic infiltrate which may obscure dermoepidermal junction is present. Satellite cell necrosis characterized by lymphocytes in close apposition to apoptotic keratinocytes is notable. Histopathological features simulate graft versus host disease and fixed drug eruption.[11],[13]

Chronic radiodermatitis occurs months to years after exposure. It may occur in the absence of any acute damage or after a variable latent period following acute changes. Thus, it is different from consequential late effects of persistent nonhealing severe acute radiodermatitis.[1] One of our cases (case 2) denied any history of preceding acute reaction, while in case 1, there was a history of acute radiation dermatitis. Chronic injury ranges from transient peau d'orange appearance and pigmentary changes which may resolve or worsen over time to persistent alterations such as loss of appendages; poikilodermatous changes including dyspigmentation, atrophy, and telangiectasia; ulceration; and fibrosis.[1],[2] Clinically, it may simulate morphea [10],[12],[14] and erythema ab igne.[10] Chronic radiodermatitis is usually permanent, progressive, and potentially irreversible.[1] Microscopic features are epidermal atrophy, hyperkeratosis, telangiectasia, loss of adnexa, fibrosis with homogenization of collagen, and atypical stellate radiation fibroblasts.[10],[11],[12],[13] Small arterioles and venules often show hyaline change in wall with narrowing of lumen.[13] The histopathological differential diagnosis includes morphea [4],[12],[14] and lichen sclerosus.[4],[14]

Cutaneous malignancy including squamous and basal cell carcinomas has been documented in a small proportion of radiotherapy-related chronic radiodermatitis;[1],[13] however, only an occasional case of basal cell carcinoma has been reported as a consequence of FICRD.[9]

The diagnosis of FIRD is challenging. In a review of 32 cases by Takikawa, 17 were misdiagnosed as herpes zoster, fixed drug eruption, scleroderma, decubitus ulcer, and trichophytosis. Sometimes, patients undergo multiple biopsies because of incorrect diagnosis.[15] Factors contributing to a delay in the diagnosis of FICRD include long latent period resulting in failure to attribute the lesion to prior procedure; localization mostly on back (thus remains unnoticed until well advanced); unfamiliarity of this entity among clinicians and pathologists; and clinicopathological resemblance to morphea. In six biopsied cases reported by Wei et al., in the absence of prior information about radiation exposure, a pathological diagnosis of radiodermatitis was made only in one case while four were misdiagnosed as morphea and one as chronic ulcer.[4]

The diagnosis of FICRD should be suspected in the presence of a well-demarcated, geometric-, rectangular-, square-, or angular-shaped lesion at specific sites such as right or left scapular and subscapular regions, upper-mid back, right midaxillary area, and right anterolateral chest.[3],[4],[6],[10],[12] In contrast to morphea, chronic radiation dermatitis is frequently associated with pain, pruritus, ulceration, and telangiectasia.[3],[14] Histopathologically, the presence of radiation fibroblasts is pathognomonic of radiodermatitis. However, radiation fibroblasts may be sparse, and particularly, in the absence of clinical suspicion of radiodermatitis, this finding may be missed.[3] Additional clues are presence of hyperkeratosis and telangiectasia and lack of lymphocytic infiltrate in radiodermatitis.[12],[14] There is a loss of CD34+ dermal dendrocytes in morphea which are preserved in radiodermatitis albeit atypical fibroblasts are negative for CD34.[12]

FICRD is often refractory to treatment and may require skin grafting. Awareness of FIRD and implementation of measures to minimize exposure are critical. Recommendations have been established for dose management and patient protection in fluoroscopic procedures. Biopsy should be avoided as it might trigger a nonhealing wound and secondary infection, but it may be necessary if the diagnosis is uncertain or to exclude development of malignancy.[3],[4]


   Conclusion Top


The diagnosis of FICRD requires high index of clinicopathological suspicion. The characteristic morphology and topography of the lesion and finding of radiation fibroblasts in a sclerodermoid background should alert the clinician and pathologist, respectively.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bray FN, Simmons BJ, Wolfson AH, Nouri K. Acute and chronic cutaneous reactions to ionizing radiation therapy. Dermatol Ther (Heidelb) 2016;6:185-206.  Back to cited text no. 1
    
2.
Singh M, Alavi A, Wong R, Akita S. Radiodermatitis: A review of our current understanding. Am J Clin Dermatol 2016;17:277-92.  Back to cited text no. 2
    
3.
Wei YA, Wang WH, Lai PC, Wei KC. Fluoroscopy-induced radiation dermatitis: A pitfall complication of percutaneous cardiac interventions. Med Imaging Interv Radiol 2016;2:e1415.  Back to cited text no. 3
    
4.
Wei KC, Yang KC, Mar GY, Chen LW, Wu CS, Lai CC, et al. STROBE – Radiation ulcer: An overlooked complication of fluoroscopic intervention: A Cross-sectional study. Medicine (Baltimore) 2015;94:e2178.  Back to cited text no. 4
    
5.
Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: A review of radiation effects on patients' skin and hair. Radiology 2010;254:326-41.  Back to cited text no. 5
    
6.
Frazier TH, Richardson JB, Fabré VC, Callen JP. Fluoroscopy-induced chronic radiation skin injury: A disease perhaps often overlooked. Arch Dermatol 2007;143:637-40.  Back to cited text no. 6
    
7.
Vance AZ, Weinberg BD, Arbique GM, Guild JB, Anderson JA, Chason DP, et al. Fluoroscopic sentinel events in neuroendovascular procedures: How to screen, prevent, and address occurrence. AJNR Am J Neuroradiol 2013;34:1513-5.  Back to cited text no. 7
    
8.
Wagner L. Radiation injury is a potentially serious complication to fluoroscopically-guided complex interventions. Biomed Imaging Interv J 2007;3:e22.  Back to cited text no. 8
    
9.
Spiker A, Zinn Z, Carter WH, Powers R, Kovach R. Fluoroscopy-induced chronic radiation dermatitis. Am J Cardiol 2012;110:1861-3.  Back to cited text no. 9
    
10.
Falay T, Erdemir VA, Savaş S, Gürel MS, Ozkur E. Fluoroscopy-induced chronic radiodermatitis. J Dermatol Res Ther 2016;2:31.  Back to cited text no. 10
    
11.
Minni JP, Nowak M, Usmani A, Kowalcyzk J, Rosenberg S, Nousari CH, et al. A unique case of subacute radiodermatitis. Cutis 2013;91:230-2.  Back to cited text no. 11
    
12.
Mundi JP, Kanchanapoomi M, Boyd KP, Patel RR, Kamino H, Cohen DE, et al. Fluoroscopy-associated radiation dermatitis. Dermatol Online J 2013;19:20712.  Back to cited text no. 12
    
13.
Patterson JW. Reactions to physical agents. In: Patterson JW, editor. Weedon's Skin Pathology. 4th ed. China: Churchill Livingstone Elsevier; 2016. p. 612-28.  Back to cited text no. 13
    
14.
Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation dermatitis: A report of two additional cases and a brief review of the literature. J Cutan Pathol 2012;39:63-7.  Back to cited text no. 14
    
15.
Takikawa M, Nambu M, Yamamoto N, Azuma R, Kiyosawa T. Radiation-induced skin injury on the upper arm following cardiac interventional radiology: A review and case report. Wounds 2012;24:91-8.  Back to cited text no. 15
    

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Correspondence Address:
Meenakshi Batrani
10, Aradhana Enclave, RK Puram, Sector 13, New Delhi - 110 066
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_566_17

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