Postirradiation morphea and subcutaneous polyarteritis nodosa: Case report and literature review

Dermatologic Sequelae Associated with Radiation Therapy

Radiation therapy is a mainstay for the treatment of primary malignancies and metastatic disease and is associated with several dermatological adverse events that are underreported in the literature. The objective of this paper was to review the literature regarding cutaneous manifestations associated with radiation therapy in order to promote awareness of the cutaneous radiation therapy-associated adverse effects. This extensive literature review was performed using the Pubmed and Embase databases. Studies were reviewed for relevance and critical evidence pertaining to cutaneous manifestations of radiation therapy. The most commonly reported cutaneous sequelae associated with radiation therapy include radiation dermatitis, non-melanoma skin cancer, radiation-associated angiosarcoma, morphea, bullous pemphigoid, lymphangioma circumscriptum, and pseudosclerodermatous panniculitis. For many of these conditions, only case reports or case series exist and there is an absence of large-scale cohort studies. Despite these limitations, this review describes the wide range of dermatological adverse events associated with radiation therapy.

Radiation-induced morphea-a rare but severe late effect of adjuvant breast irradiation : Case report and review of the literature

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.

Cutaneous polyarteritis nodosa localized to a region of lymphedema secondary to Streptococcus viridans cellulitis and multiple surgeries

Cutaneous polyarteritis nodosa (CPAN) is a chronic, indolent, single organ arteritis that generally presents with lower extremity nodules and/or livedo racemosa, accompanied by malaise and arthralgias. CPAN is often triggered by infection, commonly Group A streptococcal species, and is considered an autoimmune reaction. Scarring from surgery and obliterative lymphangiitis from bacterial cellulitis are the causes of lymphedema. Lymphedematous skin is predisposed to autoimmune disorders. Herein we report a 53-year-old woman who developed CPAN restricted to a localized area of the right upper arm-shoulder that had undergone multiple surgeries, complicated by episodes of Streptococcus viridans cellulitis. Clinically, a 15 cm diameter plaque exhibited violaceous, reticulate margins, subtle papules and nodules and central livedo racemosa. Biopsy showed numerous foci of arteritis in active, subacute and reparative stages. In addition, a broad zone of fibrosis replaced the deep dermis-subcutis zone and harbored numerous dilated lymphatic vessels scar lymphedema. Treatment consisted of high potency topical corticosteroids under occlusion; remission after 3 months therapy and follow-up. CPAN primarily affects the lower legs, a region of frequently affected by phlebolymphedema. This report of CPAN localized to an area of scar lymphedema underscores the importance of lymphatic function in the pathogenesis of CPAN.

A case of radiation-induced generalized morphea with prominent mucin deposition and tenderness

Patient: Female, 67

Final Diagnosis: Dermatomyositis

Symptoms: Muscle weakness • skin rash • subcutaneous nodules

Medication: —

Clinical Procedure: Drug administration

Specialty: Dermatology

Morphea and its variants and the "floating sign"-an additional finding in morphea

We report 2 patients with typical clinical findings of circumscribed morphea who on histopathologic examinations had histiocytes ("floating sign") surrounding individual collagen fibers in the dermis in addition to the key histologic findings of morphea. To our knowledge, there are no previous reports in the medical literature of such a phenomenon. Histopathological findings in idiopathic morphea and morphea-like conditions are reviewed.

Radiation-induced morphoea treated with UVA-1 phototherapy

Morphoea is a localized inflammatory disorder of the dermis and subcutaneous fat and radiotherapy is a rarely reported cause (estimated incidence of 2 per 1000). Morphoea is commonly mistaken for an inflammatory recurrence of breast cancer, resulting in unnecessary investigations and treatment. We report the case of a 40-year-old woman who developed radiation-induced morphoea of the breast 7 months following adjuvant radiotherapy. She was treated with topical and systemic steroids as well as psoralen plus ultraviolet (UV)A before proceeding to UVA1 phototherapy. We also review the literature and discuss other management options.

[Radio-induced breast morphoea: an unrecognized complication]

Morphoea is a localized scleroderma. Since the 1990s, it is described as a complication after irradiation for breast cancer. This complication is unrecognized and underdiagnosed. Irradiation seems to be a factor inducing an autoimmune process. Clinicians should be aware in case of an erythema in a treated area, appearing on average one year after the end of the irradiation. Histology alone can prove the diagnosis and rule out differential diagnoses: principally mastitis (carcinomatous, infectious), chronic radiodermatitis or radiation recall. Treatment of this rare complication is not consensual; it is most often topical steroids. The evolution is marked by a gradual decrease from the initial inflammation. Sclerosis persists, more or less substantially.

Post-Irradiation Morphea: Case report and review of the literature

BACKGROUND

Post-irradiation morphea (PIM) is an entity documented in the literature although still not mentioned in most of the dermatological textbooks with a frequency approximately 2 out of every 1000 patients who received radiotherapy. Most of the cases are misdiagnosed as recurrent or metastatic carcinoma.

MAIN OBSERVATIONS

We report on a 64-year-old woman who was treated with radiotherapy for breast cancer. Two years and eight months after the first dose of radiotherapy, she developed localized morphea in the irradiated area.

CONCLUSION

We report on a new case with a literature review and discuss pathogenesis, treatment modalities and post irradiation subcutaneos reactions mimicking PIM. Around 54 cases of post-irradiation morphea (PIM) were identified in the literature.

Three Presentations of Takayasu’s Arteritis in Hispanic Patients

Takayasu's arteritis (TA) is a medium and large vessel vasculitis, defined as a nonspecific aortitis that usually involves the aorta and its branches Kobayashi and Numano (2002). Its etiology remains unclear, and its complications are diverse and severe, including stenosis of the thoracic and abdominal aorta, aortic valve damage and regurgitation, and stenosis of the branches of the aorta. Carotid stenosis, coronary artery aneurysms, and renal artery stenosis resulting in renovascular hypertension are also reported sequellae of TA Kobayashi and Numano (2002). The disease was first described in Japan, but has also been diagnosed in India and Mexico Johnston (2002). Its incidence in the United States has been quoted as 2.6 patients per 1,000,000 people/year Johnston (2002). In Japan, its incidence is 3.6 patients per 1,000,000 patients/year and prevalence is 7.85 patients per 100,000 per year Morita et al. (1996). The natural history of this disease, which is commonly present in Asian populations, has only recently been studied in Hispanic patients despite the notable incidence and prevalence of TA in Mexican, South American, and Indian populations (Johnston 2002, Gamarra et al. 2010 ). We present three cases of Hispanic patients who presented with TA at Olive-View-UCLA Medical Center (OVMC). We review their clinical and radiographic presentations. Finally, we review the literature to compare the clinical features of our three patients with data regarding the presentation of TA in more traditional Asian populations.

Generalized morphea after breast cancer radiation therapy

We present a case of a 69-year-old woman who received external beam radiation for the treatment of breast cancer. Seven months later, she developed generalized morphea involving the area of irradiated skin of the breast as well as distant sites of the groin and distal lower extremity. Postirradiation morphea is an uncommon yet well-documented phenomenon, usually confined to the radiated site and the immediate surrounding tissue. To our knowledge, this is only the fourth reported case of morphea occurring distant from the radiation field. While most cases of postirradiation morphea have been shown to either resolve spontaneously or respond to topical corticosteroids, our patient required systemic therapy with methotrexate, which resulted in clinical improvement. With this paper, we hope to bring further awareness to this phenomenon and demonstrate a successful treatment response with the use of methotrexate in postirradiation generalized morphea.

Morphea of the Breast: Case Reports and Review of Literature

Morphea of the breast is an uncommon skin condition associated with autoimmune disorders and has also been described following radiotherapy. The inflammatory stage of morphea can commonly be mistaken for a breast abscess or inflammation. We report two cases of localized scleroderma affecting the breast with no history of autoimmune disease or radiation treatment. In both the cases, the lesions improved with the use of topical steroids.

Cutaneous Pseudovasculitis

Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.

Localized scleroderma

PURPOSE OF REVIEW

Localized scleroderma, also known as morphoea, has a variety of clinical manifestations that can include systemic involvement. Early recognition, diagnosis and treatment may improve the long-term outcome.

RECENT FINDINGS

A large multicentre study coordinated by the Pediatric Rheumatology European Society has yielded important information on the epidemiology and clinical manifestations of juvenile localized scleroderma, especially as it pertains to systemic manifestations. Previous results using methotrexate and corticosteroids have been confirmed. Studies on phototherapy have also demonstrated efficacy. A new immunomodulator, imiquimod, has shown promise in an initial case series.

SUMMARY

Studies over the past year highlight the wide range of extracutaneous manifestations and different forms of localized scleroderma and suggest that treatment may be beneficial.