Original contributionPostirradiation morphea: an underrecognized complication of treatment for breast cancer
Introduction
That morphea ranks among the local cutaneous side effects of radiotherapy was recognized shortly after the discovery of x-rays by Roentgen in 1885 and noted in textbooks of the same era [1]. It received little subsequent attention until the report by Colver et al [2] in 1989, describing the phenomenon in 9 patients, of whom 7 had received radiotherapy for breast cancer. Occurring as an idiosyncratic reaction, independent of the severity of acute radiodermatitis, its temporal relationship to treatment has been inconsistent and its main significance lies in its clinical mimicry of locally recurrent carcinoma. With the benefit of emerging data, it has become clear that this complication of radiotherapy can also develop as a sequel to treatment of cancers at sites other than the breast [2], [3], [4] and that it can, on occasion, extend beyond the portal of irradiation [2], [4], [5], [6], [7], [8]. Moreover, the related entity, lichen sclerosus et atrophicus (LS&A), observed not infrequently in association with morphea and considered to be part of the same spectrum of disease, has been documented to occur in this clinical setting [9], [10]. The objective of this report is to outline the clinical and microscopic characteristics of postirradiation morphea in 5 patients treated for breast cancer and to distill the literature on the subject. Our aims are (і) to highlight the diagnostic challenges presented by this entity, (іі) to expand existing knowledge of a rare but important phenomenon, and (ііі) to contribute to existing hypotheses about its pathogenesis.
Section snippets
Methods
Five cases of postirradiation morphea were encountered between 1996 and 2008 in the pathology practices of 2 of the authors. Case retrieval was via the laboratory information system (Cerner Classic). Clinical data pertaining to the patients' breast cancers, diagnosed between 1991 and 2004, related treatment and subsequent skin disease were obtained with the assistance of clinicians. These included a radiation oncologist, 2 dermatologists, and a general surgeon. Three control cases of idiopathic
Clinical findings
Clinical data related to the 5 patients, their breast cancers, radiotherapeutic regimens, and postirradiation morphea are outlined in Table 1, Table 2, Table 3, respectively. They are summarized here. At the time of the diagnosis of breast cancer, the patients ranged in age from 51 to 69 years (mean = 58). All 5 cancers involved the left breast, 4 being invasive ductal carcinomas and 1 an invasive mixed lobular and ductal carcinoma. All 5 tumors were estrogen and/or progesterone
Discussion
A summary of the 31 published cases of postirradiation morphea in patients treated for breast cancer is provided in Table 5 [2], [3], [4], [5], [6], [7], [8], [11], [12], [13], [14], [15], [16], [17]. The estimated incidence of this complication of radiotherapy is 1:500 patients [14], in contrast to that of morphea (of any etiology), which is 2.7 per 100 000 of the general population per year [7]. A difficulty in determining the exact frequency of the problem lies in the rate of accuracy of the
Acknowledgments
The authors gratefully acknowledge the clerical assistance of Mrs Andrena Brown. They also thank Mr S. Whitefield, who took the photomicrographs, in the Department of Anatomy and Neurobiology, Dalhousie University.
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