Elsevier

Human Pathology

Volume 39, Issue 11, November 2008, Pages 1680-1688
Human Pathology

Original contribution
Postirradiation morphea: an underrecognized complication of treatment for breast cancer

https://doi.org/10.1016/j.humpath.2008.04.010Get rights and content

Summary

The most common cutaneous side effects of radiotherapy include radiodermatitis and radiation fibrosis. These are influenced by the type, dose, and pattern of delivery of the treatment. Distinct from these is postirradiation morphea (localized scleroderma), an idiosyncratic treatment-related phenomenon. Within the last 20 years, approximately 31 examples of postirradiation morphea after treatment for breast cancer were reported. We describe 5 new cases of this entity and integrate our findings with those in the literature. The mean age of the patients at the time of diagnosis of cancer was 58 years; all were left-sided and treated by local excision of the tumor, ipsilateral axillary lymph node dissection, and local radiotherapy. After an interval of 4 to 12 years, the patients developed morphea in the radiation portals, with extension beyond it in one instance. Recurrent breast carcinoma was suspected clinically in 2 cases. Microscopically, changes of morphea involved the dermis in all cases and the subcutis in 2. There was associated lichen sclerosus et atrophicus in 2 cases. Our data about management and outcome are limited, but 1 patient treated with potent topical steroids experienced gradual softening of the affected skin over a 5-year period, whereas another had a mastectomy for relief of painful induration of the breast. Our findings support existing theories about the pathogenesis of this condition and link it to those of sclerodermoid graft-versus-host disease. The purpose of our communication is to draw attention to this 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.

References (24)

  • Ardern-JonesM.R. et al.

    Widespread morphea following radiotherapy for carcinoma of the breast

    Clin and Exper Dermatol

    (2003)
  • YatesV.M. et al.

    Lichen sclerosus et atrophicus following radiation therapy

    Arch Dermatol

    (1985)
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