Вы находитесь на странице: 1из 3

Fluoroscopy-Induced Chronic Radiation Dermatitis

Alison Spiker, BA b, *, Zachary Zinn, MD a , William H. Carter, MD c , Roxann Powers, MD a , and Rodney Kovach, MD a

A 62-year-old man with a history of 2 previous cardiac catheterizations presented with an itchy, nontender skin lesion over his right scapula. The skin lesion had been present for > 5 years. Review of the medical records found evidence of a prolonged and complicated cardiac catheterization 8 years previously. Physical examination revealed an 8 6 cm, well-demarcated, erythematous reticulated atrophic plaque with telangiectasias and ulcer- ation. Biopsy confirmed histologic changes consistent with radiation dermatitis. In conclu- sion, the characteristic histologic findings of radiation dermatitis, along with the location over the right scapula and the history of prolonged fluoroscopic exposure during cardiac catheterization, led to the clinical diagnosis of fluoroscopy-induced chronic radiation dermatitis. © 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:1861–1863)

The advent of therapeutic interventions such as atrial fibrillation ablation, biventricular pacing, and even complex coronary intervention has resulted in increased radiation exposure in the catheterization laboratory. Skin exposed to fluoroscopy can be injured by the radiation and is often the tissue most at risk because it receives the highest dose. 1 We present a case of a patient found to have fluoroscopy- induced chronic radiation dermatitis and review the current research surrounding the diagnosis and management of these patients.

Case Description

A 62-year-old man presented with a history of an itchy, nontender skin lesion over his right scapula, which he re- ported had been present for 5 years. His medical history included hypertension, hyperlipidemia, heart failure, coro- nary artery disease, and extensive smoking. He reported no history of excessive sun exposure or radiation therapy. The patient had 2 cardiac catheterizations with stent placement 8 and 9 years before presentation. Later review of his medical records revealed that the patient’s second cardiac catheter- ization involved stent breakage in the ostial right coronary artery requiring prolonged fluoroscopic exposure to retrieve the broken stent. The total fluoroscopy time and total dose of radiation delivered during the catheterization are un- known; there were no reporting requirements for total grays at that time. On physical examination, the lesion was an 8 6 cm, well-demarcated, erythematous reticulated atrophic plaque with telangiectasias and ulceration located over the right scapula ( Figure 1 ). Histopathology of the lesion demon- strated dilated superficial vessels; thickened, sclerotic col- lagen bundles with loss of adnexal structures; and sparsely

a Section of Dermatology, Department of Medicine, b West Virginia University School of Medicine, Morgantown, West Virginia; and c Depart- ment of Medicine, Charleston Area Medical Center, Charleston, West Virginia. Manuscript received May 23, 2012; revised manuscript received and accepted August 8, 2012. *Corresponding author: Tel: 304-532-3141; fax: 304-347-1251. E-mail address: alison.spiker@gmail.com (A. Spiker).

http://dx.doi.org/10.1016/j.amjcard.2012.08.023

scattered atypical fibroblasts ( Figure 2 ). These findings were consistent with radiation dermatitis. The patient’s his- tory of prolonged fluoroscopic exposure during cardiac catheterization combined with the location of the lesion and the characteristic histologic findings of radiation dermatitis led to the clinical diagnosis of fluoroscopy-induced chronic radiation dermatitis. Since presentation to clinic, the patient has been followed regularly for skin cancer screening and symptomatic management of his lesion.

Comments

Radiation dermatitis is well documented and common, occurring in about 90% of patients receiving radiotherapy for cancer. 2,3 Fluoroscopy-induced radiation dermatitis is uncommon, because radiation doses delivered during fluo- roscopic procedures are typically low and do not reach the threshold needed for skin injury. 4 Radiation dermatitis can develop after fluoroscopy-guided interventional procedures such as coronary angiography, percutaneous transluminal coronary angioplasty, and radiofrequency cardiac catheter ablation. 5 The location of skin injury correlates with the site of radiation beam entry and varies depending on the proce- dure. 6 Radiation dermatitis from coronary procedures is commonly found on the midback, scapular areas, right an- terolateral chest, and below the right axilla. 6 Clinical presentation of fluoroscopy-induced radiation dermatitis can vary from early reactions of erythema, epil- ation, and dermal atrophy to chronic changes such as telan- giectasia, ulceration, and necrosis. 57 Signs of acute radia- tion dermatitis are usually present but are not necessary for the development of chronic radiation dermatitis. Histologic features characteristic of radiation dermatitis include epi- dermal atrophy, dermal sclerosis, dilated superficial blood vessels, and atypical stellate fibroblasts. 8 Fluoroscopy-in- duced radiation dermatitis is diagnosed by correlating the patient’s history of a fluoroscopy-guided procedure with the location of the skin lesion and the characteristic histologic findings. 5 A biopsy is generally not recommended for chronic radiation dermatitis if the history and clinical pre- sentation are classic given poor wound healing of skin damaged by radiation.

www.ajconline.org

1862

The American Journal of Cardiology (www.ajconline.org)

1862 The American Journal of Cardiology (www.ajconline.org) Figure 1. Appearance of the skin lesion. The lesion

Figure 1. Appearance of the skin lesion. The lesion was found over the patient’s right scapula, which was the site of radiation beam entry during the cardiac catheterization. The lesion was described as an 8 6 cm, well-demarcated, erythematous reticulated atrophic plaque with telangiec- tasias and ulceration.

atrophic plaque with telangiec- tasias and ulceration. Figure 2. Histology of the skin lesion. Histologic

Figure 2. Histology of the skin lesion. Histologic examination revealed characteristic findings of radiation dermatitis. The lesion was described as having dilated superficial blood vessels; thickened, sclerotic collagen bundles with loss of adnexal structures; and sparsely scattered atypical fibroblasts.

Treatment options for radiation dermatitis consist mostly of symptomatic management and monitoring for progres- sion of the lesion. There is currently no definitive treatment

for radiation dermatitis. 2,3 Review of the existing therapies demonstrates that topical corticosteroids, such as mometa- sone furoate and beclomethasone dipropionate, reduce skin reactions after radiation. 3 Evidence for the use of topical nonsteroidal creams is conflicting and does not show a clear benefit. 3 Surgical excision and skin grafting may be re - quired for severe injuries, such as nonhealing ulcers. 5,6 Malignant transformation of the skin into squamous cell carcinoma in the area exposed to ionizing radiation has been documented. 9 There have been reports of superficial basal cell carcinomas developing 20 to 30 years after multiple diagnostic fluoroscopic procedures in patients exposed to large cumulative doses of ionizing radiation. 10,11 Cancer is an example of a stochastic effect of radiation. 1,4 Stochastic effects lack a threshold dose required for injury, whereas deterministic effects of radiation are injuries to the skin and subcutaneous tissues that occur once a threshold dose is exceeded. 1,4 Patients who undergo fluoroscopy-guided procedures should be made aware of the possibility of radiation derma- titis, especially if they will be exposed to 4 Gy. 4 In most patients, the threshold dose for clinically significant skin and hair changes is 5 Gy. 7 If a patient received an estimated total radiation dose 10 Gy, medical follow-up is appro- priate. 7 After fluoroscopic procedures, patients should be advised to monitor for any skin changes in the area exposed under fluoroscopy and should receive direct skin evaluation if exposed to higher doses. Fluoroscopic procedures are increasing in younger pa- tients, particularly radiofrequency cardiac catheter ablation as a treatment for atrial fibrillation, many of whom require 2 procedures. 12 Physicians must know thresholds of ex - posure mandating follow-up and published guidelines for reducing exposure. 1,4,13 As outlined in a recent publication by the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions, cardiac catheterization reports must include fluoroscopy time and radiation dose as minimum requirements, and patients should be informed if they received significant exposure. 14 Because there is no definitive treatment for fluoroscopy-induced radiation dermatitis, prevention is crit- ical to reducing injuries. Radiation dermatitis should be considered in any patient at late follow-up presenting with a well-demarcated, atrophic, telangiectatic ulcerated lesion arising in an area exposed to substantial fluoroscopy.

1. Miller DL, Balter S, Schueler BA, Wagner LK, Strauss KJ, Vañó E. Clinical radiation management for fluoroscopically guided interven- tional procedures. Radiology 2010;257:321–332.

2. Ryan JL. Ionizing radiation: the good, the bad, and the ugly. J Invest Dermatol 2012;132:985–993.

3. Salvo N, Barnes E, van Draanen J, Stacey E, Mitera G, Breen D, Giotis A, Czarnota G, Pang J, De Angelis C. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol 2010;17:94 –112.

4. Hirshfeld JW, Balter S, Brinker JA, Kern MJ, Klein LW, Lindsay BD, Tommaso CL, Tracy CM, Wagner LK, Creager MA, Elnicki M, Lorell BH, Rodgers GP, Weitz HH. ACCF/AHA/HRS/SCAI clinical compe- tence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular pro- cedures: a report of the American College of Cardiology Foundation/ American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Circulation 2005;111:

511–532.

Case Report/Fluoroscopy-Induced Chronic Radiation Dermatitis

1863

5. Koenig TR, Wolff D, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 2001;177:3–11.

6. Koenig TR, Mettler FA, Wagner LK. Skin injuries from fluoroscopi- cally guided procedures: part 2, review of 73 cases and recommenda- tions for minimizing dose delivered to patient. AJR Am J Roentgenol

2001;177:13–20.

7. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluo- roscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology 2010;254:326 –341.

8. Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation der- matitis: a report of two additional cases and a brief review of the literature. J Cutan Pathol 2012;39:63– 67.

9. Goldschmidt H, Sherwin WK. Reactions to ionizing radiation. J Am

Acad Dermatol 1980;3:551–579. 10. Madison JF. Basal cell epithiliomas after repeated fluoroscopic exam- inations of the chest. Arch Dermatol 1980;116:323–324.

11. Murray SJ, Prokopetz R, Miller RA. Invasive basal cell carcinoma after repeated diagnostic fluoroscopic examinations. Arch Dermatol 1986;122:628 – 629.

12. Winkle RA, Mead HR, Engel G, Patrawala RA. Long-term results of atrial fibrillation ablation: the importance of all initial ablation failures undergoing a repeat ablation. Am Heart J 2011;162:193–200.

13. Chambers CE, Fetterly KA, Holzer R, Lin PJ, Blankenship JC, Balter S, Laskey WK. Radiation safety program for the cardiac catheteriza- tion laboratory. Catheter Cardiovasc Interv 2011;77:546 –556.

14. Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JW, Oliver-McNeil SM, Popma JJ, Tommaso CL. 2012 American College of Cardiology Foundation/Society for Car- diovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: a report of the American College of Cardiology Foundation Task Force on Expert Con- sensus Documents. J Am Coll Cardiol 2012;59:2221–2305.