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Fluoroscopy-Induced Chronic Radiation Dermatitis

Alison Spiker, BAb,*, Zachary Zinn, MDa, William H. Carter, MDc, Roxann Powers, MDa, and
Rodney Kovach, MDa
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;110:18611863)

The advent of therapeutic interventions such as atrial scattered atypical fibroblasts (Figure 2). These findings
fibrillation ablation, biventricular pacing, and even complex were consistent with radiation dermatitis. The patients his-
coronary intervention has resulted in increased radiation tory of prolonged fluoroscopic exposure during cardiac
exposure in the catheterization laboratory. Skin exposed to catheterization combined with the location of the lesion and
fluoroscopy can be injured by the radiation and is often the the characteristic histologic findings of radiation dermatitis
tissue most at risk because it receives the highest dose.1 We led to the clinical diagnosis of fluoroscopy-induced chronic
present a case of a patient found to have fluoroscopy- radiation dermatitis. Since presentation to clinic, the patient
induced chronic radiation dermatitis and review the current has been followed regularly for skin cancer screening and
research surrounding the diagnosis and management of symptomatic management of his lesion.
these patients.
Comments
Case Description
Radiation dermatitis is well documented and common,
A 62-year-old man presented with a history of an itchy, occurring in about 90% of patients receiving radiotherapy
nontender skin lesion over his right scapula, which he re- for cancer.2,3 Fluoroscopy-induced radiation dermatitis is
ported had been present for 5 years. His medical history uncommon, because radiation doses delivered during fluo-
included hypertension, hyperlipidemia, heart failure, coro- roscopic procedures are typically low and do not reach the
nary artery disease, and extensive smoking. He reported no threshold needed for skin injury.4 Radiation dermatitis can
history of excessive sun exposure or radiation therapy. The develop after fluoroscopy-guided interventional procedures
patient had 2 cardiac catheterizations with stent placement 8 such as coronary angiography, percutaneous transluminal
and 9 years before presentation. Later review of his medical coronary angioplasty, and radiofrequency cardiac catheter
records revealed that the patients second cardiac catheter- ablation.5 The location of skin injury correlates with the site
ization involved stent breakage in the ostial right coronary of radiation beam entry and varies depending on the proce-
artery requiring prolonged fluoroscopic exposure to retrieve dure.6 Radiation dermatitis from coronary procedures is
the broken stent. The total fluoroscopy time and total dose commonly found on the midback, scapular areas, right an-
of radiation delivered during the catheterization are un- terolateral chest, and below the right axilla.6
known; there were no reporting requirements for total grays Clinical presentation of fluoroscopy-induced radiation
at that time. dermatitis can vary from early reactions of erythema, epil-
On physical examination, the lesion was an 8 6 cm, ation, and dermal atrophy to chronic changes such as telan-
well-demarcated, erythematous reticulated atrophic plaque giectasia, ulceration, and necrosis.57 Signs of acute radia-
with telangiectasias and ulceration located over the right tion dermatitis are usually present but are not necessary for
scapula (Figure 1). Histopathology of the lesion demon- the development of chronic radiation dermatitis. Histologic
strated dilated superficial vessels; thickened, sclerotic col- features characteristic of radiation dermatitis include epi-
lagen bundles with loss of adnexal structures; and sparsely dermal atrophy, dermal sclerosis, dilated superficial blood
vessels, and atypical stellate fibroblasts.8 Fluoroscopy-in-
a
duced radiation dermatitis is diagnosed by correlating the
Section of Dermatology, Department of Medicine, bWest Virginia
patients history of a fluoroscopy-guided procedure with the
University School of Medicine, Morgantown, West Virginia; and cDepart-
ment of Medicine, Charleston Area Medical Center, Charleston, West location of the skin lesion and the characteristic histologic
Virginia. Manuscript received May 23, 2012; revised manuscript received findings.5 A biopsy is generally not recommended for
and accepted August 8, 2012. chronic radiation dermatitis if the history and clinical pre-
*Corresponding author: Tel: 304-532-3141; fax: 304-347-1251. sentation are classic given poor wound healing of skin
E-mail address: alison.spiker@gmail.com (A. Spiker). damaged by radiation.

0002-9149/12/$ see front matter 2012 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2012.08.023
1862 The American Journal of Cardiology (www.ajconline.org)

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
Figure 1. Appearance of the skin lesion. The lesion was found over the
patients right scapula, which was the site of radiation beam entry during
exceeded.1,4
the cardiac catheterization. The lesion was described as an 8 6 cm, Patients who undergo fluoroscopy-guided procedures
well-demarcated, erythematous reticulated atrophic plaque with telangiec- should be made aware of the possibility of radiation derma-
tasias and ulceration. 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.

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