Indian Journal of Cancer
Home  ICS  Feedback Subscribe Top cited articles Login 
Users Online :1866
Small font sizeDefault font sizeIncrease font size
Navigate here
  Search
 
 » Next article
 » Previous article 
 » Table of Contents
  
Resource links
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
 »  Article in PDF (58 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free)  

 
  In this article
 »  Abstract
 »  Case Report
 »  Discussion
 »  References
 »  Article Figures

 Article Access Statistics
    Viewed4557    
    Printed158    
    Emailed3    
    PDF Downloaded402    
    Comments [Add]    
    Cited by others 5    

Recommend this journal

 

CASE REPORT
Year : 2007  |  Volume : 44  |  Issue : 4  |  Page : 157-158
 

Radiotherapy-induced depigmentation in a patient with breast cancer


Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India

Correspondence Address:
Anusheel Munshi
Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.39379

Rights and Permissions

 » Abstract 

Vitiligo is a common dermatological disorder. A middle-aged woman with preexisting vitiligo was diagnosed with breast carcinoma. After surgery and chemotherapy she received regional radiotherapy. Six months after the completion of radiotherapy she developed depigmentation in the irradiated area. This article discusses the etiology for this phenomenon and the literature in this regard.


Keywords: Breast cancer, depigmentation, radiotherapy


How to cite this article:
Munshi A, Jain S, Budrukkar A, Jalali R, Sarin R. Radiotherapy-induced depigmentation in a patient with breast cancer. Indian J Cancer 2007;44:157-8

How to cite this URL:
Munshi A, Jain S, Budrukkar A, Jalali R, Sarin R. Radiotherapy-induced depigmentation in a patient with breast cancer. Indian J Cancer [serial online] 2007 [cited 2020 Jun 3];44:157-8. Available from: http://www.indianjcancer.com/text.asp?2007/44/4/157/39379


Vitiligo is a common skin disease that is reported to affect approximately 1% of the population worldwide. [1] Though not a life-threatening disease, the effects of vitiligo can be cosmetically and psychologically devastating, resulting in a low self-esteem and poor body image. The cause of this condition is uncertain but seems to be dependent on the interaction of genetic, immunological, and neurogenic factors. [2] Here, we report a case of a patient with vitiligo who developed depigmentation in the irradiated area after radiotherapy for breast cancer. We further discuss radiation-induced Koebner's phenomenon and its molecular mechanisms.


 » Case Report Top


A 42-year-old perimenopausal woman presented with a painless lump of 3 months duration in her right breast. She had a 10-year history of untreated vitiligo on the lips and hands [Figure - 1]. She was investigated and diagnosed as having an infiltrating ductal carcinoma of breast of stage T 4B N 1 M 0 . She received four cycles of neoadjuvant chemotherapy [cyclophosphamide, adriamycin, and 5-flourouracil (CEF) regime] which resulted in a partial clinical response. She underwent modified radical mastectomy followed by two cycles of adjuvant chemotherapy with CEF. Subsequently, she received adjuvant external-beam radiotherapy (EBRT) with tele-cobalt γ-rays to the chest wall and lymphatic drainage sites up to a dose of 45 Gy in 20 fractions over 4 weeks. She had hyperpigmentation and dry desquamation (grade 2 skin reactions, according to the common toxicity criteria) in the radiotherapy portal at the time of completion, which is an expected phenomenon. On the first follow-up after 6 months she complained of progressive white discoloration of the chest wall on the irradiated side. On examination, a depigmented macular area was found, which closely matched the bitangential radiotherapy portals [Figure - 1]. On palpation, there was minimal skin atrophy, with no induration/fibrosis or change in skin elasticity.


 » Discussion Top


Vitiligo is an acquired hypomelanotic disorder characterized by circumscribed depigmented macules in the skin that result from the loss of functional melanocytes. Vitiligo patches can appear anywhere on the skin but common sites are usually around the body orifices, the genitals, or any sun-exposed areas, such as the face and hands. [1]

Radiotherapy to the skin results in acute radiation injury to the skin, which is primarily a consequence of the loss of cells from the basal layer of the epidermis, and late injury, which is primarily a function of radiation effects on the vasculature. Commonly, this leads to hyperpigmentation of the skin at the completion of the radiotherapy course. Patients with collagen vascular diseases are known to have an increased radiation sensitivity of normal tissues to radiation damage, and cases of severe radiation skin sequelae, including severe fibrosis and/or necrosis, after breast or chest wall irradiation, have been reported. [3] However, there is no evidence for increased severity of acute or chronic reactions in patients with vitiligo. Fresh depigmented lesions in the radiation portals have however been previously reported in patients with vitiligo who underwent radiation for breast cancer or other cancers. [4],[5],[6],[7] Our patient developed hypopigmentation 6 months after completion of radiotherapy, which is in contrast to the 2 months interval reported by Weizen et al. [6] Furthermore, depigmentation developed in the area irradiated by the tangential portals and not in the skin irradiated by the supraclavicular portal. This is explained by a principle of radiation physics, according to which skin sparing will be more with a direct incident portal compared to an oblique or tangential portal. Tangential portals cause increased electron build-up and consequently increase the dose delivered to the skin.

Cases of vitiligo following radiotherapy have been reported in patients with a history of vitiligo, being considered as Koebner's phenomenon (KP). [7] KP, also known as the isomorphic response, is the development of preexisting skin disease following trauma to uninvolved skin. [8] Many forms of environmental stress on skin have been reported as provocating factors for the KP; these include mechanical, chemical, thermal, and infectious stimuli; Ultra-Violet exposure; and various types of dermatitis. The suggested mechanism for this phenomenon is radiation-induced apoptosis of susceptible melanocytes. Loss of melanocytes in the irradiated skin has been demonstrated by Pajonk et al. and correlated with the dose-dependent decrease in the red/green and yellow/blue saturation and overall increase in brightness on colorimetry. [9] Free radical-mediated damage, induced by radiotherapy, may be the initial pathogenic event in melanocyte degeneration in the irradiated skin. The early cell death of melanocytes in vitiligo is related to their increased sensitivity to the oxidative stress caused by irradiation, which may arise from complex processes of abnormal synthesis and processing of tyrosinase-related protein-1 and its interaction with calnexin. [10] Keratinocyte apoptosis can cause lower expression of keratinocyte-derived factors, including stem cell factors and basic fibroblast growth factor. [11] These factors might be responsible for passive melanocyte death, leading to their detachment and transepidermal elimination, and may explain the KP in the vitiligo patients. Recently, however, inhibition of thioredoxin reductase by the high extracellular calcium levels observed in the keratinocytes of vitiligo patients has been also proposed. [7]

In patients with preexisting vitiligo, the risks and benefits of radiation therapy should be carefully weighed in order to prevent undesired cosmetic results, particularly in the setting of breast conservation therapy. Preserving the skin by using megavoltage beams and low dose per fraction might improve the cosmetic results of radiation therapy in patients with a history of vitiligo. Study of radiotherapy-induced KP may prove useful in understanding the pathophysiology of vitiligo since the etiology of the disease is still elusive. The choice of therapeutic modality in this radiosensitive group of patients should be made on a case-by-case basis.

 
 » References Top

1.Whitton ME, Ashcroft DM, Barrett CW, Gonzalez U. Interventions for vitiligo. Cochrane Database Syst Rev 2006;1:CD003263.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Perrot JL. Thyreopathies et Autoimmunisation. Lyon Med 1973;230:325-31.  Back to cited text no. 2    
3.Morris MM, Powell SN. Irradiation in the setting of collagen vascular disease: Acute and late complications. J Clin Oncol 1997;15:2728-35.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Koo SW, Suh CO, Hann SK. Vitiligo following radiotherapy for carcinoma of the breast. Br J Dermatol 1996;135:852-3.  Back to cited text no. 4  [PUBMED]  
5.Levine EL, Ribeiro GG. Vitiligo and radiotherapy: The Koebner phenomenon demonstrated in patients with vitiligo undergoing radiotherapy for carcinoma of the breast. Clin Oncol (R Coll Radiol) 1994;6:133-4.  Back to cited text no. 5  [PUBMED]  
6.Weitzen R, Pfeffer R, Mandel M. Benign lesions in cancer patients: Case 3, Vitiligo after radiotherapy for breast cancer in a woman with depigmentation disorder. J Clin Oncol 2005;23:644.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Polat M, Yalηin B, Alli N. Vitiligo at the site of radiotherapy for nasopharyngeal carcinoma. Am J Clin Dermatol 2007;8:247-9.  Back to cited text no. 7    
8.Weiss G, Shemer A, Trau H. The Koebner phenomenon: review of the literature. J Eur Acad Dermatol Venereol 2002;16:241-8.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Pajonk F, Weissenberger C, Witucki G, Henke M. Vitiligo at the sites of irradiation in a patient with Hodgkin's disease. Strahlenther Onkol 2002;178:159-62.  Back to cited text no. 9  [PUBMED]  
10.Jimbow K, Chen H, Park JS, Thomas PD. Increased sensitivity of melanocytes to oxidative stress and abnormal expression of tyrosinase-related protein in vitiligo. Br J Dermatol 2001;144:55-65.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Lee AY, Kim NH, Choi WI, Youm YH. Less keratinocyte-derived factors related to more keratinocyte apoptosis in depigmented than normally pigmented suction-blistered epidermis may cause passive melanocyte death in vitiligo. J Invest Dermatol 2005;124:976-83.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1]

This article has been cited by
1 Subsequent vitiligo after hematopoietic stem cell transplantation: A nationwide population-based cohort study from Korea
Jung Min Bae,Kwang Hyun Choi,Han Mi Jung,Sook Young Kim,Miri Kim,Gyung Moon Kim,Dong Soo Yu,Young Bok Lee
Journal of the American Academy of Dermatology. 2017; 76(3): 459
[Pubmed] | [DOI]
2 Depigmentation Within the Radiation Field in Patients With Vitiligo
Dean A. Shumway,Eyad Abu-Isa,Daniel E. Soto,Thy Thy Do,Reshma Jagsi
International Journal of Radiation Oncology*Biology*Physics. 2016; 94(2): 421
[Pubmed] | [DOI]
3 Radiation induced depigmentation disorder in two patients with breast cancer: Exploring a rare accompaniment
Ahitagni Biswas,Pritee B. Chaudhari,Pramod Kumar Julka,Goura Kishor Rath
Journal of the Egyptian National Cancer Institute. 2015;
[Pubmed] | [DOI]
4 Report of a Case of Radiation-Induced New-Onset Vitiligo with Collective Review of Cases in the Literature of Radiation-Related Vitiligo
Keechilat Pavithran,Shripad Brahmanand Pande,Makuny Dinesh
Case Reports in Medicine. 2013; 2013: 1
[Pubmed] | [DOI]
5 Risk Factors of Breast Cancer in Indian Context
Biswa Bandita,Dipti Mohanty,S. K. Pradhan,S. N. Rath,Madhusmita Sahu,Ashish Joshi
International Journal of Computational Models and Algorithms in Medicine. 2012; 3(3): 1
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
Previous article Next article

    

  Site Map | What's new | Copyright and Disclaimer
  Online since 1st April '07
  © 2007 - Indian Journal of Cancer | Published by Wolters Kluwer - Medknow