Late radiation dermatitis of the right arm after cardiac catheterization

ARTICLE

Auteur(s) : Kozo Yoneda¹, Kozo Nakai¹, Toshio Demitsu², Tetsuya Moriue¹, Junko Moriue¹, Ikumi Yokoi¹, Asuka Munehiro¹, Takahisa Noma³, Masakazu Kohno³, Yasuo Kubota¹

¹Department of Dermatology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Kitagun Mikicho, Kagawa 761-0793, Japan
²Department of Dermatology, Jichi Medical University, Omiya Medical Center, Saitama, Japan
³Division of Cardiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Kitagun Mikicho, Kagawa 761-0793, Japan

Roentogen discovered X-rays in 1895 [1, 2] and since then X-rays have been frequently employed in various medical fields. Simultaneously, skin side effects have been reported. Malignant skin changes arising from late radiodermatitis remind us that X-rays can cause serious adverse effects. Ischemic heart disease is a major health concern in Japan and all over the world. Percutaneous transluminal coronary angioplasty (PTCA) has become a common and often-repeated procedure to treat coronary atherosclerosis. The use of fluoroscopy and cineradiography in this complicated, delicate, and sometimes lengthy treatment increases the risk of radiation dermatitis. Typically, the lesion is located on the patient's back and scapula because the X-ray beam is delivered from under the table the patient lies on during the procedure [1, 2]. We present a patient with radiation dermatitis on his right arm. To our knowledge, this is the fourth report of a case demonstrating late radiation dermatitis of the right arm and the first from a dermatological field [3-5].

A 78-year-old Japanese man presented to the dermatology department with a skin lesion on the dorsal side of the right arm (figure 1A). The skin lesion had persisted for two years. Physical examination showed a 7 × 7 cm irregularly shaped hypopigmented, telangiectatic, indurated plaque, surrounded by erythema (figure 1B). The surface skin was atrophic and decreased sebaceous activity was noted. Vellus hairs were scanty. The skin was also stiffening and tethering. Neither necrosis nor an ulcer was seen. Several irregularly-shaped hyperpigmented spots were observed. There were no radiation-induced tumors on the surface of this lesion. A biopsy specimen was obtained from the center of the lesion (figures 1C, D, E). The epidermis was thin and atrophic. Rete ridges had disappeared. Slight hyperkeratosis was also seen. In the upper dermis, the collagen fibers followed an irregular course and the blood vessels were ectatic (figure 1D). Mild mononuclear cell infiltrates around the blood vessels were present. Hair follicles and sebaceous glands were absent. In the lower dermis, the collagen bundles were swollen and deeply eosinophilic (figure 1E).

Late radiation dermatitis was diagnosed. The patient denied any contact with radioactive materials or exposure to possible radiation sources. However, he had suffered from ischemic heart disease for the past six years. During this time, he was hospitalized three times for myocardial infarction and PTCA. The main vessel treated was the right coronary artery. The angle of fluoroscopy exposure was 60° left anterior oblique (LAO) (figure 2). The total dose of radiation exposure was more than 16 Gy in the medical record. Unfortunately, the total dose of radiation exposure prior to 2006 was not recorded. However, the patient remembered spending several hours in the catheterization laboratory. The patient did not complain of a burning sensation. He was put under regular clinical follow up to detect ulcers or malignant transformation.

The benefits of fluoroscopically guided interventional procedures, such as cardiac angiography or PTCA, are reflected in the increasing number of interventions that are performed each year. However, these procedures can deliver a high radiation dose to a patient's skin. Successful treatment of difficult cases requires more complex and lengthy procedures, resulting in greater radiation exposure. Although the most typical site of radiation dermatitis is the patient's back, the axillary region is sometimes irradiated and the right arm has rarely been irradiated (table 1). To our knowledge, our case is the fourth case of late irradiation dermatitis of the right arm in the English literature [3-5].
Table 1 Summary of the four patients with late radiation dermatitis of the right arm following cardiac catheterization

We report a Japanese patient with late radiation dermatitis of the right arm. When dermatologists see such lesions, the history of interventions should be investigated with consideration of future complications such as ulcer or malignancy.

Acknowledgements

References

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