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Journal of Clinical Oncology, Vol 23, No 3 (January 20), 2005: pp. 644 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.03.078
Benign Lesions in Cancer PatientsCASE 3. Vitiligo After Radiotherapy for Breast Cancer in a Woman With Depigmentation DisorderOncology Institute and Blood Bank, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel A 52-year-old woman with a history of mild vitiligo in the hands and lips presented with stage II (T1N1M0) cancer of the left breast. She underwent left radical mastectomy followed by adjuvant chemotherapy (doxorubicin and cyclophosphamide, methotrexate, and fluorouracil) and radiotherapy to the chest wall, and lymphatic drainage. The radiation dose was 50 Gy in 25 fractions over 5 weeks. Two months after completing radiotherapy, an area of depigmentation appeared. The area of depigmentation closely matched the radiotherapy field, including the chest wall and left supraclavicular and axillary areas (Fig 1). Vitiligo is a common skin disorder. It occurs worldwide in approximately 0.5% to 1% of the population, mostly in those between the ages of 10 and 30 years. The cause is unknown but might involve genetic factors, autoimmunity, toxic metabolites, and/or a higher vulnerability of melanocytes.1 Since there is no curative treatment for vitiligo, current modalities are directed toward preventing progression of the skin changes.2
Irradiation is associated with early and late toxicity to the skin and subcutaneous tissues. Patients with collagen vascular diseases have an increased radiation sensitivity of normal tissues to radiation damage, and several cases of severe radiation skin sequelae after breast or chest wall irradiation have been reported. Most of these complications consisted of severe fibrosis and/or necrosis.3,4 Depigmentation has only rarely been reported in association with irradiation, and it was documented in few vitiligo patients and in a patient with metastatic melanoma.5-8 Our patient demonstrated hypopigmentation, which developed 2 months after finishing irradiation. The suggested mechanism for hypopigmentation in this case is radiation-induced apoptosis of susceptible melanocytes. Free radical-mediated damage, induced by radiotherapy, may be the initial pathogenic event in melanocyte degeneration in the irradiated field of our patient. The early cell death of melanocytes in vitiligo is related to their increased sensitivity to oxidative stress.9 Oxidative stress can occur in irradiated human cells and may play a direct role in radiation-induced apoptosis. In patients with previous vitiligo, the risks and benefits of radiation therapy should be carefully weighed in order to prevent undesired cosmetic results, particularly if an alternative therapy is available. Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Njoo MD, Westerhof W: Vitiligo: Pathogenesis and treatment. Am J Clin Dermatol 2:167-181, 2001[CrossRef][Medline] 2. Taneja A: Treatment of vitiligo. J Dermatolog Treat 13:19-25, 2002[Medline] 3. Chen AM, Obedian E, Haffty BG: Breast-conserving therapy in the setting of collagen vascular disease. Cancer J 7:480-491, 2001[Medline]
4. Morris MM, Powell SN: Irradiation in the setting of collagen vascular disease: Acute and late complications. J Clin Oncol 15:2728-2735, 1997 5. Koo SW, Suh CO, Hann SK: Vitiligo following radiotherapy for carcinoma of the breast. Br J Dermatol 135:852-853, 1996 6. 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) 6:133-134, 1994 7. Pajonk F, Weissenberger C, Witucki G, et al: Vitiligo at the sites of irradiation in a patient with Hodgkin’s disease. Strahlenther Onkol 178:159-162, 2002[CrossRef][Medline] 8. Roth WG: [Vitiligo following x-irradiation of multiple melanoma metastases]. Hautarzt 19:178-180, 2002 9. Jimbow K, Chen H, Park JS, et al: Increased sensitivity of melanocytes to oxidative stress and abnormal expression of tyrosinase-related protein in vitiligo. Br J Dermatol 144:55-65, 2001[CrossRef][Medline]
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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