Case Number : Case 2454 - 28 November 2019 Posted By: Saleem Taibjee

thickened fibrosclerosis with scarring. no inflammation

I see as if there the vessels are showing some sort of calcification

May be a calciphylaxis

does the patient have a renal problem

however there we see a panniculitis, I do not see a panniculitis

this sort of sclerosis and non healing if multiple , I would think of malignant atrophic papulosis of dego, but there is scarring and healing there

I give up here

I bet the patient had performed earlier a fluoroscopic procedure and this is fluoroscopic induced chronic radio-dermatitis!  

agreed most likely a radiation dermatitis 

with dermal sclerosis, no adnexa, vessels and hyper chromatic fibroblasts

Could as well be a scar resulting from a thermal burn. I don't see radiation fibroblasts. Arrector pili muscles are usually preserved in radiation dermatitis but lost in thermal burn scar. 

There is sclerosis, and I think there are some radiation fibroblasts. The location is typical for fluoroscopy induced chronic radiation dermatitis. 

Totally agree with Mona!

Primary cutaneous CD4+ small/medium-sized pleomorphic T-cell lymphoma associated with an annular elastolytic giant cell granuloma

or more preferably perforating elastosis

Well done.

This is an old case from 2016-7. The case initially baffled me. Histologically I was suspecting previous radiotherapy at this site, but there was no previous record of radiotherapy. I showed the case to Eduardo Calonje who made the correct diagnosis.

Yes this is chronic radio-dermatitis arising from repeated cardiac procedures performed under fluoroscopic guidance.

After reviewing the patient's notes, and involving our medical physics dept, we were able to ascertain that the patient had the previous procedures: 2 x PCI (angioplasty) to RCA 1986 – no dose information available, 2 x PCI (angioplasty) to RCA 1992 – no dose information available, PCI (stent) to RCA in 1997 – no dose information available, Angio on 24/11/2011 (Dose / DAP: 2091cGycm² , Fluoro time: 0.9mins, Estimated entrance skin dose – 0.42Gy), PCI to RCA on 22/02/2012 (Dose / DAP: 11348 cGycm²  Fluoro time: 16.7mins, Estimated entrance skin dose – 2.27Gy), Angio on 02/09/2013 (Dose / DAP: 2981cGycm2  Fluoro time: 1.8mins, Estimated entrance skin dose – 0.60Gy).

This phenomenon was first described by Lichtenstein DA et al. Arch Dermatol 1996;132:663-7. They described 4 patients developing chronic radiodermatitis developed following multiple cardiac catheterizations and coronary angioplasties. Importantly, there can be a latency as long as 2-10 years after the 1st cardiac procedure. Cumulative radiation doses were retrospectively calculated in their series: Mean 24.6 Gy per patient, range of 11.4 to 34.9 Gy. But radiation doses as small as 11.4 Gy (during 1 or 2 procedures) are potentially harmful. 

It is perhaps surprising that we have not seen more of these cases given that there are in excess of 1 million such cardiac procedures per year in the USA alone - perhaps cases are being missed. That said, it is likely that we will see less of this in the future given the improvements in imaging technology with reduced radiation dosage.

The anatomical location of the lesion can be predicted by the positioning of the patient for the cardiac procedure. Our patient will have had imaging mostly in the left anterior oblique position, explaining location of the lesion on the right upper back. See below. BW Saleem.

Taibjee St Johns cases 2017 v9.pdf

superb sir