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Asymptomatic Vesicular Eruption on the Chest in a Breast Cancer Survivor —Diagnosis

Asymptomatic Vesicular Eruption on the Chest in a Breast Cancer Survivor —Diagnosis Diagnosis: Benign lymphangiomatous papules (BLAP) of the skin following radiotherapy. Microscopic findings and clinical course Histopathological examination of the skin biopsy specimen revealed markedly dilated lymphangiomatous spaces with discontinuous flat endothelial lining within the papillary dermis, associated with a perivascular lymphocytic infiltrate, including a few neutrophils and eosinophils. Mild spongiosis with a focal hemorrhagic vesicle was observed in the overlying epidermis. There was no evidence of cytological atypia, viral cytopathic effects, or breast carcinoma. The patient returned 1 year later and noted that the papules and vesicles had now spread to involve her central chest. She was offered surgical removal of the lesions but declined because she was asymptomatic. She is considering breast reconstruction surgery and may decide to pursue removal of the lymphangiomatous papules at that time. Discussion Benign lymphangiomatous papules (BLAP), which were first described in 19561 and named in 1999,2 are rare cutaneous vascular proliferations.2,3 Benign lymphangiomatous papules have been reported in women between the ages of 30 and 70 years, with a history of radiation therapy following surgery primarily for breast, but also for ovarian, endometrial, and other cancers.1-9 A recent BLAP case was reported with an untreated ovarian tumor.3 BLAP may occur when surgery and radiation disrupt lymphatic flow, leading to dilatation of existing lymphatic vessels, or possibly because of lymphatic vessel proliferation in reaction to surgery or radiation-induced damage of lymph vessel endothelial cells.2,3,5-7 Typically, patients present with 1 or more flesh-colored to erythematous papules or vesicles1-9 with a latency period of 6 months to 30 years following radiotherapy.7 Lesions are usually 5 mm or less in diameter4,7 and located in or near the area of previous radiation or operation,1-9 often on the anterior chest wall or axillary or inguinal folds.2,3,5,9 Some lesions may contain a translucent or milky fluid.2,3 Benign lymphangiomatous papules are generally asymptomatic3,4,6,7 and not accompanied by lymphedema.2,6,8 Findings from histopathological examination typically include vascular proliferation in the superficial dermis, with anastomosing and dilated lymphaticlike vasculature, lined by plump-to-flat endothelial cells2-9 forming a discontinuous layer.2,5,9 Vascular lumens may be empty or filled with eosinophilic, proteinaceous material,2-7,9 and endothelial-lined papillary projections may protrude into the dilated lumen.2-6,8,9 Stroma may contain a lymphohistiocytic infiltrate and plasma cells.2,4,6,7,9 Mitoses and cellular atypia are not observed.2-9 Endothelial cells stain positively for CD31,2-7,9 CD34,2-4,6 factor VIII,2-4,6 and D2-40.4,7,9 Postradiation vascular proliferations are a rare but well-documented complication of radiotherapy and comprise a range of lesions, including BLAP, benign lymphangioendothelioma, acquired lymphangioma, lymphangioma circumscriptum, atypical vascular lesions (AVL), and malignant cutaneous angiosarcoma.2-5,7-9 Most case series suggest that BLAP has benign biological behavior,2,3,5,7,9 rarely recurring after excision2,5,7 or having malignant potential.3,5,6,9 However, some authors4 suggest that postradiation vascular growths represent a clinical and histopathologic spectrum from BLAP to angiosarcoma, with some overlap of histopathologic features between atypical vascular lesions and angiosarcoma and cases of AVL progressing to angiosarcoma.8,9 Therefore, it is important to distinguish BLAP from AVLs. Clinically, BLAP are flesh colored to hyperpigmented, whereas AVLs are more violaceous and vascular in appearance. Histologically, a BLAP usually does not show infiltration, whereas an AVL may dissect through the dermis. Any postradiation vascular lesions that develop atypical clinical or histopathologic features should be fully excised and referred for appropriate treatment.4,7,8 Return to Quiz Case. References 1. Plotnick H, Richfield D. Tuberous lymphangiectatic varices secondary to radical mastectomy. AMA Arch Derm. 1956;74(5):466-46813361529PubMedGoogle ScholarCrossref 2. Diaz-Cascajo C, Borghi S, Weyers W, Retzlaff H, Requena L, Metze D. Benign lymphangiomatous papules of the skin following radiotherapy: a report of five new cases and review of the literature. Histopathology. 1999;35(4):319-32710564386PubMedGoogle ScholarCrossref 3. Bodet D, Rodr íguez-Cano L, Bartralot R, et al. Benign lymphangiomatous papules of the skin associated with ovarian fibroma. J Am Acad Dermatol. 2007;56(2):(suppl) S41-S4417097370PubMedGoogle ScholarCrossref 4. Brenn T, Fletcher CD. Radiation-associated cutaneous atypical vascular lesions and angiosarcoma: clinicopathologic analysis of 42 cases. Am J Surg Pathol. 2005;29(8):983-99616006792PubMedGoogle Scholar 5. Requena L, Kutzner H, Mentzel T, Dur án R, Rodr íguez-Peralto JL. Benign vascular proliferations in irradiated skin. Am J Surg Pathol. 2002;26(3):328-33711859204PubMedGoogle ScholarCrossref 6. Wagamon K, Ranchoff RE, Rosenberg AS, Jaworsky C. Benign lymphangiomatous papules of the skin. J Am Acad Dermatol. 2005;52(5):912-91315858490PubMedGoogle ScholarCrossref 7. Brunasso AMG, Delfino C, Ketabchi S, Difonzo EM, Massone C. Papules arising after radiotherapy for rhabdomyosarcoma. Acta Dermatovenerol Alp Panonica Adriat. 2009;18(1):24-2719350189PubMedGoogle Scholar 8. Mattoch IW, Robbins JB, Kempson RL, Kohler S. Post-radiotherapy vascular proliferations in mammary skin: a clinicopathologic study of 11 cases. J Am Acad Dermatol. 2007;57(1):126-13317572278PubMedGoogle ScholarCrossref 9. Gengler C, Coindre JM, Leroux A, et al. Vascular proliferations of the skin after radiation therapy for breast cancer: clinicopathologic analysis of a series in favor of a benign process: a study from the French Sarcoma Group. Cancer. 2007;109(8):1584-159817357996PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Asymptomatic Vesicular Eruption on the Chest in a Breast Cancer Survivor —Diagnosis

Archives of Dermatology , Volume 147 (12) – Dec 1, 2011

Asymptomatic Vesicular Eruption on the Chest in a Breast Cancer Survivor —Diagnosis

Abstract

Diagnosis: Benign lymphangiomatous papules (BLAP) of the skin following radiotherapy. Microscopic findings and clinical course Histopathological examination of the skin biopsy specimen revealed markedly dilated lymphangiomatous spaces with discontinuous flat endothelial lining within the papillary dermis, associated with a perivascular lymphocytic infiltrate, including a few neutrophils and eosinophils. Mild spongiosis with a focal hemorrhagic vesicle was observed in the overlying epidermis....
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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.147.12.1443-f
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Benign lymphangiomatous papules (BLAP) of the skin following radiotherapy. Microscopic findings and clinical course Histopathological examination of the skin biopsy specimen revealed markedly dilated lymphangiomatous spaces with discontinuous flat endothelial lining within the papillary dermis, associated with a perivascular lymphocytic infiltrate, including a few neutrophils and eosinophils. Mild spongiosis with a focal hemorrhagic vesicle was observed in the overlying epidermis. There was no evidence of cytological atypia, viral cytopathic effects, or breast carcinoma. The patient returned 1 year later and noted that the papules and vesicles had now spread to involve her central chest. She was offered surgical removal of the lesions but declined because she was asymptomatic. She is considering breast reconstruction surgery and may decide to pursue removal of the lymphangiomatous papules at that time. Discussion Benign lymphangiomatous papules (BLAP), which were first described in 19561 and named in 1999,2 are rare cutaneous vascular proliferations.2,3 Benign lymphangiomatous papules have been reported in women between the ages of 30 and 70 years, with a history of radiation therapy following surgery primarily for breast, but also for ovarian, endometrial, and other cancers.1-9 A recent BLAP case was reported with an untreated ovarian tumor.3 BLAP may occur when surgery and radiation disrupt lymphatic flow, leading to dilatation of existing lymphatic vessels, or possibly because of lymphatic vessel proliferation in reaction to surgery or radiation-induced damage of lymph vessel endothelial cells.2,3,5-7 Typically, patients present with 1 or more flesh-colored to erythematous papules or vesicles1-9 with a latency period of 6 months to 30 years following radiotherapy.7 Lesions are usually 5 mm or less in diameter4,7 and located in or near the area of previous radiation or operation,1-9 often on the anterior chest wall or axillary or inguinal folds.2,3,5,9 Some lesions may contain a translucent or milky fluid.2,3 Benign lymphangiomatous papules are generally asymptomatic3,4,6,7 and not accompanied by lymphedema.2,6,8 Findings from histopathological examination typically include vascular proliferation in the superficial dermis, with anastomosing and dilated lymphaticlike vasculature, lined by plump-to-flat endothelial cells2-9 forming a discontinuous layer.2,5,9 Vascular lumens may be empty or filled with eosinophilic, proteinaceous material,2-7,9 and endothelial-lined papillary projections may protrude into the dilated lumen.2-6,8,9 Stroma may contain a lymphohistiocytic infiltrate and plasma cells.2,4,6,7,9 Mitoses and cellular atypia are not observed.2-9 Endothelial cells stain positively for CD31,2-7,9 CD34,2-4,6 factor VIII,2-4,6 and D2-40.4,7,9 Postradiation vascular proliferations are a rare but well-documented complication of radiotherapy and comprise a range of lesions, including BLAP, benign lymphangioendothelioma, acquired lymphangioma, lymphangioma circumscriptum, atypical vascular lesions (AVL), and malignant cutaneous angiosarcoma.2-5,7-9 Most case series suggest that BLAP has benign biological behavior,2,3,5,7,9 rarely recurring after excision2,5,7 or having malignant potential.3,5,6,9 However, some authors4 suggest that postradiation vascular growths represent a clinical and histopathologic spectrum from BLAP to angiosarcoma, with some overlap of histopathologic features between atypical vascular lesions and angiosarcoma and cases of AVL progressing to angiosarcoma.8,9 Therefore, it is important to distinguish BLAP from AVLs. Clinically, BLAP are flesh colored to hyperpigmented, whereas AVLs are more violaceous and vascular in appearance. Histologically, a BLAP usually does not show infiltration, whereas an AVL may dissect through the dermis. Any postradiation vascular lesions that develop atypical clinical or histopathologic features should be fully excised and referred for appropriate treatment.4,7,8 Return to Quiz Case. References 1. Plotnick H, Richfield D. Tuberous lymphangiectatic varices secondary to radical mastectomy. AMA Arch Derm. 1956;74(5):466-46813361529PubMedGoogle ScholarCrossref 2. Diaz-Cascajo C, Borghi S, Weyers W, Retzlaff H, Requena L, Metze D. Benign lymphangiomatous papules of the skin following radiotherapy: a report of five new cases and review of the literature. Histopathology. 1999;35(4):319-32710564386PubMedGoogle ScholarCrossref 3. Bodet D, Rodr íguez-Cano L, Bartralot R, et al. Benign lymphangiomatous papules of the skin associated with ovarian fibroma. J Am Acad Dermatol. 2007;56(2):(suppl) S41-S4417097370PubMedGoogle ScholarCrossref 4. Brenn T, Fletcher CD. Radiation-associated cutaneous atypical vascular lesions and angiosarcoma: clinicopathologic analysis of 42 cases. Am J Surg Pathol. 2005;29(8):983-99616006792PubMedGoogle Scholar 5. Requena L, Kutzner H, Mentzel T, Dur án R, Rodr íguez-Peralto JL. Benign vascular proliferations in irradiated skin. Am J Surg Pathol. 2002;26(3):328-33711859204PubMedGoogle ScholarCrossref 6. Wagamon K, Ranchoff RE, Rosenberg AS, Jaworsky C. Benign lymphangiomatous papules of the skin. J Am Acad Dermatol. 2005;52(5):912-91315858490PubMedGoogle ScholarCrossref 7. Brunasso AMG, Delfino C, Ketabchi S, Difonzo EM, Massone C. Papules arising after radiotherapy for rhabdomyosarcoma. Acta Dermatovenerol Alp Panonica Adriat. 2009;18(1):24-2719350189PubMedGoogle Scholar 8. Mattoch IW, Robbins JB, Kempson RL, Kohler S. Post-radiotherapy vascular proliferations in mammary skin: a clinicopathologic study of 11 cases. J Am Acad Dermatol. 2007;57(1):126-13317572278PubMedGoogle ScholarCrossref 9. Gengler C, Coindre JM, Leroux A, et al. Vascular proliferations of the skin after radiation therapy for breast cancer: clinicopathologic analysis of a series in favor of a benign process: a study from the French Sarcoma Group. Cancer. 2007;109(8):1584-159817357996PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Dec 1, 2011

Keywords: exanthema,survivors,chest,breast cancer,papule,radiation therapy

References