B5 Skin Telangiectasia and Atrophy

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Telangiectasia or dilatations of the dermal vasculature that lie within a few millimeter of the epidermis can occur following radiation for breast cancer. Several studies examining post-mastectomy radiation have demonstrated that the incidence of telangiectasia is affected by total radiation dose,84'85'87 larger fraction size,81'84 and the occurrence of moist desquamation.85-87

The Gothenburg fractionation trials conducted during post-mastectomy radiation in Sweden in the 1970s examined the effect of radiation dose, fraction size, and doserate on the development of telangiectasia (as a measure of late skin reaction) following radiation with 12-13 MeV electrons.83'84 These studies used patients as their own control comparing effects on the right versus left irradiated parasternal region. At greater than 5 years of follow-up, the frequency of mild, moderate, and severe telangiectasia was 79%, 49%, and 20%, respectively, for 2.61 Gy delivered daily 5 times per week for 21 fractions (54.81 Gy total dose) versus 100%, 79%, and 30%, respectively, for 5 Gy delivered twice weekly for 9 fractions (45 Gy total dose) (P < 0.01).84 Another study in the Gothenburg series confirmed that the occurrence of telangiectasia were greater for

4 Gy delivered twice per week for 10, 11, and 12 fractions compared to 2 Gy delivered

5 times per week daily for 25, or 30 fractions. Within each fractionation schedule, the incidence of telangiectasia rose significantly with increasing total dose. Another study used four fractions of 7.2 Gy given once-a-week to compare the effect of delivering the dose per fraction over 4 minutes versus 32 minutes.83 Prolongation ofthe treatment time resulted in a significant reduction in the incidence oftelangiectasia: 85%, 65%, and 23%, respectively, for the minimal, distinct, and severe telangiectasia for the 4 minute treatment time versus 62%, 32% and 6%, respectively, for the prolonged treatment time of 32 minutes (P < 0.01). Bentzen et al. in the Aarhus fractionation studies described above,81 also reported the effect of fraction size and the latency for development of telangiectasia. Like fibrosis, the incidence of telangiectasia increased over time. It was not until after 4.7 years of follow-up time that 90% of the telangiectasia was expressed. The incidence of moderate to severe telangiectasia was 81% in the 2 fractions per week schedule versus 62% in the 5 fractions per week schedule.

With the incorporation of these concepts into modern radiation practice, the incidence of telangiectasia is less frequent after post-mastectomy radiation. The overall incidence of telangiectasia was 59% at 5 years for 120 post-mastectomy patients whose chest wall was irradiated using 12 or 15 MeV electrons with 50—50.4 Gy over 25—28 fractions, 5 days-a-week. The use of a scar boost for 10—16 Gy with 9 MeV electrons was the only factor found to be predictive for the development of telangiectasia.85

The development of telangiectasia after breast conserving therapy is less common but still related to fraction size and total dose. The University of Hamburg study outlined above evaluating fibrosis, demonstrated the effect of dose and fraction size on subsequent development of telangiectasia.79 Grades 2—3 telangiectasia developed in 29%, 17% and 6%, respectively, for 60 Gy delivered with 2.5 Gy fractionation 4 days-a-week, 55 Gy with 2.5 Gy fractionation 4 days-a-week, and 54 Gy with 2 Gy fractionation given 5 days-a-week with cobalt-60 teletherapy. Pezner et al. reported an overall 18% incidence of telangiectasia by 5—9 months following breast radiation that gradually increased to 30% by the second year of follow-up in 119 patients who underwent BCT and received 50—50.4 Gy at 1.8—2 Gy per fraction. On multivariate analysis, boost, patient age >60, and use of regional nodal fields was predictive for developing telangiectasia.42 The incidence of telangiectasia was 7% for the no boost group (n = 72), compared to 36% for the 47 that were boosted (P < 0.001). An even lower rate of telangiectasia was reported in the women evaluated for cosmetic outcome on the Milan III trial where the incidence was 3% in the QUART versus 0% in the QUAD arms.53

The development of telangiectasia is also associated with the occurrence and severity of moist desquamation during the acute skin reaction.86'87 From the Aarhus data, the estimated incidence of severe telangiectasia after 44 Gy in 22 fractions increases from 27% to 49% in patients who developed >grade 2 moist desquamation (10—49% of the field) as an early radiation reaction.86

Patients who are distressed by the appearance of the telangiectasia can be potentially treated with pulsed dye laser (PDL). PDL is an established treatment for cutaneous telangiectatic disorders and is considered both efficacious and safe.88 A study of 8 patients with telangiectasia post-mastectomy demonstrated that in 7 who finished PDL treatment, there was 100% vessel clearance occurred in the treated areas.89 Three patients required three treatments, 3 patients needed two treatments, and 1 patient was treated just once to obtain clearance.

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