Radiation Port Cutaneous Metastases: Reports of Two Patients Whose Recurrent Visceral Cancers Presented as Skin Lesions at the Site of Previous Radiation and Literature Review
A 65-year-old man with a history of squamous cell carcinoma of the anal canal presented in February 2011 with newly formed nodules on his scrotum. The patient had been diagnosed with cancer of the anal canal in September 2010 and was treated with chemotherapy (5-fluorouracil and cisplatin) and concurrent radiation. His radiation therapy was delivered in 29 2 Gy fractions over 38 days for a total of 58 Gy. His treatment was completed on November 4, 2010. During his therapy, he developed severe radiodermatitis which subsequently resolved completely.\nIn January 2011, he discovered several new skin lesions on his scrotum [Figures and ]. Cutaneous examination revealed eight painless nodules on his right scrotum, and two additional nodules on his right inguinal fold. All of the new lesions were restricted to the area within his radiation port. They were mildly pruritic; one had ruptured and extruded foul-smelling white material. Biopsies from both sites showed metastatic squamous cell carcinoma, indicating loco-regional failure of his chemoradiation therapy.\nRestaging chest roentgenogram and computerized axial tomography scan also discovered lung metastases. The patient was sequentially treated with several different antineoplastic agents either as single or combination drug therapy. However, there was not only increased size of previous scrotal nodules but also continued appearance of new cutaneous metastases. He was referred to the Phase 1 department to be considered for a trial of an investigational drug treatment.\nCase 2\nA 52-year-old woman was diagnosed in February 2009 with invasive ductal carcinoma in her left breast and poorly differentiated carcinoma in her right breast. She was subsequently treated with neoadjuvant chemotherapy consisting of four cycles of doxorubicin and cyclophosphamide. Following her initial chemotherapy, she received weekly paclitaxel for 12 weeks and trastuzumab every 3 weeks for 1 year.\nIn October 2009, the patient underwent modified radical mastectomy of the left breast and right lumpectomy with axillary lymph node dissection. She began radiation therapy in December 2009. This included bilateral radiation of the chest wall, internal mammary nodes, supraclavicular fossa, and axillary apex totaling 50 Gy in 25 fractions. In addition, her left infraclavicular fossa received 10 Gray in 5 fractions, and her mastectomy and lumpectomy scars were boosted with an additional 14 Gray in 7 fractions. In February 2010, she was restaged and considered to be free of cancer.\nCutaneous examination in August 2011 revealed macular erythema with pruritic, erythematous macules, superficial plaques, and small papules within the radiation port on the left chest wall [Figures and ]. She also had a nonpruritic, hyperpigmented superficial plaque with surrounding areas of erythema within the radiation port on the right breast [Figures and ]. The skin lesions had appeared 1 month earlier and had not improved with over-the-counter topical preparations applied by the patient. Biopsy of both areas revealed metastatic breast carcinoma.