Case Letter
Multiple seborrheic keratoses in a previously irradiated site
Danielle Ferreira Chagas
, Lúcia Martins Diniz, Bruna Anjos Badaró, Elton Almeida Lucas
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Dermatology Service, Hospital Universitário Cassiano Antônio Moraes, Vitória, ES, Brazil
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irradiated site" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "771" "paginaFinal" => "773" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Danielle Ferreira Chagas, Lúcia Martins Diniz, Bruna Anjos Badaró, Elton Almeida Lucas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Danielle Ferreira" "apellidos" => "Chagas" "email" => array:1 [ 0 => "daaani__@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Lúcia Martins" "apellidos" => "Diniz" ] 2 => array:2 [ "nombre" => "Bruna Anjos" "apellidos" => "Badaró" ] 3 => array:2 [ "nombre" => "Elton Almeida" "apellidos" => "Lucas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Dermatology Service, Hospital Universitário Cassiano Antônio Moraes, Vitória, ES, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 959 "Ancho" => 905 "Tamanyo" => 91352 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Detail of multiple brownish, rounded, well-defined papules with a greasy surface, restricted to the left breast.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Breast cancer is the second most common malignancy worldwide. In Brazil, 59,700 new cases were estimated for 2019. It predominantly affects women in their 50s, and the most common histological subtype is invasive ductal adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Treatment is associated with dermatological complaints in 74%–100% of cases.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Therapy involves surgery and locoregional radiotherapy, in addition to chemotherapy and hormone therapy for systemic treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Seborrheic keratosis is the most common benign cutaneous tumor, being predominantly observed in Caucasian adults. It originates in the epidermis, and a proliferation of immature keratinocytes is observed. Clinically, it is characterized by brownish, well-defined papules with agreasy surface.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> Based on clinical suspicion, dermoscopy helps in its diagnosis, which is confirmed by histopathology.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A case of multiple seborrheic keratoses restricted to the site of previous breast cancer radiotherapy is described.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A female patient, 73 years old, white, was diagnosed four years ago with invasive micropapillary carcinoma in the left breast, which required surgical intervention (quadrantectomy), chemotherapy (adriamycin, cyclophosphamide, and paclitaxel) and 30 adjuvant radiotherapy sessions. Six months ago, she noticed the onset of brownish, asymptomatic, slowly evolving papules, restricted to the skin adjacent to the surgical scar, an area previously irradiated (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). In 2019, she sought dermatological care, and the clinical examination and dermoscopy showed lesions suggestive of seborrheic keratoses, on the left breast only. At the moment, the patient is in remission and is being followed-up every six months. The histopathology of a lesion was compatible with the diagnosis, due to the presence of basaloid cells, hyperkeratosis, and formation of horn pseudocysts (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">By 2015, over 1.3 million people had been diagnosed with breast cancer worldwide.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The invasive micropapillary subtype, diagnosed in this case, is rare, representing 0.9%–2% of breast carcinomas; it is associated with aggressive clinicopathological characteristics.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Radiotherapy has numerous effects on skin tissue, ranging from acute (up to six months after therapy initiation) to chronic; depending on the location, size, and depth of the irradiated tumor, these effects can be classified as mild, moderate, or severe.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3,5</span></a> The patient presented chronic symptoms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The severity of the skin lesions caused by radiation is dependent on factors related to the treatment and the patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Those linked to treatment include the total dose and the irradiation site, fractionation time, volume and area of irradiated tissue, and the use of chemotherapy.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Among the patient-related factors, smoking, malnutrition, obesity, autoimmune diseases, and genetic factors are noteworthy.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> The only risk factors for the present patient were multiple radiotherapy and chemotherapy sessions.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The sign of Leser-Trélat is rare, and characterized by the abrupt eruption of multiple seborrheic keratoses, usually on the back, which may precede or occur after the diagnosis of the malignancy, especially lung and gastrointestinal adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The patient presented progressive lesions only at the irradiated site.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The mechanism of lesion determined by radiation is not fully understood; however, it is known that the skin is an organ in constant renewal, consisting of cells with rapid proliferation and maturation, making them vulnerable to this therapy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Basal keratinocytes and hair follicles are highly radiosensitive. Moreover, radiation damage causes inflammation, cell recruitment, DNA damage, and cytokine generation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiology of seborrheic keratosis remains unknown. Recently, it has been postulated that epidermal growth factors (oncogenes [PIK3CA] and fibroblast growth factor receptor 3 [FIGR3]) may participate in 32% and 48% of cases, respectively. Recent studies demonstrated that other oncogenes (TERT and DPH3) are also involved in the genesis of the lesions.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Eczemas and chemotherapy can trigger or increase inflammation in pre-existing seborrheic keratoses, differently from the case presented.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The diagnosis of seborrheic keratosis is clinical, and dermoscopy is useful for differentiating it from other pigmented lesions. The dermoscopic pattern is polymorphic; the most characteristic finding is horn pseudocysts, as observed in the present case. In case of diagnostic doubt, histopathology becomes indispensable.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In our patient, due to the presence of multiple lesions, the authors decided to excise one of them for histopathological examination, confirming the clinical diagnosis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment is indicated for aesthetic purposes; some options include curettage, application of trichloroacetic acid, and cryotherapy with liquid nitrogen.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In the present case, cryotherapy was applied in two sessions; a reduction in the greasy surface of seborrheic keratoses and hyperpigmentation was observed in the first session.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the literature review, no studies on seborrheic keratosis induced by radiotherapy were retrieved; the authors concluded that radiation triggered the proliferation of keratinocytes, probably through mediators that lead to the production of melanogenesis-stimulating cytokines, activation of oncogenes, and epidermal growth factors.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0085" class="elsevierStylePara elsevierViewall">Danielle Ferreira Chagas:Drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Lúcia Martins Diniz: Approval of the final version of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the manuscript.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Bruna Anjos Badaro:Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Elton Almeida Lucas:Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-12-12" "fechaAceptado" => "2020-02-10" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Chagas DF, Diniz LM, Badaró BA, Lucas EA. Multiple seborrheic keratoses in a previously irradiated site. An Bras Dermatol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.abd.2020.02.014">https://doi.org/10.1016/j.abd.2020.02.014</span></p>" ] 1 => array:2 [ "etiqueta" => "⋆⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Universitário Cassiano Antônio Moraes, Vitória, ES, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 632 "Ancho" => 905 "Tamanyo" => 71256 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple seborrheic keratoses restricted to the previously irradiated site.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 959 "Ancho" => 905 "Tamanyo" => 91352 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Detail of multiple brownish, rounded, well-defined papules with a greasy surface, restricted to the left breast.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 552 "Ancho" => 905 "Tamanyo" => 125754 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathological examination of one of the breast lesions, showing proliferation of uniform basaloid cells, elongation of the rete ridges, and hyperkeratosis. Keratin pseudocysts and melanic hyperpigmentation of the epidermis are also observed (Hematoxylin & eosin, ×10).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive micropapillary carcinoma of the breast: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y.L. Yang" 1 => "B.B. Liu" 2 => "X. Zhang" 3 => "L. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 21 | 12 | 33 |
| 2024 Outubro | 102 | 83 | 185 |
| 2024 Setembro | 166 | 95 | 261 |
| 2024 Agosto | 177 | 110 | 287 |
| 2024 Julho | 123 | 118 | 241 |
| 2024 Junho | 127 | 77 | 204 |
| 2024 Maio | 100 | 61 | 161 |
| 2024 Abril | 118 | 96 | 214 |
| 2024 Março | 120 | 78 | 198 |
| 2024 Fevereiro | 122 | 79 | 201 |
| 2024 Janeiro | 93 | 44 | 137 |
| 2023 Dezembro | 101 | 74 | 175 |
| 2023 Novembro | 77 | 70 | 147 |
| 2023 Outubro | 72 | 76 | 148 |
| 2023 Setembro | 76 | 79 | 155 |
| 2023 Agosto | 59 | 39 | 98 |
| 2023 Julho | 88 | 47 | 135 |
| 2023 Junho | 90 | 65 | 155 |
| 2023 Maio | 64 | 20 | 84 |
| 2023 Abril | 63 | 20 | 83 |
| 2023 Março | 91 | 48 | 139 |
| 2023 Fevereiro | 73 | 34 | 107 |
| 2023 Janeiro | 67 | 35 | 102 |
| 2022 Dezembro | 76 | 28 | 104 |
| 2022 Novembro | 83 | 48 | 131 |
| 2022 Outubro | 103 | 56 | 159 |
| 2022 Setembro | 78 | 61 | 139 |
| 2022 Agosto | 91 | 45 | 136 |
| 2022 Julho | 78 | 59 | 137 |
| 2022 Junho | 84 | 59 | 143 |
| 2022 Maio | 76 | 58 | 134 |
| 2022 Abril | 72 | 56 | 128 |
| 2022 Março | 58 | 66 | 124 |
| 2022 Fevereiro | 52 | 42 | 94 |
| 2022 Janeiro | 65 | 74 | 139 |
| 2021 Dezembro | 35 | 52 | 87 |
| 2021 Novembro | 50 | 55 | 105 |
| 2021 Outubro | 51 | 85 | 136 |
| 2021 Setembro | 37 | 45 | 82 |
| 2021 Agosto | 46 | 57 | 103 |
| 2021 Julho | 40 | 47 | 87 |
| 2021 Junho | 28 | 36 | 64 |
| 2021 Maio | 51 | 83 | 134 |
| 2021 Abril | 148 | 179 | 327 |
| 2021 Março | 118 | 85 | 203 |
| 2021 Fevereiro | 57 | 21 | 78 |
| 2021 Janeiro | 51 | 30 | 81 |
| 2020 Dezembro | 42 | 22 | 64 |
| 2020 Novembro | 47 | 7 | 54 |
| 2020 Outubro | 19 | 6 | 25 |
| 2020 Setembro | 17 | 15 | 32 |
| 2020 Agosto | 4 | 6 | 10 |
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