A 15-year-old patient underwent open left salpingo-oophorectomy and resection of peritoneal carcinomatous foci after imaging revealed a pelvic mass measuring 108 × 185 × 212 mm. Pathology confirmed stage IIIA1 ovarian yolk sac tumor, as well as positive immunohistochemistry for CK, SALL4, CD117, AFP (4+), and P53 (10%+), and a Ki-67 index of 70%.
As reported by Xinrong Chen of The First Clinical Medical College of Guangzhou University of Chinese Medicine in Guangzhou Guangdong, China, and colleagues, the patient began a chemotherapy regimen of cisplatin (45 mg, days 1–3), etoposide (0.22 g, days 1–3), and bleomycin (20 mg, day 1). After 3 cycles—at a cumulative bleomycin dose of approximately 60 mg—she developed painless, nonpruritic, linear hyperpigmentation on her trunk and back. Alopecia was also present, but there were no mucosal, nail, or pulmonary changes.
Positron emission tomography–computed tomography revealed minimal residual disease in the peritoneum, liver capsule, and pelvic lymph nodes. The regimen was switched to 6 cycles of albumin-bound paclitaxel, cisplatin, and ifosfamide over 4 months. Laparoscopic resection of an intrahepatic lesion showed granulomatous tissue without malignancy. At completion of chemotherapy, tumor markers normalized and intra-abdominal lesions resolved. One year after onset, hyperpigmentation persisted without symptoms.
Bleomycin-Induced Flagellate Hyperpigmentation
Photographs of the thigh, trunk, and arm.
Bleomycin-Induced Flagellar Hyperpigmentation
Thigh, trunk, and arm at 1-year follow-up.
“Despite its antitumor properties, bleomycin administration can result in distinctive cutaneous side effects, with a reported incidence of flagellate-like skin pigmentation ranging from 8 to 20%,” the researchers noted. Onset can occur within 1 to 9 weeks of initiating treatment, and pathogenesis may involve melanogenesis stimulation, inflammatory skin changes, and keratinocyte toxicity.
Management is generally supportive, and antihistamines, corticosteroids, and nonsteroidal anti-inflammatory drugs can be used for symptom relief. Discontinuation of bleomycin is rarely necessary unless toxicity is severe. The authors noted that the patient's hyperpigmentation persisted even after discontinuation of bleomycin, which raised the possibility that the other agents in the regimen also contributed to the duration of intensity of the skin changes, but they were not able to determine the precise roles of each agent in the flagellate pigmentation. They concluded, "The case presented here highlights that this reaction may occur even at moderate cumulative doses and early in treatment."
The researchers reported no conflicts of interest.
Source: Frontiers in Medicine