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Presence of CD45RO+ CD34+ cells with collagen synthesis activity in nephrogenic fibrosing dermopathy: a new pathogenic hypothesis

radiotherapy, particularly at high doses. However, subcutaneous calcification is rare. Chest wall calcification has been described following fractionated radiotherapy in the chest wall and anterior supraclavicular fields as an additional treatment following surgery for breast cancer. Calcification over the sacrum has been described following radical radiotherapy in addition to surgery for cervical cancer. All cases described a radiation field overlap, thus magnifying the existing high dose of radiation to the skin. Also, as in our patient, this complication became clinically apparent many years after the initial radiotherapy, in some cases over 20 years later. The mechanism is most likely to represent the model of dystrophic calcification secondary to local trauma. Radiation causes cell membrane damage, leading to a massive influx of calcium. The calcium then crystallizes in the mitochondria, leading to failure of cell respiration and further cell necrosis. It is still unclear why this process takes many years to become clinically apparent, although chronic hypoxia from damage to blood vessels may play a role. The only study of treatment for localized dystrophic calcification, by Meline et al. in 1975, looked at the clinical course and treatment of three patients with subcutaneous calcification on the leg, one following a burn injury, and two others following voluntary injection of essence of turpentine. Tentative surgical removal led to recurrence and subsequent ulceration of the areas. Therefore complete surgical resection of the calcified area was recommended if the area had become ulcerated, suggesting that symptoms should be severe before such treatment be considered. In our patient we feel that despite the risks associated with extensive resection of the calcified area, she has had a good cosmetic and functional outcome from previous similar surgery. Therefore, increasing discomfort affecting her everyday activities and quality of life are good reasons for proceeding with additional surgery, and she is currently awaiting further surgical intervention. The long latency of this complication of radiotherapy in a cohort of patients who received high doses of radiation in the 1970s may prompt more to consult dermatologists over the next few years with similar symptoms. As the condition is known to progress to skin ulceration and increasing discomfort, we would suggest that surgical intervention should be considered for patients presenting in a similar manner, perhaps at an earlier stage than when ulcerated, as previously recommended.