British Journal of Radiology (2005) 78, 143-146
© 2005 British Institute of Radiology
doi: 10.1259/bjr/20164607
The hyfrecator: a treatment for radiation induced telangiectasia in breast cancer patients
C M E Rowland Payne, MBBS, MRCP1,4,
N Somaiah, MBBS, MD2,4,
A J Neal, MD, MRCP, FRCR3 and
J P Glees, MD, DMRT, FRCR2,4,5
1 The London Clinic, London, 2 St. George's Hospital, London, 3 The Royal Surrey County Hospital, Guildford, 4 The Royal Marsden Hospital, Sutton, Surrey and 5 University of London, London, UK
Correspondence: Dr Navita Somaiah, Department of Radiotherapy, The Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
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Abstract
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Radiation induced telangiectasia is a common problem in breast cancer survivors. By interfering with choice of clothing and acting as an unpleasant visible reminder of their disease, it negatively affects quality of life. The hyfrecator, based on the principles of electrosurgery, is a standard treatment modality for facial telangiectasia. This study aims to demonstrate the efficacy and tolerability of the hyfrecator as a treatment for radiation induced telangiectasia. Patients with radiation induced telangiectasia of breast or chest wall were prospectively identified from the breast cancer follow up clinic and offered treatment with the hyfrecator (sessions at 8 weekly intervals). Pre- and post-treatment photographs were obtained in a standardized manner and two blinded physician observers evaluated response. A linear analogue scale (LAS) was used by the patients to evaluate treatment response and any discomfort. At the end of treatment, patients completed a quality of life questionnaire. Of 16 patients enrolled, 15 completed the study. Treatment benefited all patients with severe or marked telangiectasia. Complete disappearance of telangiectasia was achieved in the majority (88%) of patients by the end of treatment. A median of six sessions (range 3–9) was required. All but one (93%) considered the treatment worthwhile. The majority (69%) judged the treatment to be painless or only mildly painful. 73% reported an improvement in self-confidence. The treatment was well tolerated by all the patients. All patients showed a remarkable clearance of vessels with a high degree of satisfaction with the results. Treatment with the hyfrecator is very effective for radiation induced telangiectasia. Three to four sessions achieve a substantial objective and subjective reduction in telangiectasia with a concomitant improvement in quality of life. It is a cost effective, ambulant out patient procedure requiring no local anaesthesia.
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Introduction
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Approximately 30 000 women in the UK are diagnosed with invasive breast cancer each year. Radiotherapy is an accepted part of the local treatment of breast cancer following both breast conserving surgery and in selected cases, mastectomy. The total number of women being treated with radiotherapy is increasing since implementation of the National Breast Screening Programme. With higher patient expectations, the cosmetic result following breast conserving surgery and radiotherapy is an important consideration [1]. Although current technology has reduced the frequency and severity of late radiation morbidity, telangiectasia is still a significant problem.
Radiation induced telangiectasia is a well recognized manifestation of late cutaneous radiation damage [2]. It is usually confined to the site of highest dose (e.g. site of radiation boost), and can be very unsightly depending on its site, size and extent. It usually becomes apparent at 1–2 years after completion of treatment, and may slowly progress over subsequent years. In some cases it is the most obvious reminder to the patient of their illness and its treatment. However, most radiation oncologists do not offer any treatment for this condition.
The hyfrecator is a surgical diathermy unit, which uses an electrical discharge to coagulate the dilated small blood vessels that are telangiectasia. This electrosurgical device has been used for decades by dermatologists on the face, as a cosmetic procedure, and is very effective with minimal side effects [3]. One of us (CRP) has had previous experience of good results with this technique in a number of patients with radiation induced telangiectasia over the last decade. It was the reluctance of a radiotherapy colleague, fearful that this procedure would cause a necrotic ulcer that prompted us to undertake this prospective study.
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Patients and methods
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This prospective study was conducted in the Department of Clinical Oncology (Breast Unit) at The Royal Marsden Hospital (RMH), Surrey Branch. It was approved by the ethics committee of The Royal Marsden NHS Trust/The Institute of Cancer Research (Ethics No. 1419).
Patients with radiation induced telangiectasia of breast or chest wall were identified from the breast cancer follow-up clinic and invited to participate. Those who had participated in the RMH breast fractionation study [4] and those with a cardiac pacemaker or hearing aid were excluded from the study. Informed consent was obtained. Patients were recalled at a convenient date for treatment with the hyfrecator.
The Conmed hyfrecator (Conmed, Utica, NY; Figure 1
) was set at low power, 2.4–3.2 W (usually 2.6 W). No skin preparation was required. The skin was gently stretched and an epilation electrode was applied lightly every 2 mm to 3 mm along the telangiectatic vessels with passage of a controlled electrical discharge by a foot switch, with each application. Pulse frequency was approximately 50–80 pulses per minute with pulse duration of approximately 0.25 s. The entire area was treated at each session. Typically, each session lasted 3–8 min. The sessions were at 8 weekly intervals.
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Figure 1. The hyfrecator. A versatile office-based electrosurgical instrument (courtesy of Schuco International, London Ltd).
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Close up serial photographs were taken by the same medical photographer before each treatment and 8 weeks after the final treatment using colour slide film. For each patient, photographic field, camera settings, lighting and distance from subject were constant.
Before the first and 8 weeks after the last treatment session, patients completed a 10 cm LAS self assessment of telangiectasia severity. After each session, patients were asked (after reaching home) to complete another 10 cm LAS to record any discomfort felt during the session and a further one 48 h afterwards (0, "completely painless" to 10, "the worst pain imaginable"). 8 weeks after the final session, patients were also given a quality of life questionnaire to complete.
Physician-based assessments of colour photography were undertaken after the end of treatment. Three serial colour slides (pre treatment, after 3 sessions and 8 weeks after the final session) of each of the 15 patients (45 slides) were mixed together and presented randomly for independent assessment by the two blinded physician observers. Assessment was according to the following descriptive scale [5]:
Grade 0 No telangiectasia
Grade I Minimal telangiectasia
Grade II Moderate telangiectasia
Grade III Severe telangiectasia
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Results
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16 caucasian females, aged 43–72 years (mean 57 years), 2–10 years (median 5 years) post-radiation, were enrolled. One dropped out after one session (because of the travelling distance). 15 patients were treated every 8 weeks until their telangiectasia cleared or they were satisfied (range of 3–9 sessions, median 6 sessions).
All (14/15) patients with severe or marked telangiectasia benefited from treatment (Figures 2 and 3). In 88% of patients telangiectasia had completely disappeared by the end of treatment, as judged by the physicians. The treatment was well tolerated by all the patients. Discomfort was usually scored as zero (range 0–8). The majority of sessions (69%, 66/96 sessions) were scored as painless or mildly painful (LAS 0–2). A LAS 
ge;5 was recorded in only 18% (17/96) of sessions (session defined as each hospital visit per patient for treatment with the hyfrecator). Only two patients complained of mild pain (LAS 1) 48 h after treatment, the rest (87%) were symptomless. After the final treatment slight skin atrophy was noted by the dermatologist in two patients but was not noticeable to the patients. In some patients, minimal transient pinpoint bleeding was noted which ceased spontaneously or with minimal pressure and was no more than the slightest inconvenience. No other adverse effects occurred. In particular, no necrosis as a result of the treatment was observed during the study and subsequent follow-up (median 4.5 years). Also, there was no recurrence of telangiectasia in the treated vessels.
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Figure 2. (a) Pre-treatment. Extensive telangiectasia (grade III) in the radiation boost area after breast cancer treatment. (b) During treatment. After three sessions, telangiectasia (now grade I) has reduced by about 70% (same patient). (c) End of treatment. After seven sessions, telangiectasia has completely disappeared (grade 0) (same patient).
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Figure 3. The hyfrecator for radiation induced telangiectasia. Change in severity of telangiectasia, judged photographically by two blinded physician observers (in one patient two separate sites were treated, making a total of 32 observations).
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At the end of treatment, the quality of life questionnaires showed that 93% (14/15) of patients felt the treatment was worthwhile and were very satisfied with the results (Table 1). Compared with before the skin treatment began, the majority of patients (73%, 11/15) reported an improvement in their self confidence, while 60% (9/15) said that they were much less embarrassed or self conscious. Several volunteered that they were pleased to be able to wear lower cut clothes again. One patient felt confident to return to topless sunbathing.
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Discussion
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Radiation induced telangiectasia is a well recognized manifestation of late cutaneous radiation damage after radiation therapy for breast carcinoma. Univariate and multivariate analyses for the development of skin telangiectasia have shown 5-year and 7-year actuarial rates of telangiectasia to be 59% and 72%, respectively [2]. Patients who have been given an additional boost to the surgical scar are more likely to develop skin telangiectasia.
Morbidity assessments after a median follow-up time of 6.6 years, in the Danish randomized DBCG-82TM breast conservation trial, showed that skin telangiectasia, breast fibrosis and breast retraction were significantly associated with a less satisfactory cosmetic result [1]. Impaired body perception was found to be significantly associated with breast retraction and skin telangiectasia. Patients are distressed because clothing habits are compromised as a consequence of adverse skin reactions and breast retraction. In some cases it is the most obvious reminder to the patient of their previous treatment. However, unfortunately, most oncologists have to date not offered any treatment for this condition.
The hyfrecator has been, for more than half a century, the most popular electrosurgical accessory for outpatient and office-based dermatological surgery (Figure 1
). It is a low power (maximum output of 35 W) surgical diathermy unit, which produces a controlled electrical discharge of high frequency and high voltage, destroying tissue by the passage of electric current. For treatment of telangiectasias it is commonly used at a setting of 0 to 5 W. By comparison, electrocautery (typical power output of 200 W) destroys tissue through heat conduction using an electrically heated metal "burner". The hyfrecator is a compact, portable and versatile instrument (costing approximately £1000), which allows rapid and precise destruction of all types of cutaneous lesions, including telangiectasia [3]. However, until now there has been no controlled data or publication documenting its efficacy and tolerability in the treatment of post radiation telangiectasia in breast cancer patients. With the hyfrecator, three different forms of tissue destruction are possible: fulguration, desiccation and coagulation. In this study, electrodesiccation was used to treat fine telangiectasia.
Other effective treatments for post radiation telangiectasia include sclerotherapy and laser [6, 7]. Pulsed dye laser is better than the hyfrecator when erythema, rather than telangiectasia, predominates (a situation very rare after radiotherapy). In terms of efficiency and cost-effectiveness, the hyfrecator is far more advantageous (a laser usually costs tens of thousands of pounds). It is easy to use, has minimal adverse effects compared with other techniques [8, 9] and does not require special training. The treatment does not require anaesthesia or skin preparation or any of the safety procedures needed with laser therapy. Caution is required in patients with implanted cardiac pacemakers.
This study demonstrates that the hyfrecator is an effective treatment for radiation induced telangiectasia. It is well tolerated and well accepted by patients. Women, who are disturbed by post radiation telangiectasia of the breast or chest wall, will achieve a substantial objective reduction in telangiectasia and an improvement in quality of life with 3–4 sessions alone. The hyfrecator is therefore recommended as an efficient and cost-effective treatment for this distressing condition.
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Acknowledgments
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We thank Professor Peter Mortimer, Professor of Dermatology, and Mr Dennis Underwood and Mr Ray Stucky from the Medical Photography Department at the Royal Marsden Hospital, Sutton, Surrey Branch, London for their help and support in this study. We also thank Schuco International, London Ltd for their help and The Dr John Glees Cancer Research fund for financial support.
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Footnotes
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Source of funding: The Dr John Glees Cancer Research fund. 
Received for publication December 15, 2003.
Revision received September 10, 2004.
Accepted for publication October 19, 2004.
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References
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- Johansen J, Overgaard J, Rose C, Engelholm SA, Gadeberg CC, Kjaer M, et al. Danish Breast Cancer Cooperative Group (DBCG) and the DBCG Radiotherapy Committee. Cosmetic outcome and breast morbidity in breast-conserving treatment--results from the Danish DBCG-82TM National Randomized Trial in Breast Cancer. Acta Oncol 2002;41:369–80.[Medline]
- Huang EY. Predictive factors for skin telangiectasia following post-mastectomy electron beam irradiation. Br J Radiol 2002;75:444–7.[Abstract/Free Full Text]
- Hainer BL. Electrosurgery for the skin. Am Fam Physician 2002;66:1259–66.[Medline]
- Yarnold JR, Owen JR, Ashton A, Regan J, Broad B, Jackson C, et al. Fractionation sensitivity of change in breast appearance after radiotherapy for early breast cancer: long-term results of a randomised trial. Radiother Oncol 2002;64(Suppl.):S25, abstract 77.
- Turesson I, Notter G. The influence of fraction size in radiotherapy on the late normal tissue reaction--I: Comparison of the effects of daily and once-a-week fractionation on human skin. Int J Radiat Oncol Biol Phys 1984;10:593–8.[Medline]
- Lanigan SW, Joannides T. Pulsed dye laser treatment of telangiectasia after radiotherapy for carcinoma of the breast. Br J Dermatol 2003;148:77–9.[Medline]
- Gordan AB, Harmer CL, O'Sullivan M. Treatment of post-radiotherapy telangiectasia by injection sclerotherapy. Clin Radiol 1987;38:25–6.[Medline]
- Mcburney EI. Side effects and complications of laser therapy. Dermatol Clinics 2002;20:165–76.[CrossRef][Medline]
- Bihari I, Magyar E. Reasons for ulceration after injection treatment of telangiectasia. Dermatol Surg 2001;27:133–6.[Medline]
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Abstract
Introduction
