Radio-induced malignancies of the scalp about 98 patients with 150 lesions and literature review

Reducing radiation exposure and costs: CT body scout views with an enhanced protocol versus conventional radiography after shunt surgery

OBJECTIVE

Ventriculoperitoneal shunt implantation has become standard treatment for cerebrospinal fluid diversion, besides endoscopic third ventriculostomy for certain indications. Postoperative X-ray radiography series of skull, chest and abdomen combined with cranial CT are obtained routinely in many institutions to document the shunt position and valve settings in adult patients. Measures to reduce postoperative radiation exposure are needed, however, there is only limited experience with such efforts. Here, we aim to compare routine postoperative cranial CT plus conventional radiography series (retrospective arm) with cranial CT and body scout views only (prospective arm) concerning both diagnostic quality and radiation exposure.

PATIENTS AND METHODS

After introduction of an enhanced CT imaging protocol, routine skull and abdomen radiography was no longer obtained after VP shunt surgery. The image studies of 25 patients with routine postoperative cranial CT and conventional radiography (retrospective arm of study) were then compared to 25 patients with postoperative cranial CT and CT body scout views (prospective arm of study). Patient demographics such as age, sex and primary diagnosis were collected. The image quality of conventional radiographic images and computed tomography scout views images were independently analyzed by one neurosurgeon and one neuroradiologist.

RESULTS

There were no differences in quality assessments according to three different factors determined by two independent investigators for both groups. There was a statistically significant difference, however, between the conventional radiography series group and the CT body scout view imaging group with regard to radiation exposure. The effective dose estimation calculation yielded a difference of 0.05 mSv (two-tailed t-test, p = 0.044) in favor of CT body scout view imaging. Furthermore, the new enhanced protocol resulted in a reduction of cost and the use of human resources.

CONCLUSION

CT body scout view imaging provides sufficient imaging quality to determine shunt positioning and valve settings. With regard to radiation exposure and costs, we suggest that conventional postoperative shunt series may be abandoned.

Radio-induced malignancies of the scalp in adult after depilatory radiotherapy for tinea capitis in childhood: 137 cases

Introduction:

Radiation-induced malignancies are the most feared complications of radiotherapy. Depilatory radiotherapy for ringworm of the scalp in childhood was the cause of an increase in the incidence of skin tumours of the scalp in adults. The aim of our study was to describe the epidemiological, clinical and therapeutic characteristics of radiation-induced skin tumours of the scalp in order to highlight the characteristics of these tumours compared to non-radiation-induced tumours.

Methods:

This is a bi-centric retrospective study, extending over a period of 41 years, which collected 137 patients with 200 tumours of the scalp. These patients were selected after noting a history of depilatory radiotherapy for ringworm in childhood in the clinical records of all patients with scalp tumours.

We studied the epidemiological, clinical, therapeutic and evolving characteristics of this population.

Results:

The average age of consultation was 56·6 years. The sex ratio M/F was 3. Radiation dermatitis was found in 33% of cases. The average latency between depilatory radiotherapy and the appearance of radiation-induced tumours was 42·6 years. Multiple carcinomas (>2 tumours) were observed in 23·3% of cases. In 73% of cases, ulceration was the most frequent macroscopic aspect. The predominant histological type was basal cell carcinoma in 82% of cases. Radiation therapy has been the main treatment modality in 77·3% of cases, followed by surgery in 43% of cases. The appearance of new tumours on the scalp was observed in six patients.

Conclusion:

Radiation-induced tumours of the scalp are comparable in epidemiological and clinical characteristics to non-radiation-induced tumours. However, they may represent a challenge in therapeutic care and require regular monitoring.

Radio‐induced simultaneous development of squamous cell carcinoma and undifferentiated pleomorphic sarcoma of scalp

Radiotherapy was commonly applied to treat benign skin diseases such as tinea capitis. Some patients treated with radiation have developed skin malignancies over the years. This article reported a 72‐year‐old man presenting with two distinct non‐melanoma skin tumors on his scalp, including squamous cell carcinoma and metastatic pleomorphic sarcoma.

Skin Manifestations after Ionizing Radiation Exposure: A Systematic Review

Morphological and functional skin alterations secondary to the action of ionizing radiation are well documented. In addition to its application in the medical field, ionizing radiation represents a public health problem for diagnostic and therapeutic purposes due to the potential risk of exposure to unexpected events, such as nuclear accidents or malicious acts. With regard to the use of ionizing radiations in the medical field, today, they constitute a fundamental therapeutic method for various neoplastic pathologies. Therefore, the onset of adverse skin events induced by radiation represents a widespread and not negligible problem, affecting 95% of patients undergoing radiotherapy. A systematic literature search was performed from July 2021 up to August 2021 using PubMed, Embase, and Cochrane databases. Articles were screened by title, abstract and full text as needed. A manual search among the references of the included papers was also performed. This systematic review describes the various skin reactions that can arise following exposure to ionizing radiation and which significantly impact the quality of life, especially in cancer patients.

Photodynamic therapy for facial skin cancer developed in the zone of previous radiotherapy (clinical case)

The results of a 13-year clinical observation of a patient after treatment for basal cell carcinoma of the skin of the right cheek Ist cT1N0M0 are presented. The history of the course of the disease is associated with the fact that the patient underwent radiation therapy in early childhood for hemangioma of the lower eyelid of the right eye and right cheek. In 2008, against the background of post-radiation changes in the area of the right cheek, basal cell carcinoma was diagnosed at the Moscow Oncological Research Institute. P.A. Herzen. At the Center for Laser and Photodynamic Diagnostics and Tumor Therapy, the patient underwent organ-preserving PDT treatment. A course of photodynamic therapy (PDT) with 5-aminolevulic acid was carried out. Subsequently, the patient was followed up until 2021 without relapse in the PDT area. In 2016, the patient was diagnosed with a relapse of the disease in the form of a new focus of basal cell carcinoma of the upper eyelid skin on the right Iast cT1N0M0. The patient underwent a course of PDT with a chlorin e6-based photosensitizer. Complete regression of the tumor was achieved, the period of relapse-free follow-up was 5 years.

Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure

Background Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malignancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field.

Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed.

Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n = 9) and basal cell carcinomas (n = 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n = 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group.

Conclusion Long-term consequences of childhood depilatory treatments of the scalp by irradiation are now surfacing. Our experience showed that in such cases, surgeons should aim for a more aggressive approach with wide resection and primary free flap reconstruction, and that favorable long-term functional and aesthetic results can safely be achieved using this reconstruction approach.

Secondary basal cell carcinoma of scalp after radiotherapy: A case report

RATIONALE

Radiotherapy (RT) is widely used for both malignant and benign tumors in order to reduce the risk of recurrence, to promote tumor control, and to improve survival. However, there have been studies reported that RT is also a risk factor of secondary cancer. Very few cases of secondary malignancy after RT to high grade brain cancer have been reported due to short survival of this disease, and most RT-induced malignancies presented with sarcomatous histology. Here we present a patient with basal cell carcinoma (BCC) 14 years after RT to his brain.

PATIENT CONCERNS

A 28-year-old man without any underlying disease had suffered from left side weakness and clonic-tonic seizures for 12 days.

DIAGNOSES

His brain images showed a tumor in the right frontal lobe. The pathologic report confirmed anaplastic astrocytoma (WHO Grade III).

INTERVENTIONS

After craniotomy and tumor biopsy, RT was delivered. Fourteen years later, a gray-colored skin papule was noted in the previously irradiated area. The scalp biopsy revealed BCC. The scalp BCC was adequately resected. He then suffered from brain tumor recurrence and received further craniotomy for three times combined with chemotherapy with temozolomide.

OUTCOMES

After treatment, follow-up brain images showed that the disease was under control. There was no neurological sequela. For scalp BCC, no skin tumor recurrence has been noted to date after the resection 14 years after initial RT. He has survived for more than 26 years since his initial diagnosis of anaplastic astrocytoma, and more than 12 years from the diagnosis of scalp BCC.

LESSONS

Notwithstanding the risk of radiation-induced skin cancer, RT contributed to this patient's survival. The possible late adverse events should be informed to the patients.

Basal cell carcinoma induced by therapeutic radiation for tinea capitis-clinicopathological study

AIMS

An increased prevalence of aggressive histological subtypes, such as micronodular and morpheaform, has been seen, irrespective of the clinical course, in basal cell carcinoma (BCC) following irradiation for tinea capitis. The aim of this study was to assess the histopathological features of BCCs among patients irradiated for tinea capitis and correlate them with the clinical course.

METHODS AND RESULTS

The medical records and BCC biopsy specimens of individuals who were previously irradiated for tinea capitis were reviewed. Demographic data and clinical characteristics were retrieved. Biopsy specimens were evaluated for histological subtype classification and additional histopathological features. A telephone survey was conducted to assess the clinical behaviour of the tumours. Thirty-one patients (17 male; 14 female) were included. The average age at time of first biopsy was 56 years. The total number of lesions was 185, with 80% of subjects showing multiple lesions. The nodular subtype was the most prevalent, followed by superficial, micronodular and mixed tumours. One-third of the BCCs could be classified as aggressive histologically. Stromal fibroplasia and melanin deposits were common. There was no mortality related to BCC. None of the 17 patients who completed the survey had evidence of local invasiveness or metastases.

CONCLUSIONS

BCCs following radiation therapy for tinea capitis show unique histological characteristics related to aggressive behaviour. These aggressive features did not reflect the clinical behaviour in the current cohort.

Ambient temperature and risk of first primary basal cell carcinoma: A nationwide United States cohort study

The Earth's surface is warming and animal studies have shown higher temperatures promote ultraviolet radiation (UVR) skin carcinogenesis. There are, however, no population studies of long-term temperature exposure and basal cell carcinoma (BCC) risk. We linked average lifetime summer ambient temperatures (based on weather station data) and satellite-based UVR estimates to self-reported lifetime residences in the U.S. Radiologic Technologists' cohort. We assessed the relationship between time-dependent average lifetime summer ambient temperature (20-year lag) in quintiles and BCC in whites, using Cox proportional hazards regression. Risks were adjusted for time-dependent lagged average lifetime UVR and time outdoors, body mass index, eye color, and sex (baseline hazard stratified on birth cohort). During a median 19.4 years follow-up, we identified 3556 BCC cases. There was no significant trend in risk between temperature and BCC. However, BCC risk was highest in the fourth quintile of temperature (Q4 vs. Q1; hazards ratio (HR)=1.18; 95% confidence interval (CI)=1.06-1.31, p-trend=0.09). BCC risk was strongly related to average lifetime ambient UVR exposure (Q5 vs. Q1; HR=1.54 (95% CI=1.35-1.75, p-trend=<0.001)). Future studies of temperature and BCC risk should include a broad range of UVR and temperature values, along with improved indicators of exposure to temperatures and UVR.

Basal cell carcinoma after treatment of childhood acute lymphoblastic leukemia and concise review of the literature

Basal cell carcinoma (BCC) is a rare secondary malignancy which may occur more often in children with acute lymphoblastic leukemia (ALL) who have previously received radiation therapy compared to to those who received no radiation.

Dermoscopy of multiple radiation-induced basal cell carcinomas in a patient treated previously for pinealoma

BACKGROUND

Malignancies secondary to radiation, such as radiation-induced skin cancer, are possible consequences of radiation therapy. The most frequent post-radiation skin neoplasm is basal cell carcinoma.

MAIN OBSERVATION

We report a case of a 49-year-old woman who underwent multiple radiotherapy sessions for pinealoma and developed post-radiation alopecia. After 26 years the patient noticed the emergence of eighteen superficial scalp lesions in the previously irradiated areas. Dermoscopy showed predominance of ovoid nests and presence of arborizing vessels on pink background, consistent with basal cells carcinoma. The diagnosis was confirmed by histopathology.

CONCLUSIONS

There is an absolute need to guide patients through the possible late adverse events of radiotherapy. Regular dermoscopy examinations should be performed, especially in areas previously exposed to radiation.

Primary cutaneous melanoma arising in a long-standing irradiated keloid

Ionizing radiation has been used therapeutically for a variety of clinical conditions, including treatment of hypertrophic keloids. Keloids may rarely be associated with malignancy, but the use of low-dose ionizing radiation is associated with an increased risk of cutaneous malignancies. We describe a case in which a primary desmoplastic melanoma arose in a long-standing, previously irradiated keloid.

Neuroembolization may expose patients to radiation doses previously linked to tumor induction

OBJECTIVE

Epidemiological studies indicate a link between low-dose irradiation (<10,000 mGy) to the head and the local occurrence of tumors after decades of delay. Comparable radiation doses can be reached during neuro-endovascular procedures (NEP), but the incidence of similar exposures has not been completely delineated. We compared the levels of radiation to the head measured during NEP to those reported for patients developing radiation-induced cancers.

METHODS

In our prospective study we determined the cumulative maximum entrance skin doses (MESD) and the incidence of epilation in 107 consecutive patients submitted to NEP between 2003 and 2007. We also extensively searched the literature and compared our results with the data we found.

RESULTS

The cumulative MESD due to NEP was above 3,000 mGy (range 3,101-5,421 mGy) in 18 patients. In 22 we observed partial epilation within 10 weeks from the initial NEP. Sixty cases of epilation after NEP have been previously reported in the literature. The average of the reported MESD was 4,241 mGy (range 2,000-6,640 mGy).

CONCLUSION

Physical dosimetry and the incidence of partial epilation indicate that about one fifth of the patients submitted to NEP received radiation doses comparable to those linked to the occurrence of tumors. The potential risks of developing tumors after a long delay, when compared to the immediate benefits of endovascular treatment of aneurysm and arteriovenous malformations (AVM) of the brain, do not counterindicate NEP, but increased awareness of the risk should help physicians and patients to make a fully informed decision when other treatments are available.

[Normal tissue tolerance to external beam radiation therapy: skin]

Acute skin toxicity is frequent during radiation therapy and can lead to temporary arrest of the treatment. Chronic toxicity can occur and conduct to cosmetic problems. Alopecia is the most frequent toxicity concerning hair and is most of the time reversible. Several factors linked to patients influence skin toxicity, such as undernutrition, old age, obesity, smoking, skin diseases, autoimmune diseases, failure of DNA reparation. Skin, hair and nail toxicities depend also on radiation schedule. Acute toxicity is greater when dose per fraction increases. Chronic and acute toxicities are more often when total dose increases. Under 45 Gy, the risk of severe skin toxicity is low, and begins above 50 Gy. Skin toxicity depends also on the duration of radiotherapy and split course schedules are associated with less toxicities. Irradiation surface seems to influence skin toxicity but interaction is more complex. Reirradiation is often feasible in case of cancer recurrence but with a risk of grade 3-4 toxicity above all in head and neck cancer. The benefit/risk ratio has to be always precisely evaluated. Permanent alopecia is correlated with the follicle dose. Modern techniques of radiation therapy allow to spare skin.

The risk and prophylactic management of bladder cancer after various forms of radiotherapy

PURPOSE OF REVIEW

Prostate cancer is the most common cancer diagnosed in men and remains the second most lethal malignancy. Most patients undergoing treatment elect for radical prostatectomy or radiation. As the number of patients treated has increased and survival improved, delayed complications of these modalities has assumed increased importance. Recent studies report an increased risk of certain cancers after radiation for prostate cancer. This review aims to summarize recent data.

RECENT FINDINGS

Recent studies have confirmed the association of prostate radiation with secondary cancers. The most common secondary malignancy is bladder carcinoma. We have treated 44 patients with bladder cancer who had radiation therapy for prostate cancer. At diagnosis, 60% had tumor, which invaded the bladder muscle (T2 or greater disease). The mean latency from radiation to diagnosis of bladder cancer was 5.5 years.

SUMMARY

Radiation therapy for prostate cancer is associated with an increased risk of bladder cancer. In our series, patients presented at higher stage than expected from population-based studies of bladder cancer. Patients and their physicians should be aware of such risks when choosing therapy for prostate cancer. Hematuria following radiation therapy for prostate cancer should be investigated rather than being attributed to radiation-induced cystitis.

Cadaveric assessment of a new guidewire insertion device for volar percutaneous fixation of nondisplaced scaphoid fracture

PURPOSE

Volar percutaneous screw fixation (PSF) of acute nondisplaced scaphoid waist fractures allows early mobilisation of the wrist and a faster return to work than prolonged cast immobilisation. Usually, placement of the wire which guides the definitive canulated screw is performed by hand. Nevertheless, correct placement of this wire is technically difficult. We designed a guidewire insertion device (GID) to facilitate this placement.

METHODS

We compared the hand held technique with the technique using the GID in a cadaveric study. The hand held technique was performed on 16 scaphoids and the GID was used in 16 other scaphoids. The four participating surgeons were divided into two groups: two experienced surgeons and two inexperienced surgeons.

RESULTS

The GID significantly decreased procedure duration (P<0.001), number of attempts to place the wire (P<0.001), and number of image-intensifier shots (P<0.001). With both techniques, experienced surgeons were significantly faster (P=0.0083) and required significantly fewer attempts (P=0.043) than inexperienced surgeons. Using the GID, the procedure duration (P=0.0039) and the number of image-intensifier shots (P<0.001) decreased more with inexperienced surgeons than with experienced surgeons. As for the number of attempts, there was no statistical difference between the two groups (P=0.32).

CONCLUSIONS

The GID decreased the time and radiation exposure needed to achieve correct volar percutaneous wire placement in the scaphoid, compared to the conventional hand held technique. Easier wire placement may lead surgeons to use PSF instead of prolonged cast immobilisation for treating nondisplaced scaphoid fractures.

Malignant melanoma following scalp irradiation for tinea capitis

X-Rays were discovered by Roentgen in 1895 and were subsequently used in the treatment of many ailments. Numerous benign skin conditions including eczema and psoriasis have historically been treated with X-rays. During the 1930s and 1940s radiotherapy was introduced as an effective treatment for scalp ringworm (tinea capitis). Over the past few years radio-induced malignancies have been reported, with basal cell carcinoma predominating. We report a very rare case of a 64-year-old male with a 9.5mm Breslow thickness melanoma occurring over 50 years following irradiation. This case highlights the presence of another risk factor in the development of melanoma. With the increasing age of this irradiated population we may continue to see further evidence of the link between melanoma and skin irradiation.

Low-dose X-ray depilatory treatment induces trichoblastic tumors of the scalp

BACKGROUND

Depilatory radiotherapy for ringworm was largely used before antifungals were available. Patients who underwent this treatment are at high risk of developing scalp tumors or other cancers. The aim of this study was to characterize scalp tumors occurring after X-ray therapy for ringworm.

METHODS

We included cases of postradiotherapy scalp tumors recorded at the Dermatology Department of the Charles Nicolle Hospital, Tunis between 1988 and 2001. We recorded clinical descriptions and all cases were resubmitted to microscopic analysis.

RESULTS

Sixty-one tumors occurred in 33 men and 12 women with a mean age of 49.8 years. Radiodermatitis was present in 21% of patients. Tumors were basal cell carcinomas in 47 cases, trichoblastomas in 10 cases and trichoblastic carcinomas in 4 cases. Twelve patients had 2-5 tumors, with combinations of tumor types in 3 of them. Mean delay of onset of tumors after radiotherapy was 39.4 years in basal cell carcinoma cases, 38.3 years in trichoblastoma cases and 35.6 years in trichoblastic carcinoma cases.

CONCLUSIONS

This series shows that although basal cell carcinoma is the most frequent tumor in this situation, trichoblastomas are common. We describe, for the first time, radio-induced trichoblastic carcinomas. Trichoblastic tumors have not yet been described in this context because this concept is relatively recent.

Reverse latissimus dorsi musculocutaneous flap for reconstruction of lumbar radiation ulcer

The surgical treatment of large, deep defects on the midline of the lower back or lumbar area comprises difficult reconstructive challenges. Various flaps have been designed to reconstruct the defect area. We herein report a 70-year-old Japanese woman with a large, deep ulcer in the midline of the lower back, caused by postoperative radiation therapy for eccrine porocarcinoma. The ulcer was successfully treated with surgical debridement followed by reverse latissimus dorsi musculocutaneous flap. This flap is reliable and useful for reconstruction of a large, deep midline defect of the lower back, having large and bulky tissue with a sufficient blood supply.

Radiation-induced cutaneous carcinoma of the head and neck: is there an early role for p53 mutations?

BACKGROUND

Little is known about the molecular mechanisms underlying ionizing radiation-induced carcinogenesis of the skin.

AIMS

To investigate the possible role of p53 in radiodermatitis and in the development of radiation-induced cutaneous carcinomas.

METHODS

The study group comprised six patients affected by cutaneous carcinomas arising in radiodermatitis (one squamous cell carcinoma and five basal cell carcinomas), and seven patients presenting only chronic radiodermatitis. Skin specimens were evaluated for p53 immunohistochemical expression. Using laser-assisted microdissection, areas with different p53 immunoreactivity were separately submitted to DNA isolation and p53 gene analysis.

RESULTS

In the majority of cases (9/12, 75%), p53 immunoreactivity was detected in radiation-damaged epidermis. In carcinomas p53 oncoprotein was expressed by several neoplastic cells in one case (16.7%%), or by nearly all neoplastic cells in four (66.7%). SSCP band shifts were detected in 9/25 samples (36%) microdissected from irradiated epidermis and in 3/6 (50%) carcinomas. DNA sequencing demonstrated two repeatedly found mutations: a G deletion at codon 244 and an A-->G transition at codon 205, as well as hallmarks of ultraviolet mutagenic action, including a C-->T transition occurring at a dipyrimidine site and a CC-->TT tandem double-base transition.

CONCLUSION

Our data indicate that irradiation induces significant p53 alterations that may be relevant in the modification of epithelial maturation processes and may be responsible for the high risk for development of carcinomas in radiodermatitis.

Basal Cell Carcinoma of Scalp in Patients With History of Childhood Therapeutic Radiation

BACKGROUND

Basal cell carcinoma (BCC) is the most common human malignant neoplasm. Some patients with scalp BCC have had a history of childhood scalp radiation for the treatment of tinea capitis. It is not clear whether BCC in these cases has a more aggressive nature and requires a more aggressive resection. We performed a retrospective study to compare BCC tumor specification and treatment results between irradiated and nonirradiated patients.

MATERIALS AND METHODS

From 1995 to 2005, a total of 74 patients were diagnosed with scalp BCC. Thirty-eight patients (group A) had a history of childhood radiation to the scalp for the treatment of tinea capitis, and the other 36 (group B) did not. We compared these 2 groups in 16 different parameters, which included general information (age, sex), disease history (time interval from onset of lesion to the first office visit, number of admissions, total length of hospital stay), tumor specifications (number of primary lesions, invasion depth, histologic subtypes, location), surgical history (number of operations in our center and other hospitals, type of surgical treatment, margins of resection), recurrences, new lesions, and metastasis. Statistical analysis was performed using SPSS 13.0 software.

RESULTS

No significant difference in gender and age was observed between the 2 groups (P = 0.06 and P = 0.35, respectively). Patients in group A had a longer history of scalp lesions (P = 0.001). They also had more hospital admissions (P = 0.008) and operations (P = 0.01) in our center, with a longer period of hospitalization (P = 0.01). Mean number of primary lesions, the location of tumor, and the depth of invasion did not differ significantly between the 2 groups (P = 0.34, P = 0.78, and P = 0.73, respectively). There was no meaningful difference in safe resection margin for the first lesion between the 2 groups (P = 0.27); however, the number of recurrent lesions was significantly higher in group A (P = 0.003). Also, need for more aggressive resection and more complicated reconstruction was more in group A patients (P = 0.01 and P = 0.015, respectively). Only in group A new lesions and metastasis were found.

CONCLUSION

BCC in irradiated scalp has a more aggressive behavior and may need a more aggressive surgical resection. Also, these patients should be under close observation because there is a higher chance for tumor recurrence and also new lesions occurring elsewhere in the scalp.

[Multiple basal cell carcinomas following radiation therapy for nasopharyngeal cancer]

INTRODUCTION

Basal cell carcinoma (BCC) is a cutaneous, generally primary malignancy, most common among the elderly. We report the case of a patient presenting numerous BCCs several years after radiation therapy for nasopharyngeal cancer and discuss the risk factors for this tumor and the role played by radiation in its genesis.

CASE

A 30-year-old woman presented with pigmented facial lesions that had been developing over the past year. Eleven years earlier, she had had an undifferentiated nasopharyngeal carcinoma (T3N2M0), which was treated by neoadjuvant chemotherapy and then external radiation therapy. Initial cutaneous examination noted two lesions that were identified as BCC after biopsy. The tumors were excised surgically. Neither clinical nor radiological check up showed signs of basal cell nevus syndrome.

DISCUSSION

BCC is the most frequent malignant tumor. It is observed mainly among those aged 45-60 years. Disorders that might promote or complicate BCC should be systematically sought in young patients, especially basal cell nevus syndrome. While our patient may have had this syndrome, we found none of the other clinical or radiographic elements often observed with it. The occurrence of BCC within the irradiation area, the multiplicity of lesions, and the sufficient latency period are consistent with radiation-induced tumors. We found no reports in the literature of BCC following radiation treatment for nasopharyngeal cancer, but the occurrence of these tumors in our patient suggests the need for close supervision in such cases.

Long-term toxic effects of radiations: sarcomatoid carcinoma and multiple basal cell carcinoma of the limbs in chronic radiodermatitis

A 73-year-old woman was referred to our attention for the presence of severe chronic lymphoedema and neoplastic lesions of the limbs. When she was 19 years old, the patient had undergone X-ray epilation of the limbs to remove unwanted body hair. The neoplastic lesions, observed 2 years before our observation, were excised, and histological examination revealed multiple basal cell carcinomas and a spindle squamous cell carcinoma on the left thigh. The case we observed offers some interesting points of consideration as it shows that in nonexposed areas cutaneous carcinomas can appear many years after irradiation and that the same treatment consequently requires careful follow-up for life. Another point of interest is the particular hystological aspect of neoplastic lesions in the site of radiodermatitis that requires in-depth immunohistochemical investigation for an exact diagnosis. Patients with previous treatment with ionizing radiation also in nonexposed areas need lifelong follow-up to identify cutaneous tumors at an early treatable stage.

[Metachronous cancers after treatment for undifferentiated nasopharyngeal carcinoma]

OBJECTIVE

To collect second cancers occurring in the head and neck area after treatment by chemotherapy and/or radiotherapy for undifferentiated nasopharyngeal carcinoma in Tunisia.

PATIENTS AND METHODS

This is a retrospective study of patients developing second cancers after treatment for nasopharyngeal UCNT by radiotherapy and/or chemotherapy. To be retained in this study, second tumour had to be histologically different from the initial UCNT, localised in the irradiated area and occurring after a minimal delay of 3 years.

RESULTS

We collect 11 cases of second cancers occurring among 2346 patients treated from 1984 to 2001 in Tunisia (0.46%). Patients have been treated for nasopharyngeal UCNT mainly advanced T3-T4 (72%) or N2-N3 (63%). Median age was 20 years (11 to 48) with a sex-ratio of 0.3 (3 M/8 F). Treatment protocol included primary chemotherapy in 4 cases (adriamycin-cisplatin) or adjuvant (in 4) associated to the loco-regional irradiation at a mean dose of 72 Gy (70 to 75). Median delay of second cancer occurrence was 9 years (3 to 17). Tumors were epidermoid carcinomas in 4 cases, fibrosarcomas (2), osteosarcomas (2), glioblastoma (1) and basocellular carcinomas in 2. Second tumors have been treated by surgery alone in 4 cases and chemotherapy alone in 7 patients. No patient have been reirradiated. Median survival was 17 months, 4 patients died and 7 are still alive including 4 in complete remission (24+, 36, 36 and 48+ months) and 3 with progressing disease (8, 16 and 18 months).

CONCLUSION

Even very rare, second cancers after treatment for UCNT need to be detected and have a poor prognosis.

Carcinomes basocellulaires du cuir chevelu secondaires à une radiothérapie pour teigne : une série de 33 malades

Occurrence of basal cell carcinoma (BCC) following radiotherapy for tinea capitis is well known. The aim of this study was to specify the clinical and histological features of these BCC seen in 33 patients (1995-2000). Twenty seven men and six women were diagnosed with BCC. The age of onset varied between 32 an 62 years. Radiotherapy was received between 5 and 17 years of age. The interval between irradiation and the onset of carcinoma varied between 21 and 51 years. Total number of lesions was 55. Forty percent of BCC occurred on the occipital area, the number varied from 1 to 5 and the size from 2 to 45 mm. Clinically, the nodular type was found in 51% of cases. Pigment was present in 64% of cases. Histological study showed a nodular aspect in 76% and pigmentation in 63% of cases. Nodular and pigmented type were the predominant BCC occurring after radiotherapy for tinea capitis in our series. In the literature, BCC are the most frequent carcinomas occurring after radiotherapy (70-100%). Pigmentation was not described in other series. The nodular histological form was the most frequent.