Incidence of skin cancer in 5356 patients following organ transplantation

BACKGROUND

Skin cancer following solid organ transplantation is an important cause of morbidity in long-term survivors. This risk is well known but imprecisely quantified.

OBJECTIVES

We aimed to determine: (i) the skin cancer risks in transplant patients more precisely; (ii) whether the risk of malignant melanoma is altered; and (iii) whether the risk of epithelial cancers occurring at non-exposed sites is comparable with that seen in sun-exposed sites.

METHODS

We linked a population-based cohort of 5356 patients who had received organ transplants in Sweden between 1970 and 1994 with the compulsory Swedish Cancer Registry, to identify all cancer cases except basal cell carcinomas, which are not registered.

RESULTS

After a mean follow-up of 5.6 years post-transplantation, 172 of 5356 patients developed 325 non-melanoma skin cancers (excluding basal cell carcinomas) and six malignant melanomas. The relative risk of non-melanoma skin cancer was 108.6 [95% confidence interval (CI) 94.6-123.1] for men and 92.8 (95% CI 73.2-116.0) for women. The highest risks were noted for upper limbs, and the risk increased with time. No significant increase in malignant melanomas was noted: the relative risk was 1.6 (95% CI 0.5-3.7) for men and 0.5 (95% CI 0. 0-2.6) for women. Except for the lip, which is also sun-exposed, other epithelial sites did not show comparable increases in cancer risk.

CONCLUSIONS

We conclude that organ transplant recipients are at a highly increased risk for non-melanoma skin cancer and must be closely followed throughout their lives. Cancer risk associated with transplantation is higher for sun-exposed than for non-sun-exposed epithelial tissues, even among populations living in regions with low solar insolation.

Epidemiology of melanoma

Melanoma incidence and morality rates are increasing in most countries throughout the world where they are being recorded. The annual incidence rates have increased in the order of 3-7% in fair-skinned populations in recent decades. The mortality rates have increased at a rate lower than for incidence. This has been attributed to educational programs designed to improve the early detection of melanoma, as the treatment of melanoma has not changed substantially in recent decades. There has been a decrease in the thickness of melanoma with an increasing proportion of thin melanomas at diagnosis. Causation of melanoma is a combination of constitutional risk factors of which skin colour is the major factor. The presence and number of common acquired and dysplastic melanocytic naevi is also a major constitutional risk factor in fair-skinned people. The only environmental risk factor that has been shown consistently is exposure to sunlight, particularly large doses of sunlight sufficient to cause sunburn in childhood that will be remembered many years later. However, recreational activity leading to sunburn in adulthood is also associated with risk. To date, no other environmental factors have been shown epidemiologically to be clearly associated with risk of melanoma. Recent epidemiological data from some studies suggesting that there is an increased risk of melanoma in sunscreen users requires further explanation.

Temporal and spatial growth patterns in the normal and cataractous human lens

This study presents a computational model of the growth of the normal human lens and the induction of spoke-like cortical cataract in the aging lens. The anterior lens is modelled as a 2-D disk with a circumferential germinative zone. Lens cortical fibre cells in the same generation cover the surface in three identical 120 deg growth wedge-shaped sectors, with centre cardinal fibres at the 90, 210 and 330 deg meridians. In the foetal lens all primary fibre cells begin to elongate simultaneously. Anterior migration is spatially asynchronous, where the centre fibre begins to move towards the anterior pole first. The fibres at the end of the sector move last in the anterior direction. Fibre elongation advanced at constant speed until the boundary of the sector is reached. Spatio-temporal asynchrony and random fluctuations were increased for the adult lens. The model foetal lens evolved Y-shaped sutures anteriorly, and an inverted Y-shaped posteriorly. Fibre length varied periodically with meridional angle. The adult lens displayed irregular growth. If clusters of germinative cells are caused to opacify the resultant opacities are predominantly spoke-shaped. The model mimics crystalline lens fibre growth to the extent of successfully evolving lens sutures. Fluctuations in lens mass are consistent with an ordered pattern of growth. Lens senescence includes a progressive loss of spatio-temporal synchrony in fibre migration from the germinative zone. Peripheral light focusing by the anterior eye is a possible explanation for the nasal predilection and cuneiform shape of age-related cortical cataract.

The temporal and spatial epidemiology of lip cancer in England and Wales

OBJECTIVE

To examine trends in lip cancer mortality and incidence during the 20th century, and its geographical distribution, in England and Wales as a prerequisite to establishing any essential differences in the aetiology of lip and intra-oral cancer.

METHOD

Age-standardised rates for lip cancer mortality by gender from 1901 to 1991 were derived from archived OPCS data. Standardised incidence rates from 1962 to 1986 were also calculated. Registrations of lip cancer between 1979 and 1983 in the 15 RHAs covering England and Wales were obtained from the same source and standardised incidence ratios (SIR) computed.

RESULTS

Progressive and sustained falls in lip cancer mortality and incidence were recorded in the period covered. In males, these related particularly to cohorts born after 1856. In addition, the incidence of lip cancer in both genders was found to be raised in a band stretching from East Anglia to the South West and also in the Trent and Wales RHAs.

CONCLUSIONS

The findings support an hypothesis that employment in the agriculture, forestry and fishing industries, and also pipe smoking, were the major risk factors for lip cancer in the 20th century. Further research is required to differentiate between the aetiological risk factors for lip and intra-oral cancer.

Ultraviolet light exposure as a risk factor for ocular melanoma in Queensland, Australia

The state of Queensland, Australia, has one of the highest incidences of cutaneous melanoma in the world; this has been linked to the high sun exposure of the mainly Caucasian population. The role of sun exposure in the development of ocular melanoma (melanoma of the conjunctiva, iris, ciliary body or choroid) remains unclear. A case-control study involving 125 patients with ocular melanoma treated between 1972 and 1996, and 375 age- and sex-matched controls (three for each patient) was performed. A standardised telephone questionnaire examining ultraviolet exposure and other potential risk factors was administered. Cumulative lifetime ocular ultraviolet B (UV-B) exposure was assessed using the Melbourne Visual Impairment Project instrument. Risk factors identified include personal history of melanoma of the skin (odds ratio [OR] 2. 42, 95% confidence interval [CI] 0.88, 6.62) or other skin cancers (OR 1.52, CI 0.99, 2.35), and family history of ocu-lar melanoma (OR 6.89, CI 0.70, 67.38). Protective factors included olive or black skin (OR 0.72, CI 0.40, 1.31), brown iris colour (OR 0.89, CI 0.51, 1.54), high resistance to sunburn (OR 0.58, CI 0.26, 1.31), and wearing prescription glasses (OR 0.78, CI 0.48, 1.25). Sunglass wearing was not found to be protective. Cumulative lifetime ocular UV-B exposure was not found to be a risk factor for ocular melanoma. However, there were too few cases of conjunctival and iris melanoma for these to be analysed as separate sub-groups.

[Solar retinopathy acquired after gazing at the sun during prayers]

The authors present the results of a study based on six persons who developed retinopathy after gazing at the sun during prayers. Risk factors were studied and the prognosis evaluated. The mean follow-up time was 82 days. Risk factors were present in all patients. The visual acuity was reduced in all patients at first presentation and total improvement was noted in four of them. Of all six patients, only one had his ocular fundus normalized. Amsler's grid testing revealed in all patients bilateral central scotomas which persisted in four of them. Fluorescein retinal angiography, which was found to be abnormal in all cases, became normal in only one case. However, all patients continued to complain of visual disability because of the persistence of photophobia, meta-morphopsia and scotomas. In conclusion, the prognosis of solar retinopathy is variable and the recovery of visual acuity does not necessarily imply the improvement of vision. Appropriate eye protection such as solar filters must be used when gazing at the sun to protect from retinal damage.

Photo Koebner phenomenon in erythema-multiforme-like eruption induced by contact dermatitis due to bufexamac

A photo Koebner phenomenon following contact dermatitis due to bufexamac is described. A 52-year-old man presented with dermatitis on his buttocks and an erythema-multiforme (EM)-like eruption near the original lesion and on sun-exposed areas. He had been using bufexamac ointment (Anderm(R)) around and inside the anus for a few weeks before he noticed exacerbation. On patch testing, he exhibited severe contact sensitivity to bufexamac. Phototesting performed on his first visit showed that he had an abnormal reaction to UVB. An EM-like eruption similar to the original lesions developed around the irradiated sites. In this case, photosensitivity does not seem to be a drug-induced photoallergy due to systemic or topical use, but rather a photo Koebner phenomenon.

A national survey of sun safety activities at U.S. zoos

Skin cancer incidence in the United States has increased. Exposure to ultraviolet radiation (UVR) is a major risk factor for skin cancer. Every year, millions of children with their families visit outdoor leisure facilities such as zoos where overexposure to UVR may occur. This study was conducted to assess the proportion of U.S. zoos that provided sun safety activities during the summer of 1998 and their willingness to incorporate skin cancer prevention strategies at their facility in the future. A 56 item self-administered questionnaire was mailed to 140 zoos accredited by the American Zoo and Aquarium Association. A follow-up telephone survey was also conducted with 33 mail non-respondents. The response rate was 97% (N = 136). Results revealed that in the summer of 1998, only 5% of zoos provided sun safety recommendations to visitors and 25% of zoos provided recommendations to their employees. The recommendations made most often to visitors and employees were to use sunscreen and wear protective clothing. Eighty-five percent of zoos indicated interest in providing sun safety activities at their facilities in the future. The next step will be to design environmentally appropriate sun safety programs for zoos and to encourage zoos to implement these programs.

Predictors of the use of sunscreen in dermatological patients in Central Europe

BACKGROUND

There is mounting evidence that sun exposure is a cause of skin cancer. Therefore, the focus of skin cancer prevention is on sun protection. The present study investigated the use of sunscreens in a sample from the adult Central European population.

METHODS

As part of a case-control study of cutaneous melanoma, a total of 498 controls with classical dermatological disorders were selected from hospitals in Central Europe. All people underwent whole-body skin examinations and were interviewed using a standardized questionnaire.

RESULTS

Overall, 40.8% of the people never used sunscreen and of the 281 persons who used sunscreen, 41.5% applied it only once per sun bath. Persons who did not use sunscreen tended to be older (P<0.0001) and of male gender (P = 0.0004). Young people, women, and people who expressed a positive attitude to the sun spent more time in the sun and were more likely to apply sunscreens. People who worked almost always outdoors had a six times increased odds ratio of not using sunscreens (P<0.0001) compared to people who worked always indoors.

CONCLUSIONS

Men, older people, and outdoor workers should be targeted in health education campaigns. On the other hand, people who apply sunscreen as a means of sun protection should be advised about adequate usage.

High incidence and regression rates of solar keratoses in a queensland community

The presence of solar keratoses on the skin is one of the major risk factors for basal cell and squamous cell carcinomas, which constitute a growing public health problem in today's white populations. In spite of this, little is known of the natural history of solar keratoses. We conducted follow-up studies to monitor the incidence, regression, and recurrence rates of solar keratoses in a random sample (N = 96) of the Nambour community in Queensland. At baseline, 43 participants (46%) were diagnosed with at least one solar keratosis [26 men (55%), 17 women (37%)] with a total count of 494 prevalent solar keratoses. The distribution of lesions per person was highly skewed, with 11 individuals (12%) having 65% of the total number of solar keratoses. During 12 mo of follow-up, 614 incident solar keratoses were diagnosed (549 in men and 65 in women); 526 solar keratoses regressed and 53 prevalent solar keratoses recurred, giving a net 45% increase in solar keratosis numbers in men (from 354 to 512 solar keratoses) and a net 44% reduction in women (from 114 to 64). Regression rates were higher in prevalent (74%) than incident (29%) solar keratoses. Solar keratosis prevalence increased with age in both sexes, and individuals with solar keratoses at baseline were over seven times more likely to develop additional solar keratoses in the next 12 mo than those without prevalent solar keratoses at baseline. These results show that the natural history of solar keratoses in the community is one of high turnover and that a small percentage of susceptible individuals carry the major burden of solar keratoses in the community.

Drug-induced solar urticaria due to tetracycline

Solar urticaria is an uncommon disorder characterized by pruritus, erythema and whealing commencing within minutes of exposure to ultraviolet (UV) and visible light, and generally resolves in a few hours. We describe a 28-year-old woman who developed pruritus and erythema 5 min after sun exposure while on tetracycline for treatment of perioral dermatitis. Phototesting elicited urticarial reactions in the UVA, UVB and visible spectra. Repeat phototesting after cessation of tetracycline was negative. This report documents the first case of solar urticaria induced by tetracycline.

Lupus erythematosus tumidus--a neglected subset of cutaneous Lupus erythematosus: report of 40 cases

BACKGROUND

Lupus erythematosus tumidus (LET) is characterized clinically by erythematous, succulent, edematous, nonscarring plaques in sun-exposed areas. Results of histological examination show perivascular and periadnexal lymphocytic infiltration and interstitial mucin deposition. The main differential diagnoses are polymorphous light eruption, Jessner's lymphocytic infiltration of the skin, reticular erythematous mucinosis, and pseudolymphoma. Since its first description in 1930, LET has been documented rarely in the literature, and its clinical importance has not been fully appreciated.

OBSERVATIONS

We characterized 40 patients with clinical and histological features of LET observed at our department from 1984 through 1998. The onset of the disease clustered in summer because of sun exposure, and 28 (70%) of the patients showed a remarkable photosensitivity confirmed by results of provocative phototesting. A complete resolution of the skin lesions was seen after systemic therapy with antimalarials and, in some cases, with local corticosteroids or spontaneously without any treatment. In 4 (10%) of the patients, antinuclear antibodies were detected; however, there was no evidence of underlying systemic involvement in any of the patients.

CONCLUSIONS

Our data constitute the largest number of patients with LET collected until now. The clinical picture, extreme photosensitivity, histological findings, and effective treatment with antimalarials are so characteristic that LET should be considered as a separate entity and differentiated from other variants of cutaneous LE. Arch Dermatol. 2000;136:1033-1041

[Xeroderma pigmentosum]

Xeroderma pigmentosum(XP) is an autosomal recessive disease that is characterized by hypersensitivity to sunlight with high incidence of skin cancer and that exhibit variable neurological abnormalities in some groups. There are eight different complementation groups in XP; groups A through G and a variant(XP-V). XP-A through XP-G have a defect in nucleotide excision repair(NER), while XP-V has a defect in translesion DNA synthesis. Almost all of genes for XP have been cloned and their functions in the NER mechanism have been progressively unveiled. In this review, the present knowledge of the pathological features and genetic defects in XP has been discussed.

A comparison of 3 lasers and liquid nitrogen in the treatment of solar lentigines: a randomized, controlled, comparative trial

OBJECTIVE

To determine if laser therapy is superior to liquid nitrogen for the treatment of solar lentigines and if so, to determine if one laser is superior to the other lasers that were tested.

DESIGN

Randomized, controlled, comparative study with blinded observers.

SETTING

University-based dermatology clinic.

PARTICIPANTS

Twenty-seven patients with multiple solar lentigines on the backs of both hands.

INTERVENTIONS

Liquid nitrogen cryotherapy, the Medlite II frequency-doubled Q-switched Nd:YAG laser (Continuum Biomedical, Livermore, Calif), the HGM K1 krypton laser (HGM Medical Laser Systems Inc, Salt Lake City, Utah), and the DioLite 532-nm diode-pumped vanadate laser (Iridex Corp, Mountain View, Calif).

MAIN OUTCOME MEASURES

Photographs of the hands were taken prior to and 6 and 12 weeks following treatment. Blinded observers and patients evaluated each treatment on its ability to lighten pigmented lesions without causing unwanted adverse effects.

RESULTS

Many new laser systems claim an advantage for treating pigmented lesions by selectively destroying melanin. In this study, the frequency-doubled Q-switched Nd:YAG laser was most likely to provide significant lightening (P<.05), followed by the HGM K1 krypton laser, the 532-nm diode-pumped vanadate laser, and liquid nitrogen. The frequency-doubled Q-switched Nd:YAG laser also had the fewest adverse effects (P<.05), while the HGM K1 krypton laser had the most (P<.05). Of the 27 patients, 25 preferred laser therapy to cryotherapy, with the frequency-doubled Q-switched Nd:YAG laser being the most popular.

CONCLUSIONS

Laser therapy is superior to liquid nitrogen for the treatment of solar lentigines. Of the laser systems tested in this study, the frequency-doubled Q-switched Nd:YAG laser is the most effective.

Radiation therapy for extensive actinic keratosis

Actinic keratosis in the most common premalignant keratotic tumour of sun-exposed skin. A 66-year-old man developed a large actinic keratosis on his scalp, which did not respond to conventional treatment. Fractionated radiotherapy with a cumulative dose of 28 Gy resulted in complete remission without relapse during a 14-month follow-up. In older subjects in whom conventional treatment fails, low-dose fractionated radiation therapy is an effective alternative method.

A graded work site intervention program to improve sun protection and skin cancer awareness in outdoor workers in Israel

OBJECTIVES

A graded worksite intervention program to improve sun protection and skin cancer awareness of outdoor workers was implemented and evaluated longitudinally over a period of 20 months.

METHODS

Outdoor male workers (144/213 recruits) from geographically separated units of the Israel National Water Company were allocated to complete (n = 37), partial (n = 72) or minimal (n = 35) intervention groups. Subsequent to the assignment and training of local safety officers, an educational and medical screening package was provided to the corresponding groups either once, or repeatedly a year later. Personal sun protective gear was provided upon repeated intervention. Outcome measures were evaluated through self-response questionnaires administered prior to the first intervention pulse, and 8 months after the first and second interventions.

RESULTS

A 15-61% improvement in sun-protection habits was noted in the entire study population 8 months after initialization, compared to no sunscreen use, 20% sun-exposed skin area and highest mean occupational exposure dose of 1.68 MED/day at pre-test. An even greater use of sunscreen was evident 1 year later in the complete and partial intervention groups, + 80% and + 52%, respectively. The baseline rate of self-examination of the skin in the same two groups (49%) increased significantly at post-test (+ 71% and + 53%, respectively).

CONCLUSIONS

This integrated intervention program led to significantly improved sun protection and skin cancer awareness. Repeated intervention combined with the supply of sun-protective gear contributed to an even greater impact.

Gene-environment interaction in melanoma

Gene-environment interaction can be defined as a different effect of an environmental exposure in people with different genotypes, or a different effect of a genotype in people with different histories of environmental exposure. Interaction applies when one stratum (high risk) responds differently to an exposure (sun) than another stratum (low risk). Genetic predisposition would appear to be a very important modifier of risk. This paper discusses the concept of gene-environment interaction applied to cutaneous melanoma through discussion of highly penetrant genes and their interaction with sun exposure, through discussion of low penetrant genes and their interaction with sun exposure, and by suggesting a new model for investigation of gene-environment interaction in melanoma. It is stressed that this area of investigation is extremely early in its development.