Fulminant course of a microinvasive vulvar carcinoma in an immunosuppressed woman

Iatrogenic immune suppression following renal transplantation is frequently associated with certain neoplasms, including vulvar carcinoma. We describe a patient with a vulvar carcinoma less than 1 mm depth of invasion and less than 3 mm superficial spread 12 years after renal transplantation. A simple vulvectomy was performed but 4 months later disease recurred in the inguinal nodes. The patient died 20 months later with progressive disease in the retroperitoneum and liver metastases.

Radiation-induced tumors of the temporal bone

OBJECTIVE

To discuss a rare but devastating complication following radiotherapy to the head and neck: radiation-induced malignancies of the temporal bone.

STUDY DESIGN

A retrospective case review comprising five patients with radiation-induced tumors involving the temporal bone.

SETTING

A tertiary referral center.

PATIENTS

Patients with tumors involving the temporal bone who have satisfied the criteria for being considered radiation-associated.

MAIN OUTCOME MEASURES

Initial tumor histology, radiation-induced tumor histology, latency between radiotherapy and diagnosis of the radiation-associated malignancy, amount of radiation received, therapeutic interventions, and survival statistics for each patient.

RESULTS

Five cases of radiation-induced tumors of the temporal bone are presented (two osteosarcomas, two fibrosarcomas, and one squamous cell carcinoma). All five temporal bone tumors occurred in individuals that had previously received > 5,000 cGy of radiation. The initial histologic diagnoses included two astrocytomas, a glomus jugulare, a malignant meningioma, and a vestibular schwannoma. There was an average latency period of 15 years (range, 7-23 years) between completion of radiation and diagnosis of the malignancy. Four patients were treated with resection plus chemotherapy, and one decided against therapy. The prognosis was poor, with survival time of 7-14 months after the diagnosis of the radiation-induced tumor. Only one patient survived > 14 months and is currently free of disease, 3 years after diagnosis of the radiation-induced tumor.

CONCLUSIONS

Although radiation-induced tumors of the temporal bone occur with a very low incidence, their prognosis is extremely poor. The remote possibility of a radiation-associated tumor should be factored in when deciding upon the most appropriate therapeutic modality for individuals with neoplasms of the CNS and head and neck. Such considerations are particularly germane when contemplating radiation therapy for a benign lesion (e.g., glomus jugulare, acoustic neuroma, or meningioma) in an individual with a long predicted lifespan.

Lung cancer in relation to exposure to silica dust, silicosis and uranium production in South African gold miners

BACKGROUND

A nested case-control study for lung cancer was performed on a cohort of 2260 South African gold miners in whom an association between exposure to silica dust and risk of lung cancer was previously reported. The objective was to investigate an expanded set of risk factors and also cancer cell type.

METHODS

The 78 cases of lung cancer found during the follow up period from 1970 to 1986 were matched with 386 controls. Risk of lung cancer was related to smoking, exposure to silica dust, incidence of silicosis, and uranium production and the uranium content of the mine ore.

RESULTS

The risk of lung cancer was associated with tobacco smoking, cumulative dust exposure, duration of underground mining, and with silicosis. The best predictive model included pack years of cigarette consumption (adjusted relative risk (RR) = 1.0 for < 6.5 pack years, 3.5 (95% confidence interval (CI) 0.7 to 16.8) for 6.5-20 pack years, 5.7 (95% CI 1.3 to 25.8) for 21-30 pack years, and 13.2 (95% CI 3.1 to 56.2) for more than 30 pack years) and silicosis (RR = 2.45 (95% CI 1.2 to 5.2)). No association was found with uranium production. The lung tumour cell type distribution was 40.3% small cell carcinoma, 38.8% squamous cell, 16.4% adenocarcinoma, and 4.5% large cell carcinoma. Small and large cell cancer combined were associated with exposure to dust.

CONCLUSIONS

The results cannot be interpreted definitively in terms of causal association. Possible interpretations are: (1) subjects with high dust exposure who develop silicosis are at increased risk of lung cancer; (2) high levels of exposure to silica dust on its own is important in the pathogenesis of lung cancer and silicosis is coincidental; and (3) high levels of silica dust exposure may be a surrogate for the exposure to radon daughters.

Case report: primary cystic keratinizing squamous cell carcinoma of the liver in a patient with treated nasopharyngeal carcinoma

Primary squamous cell carcinoma of the liver is very rare; only 18 cases have been recorded. In the present report we document an additional case who had a unique history of stage III non-keratinizing nasopharyngeal carcinoma treated with a full course of radiotherapy in July 1993. Two small hypoechoic cyst-like lesions in the left hepatic lobe were identified at the same time. In July 1995 the 50-year-old patient reported to be suffering from abdominal fullness and tenderness. A large hypodense tumour was demonstrated in the left hepatic lobe by abdominal echography. The patient was diagnosed as having metastatic carcinoma and received two courses of pre-operative chemotherapy followed by left lobectomy of the liver and resection of adherent tissues on 9 August 1995. Pathological study demonstrated a larger hepatic cystic keratinizing squamous cell carcinoma, which most likely arose from a solitary hepatic cyst. Tumour seedings, probably secondary to tumour rupture, were also revealed on the omentum, peritoneum and diaphragm. However, regional lymph nodes were fee of tumour. Systemic work-up failed to demonstrate evidence of local recurrence of nasopharyngeal carcinoma, metastatic lesion or any second primary tumour site.

[Analysis of mutation types of p53 gene and possible carcinogenic factors in lung cancer]

Mutational spectrum of p53 gene was analyzed by polymerase chain reaction (PCR)-single strand conformational polymorphism (SSCP) and direct DNA sequencing technique in tissue specimens of primary non-small cell lung cancer (NSCLC) to study the action of p53 gene, its type of mutations and its possible relation to different carcinogens. Results revealed that mutation of p53 gene was found in 94 of 128 resected specimens of NSCLC, including point mutations in 86 cases, deletion and insertion in seven and mutation of the linking site in one, and 63.9 percent of point mutations were G-T and T-G substitution and 25.6 percent G-A and A-G. It suggested that p53 gene mutation correlated closely to the occurrence of NSCLC. Possible environmental carcinogens were discussed in the paper based on the characteristics of the p53 gene mutation.

Comparative nuclear morphometric analysis of aggressive and non-aggressive squamous cell carcinomas of the skin

Squamous cell carcinomas (SCC) are the most frequent tumours complicating organ transplantation. Whereas most SCC can be successfully treated with conventional surgery, other lesions show an aggressive course with recurrence and metastases. We assessed the value of nuclear morphometry in detecting tumours with an ab initio potential for aggressive course. Nuclear perimeter, area, feret X and feret Y were calculated semi-automatically on an image analyzer on histological sections of 15 non-aggressive, 15 aggressive and 6 recurrent SCC developed in seven organ graft recipients. We found statistically significant differences for all the parameters studied between recurrent and initially aggressive SCC, and, to a lesser extent, between non-aggressive and aggressive SCC. These results suggest that some SCC have ab initio a potential for more aggressive evolution; morphometry can be a useful adjunct in order to better study these lesions.

Malignancy arising in seborrheic keratosis: a report of two cases

We describe the pathological features of two cases of malignant transformation occurring in seborrheic keratosis. The lesions affected elderly individuals: a 79-year-old Chinese lady and a 79-year-old Chinese gentleman, both of whom had long-standing seborrheic keratoses with recent increase in size. Histologically, the malignancies identified were invasive well-differentiated squamous cell carcinoma and Bowen's disease (squamous carcinoma in situ), respectively. Pre-existing seborrheic keratoses demonstrating a zone of transition into the malignant foci were present. Aetiologic factors that have been proposed to explain these exceedingly rare occurrences have included prolonged sun damage and chronic low dose radiation exposure.

Proliferative activity and p53 protein accumulation correlate with early invasive trend, and apoptosis correlates with differentiation grade in oesophageal squamous cell carcinomas

Using oesophageal squamous cell carcinoma samples of both intramucosal and advanced types, proliferative activity (Ki-67 labelling index), p53 protein accumulation and apoptosis (in situ DNA nick end labelling) were assessed, and the relation of these values to progression or differentiation grade of tumours was analysed. In terms of proliferative activity and the proportion of positive cases with p53 accumulation, a statistically significant difference was demonstrated between intraepithelial carcinomas and intramucosal carcinomas with stromal invasion (17.2% vs 31.7% for the Ki-67 labelling index, and 23.5% vs 67.4% for the proportion of positive cases of p53 accumulation). Values for the latter were almost comparable to those of advanced carcinomas. Immunohistologically, Ki-67 positive, proliferating cells were distributed preferentially in the peripheral fronts of invading nests. Apoptotic cells were observed in the inner areas of the invading nests of the intramucosal carcinomas with stromal invasion and in more advanced lesions, but were rarely observed in the normal epithelium or intraepithelial carcinomas. Apoptotic cells were seen mainly around areas of keratinization, and the apoptotic cell index was higher in well and moderately differentiated types of advanced carcinomas than in the poorly differentiated type (2.59% vs 1.09%). An increase in proliferative activity and an accumulation of p53 protein are associated with the onset of early carcinomatous invasion, while apoptosis is closely linked with the differentiation grade of carcinoma cells.

Orbital squamous cell carcinoma following retinal detachment surgery

BACKGROUND

Orbital squamous cell carcinoma following retinal detachment surgery is a rare condition. A proposed pathogenesis involves implantation of conjunctival squamous epithelium at the time of surgery, with subsequent malignant transformation.

METHODS/RESULTS

An 81-year-old Caucasian man presented with a six-month history of a discharging painful red right eye. Ten years earlier a right scleral buckling with an encircling sponge exoplant had been performed. Examination revealed exposure of the sponge, and a large mass in the superomedial conjunctival fornix. Computed tomography revealed a mass invading around the globe in the region of the exoplant. Biopsy revealed squamous cell carcinoma. Orbital exenteration was performed.

CONCLUSION

Orbital squamous cell carcinoma may arise following retinal detachment surgery presumably due to iatrogenic conjunctival implantation deep in the orbit.

The etiology and pathogenesis of laryngeal carcinoma

Epidemiologic data suggest that the etiology and pathogenesis of laryngeal carcinoma are influenced by environmental and lifestyle-related factors, such as tobacco use, ethanol consumption, and exposure to toxic substances. In addition, dietary factors, irradiation, papilloma virus infection, and laryngopharyngeal reflux seem to be significant carcinogenic cofactors. This article presents a multi-factorial model of laryngeal mucosal carcinogenesis.

Low prevalence of human papillomavirus infection in esophageal squamous cell carcinomas from North America: analysis by a highly sensitive and specific polymerase chain reaction-based approach

Several studies have documented the frequent occurrence of human papillomavirus (HPV) DNA in esophageal squamous cell carcinomas (ESCC) in patients from geographic regions where the incidence of this type of cancer is high, such as parts of China. However, the prevalence of HPV infection in ESCC in patients from low incidence geographic regions, such as North America, remains controversial. Therefore, this study evaluates the prevalence of HPV in ESCC in patients from North America, a region where the population is considered at low risk for the development of this neoplasm. ESCCs in 51 patients from three North American cities were analyzed for the presence of HPV DNA by a highly sensitive and specific polymerase chain reaction (PCR) method. Tumor DNA was extracted from formalin-fixed, paraffin-embedded tissue specimens and assayed by PCR using an L1 HPV consensus sequence primer, as well as HPV 16 and HPV 18 E7 region primers. The use of consensus primers to the L1 region allows for detection of most known HPV types and many novel HPV types. Appropriately sized reaction products were analyzed by restriction fragment length polymorphism (RFLP) to confirm the presence and type of HPV, and to exclude products produced by amplification of human DNA sequences. After complete analysis, only one case (2%) of ESCC was HPV DNA positive. This case was independently confirmed using L1 and E7 consensus primers as HPV type 16 and was the only case that tested positive with either assay. These results show that, in contrast to geographic regions where ESCC is prevalent, HPV infection occurs infrequently in association with ESCC in patients from North America.

Epidemiology of squamous cell conjunctival cancer

The etiology of squamous cell carcinoma of the conjunctiva (SCCC) is not well known. A possible role of UVB radiation is suggested by an excess of SCCC in tropical countries and by the association between squamous cell skin cancer and exposure to UVB. Human papillomavirus type 16 also may be involved, given that it has been detected in benign and malignant conjunctival lesions and is the primary etiological agent involved in carcinoma of the anogenital tract. To examine the relationship between UVB exposure and SCCC, population-based age-adjusted incidence rates of SCCC and of conjunctival melanoma and squamous cell cancer of the eyelid were plotted against the UVB insolation of each registry site. Incidence data were examined further for patterns of second primary cancers among people with SCCC. SCCC was rare in the United States, with an incidence rate of 0.03 per 100,000 persons, although the rate was approximately 5-fold higher among males and whites. Regression analysis suggested a link between UVB exposure and SCCC rates (beta = 2.25; r = 0.58) that was as strong as that for squamous cell carcinoma of the eyelid (beta = 2.73; r = 0.62) and much stronger than for conjunctival melanoma (beta = 0.28; r = 0.02). Risk of a second malignancy after SCCC was not increased overall (20 observed and 14.1 expected), although a significant excess of salivary gland cancer (4 observed and 0.03 expected) and a borderline excess of lung cancer (6 observed and 2.4 expected) were noted. These observations suggest that UV radiation likely contributes to SCCC development. Additional research is needed to define the other exposures and host susceptibility that likely interact with UV-related genetic damage in the multifactorial development of this rare neoplasm.

Pathobiology of vulvar squamous neoplasia

Vulvar squamous carcinoma is an uncommon neoplasm that afflicts a spectrum of women and has been associated with granulomatous vulvar diseases, papillomaviruses, and chronic inflammatory disorders of the vulva. Histopathological, molecular, and epidemiological studies have revealed two subsets of vulvar squamous neoplasia, which are distinguished by their association with human papillomaviruses and patient demographics. This review summarizes the evidence both supporting the diverse pathogenesis of these tumors and the existence of factors that may be common to both groups. Ultimately, the pathway to both human papillomavirus positive and negative vulvar cancers may involve not only obvious precancerous changes but also biological events in the vulvar mucosa that precede the onset of morphological atypia.

Radiation therapy for squamous cell carcinoma in dystrophic epidermolysis bullosa: case reports and literature review

Dystrophic epidermolysis bullosa (DEB) is a debilitating systemic disease frequently associated with biologically aggressive secondary squamous cell carcinomas arising from affected skin or mucosal surfaces. Treatment of these carcinomas with surgery, chemotherapy, or radiation is complicated by inherently poor wound healing. We report on two DEB patients treated with radiation therapy for locally advanced squamous cell carcinoma, and retrospectively analyze 10 DEB patients treated with radiation, reported in the literature. Of the 11 fully available and described case results from radiation therapy, six (54%) patients demonstrated a partial tumor response. All patients receiving > 4,500 cGy developed moist skin desquamation and delayed skin healing. Radiation therapy may be of benefit in palliating DEB patients who have locally advanced carcinoma, but has been associated with enhanced normal tissue toxicity, suggesting a narrow or absent therapeutic index between irradiated carcinoma and skin.

Deleterious effects of prostaglandin E2 in oesophageal carcinogenesis

Oesophageal carcinoma is a devastating disease with a poor prognosis. This hypothesis shows how prostaglandin E2 exerts carcinogenic effects in the oesophagus. The contribution of prostaglandin E2 is related to other factors that predispose to oesophageal carcinoma. The implication of the hypothesis is that nonsteroidal anti-inflammatory drugs such as aspirin may be useful in the prevention of oesophageal carcinoma.

The lack of association between adenocarcinoma of the esophagus and gastric surgery: a retrospective study

BACKGROUND

The cause of the rapid increase in the incidence of adenocarcinoma of the esophagus since the 1970s is unknown.

OBJECTIVE

To test the hypothesis that duodenogastroesophageal reflux causes adenocarcinoma of the esophagus by comparing the frequency of gastric surgery (a human model of duodenogastroesophageal reflux) and other potential risk factors between patients with adenocarcinoma and patients with squamous cell carcinoma of the esophagus.

METHODS

Medical records of all patients with adenocarcinoma or squamous cell carcinoma of the esophagus seen at the Cleveland Clinic Foundation between 1987 and 1994 were reviewed. The following data were retrieved: age, gender, race, tumor location, history of gastric surgery and gastroesophageal reflux symptoms, and use of tobacco, alcohol, histamine-2 receptor antagonists, and proton pump inhibitors.

RESULTS

The data of 325 patients with adenocarcinoma (73.5%) and 117 patients with squamous cell carcinoma (26.5%) were analyzed. No differences were found between the groups in age, proportion with gastric surgery (patients with adenocarcinoma: 1.2%, 95% confidence interval 0.3-3.1%; patients with squamous cell carcinoma: 0.9%, 95% confidence interval 0.0-4.7%), smoking (76.7 vs 81.6%), or alcohol use (71.8 vs 79.1%). Significant risk factors associated with adenocarcinoma of the esophagus were male gender, white race, distal cancer location, and Barrett's esophagus.

CONCLUSIONS

Previous gastric surgery is rarely found in patients with esophageal cancer and is performed with equal frequency in patients with adenocarcinoma and those with squamous cell carcinoma of the esophagus. This suggests that gastric surgery and its associated duodenogastroesophageal reflux do not play a role in the etiology and rising incidence of adenocarcinoma of the esophagus. White males in their mid-60s with Barrett's esophagus who smoke and drink alcohol are at highest risk for adenocarcinoma of the esophagus.

The influence of physical activity on lung-cancer risk: A prospective study of 81,516 men and women

Physical activity is inversely related to mortality from respiratory diseases including lung cancer. Physical activity improves pulmonary function but its impact on lung-cancer risk has not been studied much. During 1972-1978, 53,242 men and 28,274 women, aged 20 to 49 years, participated in a population-based health survey and were followed until 31 December 1991. We observed a total of 413 men and 51 women with lung cancer. Leisure activity and work activity were assessed using a questionnaire in 4 categories. In a sub-cohort, physical activity was assessed twice at an interval of 3 to 5 years. Leisure but not work activity was inversely related to lung-cancer risk in men after adjustment for age, smoking habits, body-mass index and geographical residence (p for trend = 0.01). Men who exercised at least 4 hours a week had a lower risk than men who did not exercise [relative risk (RR) = 0.71; 95% confidence interval (CI) = 0.52-0.97]. Reduced risk of lung cancer was particularly marked for small-cell carcinoma (RR = 0.59; 95% CI = 0.38-0.94) and for adenocarcinoma (RR = 0.65; 95% CI = 0.41-1.05), with no association seen for squamous-cell carcinoma. In the sub-cohort in which physical activity was assessed twice, the risk of lung cancer was particularly reduced among men who were most active at both assessments (RR = 0.39; 95% CI = 0.18-0.85). No consistent association between physical activity and lung-cancer risk was observed among women. Our results suggest that leisure physical activity has a protective effect on lung-cancer risk in men. The small number of incident cases, combined with the narrow range of physical activity reported, may have limited our ability to detect an association between physical activity and lung cancer in women.

Biological effects of inhaled 144CeCl3 in beagle dogs

The biological effects of 144Ce were studied in beagle dogs that were exposed to graded activity levels of 144CeCl3 via a single, brief inhalation exposure and observed for their life span. The long-term retained body burdens ranged from 0.06 to 13 MBq/kg with a median of 1.2 MBq/kg. After a short residence time in the lung, most of the 144Ce was translocated to liver and skeleton, where the 144Ce was retained with a half-time approaching the physical half-life of 144Ce, 284 days. Significant radiation doses were delivered to the lung, 28 Gy (median) and 2.5-370 Gy (range); liver, 68 Gy (median) and 6.1-250 Gy (range); and skeleton, 21 Gy (median) and 1.9-100 Gy (range). Lesions induced by the beta-particle radiation were noted in the lung, liver, skeleton, bone marrow, and oral and nasal mucosae closely associated with bone. Early deaths (within 2.5 years) were generally related to hematological dyscrasia, radiation pneumonitis, or hepatocellular degeneration and atrophy. Neoplasms that occurred relatively early, from 2.2-6.8 years after exposure, were noted in the liver, bone, bone marrow and oral mucosa closely associated with bone. Neoplasms that occurred later, beyond 7 years after exposure, were noted in the liver, lung and nasal mucosa closely associated with bone. Increased numbers of neoplasms were not found in two other organs that had relatively high radiation doses, namely the thyroid and kidney. Only one primary bone tumor was noted, but 11 tumors of bone-associated tissues (oral and nasal mucosae and bone marrow) were found. Radiation doses and effects in tissues adjacent to bone, especially those of epithelial or marrow origin, should be considered when determining risks from internally deposited bone-seeking radionuclides, such as 144Ce. The property of 144Ce in depositing on and remaining associated with bone surfaces for long times may be an important factor in the radiation dose to bone marrow and epithelium adjacent to bone.

The effects of alcohol and smoking upon the age, anatomic sites and stage in the development of cancer of the oral cavity and oropharynx in females in the south west Netherlands

A retrospective review of 303 women, aged 40 or over, with squamous cell carcinomas of the oral cavity or oropharynx was conducted in the south-west Netherlands to study the effects of smoking and alcohol upon the age of onset, site and stage of disease. It was noted that patients presenting with oropharyngeal cancers were younger and had a higher incidence of smoking and history of heavy drinking. Age at presentation was also affected by the amount of alcohol and tobacco consumed with non-users presenting with tumors approximately 15 years later. A specific finding was that heavy drinkers and smokers tended to present with late-stage-disease.