Xeroderma pigmentosum in radiation oncology practice

Unresectable and chemoresistant conjunctival squamous cell carcinoma on xeroderma pigmentosum treated by salvage radiation therapy: A case report and a review of the literature

Xeroderma pigmentosum (XP) is a rare genetic disease, which vital prognosis is conditioned by the occurrence of cancers essentially of the skin and ocular surfaces, requiring an early and adapted management. Radiation therapy (RT) is a very effective modality in the therapeutic arsenal alongside surgery, but it remains underused as it is wrongly considered to be deleterious for these patients. In this article, we report the case of a 10-years-old girl with XP treated with external beam RT for a squamous cell carcinoma (SCC) of the right ocular conjunctiva. The clinical tolerance was excellent and we obtained a good tumoral response. Therefore, the place of RT in these patients could/should be reconsidered, especially since these suspicions have still not been confirmed.

Minimal ionizing radiation sensitivity in a large cohort of xeroderma pigmentosum fibroblasts

We have examined our ionizing radiation survival data for 33 xeroderma pigmentosum (XP) primary fibroblast lines and compared the data to that of 53 normal fibroblast lines, 7 Cockayne syndrome (CS) lines, 4 combined XP/CS lines and 8 ataxia-telangiectasia fibroblast lines. Although there are differences in radiosensitivity between cell lines within each class, we have no convincing evidence that XP lines as a group are more sensitive to ionizing radiation than the general population. However, because the XP phenotype may lead to premature ageing, especially of sun-exposed tissues, we would still advocate caution when XP patients come to radiotherapy. Our results confirm the extreme ionizing radiation hypersensitivity of ataxia-telangiectasia; they are also consistent with a tendency for slight hypersensitivity in CS, but not (necessarily) in combined XP/CS.

Four radiation hypersensitivity cases and their implications for clinical radiotherapy

BACKGROUND AND PURPOSE

Over a 20 year period, four out of 2000 paediatric radiotherapy patients, treated at St. Bartholomew's Hospital (three with lymphoma, one with angiosarcoma), have revealed extreme/fatal clinical hypersensitivity in normal tissues.

PATIENTS AND METHODS

Cellular hypersensitivity was confirmed in vitro and attributed to the ataxia-telangiectasia (A-T) gene in cases I and II, a newly described defect in the DNA ligase 4 gene in case III, and a novel and as yet incompletely defined, molecular defect in case IV who presented with xeroderma pigmentosum (XP).

RESULTS

The severe clinical hypersensitivity preceded the cellular and molecular analysis, but did not manifest as a clinically exaggerated normal tissue reaction until 3+ weeks after the start of a conventionally fractionated course of radiotherapy, by which time the latent damage had been inflicted. There were no clinical stigmata to alert the clinician to a predisposing syndrome in two patients (cases I and II). We point out that approximately 20% of A-T patients are classified as variants with delayed expression of clinical symptoms, and case II falls into this category.

CONCLUSIONS

As lymphoma (incidence, one in 100000 children) constituted the majority of the diagnoses, questions arise as to: (1), the probability of other centres having experienced and being presented in the future with similar problems (particularly bearing in mind that other oncologically predisposing radiosensitivity syndromes have not been not represented in our experience); and (2), the appropriateness, efficiency and applicability of predictive assays. Unambiguous cellular radiosensitivity would have been apparent from clonal assays on fibroblast cultures from all four cases prior to treatment, but such assays take 4-6 weeks to produce results. While estimates of chromosome damage or clonal assays on pre-treatment blood derived cells would be faster, there is a health economics issue as to the general applicability of such 'screening' assays.