Ionizing radiation therapy in dermatology

Treatment of Darier Disease with Radiation Therapy: Case Report and Literature Review

Darier's disease (DD) is an autosomal dominant genodermatosis characterized by hyperkeratotic papules, often accompanied by scaling and crusting. Managing DD presents significant challenges due to the absence of an effective cure, with only symptom targeting treatments currently available. This study presents a case of refractory DD that showed poor response to established pharmacological treatments but demonstrated improvement with low-dose superficial X-ray radiotherapy (SRT). The radiation was delivered as a single 200 cGy treatment, which visibly improved the condition. Considering the different degrees of side effects, sequelae, and risk of developing radiation-induced cancer after exposure to moderate levels of radiation, it may be considered that we attempt to treat recalcitrant DD initially by applying a low dose of radiation in order to mitigate these undesired side effects. If larger doses or additional courses are necessary due to inadequate response, the risks and benefits must be carefully evaluated and discussed with patients.

Electronic brachytherapy for treatment of non-melanoma skin cancers: clinical results and toxicities

Purpose

Although surgical approaches are standard for most non-melanomatous skin cancers, some patients are not candidates due to medical co-morbidities or functional or cosmetic or lesion location. High-dose-rate electronic brachytherapy (HDR-EBT) may be an alternative treatment modality.

Material and methods

A retrospective chart review was conducted from April 2011 to April 2013. All lesions were pathologically confirmed as malignant basal cell or squamous cell carcinoma. A HDR-EBT system delivered a median biological equivalent dose of 50 Gy total to a depth of 0.1-0.5 cm using various sizes of applicators. Treatment feasibility, acute and late toxicity, cosmetic outcomes, and local recurrence were assessed.

Results

Thirty-three patients with a mean age of 76 years with 50 cutaneous lesions were treated. Locations included 17 extremity lesions and 33 head and neck lesions. After treatments, acute grade 3 moist desquamation developed in 9 of the lesions (18%). Acute grade 4 ulceration developed in 3 lesions in the lower extremity (6%) and 1 upper lip lesion (2%). These toxicities were improved after a median of 20 days. Amongst the 4 lesions with grade 4 toxicities, a greater proportion were in lower extremity lesions compared to head and neck lesions (75% vs. 25%). There was no difference in the rate of grade 3 and 4 toxicities between patients aged ≤ 75 years and aged > 75 years (p = 0.082). With a mean long-term follow-up of 45.6 months, there was 1 local recurrence treated with surgery and no reported late toxicities.

Conclusions

Our experience with HDR-EBT for non-melanomatous skin cancers is encouraging in terms of efficacy and convenience for patients. Our long-term follow-up shows a good response in all treated sites. Caution should be used for extremity sites, and more fractionated regimens should be considered to avoid severe acute toxicities.

Few X-ray and PUVA treatments accelerate photocarcinogenesis in hairless mice

PUVA is a treatment that combines oral methoxypsoralen (8-MOP) with ultraviolet radiation A (UVA). It is used for severe psoriasis and the early stages of T-cell lymphoma. X-rays are an effective treatment for skin cancers. Both treatments are in higher doses used to treat skin malignancies and simultaneously increase the risk of keratinocyte cancer. The main objective of this study was to test whether a few PUVA or X-ray treatments could delay the development of ultraviolet radiation (UVR)-induced skin tumors in a well-established hairless mouse model. Three groups of immunocompetent mice (total, N = 75) were included in the study. All groups were UVR-exposed during the study period. In addition, one group was treated with PUVA and another group was treated with X-rays at days 45, 52, 90 and 97. A control group was treated with UVR only. We recorded when the first, second and third skin tumors were induced in each mouse. Skin tumors developed significantly earlier in both the PUVA and X-ray groups (median, 188 days) than in the control mice (median, 215 days; p < 0.001). Therefore, a few X-ray and PUVA treatments both significantly accelerated the development of skin tumors in hairless mice, compared to UVR controls. Neither treatment showed a delay of UVR-induced skin tumors and caution should be exercised before applying these treatments to sun-damaged skin.

Dermatologic Sequelae Associated with Radiation Therapy

Radiation therapy is a mainstay for the treatment of primary malignancies and metastatic disease and is associated with several dermatological adverse events that are underreported in the literature. The objective of this paper was to review the literature regarding cutaneous manifestations associated with radiation therapy in order to promote awareness of the cutaneous radiation therapy-associated adverse effects. This extensive literature review was performed using the Pubmed and Embase databases. Studies were reviewed for relevance and critical evidence pertaining to cutaneous manifestations of radiation therapy. The most commonly reported cutaneous sequelae associated with radiation therapy include radiation dermatitis, non-melanoma skin cancer, radiation-associated angiosarcoma, morphea, bullous pemphigoid, lymphangioma circumscriptum, and pseudosclerodermatous panniculitis. For many of these conditions, only case reports or case series exist and there is an absence of large-scale cohort studies. Despite these limitations, this review describes the wide range of dermatological adverse events associated with radiation therapy.

Preclinical quantitative in-vivo assessment of skin tissue vascularity in radiation-induced fibrosis with optical coherence tomography

Radiation therapy (RT) is widely and effectively used for cancer treatment but can also cause deleterious side effects, such as a late-toxicity complication called radiation-induced fibrosis (RIF). Accurate diagnosis of RIF requires analysis of histological sections to assess extracellular matrix infiltration. This is invasive, prone to sampling limitations, and thus rarely used; instead, current practice relies on subjective clinical surrogates, including visual observation, palpation, and patient symptomatology questionnaires. This preclinical study demonstrates that functional optical coherence tomography (OCT) is a useful tool for objective noninvasive in-vivo assessment and quantification of fibrosis-associated microvascular changes in tissue. Data were collected from murine hind limbs 6 months after 40-Gy single-dose irradiation and compared with nonirradiated contralateral tissues of the same animals. OCT-derived vascular density and average vessel diameter metrics were compared to quantitative vascular analysis of stained histological slides. Results indicate that RIF manifests significant microvascular changes at this time point posttreatment. Abnormal microvascular changes visualized by OCT in this preclinical setting suggest the potential of this label-free high-resolution noninvasive functional imaging methodology for RIF diagnosis and assessment in the context of clinical RT.

Orthovoltage X-rays for Postoperative Treatment of Resected Basal Cell Carcinoma in the Head and Neck Area

Background:

Surgery is the golden standard for treating basal cell carcinomas. In case of positive tumor margins or recurrent disease, postoperative adjuvant or salvaging therapy is suggested to achieve good local control.

Objective:

To retrospectively report on local control and toxicity of postoperative radiotherapy by means of orthovoltage X-rays for residual or recurrent basal cell carcinoma after surgery in the head and neck area.

Methods:

Sixty-six surgically resected residual or recurrent basal cell carcinomas of the head and neck region were irradiated postoperatively by means of orthovoltage X-rays at the Netherlands Cancer Institute between January 2000 and February 2015.

Results:

After a median follow-up duration of 30.5 months, only 5 recurrences were reported. The 5-year local control rates at 1, 3, and 5 years were 100%, 87%, and 87%, respectively. The 5-year local control rate was 92% for immediate postoperative radiotherapy of incompletely resected basal cell carcinomas, 90% for recurrences after 1 previously performed excision, and 71% for multiple recurrences, namely, a history of more than 1 excision ( P = .437). Acute toxicity healed spontaneously within 3 months. Late toxicities were mild.

Conclusion:

Radiotherapy by means of orthovoltage X-ray is an excellent alternative for re-excision in case of incompletely resected or recurrent basal cell carcinomas that are at risk of serious functional and cosmetic impairments after re-excision, with a 5-year local control rate of 87% and a low toxicity profile.

Head and Neck Non-Melanoma Skin Cancer Treated By Superficial X-Ray Therapy: An Analysis of 1021 Cases

INTRODUCTION

To report a single-institutional experience with the use of Superficial X-Ray Therapy (SXRT) for head and neck non-melanoma skin cancer (N-MSC) and to compare outcomes by prescribed fractionation schedules.

MATERIALS AND METHODS

The medical records of 597 patients with 1021 lesions (720 BCC, 242 SCC, 59 SCC in situ) treated with kilovoltage radiation from 1979-2013 were retrospectively reviewed. The majority of patients were treated according to 1 of 3 institutional protocols based on the discretion of the radiation oncologist: 1) 22 x 2.5 Gy; 2) 20 x 2.5 Gy; 3) 30 x 2.0 Gy. "T" stage at first presentation was as follows: Tis (59); T1 (765); T2 (175); T3 (6), T4 (9); Tx, (7). All patients were clinical N0 and M0 at presentation. Chi-square test was used to evaluate any potential association between variables. The Kaplan-Meier method was used to analyze survival with the Log Rank test used for comparison. A Cox Regression analysis was performed for multivariate analysis.

RESULTS

The median follow up was 44 months. No significant difference was observed among the 3 prescribed fractionation schemes (p = 0.78) in terms of RTOG toxicity. There were no failures among SCC in situ, 37 local failures (23 BCC, 14 SCC), 5 regional failures (all SCC) and 2 distant failures (both SCC). For BCC, the 5-year LC was 96% and the 10-year LC was 94%. For SCC the corresponding rates of local control were 92% and 87%, respectively (p = 0.03). The use of >2.0 Gy daily was significantly associated with improved LC on multivariate analysis (HR: 0.17; CI 95%: 0.05-0.59).

CONCLUSION

SXRT for N-MSC of the head and neck is well tolerated, achieves excellent local control, and should continue to be recommended in the management of this disease. Fractionation schedules using >2.0 Gy daily appear to be associated with improved LC.

Novel application of high-dose rate brachytherapy for severe, recalcitrant palmoplantar pustulosis

Palmoplantar pustulosis (PPP) is a chronic pustular dermatitis of the palms and soles, which is frequently associated with significant pruritus and pain, often limiting daily activities. We present the case of a 36-year-old man with severe PPP who had treatment failure with multiple medical therapies but showed marked improvement with high-dose rate brachytherapy. Brachytherapy has the advantage of providing a conformal dose distribution over complex curved surfaces, such as the foot and ankle. Our observations suggest that brachytherapy may be a well-tolerated treatment option for patients with severe, refractory PPP.

Orthovoltage for basal cell carcinoma of the head and neck: Excellent local control and low toxicity profile

OBJECTIVES/HYPOTHESIS

Evaluation of treatment results of orthovoltage X-rays for a selection of previously untreated favorable basal cell carcinomas (BCC) in the head and neck area concerning local control, cosmetic and functional outcome, and toxicity profile.

METHODS

A consecutive series of patients with primarily treated BCCs who were irradiated by means of orthovoltage X-rays in the Netherlands Cancer Institute in Amsterdam between January 2000 and February 2015 were retrospectively evaluated.

RESULTS

Two hundred fifty-three BCCs in 232 patients were primarily treated with orthovoltage X-rays. The local control rates at 1, 3, and 5 years for this selection of basal cell carcinomas were 98.9%, 97.5%, and 96.3%, respectively. Tumor size was the only significant predictor for local control because BCCs < 20 mm had a significantly higher 5-year local control rate than lesions ≥ 20 mm (96.8% vs. 89.4%, P = 0.041). Acute toxicity healed spontaneously without medical intervention, and late toxicity rates were low. Functional impairments were negligible, and the cosmetic outcome was excellent.

CONCLUSION

Orthovoltage therapy for well-selected favorable BCCs in the head and neck area resulted in excellent local control rates, a low toxicity profile, and apparently satisfactory functional and cosmetic outcomes. Orthovoltage irradiation is a good alternative for surgery for BCCs with favorable histologic prognosis at locations that are at risk for postoperative functional or cosmetic changes, such as the nose or canthus.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1796-1802, 2016.

Commissioning a 50-100 kV X-ray unit for skin cancer treatment

This study provides the authors' experience along with dosimetric data from the commissioning of two Sensus SRT‐100 50‐100 kV X‐ray units. Data collected during the commissioning process included: a) HVL, b) output (dose rate), c) applicator cone factors, and d) percentage depth dose. A Farmer‐type chamber (PTW‐N23333), and a thin‐window parallel plate ion chamber (PTW‐N23342) were used for dose rate measurements and dose profiles were measured with EBT3 GafChromic film. The average HVL values for 50, 70, and 100 kV of the two treatment units were found to be 0.52, 1.15, and 2.20 mm Al, respectively. The HVL's were 5%–9% lower when measured with the Farmer chamber, as compared to measurements with the parallel plate chamber, for energies of 70 and 100 kV. Dose rates were also measured to be 3%–4% lower with the Farmer chamber. The dose rate variation between the two units was found to be 2%–9% for 50, 70, and 100 kV. The dose uniformity over a circle of 2 cm diameter was within 4% in four cardinal directions; however, the dose profiles for the 5 cm applicator were nonuniform, especially in the cathode–anode direction. Measurements indicated as much as 15% lower dose for the 50 kV beam at field edge on the anode side, when normalized to the center. The crossline profile was relatively more symmetric, with a maximum deviation of 10% at the field edge. All ion chamber readings agreed with film measurements within 3%. The nonuniform profile produced by these units may introduce uncertainty in dose rate measurements, especially for larger applicators. Since there is no intrinsic tool (crosshair or field light) for alignment with the beam axis, the user should take care when positioning the chamber for output measurements. The data obtained with a Farmer‐type chamber should be used cautiously and as a reference only for the SRT‐100 X‐ray treatment unit.

PACS number: 87.53.Bn

Grenz ray treatment of lentigo maligna and early lentigo maligna melanoma

BACKGROUND

Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM). A wide variety of modalities has been used to manage LM, including conventional surgery, staged excision, Mohs micrographic surgery, cryotherapy, radiotherapy, laser therapy, and, recently, imiquimod.

OBJECTIVES

Soft x-radiation is an accepted treatment for LM/LMM. The aim of the present study was to evaluate the efficacy and safety of ultra-soft x-ray/grenz-ray (GR) treatment in patients with LM and early LMM.

METHODS

Five hundred ninety-three patients were treated with GR (primary therapy, n = 350; partial excision followed by GR, n = 71; radical excision followed by GR as recurrence-prophylactic treatment, n = 172) at the Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden between 1990 and 2009. The treatment was given twice a week over 3 consecutive weeks in total doses of 100 to 160 Gy. Dosage depended on the stage of LM and the depth of periadnexal atypical melanocytic extension in histologically examined materials before treatment. Four hundred twenty-five patients have been followed up for at least 2 years; of these, 241 for 5 years.

RESULTS

Overall, 520 of 593 patients (88%) showed complete clearance after one fractionated treatment. Residual lesions were seen in 15 patients, and 58 relapsed, 53 of whom (72%) within 2 years.

LIMITATION

Woods light examination was not used in the clinical diagnosis of lentigo maligna.

CONCLUSIONS

GR is an efficient and safe treatment in LM and early LMM when administered according to the recommendations presented herein. Moreover, GR offers an excellent cosmetic result.

Radiation-induced mast cell mediators differentially modulate chemokine release from dermal fibroblasts

BACKGROUND

Ionizing radiation has been demonstrated to result in degranulation of dermal mast cells. Chemokines are thought to play a crucial role in the early phase of the cutaneous radiation reaction. In human skin, mast cells are located in close proximity to dermal fibroblasts, which thus are a potential target for the action of mast cell mediators.

OBJECTIVE

In this study, we evaluated the effects of mast cell-derived histamine, serotonin, tumour necrosis factor (TNF)-α and tryptase on chemokine release from dermal fibroblasts.

METHODS

Human mast cells (HMC-1) were investigated for histamine release and cytokine production after ionizing radiation using enzyme-linked immunosorbent assay (ELISA) and flow cytometry. Receptor expression on human fetal foreskin fibroblasts (HFFF2) and human adult skin fibroblasts (HDFa) was examined by flow cytometry. Chemokine mRNA and protein expression were analyzed by gene array and ELISA, respectively.

RESULTS

Ionizing radiation significantly increased histamine release and cytokine expression by HMC-1 cells. Receptors for histamine, serotonin, TNF-α and tryptase were detected both in HFFF2 and in HDFa cells. Dermal fibroblasts constitutively expressed distinct sets of chemokine mRNA. Mast cell mediators differentially affected the release of chemokines CCL8, CCL13, CXCL4 and CXCL6 by fibroblasts.

CONCLUSIONS

Our data suggest that radiation-induced mast cell mediators have a tremendous impact on inflammatory cell recruitment into irradiated skin. We postulate the activation of mast cells to be an initial key event in the cutaneous radiation reaction, which might offer promising targets for treatment of both normal tissue side effects in radiation therapy and radiation injuries.

Basal cell carcinoma over chest wall (sternum) treated with dufourmentel flap: report of a case with review of literature

Basal cell carcinoma (BCC) is the most common malignancy of the skin, accounting for approximately 70–80% of all cutaneous cancers. The commonest site of basal cell carcinoma is the face; 80% arise above a line from the corner of the mouth to the ear lobe. The lifetime ultraviolet radiation damage is the most important factor in its pathogenesis, and the vast majority is observed on sun-exposed skin. BCCs can develop in sun-protected areas, but its occurrence is rare. Here we are reporting a case of rare site of BCC with review of literature in a 65-year-old male who presented with a lesion over anterior chest wall. A clinical diagnosis of BCC was made and patient was subjected to excision biopsy. Biopsy revealed it to be a BCC and it was treated with a Dufourmentel flap.

Eczematous dermatitis after vascular laser therapy: a report of two cases

Eczematous dermatitis was found in two port wine stain (PWS) lesions in two different individuals following variable pulsed 532-nm laser therapy. Both of the individuals described in this report had received low-dose superficial X-ray several years prior to the development of the eczematous dermatitis. The eczematous dermatitis in the PWS lesions was characterized by oozing, crusting, and pruritus, which showed a tendency to expand to other sites when exacerbated. Treatment with topical corticosteroid ointments produced some temporary improvement, but the dermatitis in both cases recurred when the topical medications were stopped. The mechanism of action for the development of an eczematous dermatitis in a PWS remains unclear, but may be related to multiple factors including abnormal hemodynamic forces resulting from the malformed vessels, an abnormal production of cytokines, local pathophysiological and immunological changes resulting from either the X-ray therapy or the laser therapy, and atopic constitution inherent in these individuals. These hypotheses and ideas need further study for additional insight into this rare, but reported adverse event.

Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: our experience in 671 lesions

BACKGROUND

The skin overlying the nose cartilage is a particularly frequent localization of skin carcinoma (about 25% of all carcinomas occurring on the head and neck). It is therefore of great practical interest to identify the best therapy, able to combine effectiveness with a good cosmetic and functional result.

OBJECTIVE

To verify both the therapeutic effectiveness of dermatologic radiotherapy and its 'toxicity' in the treatment of a large number of skin carcinomas overlying the cartilage of the nose.

METHODS

A retrospective study was done on 671 basal and squamous cell carcinomas treated by kilovoltage radiotherapy in the period 1972-2007.

RESULTS

The mean follow-up time was 38.016 months (range, 1-351 months). The 5-year cure rate was 88.09%. Cosmetic results were evaluated as 'good' or 'acceptable' in 96.84% of the treated lesions in complete remission. So far, no complication or sequelae to the radiologic treatment have been observed.

CONCLUSION

Dermatologic radiotherapy showed to be a safe, effective and non-invasive method, superior, on the basis of the literature data, to any other available therapeutic modality in the management of basal and squamous cell skin carcinomas localized over the nasal cartilages.

Medical radiation exposure and breast cancer risk: findings from the Breast Cancer Family Registry

Moderate to high-dose radiotherapy is known to increase the risk of breast cancer. Uncertainties remain about the effects of low-dose chest X-rays, particularly in individuals at increased genetic risk. We analyzed case-control data from the Breast Cancer Family Registry. Self-reported data on therapeutic and diagnostic radiation exposures to the chest were available for 2,254 breast cancer cases and 3,431 controls (1,556 unaffected sisters and 1,875 unrelated population controls). We used unconditional logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (CI) associated with radiation exposure, after adjusting for age, study center, country of birth, and education. Increased risks for breast cancer were found for women who had radiotherapy for a previous cancer (OR=3.55, CI=1.47-8.54) and diagnostic chest X-rays for tuberculosis (OR=2.49, CI=1.82-3.40) or pneumonia (OR=2.19, CI=1.38-3.47). Risks were highest for women with a large number of exposures at a young age or exposed in earlier calendar years. There was no evidence of increased risk associated with other diagnostic chest X-rays (not including tuberculosis or pneumonia), both in women with and without indicators of increased genetic risk (i.e., diagnosed at age <40 years or family history of breast cancer). Given the widespread and increasing use of medical diagnostic radiation, continued surveillance of breast cancer risk is warranted, particularly in women at specific genetic risk, such as those carrying mutations in BRCA1 or BRCA2.

Increased breast cancer risk after radiotherapy for acne among women with skin cancer

BACKGROUND

Radiotherapy was commonly used to treat benign conditions, especially skin diseases, during the first half of the twentieth century. Previous studies have shown that radiotherapy for some of these conditions increases the risk of developing breast cancer. Although breast cancer associated with previous radiotherapy for acne has been reported, no statistically significant correlation has been established.

OBJECTIVE

The aim of this study was to determine whether radiotherapy for acne is a risk factor for subsequent development of breast cancer.

METHODS

A retrospective nested case-control study was conducted using the cohort of all patients referred for Mohs micrographic surgery to the senior author (R. G. B.) from 1978 to 2003. The case group consisted of 244 women who were skin cancer patients and who had received radiotherapy for acne. The control group consisted of 244 age-matched women skin cancer patients from the same records randomly selected within the initial Mohs micrographic surgery treatment year. Clinical data from both groups regarding cancer history and radiotherapy were extracted and statistically analyzed.

RESULTS

Women skin cancer patients who had received radiotherapy for acne have a prevalence of breast cancer of 15% compared with 6.6% in control women skin cancer patients, for an odds ratio (OR) of 2.5 (P = .0033; 95% confidence interval, 1.3-4.6). Increased prevalence is correlated with age at treatment younger than 20 years (age-adjusted OR, 2.9; age-adjusted P = .002), treatment sessions numbering 5 or more (age-adjusted OR, 3.5; age-adjusted P = .005), and treatment year occurring before 1950 (age-adjusted OR, 2.9; age-adjusted P = .00013).

LIMITATIONS

The data used are based primarily on patient history and physical examinations and are therefore limited by the accuracy of the patient and the caregiver.

CONCLUSION

Women with skin cancer exposed to previous radiotherapy for acne are significantly more likely to develop breast cancer than their age-matched controls with skin cancer. Therefore all women previously treated for acne with radiotherapy should be identified and closely monitored for subsequent breast cancer development.

Office-based radiation therapy for cutaneous carcinoma: Evaluation of 710 treatments

Skin cancers are the most common malignancies and, historically, ionizing radiation has played an important role in their treatment. However, less experienced dermatologists generally consider radiation last in the line of therapeutic options. The authors sought to evaluate the effectiveness and safety of office-based elective radiation therapy for cutaneous carcinoma. A retrospective study of 604 basal cell carcinomas (BCCs) and 106 squamous cell carcinomas (SCCs) irradiated between 1971-96 was performed. The percentage of patients who developed tumor recurrence during the follow-up period was calculated using Kaplan-Meier survival curves. Cox's proportional model was used to assess the prognostic factors that might have influenced the recurrences. The recurrence rates for BCC and SCC were 11.5 and 16.5 per 1000 patient-years, respectively. The 5-year cure rates were 94.4% for BCC and 92.7% for SCC, and the 15-year cure rates were 84.8% and 78.6%, respectively. Tumor location on the nasolabial fold (OR 4.4; 95% IC, 1.3-14.7) and tumor size > or = 10 mm (OR 2.14; 95% IC, 1.03-4.45) were independent predictors of BCC recurrence. This study suggested that radiation therapy is an effective treatment for BCC and SCC and should be considered as a first option in many cases.

Intercellular adhesion molecule-1: a consistent inflammatory marker of the cutaneous radiation reaction both in vitro and in vivo

BACKGROUND

Radiation damage to skin is a key diagnostic and prognostic parameter for patients accidentally exposed to radiation. Moreover, skin is a target organ for crucial side-effects of routine radiotherapy. The pathophysiology of the cutaneous radiation reaction is in many respects still unknown. The acute inflammatory radiation reaction of skin has been shown to involve alterations in cell-cell and cell-matrix interactions, which are mediated by cellular adhesion molecules.

OBJECTIVES

To evaluate the effect of ionizing radiation on intercellular adhesion molecule-1 (ICAM-1) expression in human skin cells.

METHODS

Dermal monolayer cells, a three-dimensional skin model and skin biopsies were investigated for ICAM-1 expression after ionizing radiation using flow cytometry, quantitative reverse transcription-polymerase chain reaction and immunohistochemistry. ICAM-1 expression in monolayer cells pretreated with protein kinase inhibitors and dexamethasone prior to irradiation was analysed by flow cytometry.

RESULTS

Using different sources of skin cells, we demonstrated a consistent upregulation of both ICAM-1 mRNA and protein expression by ionizing radiation. Blocking experiments revealed that tumour necrosis factor-alpha, another ICAM-1 inducer, does not account for the effect of radiation. Radiation-induced upregulation of ICAM-1 expression was significantly attenuated by inhibitors to protein kinase C, mitogen-activated protein (MAP) ERK kinase, p38 MAP kinase and phosphatidylinositol 3-kinase. The anti-inflammatory agent dexamethasone suppressed the effect of radiation on ICAM-1 expression, suggesting its usefulness to treat the cutaneous radiation reaction.

CONCLUSIONS

Our data suggest that ICAM-1 is a consistent inflammatory parameter of the cutaneous radiation reaction both in vitro and in vivo that might provide new therapeutic options for diagnosis and treatment of effects of radiation.

Aggressive basal cell carcinoma with invasion of the parotid gland, facial nerve, and temporal bone

Aggressive variants of basal cell carcinoma (BCC), such as infiltrating, morpheaform, and basosquamous types, are associated with invasion of underlying tissues and are often difficult to treat.1 BCCs located in embryonic fusion planes, such as the periauricular region, are thought to exhibit deep extension and, subsequently, high recurrence rates, although this theory has been challenged and remains controversial.2-4 Despite the known features of aggressive BCC, parotid gland invasion and temporal bone and facial nerve involvement are rarely reported occurrences. We describe two patients with morpheaform BCC in the periauricular region demonstrating direct invasion of the parotid gland and concomitant facial nerve involvement. These patients require complex surgical management, as highlighted in this report.

Cutaneous squamous cell carcinoma: a comprehensive clinicopathologic classification

Cutaneous squamous cell carcinoma (SCC) includes many subtypes with widely varying clinical behaviors, ranging from indolent to aggressive tumors with significant metastatic potential. However, the tendency for pathologists and clinicians alike is to refer to all squamoid neoplasms as generic SCC. No definitive, comprehensive clinicopathological system dividing cutaneous SCCs into categories based upon their aggressiveness has yet been promulgated. Therefore, we have proposed the following based upon the malignant potential of SCC variants, separating them into categories of low (< or = 2% metastatic rate), intermediate (3-10%), high (greater than 10%), and indeterminate behavior. Low-risk SCCs include SCC arising in actinic keratosis, HPV-associated SCC, tricholemmal carcinoma, and spindle cell SCC (unassociated with radiation). Intermediate-risk SCCs include adenoid (acantholytic) SCC, intraepidermal epithelioma with invasion, and lymphoepithelioma-like carcinoma of the skin. High-risk subtypes include de novo SCC, SCC arising in association with predisposing factors (radiation, burn scars, and immunosuppression), invasive Bowen's disease, adenosquamous carcinoma, and malignant proliferating pilar tumors. The indeterminate category includes signet ring cell SCC, follicular SCC, papillary SCC, SCC arising in adnexal cysts, squamoid eccrine ductal carcinoma, and clear-cell SCC. Subclassification of SCC into these risk-based categories, along with enumeration of other factors including tumor size, differentiation, depth of invasion, and perineural invasion will provide prognostically relevant information and facilitate the most optimal treatment for patients.

Cutaneous squamous cell carcinoma: a comprehensive clinicopathologic classification. Part one

Cutaneous squamous cell carcinoma (SCC) includes many subtypes with widely varying clinical behaviors, ranging from indolent to aggressive tumors with significant metastatic potential. However, the tendency for pathologists and clinicians alike is to refer to all squamoid neoplasms as generic SCC. No definitive, comprehensive clinicopathological system dividing cutaneous SCCs into categories based upon their aggressiveness has yet been promulgated. Therefore, we have proposed the following based upon the malignant potential of SCC variants, separating them into categories of low (< or = 2% metastatic rate), intermediate (3-10%), high (greater than 10%), and indeterminate behavior. Low-risk SCCs include SCC arising in actinic keratosis, HPV-associated SCC, tricholemmal carcinoma, and spindle cell SCC (unassociated with radiation). Intermediate-risk SCCs include adenoid (acantholytic) SCC, intraepidermal epithelioma with invasion, and lymphoepithelioma-like carcinoma of the skin. High-risk subtypes include de novo SCC, SCC arising in association with predisposing factors (radiation, burn scars, and immunosuppression), invasive Bowen's disease, adenosquamous carcinoma, and malignant proliferating pilar tumors. The indeterminate category includes signet ring cell SCC, follicular SCC, papillary SCC, SCC arising in adnexal cysts, squamoid eccrine ductal carcinoma, and clear-cell SCC. Subclassification of SCC into these risk-based categories, along with enumeration of other factors including tumor size, differentiation, depth of invasion, and perineural invasion will provide prognostically relevant information and facilitate the most optimal treatment for patients.

Three-year retrospective review of superficial radiotherapy for skin conditions in a Perth radiotherapy unit

Western Australia has only two superficial radiotherapy units, one of which is located at Fremantle Hospital, and run by the radiation oncologists of Perth Radiation Oncology Centre. A 3-year retrospective review was undertaken of all patients who underwent treatment at this unit from 1999 to 2001. Patients were identified from the unit's log book, and data was collected from their files. For malignant skin conditions, 369 lesions were treated in 259 patients over the study period. The patients' median age was 76 years. A wide variety of conditions were treated, but the most common diagnoses were basal cell carcinoma (237 lesions) and squamous cell carcinoma (92 lesions), most commonly located in the head region. The most frequently used treatment schedule was 36 Gy in six fractions over a 3-week period. Where radiotherapy was administered as primary treatment, the diagnoses had been biopsy-proven in only 53% of cases. Fifty-four patients underwent treatment of benign skin disease over the study period; most commonly keloid scars (41 patients) followed by warts (six patients). We conclude that superficial radiotherapy has a distinct role in dermatology, particularly for skin carcinomas around the nose and eyes, which cannot presently be superseded by electron beam therapy.

Basal cell carcinoma of the lip treated with radiotherapy

Basal cell carcinoma (BCC) of the lip is uncommon relative to other cutaneous sites for BCC, such as the central face or scalp. A female predisposition and predilection for the upper lip have been previously documented. A retrospective analysis of patients treated for BCC of the lip was undertaken within the department of Radiation Oncology, Westmead Hospital, Sydney. Twenty patients were identified; 12 women and 8 men. The majority (15/20) had T1 lesions of the upper lip (17/20). Eleven patients were referred for radiotherapy alone and nine for adjuvant radiotherapy following either incomplete excision or local recurrence. With a mean follow up of 36 months no patient has recurred following either definitive or adjuvant radiotherapy. Despite the majority of BCCs of the lip being amenable to surgery fractionated external beam radiotherapy remains an option especially when functional and/or cosmetic concerns are an issue. We present the findings from this small case series and use our findings to illustrate the role of radiotherapy in treating BCC of the lip.

Er:YAG laser skin resurfacing

Recent advances in Er:YAG laser technology have dramatically enhanced the ability to resurface the skin safely. Selection of precise ablation and coagulation levels allows laser surgeons to modify these variables to fit the esthetic concerns of individual patients. These systems truly represent a viable alternative to conventional CO2 laser resurfacing.

Recognition and management of high-risk cutaneous tumors

The majority of cutaneous malignancies can be treated by the military dermatologist in a clinical setting. Recognition of tumors at high risk for recurrence or metastasis is important for any dermatologist but especially list care. Providing optimal care includes knowledge about which patients should be medavacced to larger medical centers for advanced surgical and medical treatments.

[Managing cutaneous melanoma]

Cutaneous melanoma represents the main cause of death among skin cancers. Early diagnosis gives, for the time being, the only possibility for high rate of curative treatment. Diagnosis is based on pathological findings, and at primary tumor stage. Breslow thickness of the lesion is the best prognostic index. At local stage of the disease, treatment is precisely codified by international recommendations and consensus conferences. Follow-up after surgical treatment is also well codified. Treatment of lymph node invasion or metastatic disease is, on the other hand, less codified. Despite recent advances, especially in immunotherapy, treatment of advanced stages of melanoma remains difficult.