Multiple nonmelanoma skin cancer in an exposed Australian population

Comparison of skin cancer risk between renal transplant recipients and patients with glomerular diseases in rural Queensland

INTROUDCTION

There is increased risk of skin cancer in patients with gloermular disease or those with renal transplant.

OBJECTIVES

To compare the risk of skin cancer between kidney recipients (KTRs) and patients with glomerular disease (GD).

DESIGN

The cohort comprised patients with KTRs (n = 61) and GD (n = 51) in Central and Central West Queensland, Australia. A quantitative cohort study was undertaken to study the risk of skin cancer in rural communities between two subgroups of patients with kidney diseases in relationship to immunosuppression. Statistical analyses of the differences in incidence of skin cancers between the two groups were done by chi-square test, Fisher's exact test, independent t-test and McNemar's test.

FINDINGS

KTRs with non-melanoma skin carcinoma (NMSC) increased significantly after treatment with immunosuppressants (pre-transplantation, n = 11 [18.0%], post-transplantation, n = 28 [45.9%]; p < 0.001). There were no differences in number of patients with NMSC observed in the GD group (pre-diagnosis, n = 6 [11.8%], post-diagnosis, n = 7 [13.7%]; p = 1.000). Compared to the risks at 1 year post-immunosuppressants, the incidence of NMSC of KTRs increased significantly at 3 years (20.3% vs. 35.4%, p < 0.001) and 5 years (20.3% vs. 62.2%, p < 0.001) post-immunosuppressants, whereas the increased incidence of NMSC was observed only at 5 years (2.1% vs. 11.8%, p = 0.012) in the GD cohort. The mean cumulative number of NMSC in KTRs increased significantly at 3 years (p = 0.011), and 5 years (p = 0.001) post-immunosuppressants, compared to the risks at 1 year post-immunosuppressants, however, no differences were noted in the GD cohort.

DISCUSSION

Immunosuppressants increased the risk of NMSC in KTRs. The increased risk is likely dependent on the intensity and duration of immunosuppressants.

CONCLUSION

In patients with a high risk of NMSC, reducing skin cancer risk should be considered in conjunction with the optimisation of treatment.

Protocol for an open randomised controlled trial investigating Fibrin Glue in Skin grafts for Skin cancer (FiGSS)

INTRODUCTION

Skin cancer is a common disease in the tropics, and oncological resection typically requires reconstruction with skin grafts. Fibrin glue, initially established as a haemostatic agent, has been studied extensively as an adhesive for skin grafts in burns. This study aims to investigate the use of fibrin as an adhesive for split skin grafts in skin cancers.

METHODS AND ANALYSIS

The study design is a prospective randomised controlled trial with the aim of investigating the impact of two different methods of split skin graft fixation. The intervention of fibrin glue will be compared with the control of staples or sutures. The trial will be conducted at two sites, a public hospital and a private hospital in Townsville, Australia, over a 24-month period with 334 participants to be recruited. Consecutive patients presenting for skin excisions and grafting will be eligible to participate in this study. Randomisation will be on the level of the patient. The primary outcome is graft take based on wound healing at 1 month. Secondary outcomes will be pain on dressing changes and operative time.

ETHICS AND DISSEMINATION

The study has been approved by The Townsville University Hospital Human Research Ethics Committee. Findings will be disseminated in conference presentations and journals and through online electronic media.

TRIAL REGISTRATION NUMBER

ACTRN12618000484246.

Prevalence of Squamous and Basal Cell Carcinomas in African Albino Skin Cancer Lesions: A Systematic Review and Meta-Analysis of Proportion

Objective

To estimate the prevalence of cutaneous SCC and BCC in all histologically confirmed skin cancer lesions in African albinos.The following five databases are as follows: African Journals Online (AJOL), PubMed, Europe PMC, and Google Scholar were searched for relevant articles. Study Selection: included studies were case series and cross-sectional studies of histologically confirmed skin cancers in African albinos. Data extraction and synthesis: data extraction and synthesis was informed by the meta-analysis of observational studies in epidemiology guideline. By random effect meta-analysis, we calculated the pooled prevalence of SCC and BCC in skin cancer lesions of the African albinos.

Result

We abstracted 695 skin cancer lesions from 540 African albinos (275 male and 241 female albinos with sex not stated in 24 subjects). There were 419 SCCs and 249 BCCs. By meta-analysis, the pooled prevalence of SCC is 64% (95% CI; 50–77%). The prevalence for BCC is 31% (95% CI; 19–45%).

Conclusion

Overall, squamous cell carcinoma is the predominant type of keratinocyte carcinoma reported in African albinos. SCC is preponderant in case series of surgical excision biopsies while BCC predominates in studies reporting on albino skin surveillance programmes.

Method of Assessing Skin Cancerization and KeratosesTM (MASCK™): development and photographic validation in multiple anatomical sites of a novel assessment tool intended for clinical evaluation of patients with extensive skin field cancerization

BACKGROUND

A range of 'field-directed' treatments is available for the management of extensive skin field cancerization (ESFC), but to date, the only validated objective quantitative tools are limited to assessment of actinic keratoses (AKs) affecting the head.

AIMS

To develop a versatile quantitative instrument for objective clinical assessment of ESFC and perform initial internal validation across multiple anatomical zones.

METHODS

The study comprised instrument development, pilot testing and instrument refinement and two rounds of reliability and inter-rater validation testing. The study was noninterventional and used a convenience sample of de-identified patient photographs selected based on preset criteria. An expert panel developed the instrument and scoring system via a modified Delphi voting process. A sample of 16 healthcare professionals from multiple specialties undertook the pilot testing, and a panel of seven dermatologists were involved in validation testing. Validation was determined by assessment of overall inter-rater agreement using Gwet chance-corrected agreement coefficients (ACs).

RESULTS

The instrument produced, called the Method for Assessing Skin Cancer and Keratoses™ (MASCK™), comprises the Skin Field Cancerization Index (SFCIndex), derived from area of skin involvement and AKs (number and thickness), a global assessment score and a cancer-in-zone score, and uses Likert scales for quantitative scoring. The SFCIndex is a composite score comprising the number and thickness of AKs multiplied by area of skin involvement. ACs for the SFCIndex components, the overall SFCIndex score and the global assessment score were > 0.80 (rated 'almost perfect') while the AC for the cancer-in-zone metric was lower (0.33, rated 'fair'). Internal consistency was demonstrated via positive correlation between the overall SFCIndex score and the global assessment score.

CONCLUSIONS

Our study found near-perfect agreement in inter-rater reliability when using MASCK to assess the severity of ESFC in multiple anatomical sites. Further validation of this novel instrument is planned to specifically assess its reliability, utility and feasibility in clinical practice.

The incidence and clinical analysis of non-melanoma skin cancer

Non-melanoma skin cancers (NMSCs) are the most common malignancies diagnosed in Caucasian populations. Basal cell carcinoma (BCC) is the most frequent skin cancer, followed by squamous cell carcinoma (SCC). Unfortunately, most European cancer registries do not record individual types of NMSC. To evaluate the incidence of primary BCCs and SCCs regarding age, sex, tumour site and tumour subtype to determine trends in epidemiology of both cancers. Retrospective analysis of BCCs and SCCs diagnosed and treated across seven sites in Poland from 1999 to 2019. We recorded 13,913 NMSCs occurring in 10,083 patients. BCC represented 85.2% of all cases. SCC patients were older than BCC patients (77.1 ± 11.3 years vs. 70.1 ± 12.3 years, p < 0.01). The nodular subtype was the most common subtype of BCC, followed by the superficial and infiltrative subtypes. The superficial BCC subtype was more common on photoprotected areas (p < 0.01), whereas the nodular BCC subtype occurred on the face (p < 0.01). The high-risk SCC subtypes were more common on face compared to low-risk SCC subtypes (p < 0.01). BCC and SCC are common malignancies developing at various ages and anatomical sites. These data underline the need for better registration policies regarding NMSC in order to improve prevention and treatment strategies for these tumours.

Narrative review of the epidemiology/biology of basal cell carcinoma: a need for public health consensus

Basal cell carcinoma (BCC) is the most common skin malignancy afflicting modern Australian society. The most influential response to rising BCC incidence rates has been through public health primary prevention campaigns (PPC) which have persevered since the 1980s. These campaigns are widely heralded a success but clinical data quantifying these benefits are limited due to an absence of legislation around BCC reporting. A non-systematic search of the literature was conducted identifying articles investigating the incidence and clinical characteristics of BCC over the past 40 years, as well as the economic viability of the PPC. There is robust evidence supporting stabilizing rates of BCC incidence in Australia. Similarly, multiple studies have shown the economic benefits of PPC through cost analysis. Anatomical and histological data are reported inconsistently, consequently limiting analysis of changes in BCC clinical characteristics. The consensus throughout the literature is that BCC is a significant public health issue that requires legislative reform. This narrative literature review serves to highlight the need for statutory changes around non-melanocytic skin cancer data collection to enable appropriate analysis and evaluation of current management strategies.

Primary cutaneous malignancies in nonalbino and albino Africans

BACKGROUND

The pigmented skin of black Africans has been credited with reduction in risk of skin cancer. African albinos have inherited defects in skin melanin deposition, which predisposes them to ultraviolet radiation-induced cutaneous carcinogenesis. We compared the manifestation of skin cancers between albino and nonalbino Africans aiming to describe the effect of pigmentation or lack of it on the epidemiological characteristics of skin cancer in Africans.

MATERIALS AND METHODS

Cutaneous malignancies seen in our institution over a 19-year period were analyzed using SPSS statistical software. Results were presented in tables of frequencies. Continuous variables were presented as mean with standard deviation and compared with independent sample t-test and ANOVA. Alpha level of <0.05 was considered significant.

RESULT

There were 86 albinos and 364 nonalbinos in the study. Mean age (SD) at presentation for albinos was 41 (14) years and for nonalbinos 52 (17) years. Albinos had most tumors in the head and neck region and upper extremities. For nonalbinos, lower extremities followed by anogenital region were the most common body site of cutaneous malignancy. Squamous cell carcinoma was the most common type of skin cancer in the albino and nonalbino patients. No case of malignant melanoma was diagnosed in the albino group.

CONCLUSION

Albino skin cancer patients were much younger than nonalbinos. Albinos and nonalbinos differ in body site distribution of skin cancers. Distribution of keratinocyte carcinomas in albinos parallels the reported findings in Caucasians. Albinos may have some level of protection from cutaneous melanoma in spite of hypomelanized skin.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the commonest cancer affecting white-skinned individuals, and worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs. First-line treatment is usually surgical excision, but alternatives are available. New published studies and the development of non-surgical treatments meant an update of our Cochrane Review (first published in 2003, and previously updated in 2007) was timely.

OBJECTIVES

To assess the effects of interventions for BCC in immunocompetent adults.

SEARCH METHODS

We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions for BCC in immunocompetent adults with histologically-proven, primary BCC. Eligible comparators were placebo, active treatment, other treatments, or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcome measures were recurrence at three years and five years (measured clinically) (we included recurrence data outside of these time points if there was no measurement at three or five years) and participant- and observer-rated good/excellent cosmetic outcome. Secondary outcomes included pain during and after treatment, early treatment failure within six months, and adverse effects (AEs). We used GRADE to assess evidence certainty for each outcome.

MAIN RESULTS

We included 52 RCTs (26 new) involving 6690 participants (median 89) in this update. All studies recruited from secondary care outpatient clinics. More males than females were included. Study duration ranged from six weeks to 10 years (average 13 months). Most studies (48/52) included only low-risk BCC (superficial (sBCC) and nodular (nBCC) histological subtypes). The majority of studies were at low or unclear risk of bias for most domains. Twenty-two studies were industry-funded: commercial sponsors conducted most of the studies assessing imiquimod, and just under half of the photodynamic therapy (PDT) studies. Overall, surgical interventions have the lowest recurrence rates. For high-risk facial BCC (high-risk histological subtype or located in the facial 'H-zone' or both), there may be slightly fewer recurrences with Mohs micrographic surgery (MMS) compared to surgical excision (SE) at three years (1.9% versus 2.9%, respectively) (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.16 to 2.64; 1 study, 331 participants; low-certainty evidence) and at five years (3.2% versus 5.2%, respectively) (RR 0.61, 95% CI 0.18 to 2.04; 1 study, 259 participants; low-certainty evidence). However, the 95% CI also includes the possibility of increased risk of recurrence and no difference between treatments. There may be little to no difference regarding improvement of cosmetic outcomes between MMS and SE, judged by participants and observers 18 months post-operatively (one study; low-certainty evidence); however, no raw data were available for this outcome. When comparing imiquimod and SE for nBCC or sBCC at low-risk sites, imiquimod probably results in more recurrences than SE at three years (16.4% versus 1.6%, respectively) (RR 10.30, 95% CI 3.22 to 32.94; 1 study, 401 participants; moderate-certainty evidence) and five years (17.5% versus 2.3%, respectively) (RR 7.73, 95% CI 2.81 to 21.3; 1 study, 383 participants; moderate-certainty evidence). There may be little to no difference in the number of participant-rated good/excellent cosmetic outcomes (RR 1.00, 95% CI 0.94 to 1.06; 1 study, 326 participants; low-certainty evidence). However, imiquimod may result in greater numbers of good/excellent cosmetic outcomes compared to SE when observer-rated (60.6% versus 35.6%, respectively) (RR 1.70, 95% CI 1.35 to 2.15; 1 study, 344 participants; low-certainty evidence). Both cosmetic outcomes were measured at three years. Based on one study of 347 participants with high- and low-risk primary BCC of the face, radiotherapy may result in more recurrences compared to SE under frozen section margin control at three years (5.2% versus 0%, respectively) (RR 19.11, 95% CI 1.12 to 325.78; low-certainty evidence) and at four years (6.4% versus 0.6%, respectively) (RR 11.06, 95% CI 1.44 to 84.77; low-certainty evidence). Radiotherapy probably results in a smaller number of good participant- (RR 0.76, 95% CI 0.63 to 0.91; 50.3% versus 66.1%, respectively) or observer-rated (RR 0.48, 95% CI 0.37 to 0.62; 28.9% versus 60.3%, respectively) good/excellent cosmetic outcomes compared to SE, when measured at four years, where dyspigmentation and telangiectasia can occur (both moderate-certainty evidence). Methyl-aminolevulinate (MAL)-PDT may result in more recurrences compared to SE at three years (36.4% versus 0%, respectively) (RR 26.47, 95% CI 1.63 to 429.92; 1 study; 68 participants with low-risk nBCC in the head and neck area; low-certainty evidence). There were no useable data for measurement at five years. MAL-PDT probably results in greater numbers of participant- (RR 1.18, 95% CI 1.09 to 1.27; 97.3% versus 82.5%) or observer-rated (RR 1.87, 95% CI 1.54 to 2.26; 87.1% versus 46.6%) good/excellent cosmetic outcomes at one year compared to SE (2 studies, 309 participants with low-risk nBCC and sBCC; moderate-certainty evidence). Based on moderate-certainty evidence (single low-risk sBCC), imiquimod probably results in fewer recurrences at three years compared to MAL-PDT (22.8% versus 51.6%, respectively) (RR 0.44, 95% CI 0.32 to 0.62; 277 participants) and five years (28.6% versus 68.6%, respectively) (RR 0.42, 95% CI 0.31 to 0.57; 228 participants). There is probably little to no difference in numbers of observer-rated good/excellent cosmetic outcomes at one year (RR 0.98, 95% CI 0.84 to 1.16; 370 participants). Participant-rated cosmetic outcomes were not measured for this comparison. AEs with surgical interventions include wound infections, graft necrosis and post-operative bleeding. Local AEs such as itching, weeping, pain and redness occur frequently with non-surgical interventions. Treatment-related AEs resulting in study modification or withdrawal occurred with imiquimod and MAL-PDT.

AUTHORS' CONCLUSIONS

Surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with MMS over SE for high-risk facial primary BCC (low-certainty evidence). Non-surgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior. Of the non-surgical treatments, imiquimod has the best evidence to support its efficacy. Overall, evidence certainty was low to moderate. Priorities for future research include core outcome measures and studies with longer-term follow-up.

Histopathological discrepancy between biopsy and Mohs micrographic surgery in keratinocyte carcinoma: A 464 case series in an Australian population

BACKGROUND/OBJECTIVES

Therapeutic approaches to keratinocyte carcinoma rely on the accuracy of the biopsy to correctly identify, grade or subtype the tumour. Several studies have investigated the frequency and nature of histopathological discordance between the biopsy and final excision specimen. We analysed information extracted from an Australian Mohs micrographic surgery (MMS) database and compared similar studies.

METHODS

An Australian MMS database was retrospectively reviewed for a period of one year. Correlation was made between the preoperative lesion diagnosis based on the formal pathology report and the histopathological results reported at the time of MMS. A systematic PubMed review of similar articles was also performed.

RESULTS

A total of 464 cancers (406 BCC and 58 SCC) in 399 patients were included. The overall discrepancy rate in the histopathological classification of keratinocyte carcinoma in our study (42.2%) and the proportion of cases in which the biopsy underestimated the aggressiveness of the tumour (12.9%) were consistent with those found in similar studies. The percentage of biopsies that failed to identify an aggressive BCC subtype (31.6%), and that of biopsy-proven superficial BCC that demonstrated an invasive component in MMS (79.3%), were higher in our study than in comparable studies. The high prevalence of mixed histopathological subtypes, especially amongst BCC with discordant histopathological results, appeared as an important contributing factor.

CONCLUSIONS

Despite subtle differences, the results from this Australian study support the results from similar studies and highlight that the biopsy report should be carefully interpreted in combination with the clinical findings.

Development of Multiple-Lesion Basal Cell Carcinoma of the Skin: A Comprehensive Review

An interesting clinical feature of basal cell carcinoma (BCC) of the skin is a marked variation in tumor number, sites, and accrual. Some individuals develop only a single BCC lesion with no impact on health status, while a significant proportion is affected repeatedly with new primary tumors at various body sites. Approximately 29% of patients with a first BCC will develop at least 1 more lesion during their lifetime. The candidate predictors for multiple BCC development include younger age and a superficial BCC subtype at the time of the first diagnosis, red hair phenotype, initial or frequent tumor location on the trunk or on the upper limbs, and male gender. The pathogenesis of multiple BCC development does not seem to be related to greater UVR exposure. Individual genetic susceptibility may have a greater impact than extrinsic factors. In clinical practice, it is meaningful to estimate the probability of new BCC development in patients who have an initial lesion. A reliable prediction model for individualized risk stratification remains a subject of continued research; however, a focus on the risk factor profile is beneficial for clinical screening and may help clinicians to determine the individuals who should be followed up more closely.

Nanomedicines to Treat Skin Pathologies with Natural Molecules

The skin and mucous membranes are subjected to many disorders and pathological conditions. Nature offers a wide range of molecules with antioxidant activity able to neutralize, at least in part, the formation of free radicals and therefore to counteract the phenomena of cellular aging. Since synthetic drugs for the treatment of skin diseases can induce resistance, it is particularly interesting to use compounds of plant origin, transporting them in pharmaceutical forms capable of controlling their release and absorption. This review provides an overview of new findings about the use of lipid-based nanosystems for the delivery of natural molecules useful on the topical treatment of skin disorders. Several natural molecules encapsulated in lipid nanosystems have been considered in the treatment of some skin pathologies or diseases. Particularly, the use of rosemary and eucalyptus essential oil, saffron derivatives, curcumin, eugenol, capsaicin, thymol and lycopene has been reported. The molecules have been alternatively encapsulated in viscous systems, such as the organogels, or in liquid systems, such as ethosomes, transferosomes, solid lipid nanoparticles and monoolein based dispersions thickened by inclusion in carbomer gels. The nanostructured forms have been in vitro and in vivo investigated for the treatment of skin disorders due to dehydration, inflammation, melanoma, wound healing, fungal infections or psoriasis. The data reported in the different studies have suggested that the cutaneous application of lipid nanosystems allows a deep interaction between lipid matrix and skin strata, promoting a prolonged release and efficacy of the loaded natural molecules. This review suggests that the application of natural molecules onto the skin by lipid-based nanosystems can provide numerous clinician benefits in dermatology and cosmetics.

Current Role of Radiotherapy in Non-melanoma Skin Cancer

Non-melanoma skin cancer (NMSC) represents the most frequently diagnosed malignancy worldwide, most being cutaneous basal cell and squamous cell carcinoma. The global incidence of NMSC continues to increase as the global population ages. Numerous treatment options are available for NMSC patients, with radiotherapy an efficacious and tissue-preserving non-surgical option. External beam radiotherapy and brachytherapy are modalities with specific indications and advantages in treating NMSC. Where excision is not an option (medically/technically inoperable) or considered less ideal (e.g. cosmetic or functional outcome), radiotherapy offers an excellent alternative. Inoperable elderly and/or co-morbid patients of poor performance status can benefit from short-course hypofractionated radiotherapy, with very acceptable toxicity. Adjuvant radiotherapy in patients with unfavourable pathology can decrease the risk of local and regional recurrence and associated morbidity and mortality. Radiotherapy has advantages and disadvantages and it is important for clinicians to understand these. Managing patients with NMSC is carried out by clinicians from multiple disciplines but it is imperative that they are all aware of the role of radiotherapy in their patients in various clinical settings. Here we aim to discuss the role and indications for recommending radiotherapy in patients with NMSC.

Efficacy of hypofractionated radiotherapy in patients with non-melanoma skin cancer: Results of a systematic review

Radiation oncologists are increasingly tasked with the management of elderly patients with non-melanoma skin cancer, unsuitable for surgical intervention due to inoperable lesions and/or poor performance status. In this cohort, hypofractionated radiotherapy, delivered either daily, alternative daily or once weekly is highly effective. A systematic literature search was conducted of PUBMED, MEDLINE and EMBASE databases using the algorithm ('radiotherapy' OR 'radiation therapy' OR 'brachytherapy') AND ('hypofraction' OR 'hypofractionated' OR 'hypofractionation') AND ('skin neoplasms' OR 'carcinoma' OR 'malignancy') AND ('skin' OR 'epidermis' OR 'epidermal' OR 'cutaneous'). Forty relevant publications (1983-2017) encompassing 12,337 irradiated lesions were retrieved. Studies documented a mean age of 71.73 years and male predilection (54.5%). Both external beam radiotherapy and brachytherapy were utilized. Tumour subtype was squamous cell carcinoma (23.5%), basal cell carcinoma (75.2%) or others (1.3%). Irradiated lesions were primary (or denovo) (92.6%), located on the head and neck (95.7%) and received definitive therapy (96.5%). Analysis demonstrated a mean weighted total radiotherapy dose (38.15 Gy), dose per fraction (7.95 Gy) and treatments per week (2.98). Despite significant heterogeneity in the study population, the radiotherapy delivered and follow-up, local recurrence rate (crude or Kaplan-Meier analysis) did not exceed 7.9% in all but three of the 36 publications providing these data. Twenty-nine publications documented local control exceeding 90%. There is a body of evidence documenting the efficacy of hypofractionated radiotherapy as an option that confers no obvious disadvantage in local control when compared to traditional more protracted radiotherapy schedules.

Defect Reconstruction of the Nose After Surgery for Nonmelanoma Skin Cancer: Our Clinical Experience

Objective

This study aimed to investigate reconstruction methods according to nasal subunits in patients who were surgically treated with diagnosis of non-melanoma skin cancer of the nose.

Methods

All patients were retrospectively investigated. This study was conducted between April 2004 and December 2010; 180 patients who were surgically treated with diagnoses of skin basal cell carcinoma, squamous cell carcinoma, cancer of skin appendages, and precancerous lesions and 194 lesions were included. The types of repair performed were divided into seven main groups: Secondary healing, primary closure, skin graft, local flap, auricular composite graft, subtotal reconstruction and prosthesis application.

Results

Among the 180 patients, 110 (61.1%) were males and 70 (38.9%) were females. The mean duration of follow-up was 39.8 (range, 32-81) months. Repair was by a local flap, a primary suture, a skin graft, and an auricular composite graft in 133, 16, 38, and 2 defects, respectively. Four defects were left for secondary healing. A prosthesis was applied to one patient. Totally, 194 defects were treated by surgery.

Conclusion

Although nonsurgical treatment options such as radiotherapy or cryotherapy may be effectively used, surgery is the main treatment option for cancer of the nasal skin. Nasal subunits have distinct characteristics; thus, optimal reconstruction should be preferred for each subunit. The objective of the reconstruction is not only closing the defect. Closing the defect appropriately with the optimal flap and in proper with the aesthetic subunits is the most important point in reconstruction of the nose.

Incidence of Nonmelanoma Skin Cancer in New Brunswick, Canada, 1992 to 2001

Background:

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), collectively referred to as nonmelanoma skin cancer (NMSC), cause significant morbidity and generate a substantial cost to the health care system. Canadian data on the incidence of NMSC are lacking.

Objective:

To study the incidence and characteristics of NMSC in New Brunswick, Canada (population 729,498 people in 2001), by using the Provincial Cancer Registry.

Method:

Data were obtained from 1992 to 2001 from the New Brunswick Provincial Cancer Registry, to which reporting of all cancers is mandatory. Multiple tumors of a given histologic type are recorded only once in the registry per individual per lifetime. A descriptive analysis of incidence rates of BCC and invasive SCC of the skin was performed in relation to gender, age, and anatomic location. The main outcome measures were the age- and sex-specific incidence rates of BCC and SCC. Age standardization was performed using the Canadian, US, and world standard populations.

Results:

When adjusted to the world standard population, the age-standardized incidence rates (ASIRs) per 100,000 population for BCC from 1992 through 2001 were 87 for males and 68 for females. For invasive SCC, the ASIRs per 100,000 population were 34 for males and 16 for females. There was an increasing incidence trend for both BCC and invasive SCC over the 10-year study period, with minimal change in the incidence of SCC in women. The overall ratio of BCC to invasive SCC in the population was 2.8 to 1. The approximate lifetime probabilities of developing BCC and invasive SCC were 13% and 5%, respectively.

Conclusions:

The incidence of NMSC in the province of New Brunswick is similar to that reported from 1973 through 1987 in the province of British Columbia, higher than those reported in most parts of Europe, and lower than all published rates in the United States and Australia. Owing to the inability of the registry to account for tumor multiplicity, the actual annual number of all NMSC lesions in this population is likely much higher.

Validating the use of Medicare Australia billing data to examine trends in skin cancer

Background:  Epidemiological data surrounding non-melanomatous skin cancer (NMSC) is highly variable, in part due to the lack of government cancer registries. Several studies employ the use of Medical Australia (MA) rebate data in assessing such trends, the validity of which has not been studied in the past. Conversely, melanoma skin cancer is a notifiable disease, and thus, MA and cancer registry data is readily available. The aim of the current study is to assess the use of MA for epidemiological measures for skin cancers, by using melanoma as a disease sample.

Methods:  Following ethics approval, data from MA and Victorian Cancer Registry (VCR) from 2004-2008 were extracted. Incidence of MA and VCR unique melanoma cases were compared and stratified by age and local government area (LGA). Regression and a paired-samples t-test were performed.

Results: During the study period; 15,150 and 13,886 unique melanoma patients were identified through VCR and MA data sources respectively. An outlier in the >80­ year age group was noted between MA and VCR data. When stratified by age, significant correlation between MA and VCR was observed for all patients (gradient 0.91, R²= 0.936) and following exclusion of >80 patients (gradient 0.96, R²= 0.995). When stratified by LGA, a high degree of observation was observed for all patients (gradient 0.94, R²= 0.977) and following exclusion of >80 patients (gradient 0.996, R²= 0.975).

Conclusion: Despite the inclusion of outlier data groups, acceptable correlation between MA and VCR melanoma data was observed, suggesting that MA may be suitable for assessing epidemiological trends. Such principals may be used to validate the use of MA data for similar calculations assessing NMSC trends.

Multiple skin neoplasms in subjects under 40 years of age in Goiania, Brazil

OBJECTIVE

To describe the trend for malignant skin neoplasms in subjects under 40 years of age in a region with high ultraviolet radiation indices.

METHODS

A descriptive epidemiological study on melanoma and nonmelanoma skin cancers that was conducted in Goiania, Midwest Brazil, with 1,688 people under 40 years of age, between 1988 and 2009. Cases were obtained from Registro de Câncer de Base Populacional de Goiânia (Goiania’s Population-Based Cancer File). Frequency, trends, and incidence of cases with single and multiple lesions were analyzed; transplants and genetic skin diseases were found in cases with multiple lesions.

RESULTS

Over the period, 1,995 skin cancer cases were observed to found, of which 1,524 (90.3%) cases had single lesions and 164 (9.7%) had multiple lesions. Regarding single lesions, incidence on men was observed to have risen from 2.4 to 3.1/100,000 inhabitants; it differed significantly for women, shifting from 2.3 to 5.3/100,000 (Annual percentage change – [APC] 3.0%, p = 0.006). Regarding multiple lesions, incidence on men was observed to have risen from 0.30 to 0.98/100,000 inhabitants; for women, it rose from 0.43 to 1.16/100,000 (APC 8.6%, p = 0.003). Genetic skin diseases or transplants were found to have been correlated with 10.0% of cases with multiple lesions – an average of 5.1 lesions per patient. The average was 2.5 in cases without that correlation.

CONCLUSIONS

Skin cancer on women under 40 years of age has been observed to be increasing for both cases with single and multiple lesions. It is not unusual to find multiple tumors in young people – in most cases, they are not associated with genetic skin diseases or transplants. It is necessary to avoid excessive exposure to ultraviolet radiation from childhood.

Incidence and prevalence of non-melanoma skin cancer in Australia: A systematic review

Non-melanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common cancer occurring in people with fair skin. Australia has been reported to have the highest incidence of NMSC in the world. Using a systematic search of the literature in EMBASE and Medline, we identified 21 studies that investigated the incidence or prevalence of NMSC in Australia. Studies published between 1948 and 2011 were identified and included in the analysis. There were six studies that were conducted on national level, two at state level and 13 at the regional level. Overall, the incidence of NMSC had steadily increased over calendar-years in Australia. The incidence of NMSC per 100,000 person-years was estimated to be 555 in 1985; 977 in 1990; 1109 in 1995; 1170 in 2002 and 2448 in 2011. The incidence was higher for men than women and higher for BCC than SCC. Incidence varied across the states of Australia, with the highest in Queensland. The prevalence of NMSC was estimated to be 2% in Australia in 2002. The incidence and prevalence of NMSC still need to be accurately established at both national and state levels to determine the costs and burden of the disease on the public health system in Australia.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Caffeine intake and risk of basal cell and squamous cell carcinomas of the skin in an 11-year prospective study

PURPOSE

Caffeine may repair skin damage induced by excessive exposure to ultraviolet light. The purpose of this study was to investigate the association between caffeine intake and incidence of basal cell (BCC) and squamous cell carcinoma (SCC). We also assessed the associations between coffee consumption and incidence of these skin cancers.

METHODS

Caffeine intake and consumption of coffee were estimated from food frequency questionnaires assessed in 1992, 1994, and 1996 among 1,325 randomly selected adult residents of a subtropical Australian community. All histologically confirmed tumours of BCC and SCC occurring between 1997 and 2007 were recorded. Associations with BCC and SCC were assessed using Poisson and negative binomial regression models and were adjusted for confounders including skin type and indicators of past sun exposure.

RESULTS

There was no association between total caffeine intake and incidence of BCC or SCC. Participants with prior skin cancers, however, had a 25% lower risk of BCC if they were in the highest tertile of total caffeine intake (equivalent to daily consumption of four cups of regular coffee) compared with the lowest tertile (multivariable RR 0.75; 95% CI 0.57-0.97, P trend = 0.025). There was no dose-response relationship with SCC. Consumption of neither caffeinated nor decaffeinated coffee was associated with BCC or SCC.

CONCLUSIONS

Among people with prior skin cancers, a relatively high caffeine intake may help prevent subsequent BCC development. However, caffeine intake appears not to influence the risk of SCC.

Intake of omega-3 and omega-6 fatty acids and risk of basal and squamous cell carcinomas of the skin: a longitudinal community-based study in Australian adults

Intake of omega-3 and omega-6 fatty acids may modify the risk of basal and squamous cell carcinoma of the skin (BCC and SCC), but population-based evidence is limited and inconsistent. We examined prospectively associations between intake of omega-3 and omega-6 fatty acids estimated from food frequency questionnaires and BCC and SCC incidence among 1322 randomly selected adults in Nambour, Australia. Relative risks (RR) and 95% confidence intervals (CI) were estimated based on histologically confirmed tumors diagnosed between 1997 and 2007. Incidence of BCC was lowest in the middle third of both total omega-6 intake (RR(mv.adj) = 0.74, 95% CI = 0.56-0.97) and linoleic acid intake (RR(mv.adj) = 0.75, 95% CI = 0.57-0.99) compared with the lowest third of intake. Evidence for associations with SCC was weak, though persons with arachidonic acid intake in the middle third had a marginally increased risk of SCC (RR(mv.adj) = 1.42, 95% CI = 1.00-2.02). Consumption of omega-3 fatty acids was not associated with subsequent skin cancer risk. Suggestion that intake of arachidonic acid may be associated with increased SCC incidence and total omega-6 with reduced BCC from our study is still highly uncertain and may be due to chance. These data do not support an association between these fatty acids and risk of BCC or SCC.

A systematic review of worldwide incidence of nonmelanoma skin cancer

BACKGROUND

  Nonmelanoma skin cancer (NMSC) is the most common cancer affecting white-skinned individuals and the incidence is increasing worldwide.

OBJECTIVES

This systematic review brings together 75 studies conducted over the past half century to look at geographical variations and trends worldwide in NMSC, and specifically incidence data are compared with recent U.K. cancer registry data.

METHODS

Following the development of a comprehensive search strategy, an assessment tool was adapted to look at the methodological quality of the eligible studies.

RESULTS

Most of the studies focused on white populations in Europe, the U.S.A. and Australia; however, limited data were available for other skin types in regions such as Africa. Worldwide the incidence for NMSC varies widely with the highest rates in Australia [>1000/100, 000 person-years for basal cell carcinoma (BCC)] and the lowest rates in parts of Africa (< 1/100, 000 person-years for BCC). The average incidence rates in England were 76·21/100, 000 person-years and 22·65/100, 000 person-years for BCC and squamous cell carcinoma (SCC), respectively, with highest rates in the South-West of England (121·29/100, 000 person-years for BCC and 33·02/100, 000 person-years for SCC) and lowest rates by far in London (0·24/100, 000 person-years for BCC and 14·98/100, 000 person-years for SCC). The incidence rates in the U.K. appear to be increasing at a greater rate when compared with the rest of Europe.

CONCLUSIONS

NMSC is an increasing problem for health care services worldwide. This review highlights a requirement for prevention studies in this area and the issues surrounding incomplete NMSC registration. Registration standards of NMSC should be improved to the level of other invasive disease.

CXCR3/ligands are significantly involved in the tumorigenesis of basal cell carcinomas

Basal cell carcinoma (BCC) is the most common skin malignancy encountered worldwide. We hypothesized that CXC chemokines, small cytokines involved in inducing directed leukocyte chemotaxis, could play a key role in the modulation of BCC growth. In this study, quantitative RT-PCR revealed that the chemokines CXCL9, 10, 11, and their receptor CXCR3 were significantly upregulated by an average 22.6-fold, 9.2-fold, 26.6-fold, and 4.9-fold, respectively in BCC tissue samples as compared with nonlesional skin epithelium. Immunohistochemistry analysis revealed that CXCR3, CXCL10, and CXCL11, but not CXCL9, colocalized with cytokeratin 17 (K17) in BCC keratinocytes. In addition, CXCR3 and its ligands were expressed in cells of the surrounding BCC stroma. The chemokines and K17 were also expressed in cultured human immortalized HaCaT keratinocytes. Exposure of HaCaT cells or primary BCC-derived cells to CXCL11 peptides in vitro significantly increased cell proliferation. In primary BCC-derived cell cultures, addition of CXCL11 progressively selected for K17+/CXCR3+ co-expressing cells over time. The expression of CXCR3 and its ligands in human BCC keratinocytes, the enhancement of keratinocyte cell proliferation by CXCL11, and the homogeneity of K17+ BCC cells in human BCC-isolated cell population supported by CXCR3/CXCL11 signaling all suggest that CXCR3 and its ligands may be important autocrine and/or paracrine signaling mediators in the tumorigenesis of BCC.

Incidence of basal cell carcinoma multiplicity and detailed anatomic distribution: longitudinal study of an Australian population

A proportion of individuals are affected multiple times by basal cell carcinoma (BCC), but the rate and extent to which this occurs is unknown. We therefore prospectively estimated BCC incidence in a subtropical Australian population, focusing on the rate at which persons develop multiple primary BCCs and the precise anatomic sites of BCC occurrence. Between 1997 and 2006, 663 BCCs were confirmed in 301 of 1,337 participants in the population-based Nambour Skin Cancer Study. The incidence of persons affected multiple times by primary BCC was 705 per 100,000 person years compared to an incidence rate of people singly affected of 935 per 100,000 person years. Among the multiply and singly affected alike, site-specific BCC incidence rates were far highest on facial subsites, followed by upper limbs, trunk, and then lower limbs. We conclude that actual BCC tumor burden is much greater in the population than is apparent from normal incidence rates. Anatomic distribution of BCC is consistent with general levels of sun exposure across body sites.

Accuracy of clinical diagnosis of skin lesions

BACKGROUND

Skin cancer is an increasing problem in fair-skinned populations worldwide. It is important that doctors are able to diagnose skin lesions accurately.

OBJECTIVES

To compare the clinical with the histological diagnosis of excised skin lesions from a set of epidemiological data. We analysed diagnostic accuracy stratified by histological subtype and body site and examined the histological nature of misclassified diagnosis.

METHODS

All excised and histologically confirmed skin cancers in Townsville/Thuringowa, Australia from December 1996 to October 1999 were recorded. Positive predictive values (PPVs) and sensitivities were calculated for the clinical diagnoses and stratified by histological subtype and body site.

RESULTS

Skin excisions in 8694 patients were examined. PPVs for the clinical diagnoses were: basal cell carcinoma (BCC) 72.7%; squamous cell carcinoma (SCC) 49.4%; cutaneous melanoma (CM) 33.3%. Sensitivities for the clinical diagnosis were: BCC 63.9%; SCC 41.1%; CM 33.8%. For BCC, PPVs and sensitivities were higher for the trunk, the shoulders and the face and lower for the extremities. The reverse pattern was seen for SCCs.

CONCLUSIONS

Diagnostic accuracy was highest for BCC, the most prevalent lesion. Most excisions were correctly diagnosed or resulted in the removal of malignant lesions. With nonmelanocytic lesions, doctors tended to misclassify benign lesions as malignant, but were less likely to do the reverse. Although a small number of clinically diagnosed common naevi subsequently proved to be melanoma (6.3%), a higher proportion of all melanomas had been classified as common naevi (20.9%). Accuracy of diagnosis was dependent on body site.

Malignant melanoma and nonmelanoma skin cancers in Northrhine-Westphalia, Germany: a patient- vs. diagnosis-based incidence approach

BACKGROUND

Dermatologists have repeatedly criticized that the public health importance of nonmelanoma skin cancers is not appropriately reflected by the patient-based cancer incidence rates of population-based cancer registries. The aims of this study were to estimate the patient incidence rates of squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and skin melanoma, and to study the effect of multiple primary skin tumors on the incidence rates.

METHODS

We used a network of physicians covering a population of about 75,000 individuals to register all newly diagnosed invasive skin cancers (996 diagnoses in 796 patients), including BCC, SCC, and skin melanoma, from July 1998 to June 2003. We calculated age-standardized (world standard population) incidence rates (cases per 100,000 person-years) for the first diagnoses (called "patient incidence") and for any diagnoses of BCC, SCC, and skin melanoma (called "case incidence").

RESULTS

The patient incidence rates of BCC were 63.6 in men and 54.0 in women, and the case incidence rates of BCC were 82.7 and 71.1, respectively. The patient incidence rates of SCC were 17.4 in men and 9.7 in women, and the case incidence rates were 20.4 and 10.2, respectively. The patient and case incidence rates of skin melanoma were about the same at 13.6 in men and 18.5 in women. Twenty-five per cent of the BCC patients and 14% of the SCC patients suffered from more than one BCC and SCC, respectively, during the 5-year period.

CONCLUSIONS

Patient incidence rates of BCC and SCC substantially underestimate the burden of nonmelanoma skin cancer in the population.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the commonest skin cancer. BCCs are slow-growing, locally invasive, epidermal skin tumours which mainly affect white skinned people. The first line treatment is usually surgical excision, but numerous alternatives are available.

OBJECTIVES

To assess the effects of treatments for basal cell carcinoma.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (January 2006), the Cochrane Central Register of Controlled Trials (The Cochrane LIbrary Issue 1, 2006), the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 1, 2006), MEDLINE (2004 to January 2006), EMBASE (2005 to January 2006), the metaRegister of Controlled Trials (February 2006). Cited references of all trials identified and key review articles were searched. Pharmaceutical companies were contacted where appropriate for reviews or unpublished trials.

SELECTION CRITERIA

Inclusion criteria were adults with one or more histologically proven, primary basal cell carcinoma. The primary outcome measure was recurrence at three to five years, measured clinically. The secondary outcome included early treatment failure within six months, measured histologically. Adverse treatment effects included aesthetic appearance and pain during and after treatment.

DATA COLLECTION AND ANALYSIS

Two authors independantly carried out study selection and assessment of methodological quality.

MAIN RESULTS

Twenty seven studies were identified. Only one RCT of surgery versus radiotherapy had primary outcome data at four years, showing significantly more persistent tumours and recurrences in the radiotherapy group as compared to the surgery group, (RR 0.09, 95%CI, 0.01 to 0.69). One study found no significant difference for recurrence at 30 months when Moh's micrographic surgery was compared to surgery for high risk facial BCCs, (RR 0.64, 95%CI 0.16,2.64). One study of methylaminolevulinate photodynamic therapy (MAL PDT) versus cryotherapy found no significant difference in recurrences in the MAL PDT group when compared to cryotherapy at one year (RR 0.50, 95% CI 0.22,1.12). Cryotherapy showed no significant difference in recurrences at one year when compared to surgery on one small study. When radiotherapy was compared to cryotherapy there were significantly fewer recurrences at one year in the radiotherapy group compared to the cryotherapy group.Short-term studies suggest a success rate of 87 to 88% for imiquimod in the treatment of superficial BCC using a once-daily regimen for 6 weeks and a 76% treatment response when treating nodular BCC for 12 weeks, when measured histologically.

AUTHORS' CONCLUSIONS

Overall there has been very little good quality research on treatments for BCC. Most trials have only evaluated BCCs in low risk locations. Surgery and radiotherapy appear to be the most effective treatments with surgery showing the lowest failure rates. Although cosmetic outcomes appear good with PDT, long term follow up data are needed. Other treatments might have some use but few have been compared to surgery. An ongoing study comparing imiquimod to surgery should clarify whether imiquimod is a useful option.

Cutaneous squamous cell carcinoma of the lower limbs in Goiânia, Goiás, Brazil

BACKGROUND

Cutaneous squamous cell carcinoma is a common malignant neoplasm that affects areas that are exposed to the sun in fair-skinned people. It occurs less frequently on the lower limbs where other etiological factors are involved.

OBJECTIVE

To determine the epidemiological aspects of cutaneous squamous cell carcinoma of the lower limbs in Goiânia.

METHODOLOGY

Forty-three cases of cutaneous squamous cell carcinoma of the lower limbs from the Cancer Registry of the Population Base of Goiás, for the period between 1995 and 1999, were included in the study.

RESULTS

Among the cases of cutaneous squamous cell carcinoma registered in this 5-year interval, 43 (4.6%) represented cases affecting the lower limbs. Of these individuals, seven (16.3%) were male and 36 (83.7%) female (P < 0.001). Those in the age group of 60 years and above represented 90.7% of the cases (P < 0.001). None of the patients had metastasis.

CONCLUSION

Cutaneous squamous cell carcinomas on the lower limbs are more frequently seen in women older than 60 years of age, and they rarely metastasize.

Orbital exenteration for invasive skin tumours

Orbital exenteration aims at local control of disease invading the orbit that is potentially fatal or relentlessly progressive. Of all exenterations presenting to ophthalmologists, 40-50% are required for tumours in the eyelid or periocular skin. 99% of these are basal cell carcinomas and 4-6% each are squamous cell carcinomas or sebaceous gland carcinomas. Orbital invasion results in progressive fixation of the tumour to bone and reduced ocular motility. Perineural invasion of branches of the trigeminal nerve leads to numbness or pain, and that the facial nerve, to weakness. Biopsy identifies the cell type and the presence of perineural invasion. CT and MRI scanning help in the assessment of tumour spread within the orbit. Management should be in collaboration with an oncologist. Exenteration may be total-the removal of all orbital contents-or lid-sparing if the tumour is placed posteriorly. The socket may be allowed to heal by granulation or lined with a split skin graft or local flap. Complications may be seen following 20-25% of exenterations and include fistulae, tissue necrosis, exposed bone, and infection. Incomplete clearance of tumours occurs in about 38% of total exenterations and 17% of subtotal. The overall 5-year survival is 55-65%, but significantly worse if there was perineural spread. Facial prostheses may be mounted on glasses or secured with tissue glue or osseointegrated implants. Excellent cosmetic results can be achieved but many patients prefer to wear a patch.

Non‐melanoma skin cancer in Australia: the 2002 national survey and trends since 1985

OBJECTIVES

To measure the incidence of treated non-melanoma skin cancer (NMSC) in Australia in 2002 and investigate trends since 1985 by histological type, sex, age group, latitude and skin type.

DESIGN

Face-to-face survey between 1 January and 31 December 2002 using stratified sampling of households to identify people treated for skin cancer in the previous 12 months. Self-reported diagnoses were confirmed with treatment providers. Data from similar surveys conducted in 1985, 1990 and 1995 were used to assess trends.

SETTING

Whole of Australia (population 19.6 million).

PARTICIPANTS

Of 57 215 people interviewed, 4098 said they had been treated for skin cancer in the past year and 3198 gave permission for their diagnoses to be confirmed with their doctor.

RESULTS

817 people were confirmed as having at least one skin cancer treated in the past year. The age-standardised rate per 100 000 population for NMSC was 1170, for basal cell carcinoma (BCC) 884, and for squamous cell carcinoma (SCC) 387. The estimated number of NMSC cases in Australia for 2002 was 374 000. Cumulative risks to age 70 years of having at least one NMSC were 70% for men and 58% for women. Rates of BCC and SCC have increased since 1985, and the increases greatest for people aged 60 years and older; rates for those younger than 60 years have stabilised.

CONCLUSIONS

The incidence of treated NMSC in Australia in 2002 was more than five times the incidence of all other cancers combined. Although the overall NMSC rates have risen since 1985, the stabilisation of rates for people younger than 60 years who were exposed to skin cancer prevention programs in their youth highlights the importance of maintaining and strengthening these programs.

Food intake and risk of squamous cell carcinoma of the skin in a community: The Nambour skin cancer cohort study

There is some evidence that dietary factors may modify the risk of squamous cell carcinoma (SCC) of the skin, but the association between food intake and SCC has not been evaluated prospectively. We examined the association between food intake and SCC incidence among 1,056 randomly selected adults living in an Australian sub-tropical community. Measurement-error corrected estimates of intake in 15 food groups were defined from a validated food frequency questionnaire in 1992. Associations with SCC risk were assessed using Poisson and negative binomial regression to the persons affected and tumour counts, respectively, based on incident, histologically confirmed tumours occurring between 1992 and 2002. After multivariable adjustment, none of the food groups was significantly associated with SCC risk. Stratified analysis in participants with a past history of skin cancer showed a decreased risk of SCC tumours for high intakes of green leafy vegetables (RR = 0.45, 95% CI = 0.22-0.91; p for trend = 0.02) and an increased risk for high intake of unmodified dairy products (RR = 2.53, 95% CI: 1.15-5.54; p for trend = 0.03). Food intake was not associated with SCC risk in persons who had no past history of skin cancer. These findings suggest that consumption of green leafy vegetables may help prevent development of subsequent SCCs of the skin among people with previous skin cancer and that consumption of unmodified dairy products, such as whole milk, cheese and yoghurt, may increase SCC risk in susceptible persons.

CLINICAL DIAGNOSIS OF SKIN TUMOURS: HOW GOOD ARE WE?

BACKGROUND

Few studies have addressed the accuracy of clinical diagnosis of skin malignancies. The present prospective study aims to determine the accuracy with which these lesions are diagnosed and attempts to identify the factors influencing the accuracy of clinical diagnosis.

METHODS

All patients undergoing surgical excision of a skin cancer with curative intent from January 2001 to December 2002 at Peter MacCallum Cancer Institute, Melbourne, Australia were prospectively studied. Data were entered into the Filemaker Pro program and analysed using the SPSS software package.

RESULTS

A total of 2582 lesions were surgically excised from 1223 patients. Of these 47% were basal cell carcinomas (BCC), 20% were squamous cell carcinomas (SCC), 0.9% were malignant melanomas (MM), and 32.1% were benign or premalignant. Tumours, benign and malignant, were found to be more common in men. The sensitivity for clinical diagnosis of malignancy was 97.5% while the positive predictive value (PPV) for clinical diagnosis of malignancy was 70.3%. BCC and SCC was diagnosed with a sensitivity of 89% and 56.3%, and PPV of 64.5% and 40.3%, respectively (P < 0.001). 23 MM were excised with a sensitivity of clinical diagnosis of 47.8% and PPV of 30.6%. Sensitivity and PPV were also assessed according to clinical experience of the surgeon, site of the lesion and whether surgery was performed for a primary or a recurrent lesion. Sensitivity and PPV were higher for lesions diagnosed by consultant surgeons when compared with surgical trainees (P < 0.001) - MM was diagnosed with a sensitivity of 100% by consultant surgeons.

CONCLUSION

The present study shows sensitivity and PPV rates comparable to published figures.

Cancer-associated molecular signature in the tissue samples of patients with cirrhosis

Several types of aggressive cancers, including hepatocellular carcinoma (HCC), often arise as a multifocal primary tumor. This suggests a high rate of premalignant changes in noncancerous tissue before the formation of a solitary tumor. Examination of the messenger RNA expression profiles of tissue samples derived from patients with cirrhosis of various etiologies by complementary DNA (cDNA) microarray indicated that they can be grossly separated into two main groups. One group included hepatitis B and C virus infections, hemochromatosis, and Wilson's disease. The other group contained mainly alcoholic liver disease, autoimmune hepatitis, and primary biliary cirrhosis. Analysis of these two groups by the cross-validated leave-one-out machine-learning algorithms revealed a molecular signature containing 556 discriminative genes (P <.001). It is noteworthy that 273 genes in this signature (49%) were also significantly altered in HCC (P <.001). Many genes were previously known to be related to HCC. The 273-gene signature was validated as cancer-associated genes by matching this set to additional independent tumor tissue samples from 163 patients with HCC, 56 patients with lung carcinoma, and 38 patients with breast carcinoma. From this signature, 30 genes were altered most significantly in tissue samples from high-risk individuals with cirrhosis and from patients with HCC. Among them, 12 genes encoded secretory proteins found in sera. In conclusion, we identified a unique gene signature in the tissue samples of patients with cirrhosis, which may be used as candidate markers for diagnosing the early onset of HCC in high-risk populations and may guide new strategies for chemoprevention. Supplementary material for this article can be found on the HEPATOLOGY website (http://interscience.wiley.com/jpages/0270-9139/suppmat/index.html).