Case of Merkel cell carcinoma with squamous cell carcinoma possibly arising in chronic radiodermatitis of the hand

Occupational radiation dose on the hand of assisting medical staff in diagnostic CT scans

Chronic radiation exposure increases the risk of skin damage of medical personnel engaged in radiology. However, hand dose measurements in computed tomography (CT) for diagnostic purposes have not been evaluated. The occupational radiation dose to the hands of CT assistants was herein investigated to evaluate its compliance with the equivalent dose limit for the hand (500 mSv/year). The occupational doses of nine CT assistants were measured in 89 cases (April 2017-May 2018) by installing radio-photoluminescence glass dosemeters (GD-302 M) (70-μm dose-equivalent conversion coefficient = 0.37) on the dorsal aspect of both hands. The occupational dose to the hand was the highest with head holding (right: 1.14 mSv/CT scan, left: 1.07 mSv/CT scan). Considering the results for annual work, even for head holding, the hand dose of the CT-assisting personnel was insignificant. However, CT assistants should be mindful of the possibility of locally higher doses to hands.

Protective Attitudes toward Occupational Radiation Exposure among Spine Surgeons in Japan: An Epidemiological Description from the Survey by the Society for Minimally Invasive Spinal Treatment

Background and Objectives: The global trend toward increased protection of medical personnel from occupational radiation exposure requires efforts to promote protection from radiation on a societal scale. To develop effective educational programs to promote radiation protection, we clarify the actual status and stage of behavioral changes of spine surgeons regarding radiation protection. Materials and Methods: We used a web-based questionnaire to collect information on the actual status of radiation protection and stages of behavioral change according to the transtheoretical model. The survey was administered to all members of the Society for Minimally Invasive Spinal Treatment from 5 October to 5 November 2020. Results: Of 324 members of the Society for Minimally Invasive Spinal Treatment, 229 (70.7%) responded. A total of 217 participants were analyzed, excluding 12 respondents who were not exposed to radiation in daily practice. A trunk lead protector was used by 215 (99%) participants, while 113 (53%) preferred an apron-type protector. Dosimeters, thyroid protector, lead glasses, and lead gloves were used by 108 (50%), 116 (53%), 82 (38%), and 64 (29%) participants, respectively. While 202 (93%) participants avoided continuous irradiation, only 120 (55%) were aware of the source of the radiation when determining their position in the room. Regarding the behavioral change stage of radiation protection, 134 (62%) participants were in the action stage, while 37 (17%) had not even reached the contemplation stage. Conclusions: We found that even among the members of the Society for Minimally Invasive Spinal Treatment, protection of all vulnerable body parts was not fully implemented. Thus, development of educational programs that cover the familiar risks of occupational radiation exposure, basic protection methods in the operating room, and the effects of such protection methods on reducing radiation exposure in actual clinical practice is warranted.

Combined Merkel Cell Carcinoma with Nodal Presentation: Report of a Case Diagnosed with Excisional but Not Incisional Biopsy and Literature Review

Merkel cell carcinoma (MCC) is a rare primary neuroendocrine carcinoma (NEC) of the skin. As compared to pure MCCs, combined MCCs are aggressive and exhibit a higher probability of metastasis. A correct diagnosis might be missed, especially when the biopsy sample is too small or too superficial. We report a 79-year-old Taiwanese male who presented with lymphadenopathy suspicious for lymphoma. A nodal biopsy showed metastatic NEC. A skin tumor in the lower back was identified, and an incisional biopsy showed only squamous cell carcinoma (SCC). A subsequent excisional biopsy was performed based on the advice of the senior pathologist because of the presence of metastatic nodal NEC. Finally, a diagnosis of combined MCC and SCC was confirmed. Our literature review identified 13 cases of combined MCC with nodal metastasis as initial presentations, all with an aggressive clinical course. Both the MCC and non-MCC components could be present in the metastatic nodes. Metastases of pure MCC cells were observed in three combined MCCs in sun-protected areas, probably pointing to a distinct pathogenesis. Excision or punch biopsy to include the deep dermal NEC component is recommended as timely diagnosis is mandatory for appropriate management of patients with this rare skin cancer.

Unique presentation of Merkel cell tumour affecting the hand

Merkel cell carcinoma (MCC) is a rare and highly aggressive skin cancer which most commonly occurs on the head and neck. A limited number of cases of MCC of the hand have been reported in the English literature. We describe a case of MCC of the hand in a man in his late 60s. The lesion presented on the dorsum of the left fifth digit, with metastasis to the left axillary lymph nodes. The primary lesion grew rapidly over a span of 3 months. The patient was treated with two courses of neoadjuvant nivolumab, amputation of the digit and left axillary lymph node resection followed by radiotherapy to the left hand and left axilla. He continues to follow-up for radiotherapy treatment 3 months postoperatively.

Association of occupational direct radiation exposure to the hands with longitudinal melanonychia and hand eczema in spine surgeons: a survey by the society for minimally invasive spinal treatment (MIST)

PURPOSE

To investigate the association between occupational direct radiation exposure to the hands and longitudinal melanonychia (LM) and hand eczema in spine surgeons.

METHODS

A web-based questionnaire survey of the Society for Minimally Invasive Spinal Treatment (MIST) in Japan was conducted. The proportion of LM and hand eczema in hands with high and low-radiation exposure was compared using Fisher's exact test. The odds ratios (ORs) and their 95% confidence intervals (CIs) for the prevalence of LM and hand eczema in the high-radiation exposure hands were calculated using generalized estimating equations for logistic regression as control for the correlation of observations among the same individuals and possible confounders.

RESULTS

Among 324 members of the society, responses were received from 229 members (70.7%). A total of 454 hands from 227 participants were analysed. The prevalence of LM and hand eczema was 43% and 29%, respectively. In a hand-by-hand comparison, more hands had LM in the high-radiation exposure group than the low-radiation exposure group (90 [40%] vs. 39 [17%], respectively, p < 0.001). A similar trend was observed for hand eczema (63 [28%] vs. 33 [15%], respectively, p = 0.001). The adjusted OR for high-radiation exposure hands was 3.18 (95% CI: 2.24-4.52). Consistent results were obtained for hand eczema, with an adjusted OR of 2.26 (95% CI: 1.67-3.06).

CONCLUSION

The present study suggests that direct radiation exposure to physician's hands is associated with LM and hand eczema. Those with LM and radially biased hand eczema may have had high direct radiation exposure.

Radiation exposure and the orthopedic surgeon's hand: Measurement of the equivalent dose over 13 months

Exposure to ionizing radiation in the operating room is governed by practical prevention and protection measures on the international, national and local levels. We evaluated the equivalent dose to the hand of an orthopedic surgeon over 13 months. An orthopedic surgeon wore a ring dosimeter on the ring finger of his right hand for all surgical procedures requiring intraoperative fluoroscopy between March 2014 and April 2015. Monthly doses were evaluated by the IRSN over the study period. The number and type of procedures were compiled as well as the type of fluoroscopy unit used. Four hundred procedures were performed during this period, including 182 with fluoroscopy. The equivalent cumulative dose at the hand was 4,75 mSv. No correlation was found with the type of procedure or type of fluoroscopy unit (conventional or mini C-arm). Equivalent doses were below the annual regulatory limit in France of 500 mSv. These results are consistent with those reported in the literature. However, recent studies have noted that both younger surgeons in training and more experienced surgeons must remember to use radiation protection measures.

Merkel Cell Carcinoma of the Hand: A Case Report and Review of the Literature

Background: Merkel cell carcinoma (MCC) is a relatively rare and aggressive cutaneous neuroendocrine malignancy characterized by high incidence of local recurrence, distant metastases, regional nodal metastases, and high mortality. Clinically, MCC presents as a persistent asymptomatic red/pink shaped nodule, usually smaller than 2 cm with nontender intracutaneous swelling, with rapidly growing localized disease with lymph node metastases preceding distant metastases. Because of its rare nature and the lack of comprehensive understanding of the disease, management of MCC has been controversial. Methods: An 87-year-old retired Caucasian male with a history of tobacco use, chronic sun exposure, and multiple squamous and basal cell carcinomas presented with a 1.8 × 1.3 cm red, nontender nodule on the dorsum of the proximal phalanx of the left long finger first noticed 6 months prior to presentation. Biopsy was consistent with MCC after which he was treated with wide local excision, full-thickness skin grafting, and sentinel lymphadenectomy (1/4 nodes positive) followed by adjuvant radiation therapy. Results: He recovered appropriately and was clinically and radiographically disease free at 2.5-year follow-up. Conclusion: Although it remains rare, MCC has increased in incidence over the last several decades and has a predilection to occur over sun exposed areas. Highly aggressive, it has a high incidence of regional and distant metastasis as well as local recurrence. As a result, it is important that practitioners involved in the care of skin and hand lesions be aware of this condition and the need for a multidisciplinary treatment approach.

Unexpected maspin immunoreactivity in Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare but aggressive cutaneous neuroendocrine tumor, which multifactorial etiopathogenesis seems to be related to ultraviolet radiation, Merkel cell polyomavirus (MCV), and immunosuppression. In this paper, we present three cases of diagnosed MCC in apparently healthy Caucasians, two of them located in a sun-exposed area. They represented 0.25 % of all cutaneous malignant tumors diagnosed in our department. In the first case, MCC was diagnosed in the frontal region of a 67-year-old male, the second case was located in the right thigh of a 55-year-old female, whereas the third case involved the upper trunk of a 62-year-old female. All of these cases were diagnosed in the pT1 stage, having a diameter smaller than 2 cm, but the invasion depth involved the hypodermis. Microscopically, they consisted of small cells with round-oval nuclei having finely dispersed chromatin and well-defined nucleoli. Immunohistochemically, the tumor cells displayed positivity for keratin 20 and neuroendocrine markers, being negative for keratin 7 and S100 protein. Maspin immunoreactivity was seen in cases 1 and 3. Not one of the cases expressed DOG-1 or even TTF-1. Furthermore, this is the first report in literature about maspin positivity in MCC that might be related to sun exposure.