Reconstruction of Moderately and Severely Atrophic Scalp-A Multicentric Experience in Surgical Treatment of Patients Irradiated for Tinea Capitis in Childhood and Surgical Algorithm

Background and Objectives: Before the introduction of griseofluvin, the use of X-ray radiation was the treatment of choice for tinea capitis. More than half a century later various types of tumors have been found to be associated with childhood irradiation due to tinea capitis, most commonly cancers of the head and neck, as well as brain tumors. The often unusually aggressive and recurrent nature of these tumors necessitates the need for repeated surgeries, while the atrophic skin with an impaired vascular supply due to radiation often poses an additional challenge for defect reconstruction. We present our experience in the surgical treatment of such patients. Materials and Methods: This is a retrospective cohort study. In this study, 37 patients treated for acquired defects of the scalp with a history of irradiation therapy due to tinea capitis in childhood were included in this study, 24 male and 13 female patients. The mean age at the first appointment was 60.6 ± 7.8, with the youngest included patient being 46 and the oldest being 75 years old. Patients' characteristics, surgical treatment, and complications were analyzed and a reconstructive algorithm was developed. Results: Local flaps were used for reconstruction in 34 patients, direct sutures were used in 10 patients and 20 patients received split-thickness skin grafts for coverage of both primary and secondary defects for reconstruction of flap donor sites. One regional flap and one dermal substitute covered by an autologous skin graft were also used for reconstruction. Complications occurred in 43.2% of patients and were significantly associated with the presence of comorbidities (p = 0.001), aseptic bone necrosis (p = 0.001), as well as skin atrophy in frontal, occipital, and parietal region (p = 0.001, p = 0.042 and p = 0.001, respectively). A significant correlation between major complications and moderate skin atrophy was found only in the parietal region (p = 0.026). Conclusions: Unfortunately, many protocols developed for scalp reconstruction are not applicable in the setting of severe or diffuse scalp skin atrophy associated with high tumor recurrence rate and radiation-induced vascular impairment, such as in tinea capitis patients in Serbia. An algorithm has been developed based on the authors' experience in managing these patients.

Multiple Basal Cell Carcinomas of the Scalp After Radiotherapy: Genomic Study in a Case With Latency Period Over 80 Years

ABSTRACT

Basal cell carcinoma (BCC) has been linked mostly to ultraviolet radiation exposure, but ionizing radiation has also been implicated in the genesis of a subset of BCCs occurring after radiotherapy. We present a 93-year-old woman with 4 BCCs of the scalp after radiotherapy for tinea capitis, diagnosed after a latency period of over 80 years. The largest lesion was located on the right temporal region and corresponded to a BCC of mixed type, with nodular, infiltrative, and micronodular components. We performed genomic study with array comparative genomic hybridization in samples from each BCC, which revealed more imbalances in the largest lesion than in the remaining ones, correlating with its higher histological complexity. Furthermore, this was the only lesion presenting loss at 2p22.3, where is mapped the BIRC6 gene associated with regulation of apoptosis, and loss at 16q24.3, where is mapped FANCA gene, responsible for DNA repair and maintenance of chromosome stability. Despite these differences, there were aberrations shared by all tumor samples, suggesting a common genetic signature. Our report describes, to the best of our knowledge, the longest latency period between exposure to radiotherapy and the diagnosis of BCC. The genomic study showed imbalances common to all tumor samples but also differences that could explain their heterogeneity in terms of histological subtype and biological potential. In addition, these differences could also be a consequence of different times in the evolution of the lesions at the moment of presentation, thus having a diverse combination of accumulated genomic imbalances.

Childhood Exposure to Low to Moderate Doses of Ionizing Radiation and the Risk of Vascular Diseases

In the Tinea Capitis Study (Israel, 1966-2011), we assessed the association between childhood exposure to low to moderate doses of ionizing radiation (IR) to the head and neck and the development of vascular diseases (ischemic heart disease, carotid artery stenosis, and stroke) in adulthood. The study included 17,734 individuals from the Tinea Capitis cohort (7,408 irradiated in childhood and 10,326 nonirradiated), insured by Israel's largest health provider. Individual dosimetry was estimated based on measurements made on a head phantom and original treatment records. The mean doses were 1.5, 0.09, 0.78, and 0.017 Gy to brain, thyroid, salivary gland, and breast, respectively. Data on vascular diseases was abstracted from computerized medical records. Using Poisson regressions, we examined the association of radiation with morbidity. Any vascular disease was reported for 2,221 individuals. Adjusted for age, sex, socioeconomic status, smoking, hypertension, and diabetes, exposure to IR increased the risk of developing any vascular diseases (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.09, 1.29), stroke (RR = 1.35, 1.20, 1.53), carotid artery stenosis (RR = 1.32, 1.06, 1.64), and ischemic heart disease (RR = 1.12, 1.01, 1.26). The risk of developing vascular diseases was positively associated with dose and inversely associated with age at exposure. In conclusion, the results indicate that early exposure to low to moderate doses of IR increases the risk of cerebro- and cardiovascular impairments.

Does Severity of Hair Loss Matter? Factors Associated with Mental Health Outcomes in Women Irradiated for Tinea Capitis in Childhood

Hair loss resulting from childhood irradiation for tinea capitis has been linked to mental health effects in women. However, the association of hair loss severity with mental health in this population is unknown. To address this gap, this study examined the association between hair loss severity and mental health outcomes in women irradiated for tinea capitis in childhood as well as the factors that contribute to these outcomes. Medical records, held at the archives of the Israel National Center for Compensation of Scalp Ringworm Victims, were retrospectively reviewed for 2509 women who received compensation for full or partial alopecia resulting from irradiation for tinea capitis. Mental health outcomes were determined by the number of mental health conditions reported. The results show that among women with more hair loss, risk was increased for a range of mental health problems, especially social anxiety (RR 2.44, 95% CI 2.09–2.87). Hair loss severity emerged as a significant predictor of mental health, adding to the effects of other predictors such as family, social and physical health problems (β = 0.13, 95% CI 0.27, 0.56). The effects of hair loss severity on mental health outcomes were mediated by women’s negative social experiences (indirect = 0.72, 95% bias-corrected confidence interval, 0.53–1.08). Healthcare professionals supporting women with hair loss after irradiation for childhood tinea capitis should be alert to a history of severe levels of hair loss.

Indurated purple plaques on the scalp

Cutaneous epithelioid angiosarcoma is a rare neoplasm of vascular endothelial cell origin that can mimic a cutaneous lymphoma, metastatic carcinoma, or Kaposi sarcoma. It is one of the most malignant cutaneous tumors and early diagnosis is essential, as the tumor metastasizes quickly. We describe a 75-year-old man who presented with three tender, indurated violaceous plaques on his scalp. Biopsy revealed a poorly circumscribed infiltrate extending into the subcutaneous fat, composed of atypical epithelioid cells lining vascular spaces. We provide a brief review of the clinical presentation, histopathologic features, differential diagnosis, and management of this rare tumor.

Meningiomas after Radiotherapy for Tinea Capitis - Still No History

Aims and background

To review the clinical, radiological and histological findings of 19 patients with radiation-induced intracranial meningiomas treated at our neurosurgical department between 1981 and 1996.

Method

The records of 18 patients with intracranial meningiomas who underwent low-dose radiation for tinea capitis in childhood, and of one patient irradiated for pituitary adenoma, were analyzed in respect of the previously reported features of postradiation meningiomas.

Results

The mean age of the patients with low-dose radiation-induced meningiomas was 58 years and the mean shortest onset latency was 48 years. The male to female ratio was 1.1:1. Forty-seven percent of patients presented with mental changes and/or focal neurological signs, 21% with signs of increased intracranial pressure and 26% with seizures. Calvarial location of the meningiomas was found in 54% of patients and in one patient the tumor arose from the skull base. Multiple tumors were present in 15% of patients and 29% of the meningiomas displayed malignant features on histological examination. A significantly lower meningioma recurrence rate was found in our series compared to the recurrence rate in the reported series of postradiation meningiomas. Five patients had a history of a second neoplasm other than meningioma.

Conclusion

Our series of low-dose radiation-induced meningiomas represents one of the largest of its kind in the English literature. The patients did not differ substantially in sex ratio, tumor localization, multiplicity and histological features from the previously reported postradiation meningioma patients, except for the significantly lower tumor recurrence rate. It would seem that over the next years we will be further witnessing the deleterious effects of low-dose radiation administered in childhood.

TERT promoter mutations: a genetic signature of benign and malignant thyroid tumours occurring in the context of tinea capitis irradiation

OBJECTIVE

The aim of this study is to evaluate the frequency and molecular characteristics of TERTp mutations in thyroid adenomas and carcinomas occurring in the low-dose radiation exposure tinea capitis setting.

DESIGN AND METHODS

Twenty-seven patients with 34 well-differentiated thyroid carcinomas and 28 patients with 29 follicular adenomas diagnosed in a Portuguese tinea capitis cohort were studied. Blood samples were obtained from all the patients. Screening for TERTp mutations was performed by PCR amplification followed by Sanger sequencing. A series of 33 sporadic thyroid adenomas was used as control.

RESULTS

TERTp mutations were detected in six of the 28 patients with adenoma (21.4%) and in four of the 27 patients with carcinoma (14.8%). Three tumours (two carcinomas and one adenoma) had the tandem mutation -124/-125 GG>AA (30.0%), whereas the remaining seven had the -124G > A. The 20.7% frequency of TERTp mutations in adenomas contrasts with the absence of mutations in the adenomas from the control group and from most series on record, whereas the one found in carcinomas (11.8%) is similar to those reported in the literature for sporadic carcinomas.

CONCLUSION

TERTp mutations, including the tandem mutation -124/-125 GG>AA not described previously in thyroid tumours, appear to represent a genetic signature for thyroid tumours in patients submitted to low-dose X-ray irradiation. The high frequency of TERTp mutations in the adenomas of our cohort contrasts with their absence in sporadically occurring, as well as in adenomas of the Chernobyl series.

Genetic alterations in thyroid tumors from patients irradiated in childhood for tinea capitis treatment

OBJECTIVE

Exposure to ionizing radiation at young age is the strongest risk factor for the occurrence of papillary thyroid carcinoma (PTC). RET/PTC rearrangements are the most frequent genetic alterations associated with radiation-induced PTC, whereas BRAF and RAS mutations and PAX8-PPARG rearrangement have been associated with sporadic PTC. We decided to search for such genetic alterations in PTCs of patients subjected in childhood to scalp irradiation.

DESIGN

We studied 67 thyroid tumors from 49 individuals irradiated in childhood for tinea capitis scalp epilation: 36 malignant (12 cases of conventional PTC (cPTC), two cPTC metastases, 20 cases of follicular variant PTC (FVPTC), one oncocytic variant of PTC and one follicular carcinoma) and 31 follicular thyroid adenomas.

METHODS

The lesions were screened for the BRAF(V600E) and NRAS mutations and for RET/PTC and PAX8-PPARG rearrangements.

RESULTS

BRAF(V600E) mutation was detected in seven of 14 (50%) cPTC and two of 20 FVPTC (10%) (P=0.019). NRAS mutation was present in one case of FVPTC (5%). RET/PTC1 rearrangement was found, by RT-PCR, in one of 17 cases (5.9%) and by fluorescence in situ hybridization in two of six cases (33%). PAX8-PPARG rearrangement was not detected in any carcinoma. None of the follicular adenomas presented any of the aforementioned genetic alterations.

CONCLUSIONS

The prevalence of BRAF(V600E) mutation in our series is the highest reported in series of PTCs arising in radiation-exposed individuals. The prevalence of RET/PTC1 rearrangement fits with the values recently described in a similar setting.

The mass campaign to eradicate ringworm among the Jewish community in Eastern Europe, 1921-1938

Between the years 1921 and 1938, 27,600 children were irradiated during a mass campaign to eradicate ringworm among the Jewish community in East Europe. The ringworm campaign was the initiative of the American Jewish Joint Distribution Committee together with the Jewish health maintenance organization OZE (The Society for the Protection of Jewish Health). We describe this campaign that used x-rays to eradicate ringworm and its mission to enhance public health among Jewish communities in Eastern Europe during the period between the world wars. We discuss the concepts behind the campaign, the primary health agents that participated in it, and the latent medical ramifications that were found among children treated for ringworm, many years after treatment--pathologies that can be linked to the irradiation they received as children. Our research is based on historical archival materials in the United States, Europe, and Israel.

[Cutaneous carcinoma induced by radiotherapy: a report of 31 cases]

BACKGROUND

Depilatory radiotherapy was used in the sixties as a treatment for ringworm in Tunisia. Subsequently some of these patients developed radio-induced carcinomas of the scalp.

AIM

To present the epidemiological, clinical, pathological,therapeutic features and out come of radio-induced cutaneous carcinomas.

METHODS

We conducted a retrospective study performed in the dermatology department of the La Rabta hospital of Tunis over a 6- year-period recording all histologically confirmed carcinomas in patients irradiated in childhood for tinea capitis.

RESULTS

Thirty one patients were included with 49 tumors: 47 basal cell carcinomas and 2 squamous cell carcinomas. The average latent period between the irradiation and the appearance of the carcinomas was of 35.7 years. The average age was 53 years. A male predominance was noted, with a sex ratioM/F of 6.75. Clinically, basal cell carcinomas were nodular in all cases. Surgery was indicated in 90% of cases. Cryosurgery and radiotherapy were used respectively in 1 and 2 patients.

CONCLUSION

Our study shows that radio-induced cutaneous carcinomas are widely dominated by basal cell carcinoma. They arise, approximately, ten years earlier than carcinoma in patients with no history of scalp irradiation. However X-ray exposure does not seem to influence clinical or histological presentation, therapeutic modalities nor prognosis of these tumors. The prognosis of radioinduced cutaneous carcinomas was globally similar to that of other cutaneous carcinomas with same histological type and equivalent degree of invasion.

Malignant melanoma following scalp irradiation for tinea capitis

X-Rays were discovered by Roentgen in 1895 and were subsequently used in the treatment of many ailments. Numerous benign skin conditions including eczema and psoriasis have historically been treated with X-rays. During the 1930s and 1940s radiotherapy was introduced as an effective treatment for scalp ringworm (tinea capitis). Over the past few years radio-induced malignancies have been reported, with basal cell carcinoma predominating. We report a very rare case of a 64-year-old male with a 9.5mm Breslow thickness melanoma occurring over 50 years following irradiation. This case highlights the presence of another risk factor in the development of melanoma. With the increasing age of this irradiated population we may continue to see further evidence of the link between melanoma and skin irradiation.

Low-dose X-ray depilatory treatment induces trichoblastic tumors of the scalp

BACKGROUND

Depilatory radiotherapy for ringworm was largely used before antifungals were available. Patients who underwent this treatment are at high risk of developing scalp tumors or other cancers. The aim of this study was to characterize scalp tumors occurring after X-ray therapy for ringworm.

METHODS

We included cases of postradiotherapy scalp tumors recorded at the Dermatology Department of the Charles Nicolle Hospital, Tunis between 1988 and 2001. We recorded clinical descriptions and all cases were resubmitted to microscopic analysis.

RESULTS

Sixty-one tumors occurred in 33 men and 12 women with a mean age of 49.8 years. Radiodermatitis was present in 21% of patients. Tumors were basal cell carcinomas in 47 cases, trichoblastomas in 10 cases and trichoblastic carcinomas in 4 cases. Twelve patients had 2-5 tumors, with combinations of tumor types in 3 of them. Mean delay of onset of tumors after radiotherapy was 39.4 years in basal cell carcinoma cases, 38.3 years in trichoblastoma cases and 35.6 years in trichoblastic carcinoma cases.

CONCLUSIONS

This series shows that although basal cell carcinoma is the most frequent tumor in this situation, trichoblastomas are common. We describe, for the first time, radio-induced trichoblastic carcinomas. Trichoblastic tumors have not yet been described in this context because this concept is relatively recent.

Risk of thyroid cancer after childhood exposure to ionizing radiation for tinea capitis

BACKGROUND

The thyroid gland is known to be sensitive to the carcinogenic effect of ionizing radiation, especially in children. The role of potential modifiers of the risk and latency period effects needs further investigation. We examined the effect of low doses of ionizing radiation (4.5-49.5 cGy) on the risk of developing thyroid cancer after long latent periods of up to 54 yr after childhood exposure.

METHODS

The study population included 10,834 individuals irradiated against tinea capitis in the 1950s and two matched nonirradiated groups (general population and siblings) for comparison. Cancer statistics and vital status data were obtained from national registries, updated to December 2002. Excess relative and absolute risks [excess relative risk per gray (ERR/Gy), excess absolute risk (EAR)] were estimated using Poisson regression for survival analysis.

RESULTS

Within the study period, 159 cases of thyroid cancer were diagnosed. Total ERR/Gy and excess absolute risk per gray per 10(4) person-years for developing thyroid cancer reached 20.2 (95% confidence interval 11.8-32.3) and 9.9 (95% confidence interval 5.7-14.7), respectively. The risk was positively associated with dose and negatively associated with age at exposure. ERR/Gy was significantly elevated 10-19 yr after exposure, peaking at 20-30 yr, and decreasing dramatically (although still significantly elevated) 40 yr after exposure.

CONCLUSIONS

Our findings agree with patterns of risk modification seen in most studies of radiation-induced thyroid cancer, although risk per unit dose seems higher. Our data show that 40 yr after irradiation, ERR decreases dramatically, although remaining significantly elevated. The hypothesis of different genetic susceptibility of the Jewish population deserves further exploration.

Estimation of cancer risks from radiotherapy of benign diseases

BACKGROUND

The effective-dose method which was proposed by the ICRP (International Commission of Radiation Protection) for the estimation of risk to the general population from occupational or environmental, low-dose radiation exposure is not adequate for estimating the risk of cancer induction by radiotherapy of malignant or nonmalignant diseases.

METHODS

The risk of cancer induction by radiotherapy of benign diseases should be based on epidemiologic data directly derived from follow-up studies of patients who had been given radiotherapy for nonmalignant diseases in the past.

RESULTS

Risk factors were derived from epidemiologic studies of patients treated with irradiation for nonmalignant diseases to be used for selecting treatment options and optimizing treatment procedures.

CONCLUSION

In most cases, cancer risks estimated by the effective-dose method may overestimate the true risks by one order of magnitude, yet in other cases even may underestimate it. The proposed method using organ-specific risk factors may be more suitable for treatment planning.

[Profile of basal cell carcinomas of the scalp after radiotherapy for tinea capitis (about 63 cases)]

The induction of basal cell carcinoma (BCC) of the scalp by X-ray therapy for tinea capitis is well known. The aim of the study was to specify the epidemiological, clinical and histological characteristics of this disease. In a retrospective study, we collected data from the files of 63 patients, with a history of radiotherapy for tinea capitis, followed between January 1995 and December 2004. Fifty one men and 12 women with a total of 108 BCC of the scalp are reported (1.76 lesion per patient and 1.13 cm on average of diameter). The mean age at the occurrence of the BCC was 45.5 years. Thirty seven percent of BCC occurred on the occipital area; 28.7% were in the parietal site. The most frequent clinical aspect was the nodular BCC (51%) and the cicatricial BCC (35%). Histological study showed a nodular aspect in 74 % and pigmentation in 62% of cases. It is concluded that BCC of the scalp following X-ray therapy for tinea capitis have some clinical and histological particularities. It represents the most frequent tumour developing on irradiated scalp.

Long-term follow-up for brain tumor development after childhood exposure to ionizing radiation for tinea capitis

Ionizing radiation is an established risk factor for brain tumors, yet quantitative information on the long-term risk of different types of brain tumors is sparse. Our aims were to assess the risk of radiation-induced malignant brain tumors and benign meningiomas after childhood exposure and to investigate the role of potential modifiers of that risk. The study population included 10,834 individuals who were treated for tinea capitis with X rays in the 1950s and two matched nonirradiated groups, comprising population and sibling comparison groups. The mean estimated radiation dose to the brain was 1.5 Gy. Survival analysis using Poisson regression was performed to estimate the excess relative and absolute risks (ERR, EAR) for brain tumors. After a median follow-up of 40 years, an ERR/Gy of 4.63 and 1.98 (95% CI = 2.43-9.12 and 0.73-4.69) and an EAR/Gy per 10(4) PY of 0.48 and 0.31 (95% CI = 0.28-0.73 and 0.12-0.53) were observed for benign meningiomas and malignant brain tumors, respectively. The risk of both types of tumors was positively associated with dose. The estimated ERR/Gy for malignant brain tumors decreased with increasing age at irradiation from 3.56 to 0.47 (P = 0.037), while no trend with age was seen for benign meningiomas. The ERR for both types of tumor remains elevated at 30-plus years after exposure.

Low-grade primary meningeal lymphoma: case report and review of the literature

Primary meningeal lymphoma is a rare occurrence. We present a case of an immunocompetent patient operated on for a fronto-parietal lesion similar to a meningioma, which the histological examination diagnosed as a mucosa-associated lymphoid tissue (MALT)-type lymphoma. She received no further post-operative treatment and after 36 months showed no evidence of disease. In a review of the literature, we identified 14 similar cases of MALT lymphoma pre-operatively diagnosed as meningioma. Recognition of this rare meningeal location of a lymphoma involving the central nervous system is useful for a proper diagnosis and adequate treatment.

Radiation-induced intracranial meningiomas: review of six operated cases

It is well known that radiation can induce meningiomas. These tumors usually arise in patients with a history of low-dose radiation to the scalp for treatment of tinea capitis or high-dose radiation for a previous brain tumor. Radiation-associated meningiomas (RAMs) morphologically resemble their spontaneously arising counterparts. However, RAMs frequently present a more malignant phenotype and, as such, are diagnosed as "atypical" or "aggressive" meningiomas and occur predominantly in younger patients. This paper describes six cases of radiation-associated intracranial meningiomas in patients previously treated with low-dose radiation to the scalp for tinea capitis.

Intracranial Meningiomas Developing at Long Intervals Following Low-Dose X-Ray Irradiation of the Head

Five patients are reported who underwent X-ray epilation in childhood for tinea capitis and who developed meningiomas after about four decades. X-ray irradiation resulted in permanent alopecia in four of the five patients. In four patients the tumors were found on the convexity, one patient had a tuberculum sellae meningioma. All five patients underwent surgery. Recurrence was noted in three of the five patients, one of them was reoperated. No malignant features, but signs of atypia were found at histopathological examination. The development of meningiomas after low-dose irradiation with long latency periods, the predominant calvarial location of the tumors, the high recurrence rates, the absence of malignant traits but the presence of atypias are features overwhelmingly common with similar cases published in the literature. The fact that two of the five patients were sisters stresses the importance of genetic factors in the evolution of these tumors.

Carcinomes basocellulaires du cuir chevelu secondaires à une radiothérapie pour teigne : une série de 33 malades

Occurrence of basal cell carcinoma (BCC) following radiotherapy for tinea capitis is well known. The aim of this study was to specify the clinical and histological features of these BCC seen in 33 patients (1995-2000). Twenty seven men and six women were diagnosed with BCC. The age of onset varied between 32 an 62 years. Radiotherapy was received between 5 and 17 years of age. The interval between irradiation and the onset of carcinoma varied between 21 and 51 years. Total number of lesions was 55. Forty percent of BCC occurred on the occipital area, the number varied from 1 to 5 and the size from 2 to 45 mm. Clinically, the nodular type was found in 51% of cases. Pigment was present in 64% of cases. Histological study showed a nodular aspect in 76% and pigmentation in 63% of cases. Nodular and pigmented type were the predominant BCC occurring after radiotherapy for tinea capitis in our series. In the literature, BCC are the most frequent carcinomas occurring after radiotherapy (70-100%). Pigmentation was not described in other series. The nodular histological form was the most frequent.

Ret/PTC activation in benign and malignant thyroid tumors arising in a population exposed to low-dose external-beam irradiation in childhood

Ionizing radiation is the strongest risk factor known for the development of thyroid neoplasia. Although ret/PTC rearrangements have been identified in both spontaneous and radiation-induced papillary thyroid cancer, they seem more frequent among radiation-associated tumors. We studied the frequency of ret/PTC activation in a group of sporadic and radiation-induced thyroid carcinomas (n = 49) and adenomas (n = 13) among 44 individuals treated for Tinea Capitis with low-dose external irradiation as well as in 18 nonirradiated subjects. Total RNA recovered from paraffin-embedded thyroid cancer surgical specimens was analyzed for ret/PTC 1, 2, and 3 mutations using RT-PCR with Southern blotting to maximize detection sensitivity. Ret/PTC rearrangements were identified in 42.9% of thyroid carcinoma and 46.2% of adenoma subjects. Among the positive carcinoma specimens, three were follicular carcinomas. Ret/PTC 1, the predominant rearrangement, was more prevalent in nonirradiated compared with irradiated carcinomas (66.7 vs. 27.0%; P = 0.04). Ret/PTC activation was associated with male gender. The strengths of this study included analysis of age-, gender-, and ethnicity-matched groups; molecular analysis using two techniques; and a complete blinding of laboratory analysis from clinical features. The differences seen between these and other published results may be related to differences in radiation doses to the thyroid, latency period between time of radiation exposure and development of clinically apparent thyroid cancer, and ethnic background of the study populations.

Radio-induced malignancies of the scalp about 98 patients with 150 lesions and literature review

INTRODUCTION

- The induction of malignant diseases is one of the most concerning late effects of ionizing radiation. The topic of this study deals with skin tumors developed in the irradiated areas in children given X-ray therapy for tinea capitis.

MATERIAL AND METHODS

- All patients with malignant tumors of the scalp referred to Salah Azaiz Institute between 1970 and 2001 have been questioned in order to determine if there had been a prior X-ray irradiation for tinea capitis, its modality, and its consequences. The first scalp irradiation goes back to 1922 and the last was performed in 1963.

RESULTS

- Ninety-eight patients with 150 radio-induced cancers of the scalp following irradiation for tinea capitis are reported (1.5 lesion per patient). The patients were irradiated in various hospitals and dispensaries throughout the country. Eighty-one patients (82%) had only one session of radiation. The average age at irradiation was 12 (+/-6) years, the latent period for radiation-induced skin cancers was 36 (+/-14) years. In 61 patients (62%), the scalp appeared normal and in 38% radiodermatitis was noted. Patient age at diagnosis of malignancy varied from 20 to 83 years with an average of 47 years. Basal cell carcinomas (125 cases) and spinocellular carcinomas (16 cases) were the most common, three other cases of annexial tumors, two malignant non-Hodgkin's lymphomas and four melanoma lesions are also present. Radiotherapy was used for the treatment of 74 patients (alone in 42 and associated with surgery in 32 patients); 14 patients had exclusive surgical excision.

CONCLUSIONS

- Basal cell carcinomas are the most frequent tumors arising on chronic radiodermatitis. In spite of the long latency period, patients' young age at irradiation explained the occurrence of these cancers at a relatively young age. Literature review is suggesting recessive mutation of tumor-suppressor genes as the characteristic abnormality in radio-induced cancer.

Squamous Cell Carcinoma of the Scalp After Radiotherapy for Tinea Capitis

BACKGROUND

Radiotherapy for tinea capitis was widely used in the 1930s and 1940s. There is a fourfold increase in the risk for developing nonmelanoma skin cancer in the scalp. Excision of lesions is challenging, as tissue around the wound is atrophic and susceptible to ischemia.

OBJECTIVE

To discuss the risk of skin cancer in the older patient who received scalp radiotherapy in childhood and options for scalp reconstruction after excision.

METHODS

A woman developed squamous cell carcinoma on the scalp 67 years after radiotherapy for tinea capitis.

RESULTS

The large excision defect was successfully grafted, avoiding the need for complex scalp reconstruction.

CONCLUSION

Patients who received scalp radiotherapy in childhood are at increased risk of developing nonmelanoma skin cancer. The unique anatomy of scalp tissue makes it difficult to close excisional defects. Skin grafting often fails, and complex flaps or the importation of vascularized tissue may be required.

A Reanalysis of Thyroid Neoplasms in the Israeli Tinea Capitis Study Accounting for Dose Uncertainties

In the 1940s and 1950s, children in Israel were treated for tinea capitis by irradiation to the scalp to induce epilation. Follow-up studies of these patients and of other radiation- exposed populations show an increased risk of malignant and benign thyroid tumors. Those analyses, however, assume that thyroid dose for individuals is estimated precisely without error. Failure to account for uncertainties in dosimetry may affect standard errors and bias dose-response estimates. For the Israeli tinea capitis study, we discuss sources of uncertainties and adjust dosimetry for uncertainties in the prediction of true dose from X-ray treatment parameters. We also account for missing ages at exposure for patients with multiple X-ray treatments, since only ages at first treatment are known, and for missing data on treatment center, which investigators use to define exposure. Our reanalysis of the dose response for thyroid cancer and benign thyroid tumors indicates that uncertainties in dosimetry have minimal effects on dose-response estimation and for inference on the modifying effects of age at first exposure, time since exposure, and other factors. Since the components of the dose uncertainties we describe are likely to be present in other epidemiological studies of patients treated with radiation, our analysis may provide a model for considering the potential role of these uncertainties.

Radiation-induced schwannomas of the nervous system. Report of five cases and review of the literature

Radiation therapy has important delayed effects on the central nervous system. Prominent among these effects is radiation necrosis of nervous tissue, but an oncogenic effect is also recognized. Both benign and malignant intracranial tumors can develop in irradiated fields, particularly in children. Most of these tumors are sarcomas, meningiomas or gliomas and only occasionally schwannomas. We report 5 cases of postirradiation acoustic nerve schwannoma observed in our Department.

Prolactinoma and other head and neck tumors after scalp irradiation

Tumors of the thyroid and parathyroid glands may develop together or separately in patients who previously have been exposed to head and neck irradiation. Whether cranial irradiation confers an increased risk for pituitary adenoma remains unknown. We report the case of a 52-year-old woman who was treated during childhood for tinea capitis with scalp irradiation and later in life developed a prolactin-secreting tumor, a parathyroid adenoma, a benign thyroid lesion, and a basal cell carcinoma of the skin. She was treated successfully with bromocriptine and surgical removal of the parathyroid adenoma. Molecular analysis of the parathyroid tissue failed to demonstrate any abnormality of the multiple endocrine neoplasia Type 1 gene. This case report is the first to describe a prolactin-secreting tumor that developed in association with other endocrine neoplasia after head and neck irradiation. Our case suggests that multiple endocrine neoplasia may develop in a sporadic pattern after scalp irradiation.

Radiation-induced meningioma: a descriptive study of 253 cases

OBJECT

Ionizing radiation is the only established risk factor recognized today in the causation of meningioma. The aim of the present report is to describe the demographic and clinical characteristics of a large series of 253 patients with radiation-induced meningiomas (RIMs). These parameters were compared with those of 41 patients with meningiomas in whom there was no previous history of irradiation (non-RIM group) and with other series of patients presented in the literature.

METHODS

The cases of RIM were recruited from a cohort of approximately 11,000 individuals who had been treated with ionizing radiation during childhood for tinea capitis and from a group of individuals who, as adults, applied for compensation because of that treatment. The non-RIM group was identified through the Israeli Cancer Registry. Exposure to radiation was carefully validated among all cases of RIM and absence of previous irradiation was verified for all patients in the non-RIM group. Significantly, a lower patient age at diagnosis, higher prevalence of calvarial tumors, higher proportion of multiple meningiomas, and a nonsignificant higher recurrence rate were observed among patients with RIM compared with the non-RIM group. The mean latency period from date of radiation exposure to development of a meningioma among the RIM group was approximately 36 years.

CONCLUSIONS

The findings of this study agree with those of other studies indicating the demographic, clinical, and even genetic variability between RIM and non-RIM cases. The existence of two different subtypes of meningiomas may have profound implications for screening, early diagnosis, and therapy of meningiomas.

A possible association between ionizing radiation and pituitary adenoma: a descriptive study

BACKGROUND

Despite the recognition of ionizing radiation as a causal risk factor for a variety of solid tumors (including brain tumors), to date, such an association with pituitary adenoma (PA) has not been demonstrated.

METHODS

To evaluate a possible association between past exposure to radiation and the occurrence of PA, the authors reviewed about 4900 medical records of patients who had been irradiated in childhood for tinea capitis. An additional search for patients was performed using the Israel Cancer Registry. The average radiation dose to the pituitary gland was estimated as 0.56 grays, and, for all patients, a meticulous validation of the irradiation was performed.

RESULTS

A group of 16 patients who developed symptomatic PA after childhood exposure to radiotherapy were identified. Overall, the clinical and demographic characteristics of these patients were similar to other series reported in the literature. There was an apparently high rate of second primary tumors (25%), all of them in the irradiated area, diagnosed among this group. The methodologic issues that limit the demonstration of a possible association between radiation and PA and the epidemiologic and experimental findings in the literature are discussed.

CONCLUSIONS

In view of the ample amount of evidence identifying low-dose ionizing radiation as a risk factor for a number of intracranial tumors as well as for tumors arising in endocrine organs, a radiation immunity of the pituitary gland is difficult to accept. Hence, the authors suggest that this series should be considered as preliminary observation that supports the role of ionizing radiation in the development of this tumor.

'Clicking-brain syndrome': a curious cause of insomnia

This case report describes a curious cause of insomnia. A 93-year-old woman presented to our follow-up clinic with the complaint of insomnia secondary to an audible click emanating from her skull. The site of loud biphasic-sound production corresponded to an area of the scalp where a squamous cell carcinoma had been removed 11 years previously.

Thyroid cancer following scalp irradiation: a reanalysis accounting for uncertainty in dosimetry

In the 1940s and 1950s, over 20,000 children in Israel were treated for tinea capitis (scalp ringworm) by irradiation to induce epilation. Follow-up studies showed that the radiation exposure was associated with the development of malignant thyroid neoplasms. Despite this clear evidence of an effect, the magnitude of the dose-response relationship is much less clear because of probable errors in individual estimates of dose to the thyroid gland. Such errors have the potential to bias dose-response estimation, a potential that was not widely appreciated at the time of the original analyses. We revisit this issue, describing in detail how errors in dosimetry might occur, and we develop a new dose-response model that takes the uncertainties of the dosimetry into account. Our model for the uncertainty in dosimetry is a complex and new variant of the classical multiplicative Berkson error model, having components of classical multiplicative measurement error as well as missing data. Analysis of the tinea capitis data suggests that measurement error in the dosimetry has only a negligible effect on dose-response estimation and inference as well as on the modifying effect of age at exposure.

Multiple basal cell carcinomas developed after radiation therapy for tinea capitis: a case report

Development of skin neoplasms is the most important complication of radiation therapy. There are contradictive reports about the type of these neoplasms. Squamous cell carcinomas are considered the most frequent tumors arising on chronic radiodermatitis areas, but recent studies have demonstrated that the type of neoplasm occurring in response to ionizing radiation exposure depends on several factors. Herein we report a patient who had received low-dose radiation for the treatment of tinea capitis and developed multiple basal cell carcinomas in the radiated areas after a long latent period of 53 years.

Cancer risk from low-level ionizing radiation: the role of age at exposure

This article examines methodological issues related to epidemiologic investigations of the influence of age at exposure on radiation risk estimates; the epidemiologic literature on the role of age at exposure in radiation-cancer associations; and biological mechanisms that may account for associations observed in these studies. There is substantial evidence that young children, and especially the fetus, are highly vulnerable to ionizing radiation. Investigations also suggest that sensitivity may increase at the oldest ages of exposure. Further attention to modifying factors in radiation-cancer associations, such as age at exposure, may help to protect workers and the public by improving our understanding of sensitivity variation within populations.

An iatrogenic epidemic of benign meningioma

Head irradiation, the acceptable mode of treatment for tinea capitis in the past, is recognized today as a causative factor for meningioma. This treatment was applied en mass to immigrants coming to Israel from North Africa and the Middle East during the 1950s. In order to estimate the effect of the differential radiation treatment on the rates of meningioma in the total population, the authors assessed time trends of this disease in Israel over the past 40 years by main ethnic origin. Cohort analysis shows a marked incidence rise in the North African-born cohorts born in 1940-1954 starting from the 1980s. A similar pattern is seen in the Middle Eastern born, although the increase is not as sharp. In consequence, there is a crossover of the interethnic incidence curves in the 1940-1949 cohort. Comparison of the relative risk between 1940-1954 cohorts that comprised most of the irradiated with 1930-1939 cohorts, who were largely free of the radiation, shows that the North African born have the largest relative risk of 4.62, followed by the Middle Eastern born, with a relative risk of 1.95, while the European-American born have a relative risk close to 1. The differences between the three areas of birth are statistically significant. The data illustrate the potential risk of administering highly potent therapy for an essentially benign disease that led, in turn, to a drastic change in the national meningioma pattern.

Multiple skull base meningioma: case report

BACKGROUND

The incidence of multiple skull base meningiomas varies from 1 to 3% in different series. Skull base meningiomas are rare. The pathogenetic role of low-dose radiation seems to be fairly well established in the oncogenesis of meningiomas. Calvarial location and multiplicity seem to be among the distinctive features of radiation-induced meningiomas. Skull base location is a very rare occurrence, mainly because the path of irradiation does not significantly involve this region.

CASE REPORT

We describe a rare case of simultaneous occurrence of two skull base meningiomas in a 66-year-old female. This patient underwent low-dose irradiation for tinea capitis when she was 8 years old. The patient complained of nuchal pain, paresthesias in both hands, and progressive weakness on her right side. She was admitted to the hospital in September 1994. An MRI showed two masses, one located at the level of the tuberculum sellae and the other at the foramen magnum. These seemed very likely to be multiple meningiomas. The latter lesion, which was more symptomatic and dangerous, was operated on first. Six months later, elective treatment of the suprasellar meningioma was performed with success.

CONCLUSION

The actual role of previous head irradiation in the oncogenesis of the present meningiomas remains somewhat unclear. Proper management and judicious use of skull base surgery techniques were key factors in the successful treatment of the patient.