Correspondence
Nonmelanoma Cancers of the Skin
N Engl J Med 1993; 328:1199-1200April 22, 1993
- Article
To the Editor:
In their review article “Nonmelanoma Cancers of the Skin” (Dec. 3 issue),1 Drs. Preston and Stern should have pointed out that radiation therapy properly delivered by competent radiation oncologists results in a tumor recurrence rate of 5 percent for basal-cell carcinoma and 10 percent for squamous-cell carcinoma. Furthermore, their description of “undesirable contour changes” is not borne out by the existing literature. Chondritis, tissue necrosis, and wound breakdown, which they describe as potential complications of radiation therapy, are observed in less than 2 percent of the patients treated. Their statement that “Longer-term difficulties, including carcinogenesis and radiation dermatitis, argue against its use in patients under 50 years of age” is not supported by any published data.
The current dose and fractionation schedules for obtaining optimal results are usually based on the delivery of three to five fractions per week for four to six weeks, a period substantially longer than the period mentioned by the authors.
We reported2,3 on 339 cases of nonepithelial skin cancers treated with irradiation; the rate of tumor control was 95 to 97 percent for basal-cell carcinomas, 90 to 100 percent for squamous-cell carcinomas less than 3 cm in diameter, and 85 to 88 percent for lesions 3 to 5 cm in diameter. Excellent or good cosmetic results were noted in 92 percent of the patients. The sequelae of therapy (usually skin atrophy and telangiectases) were related to the tumor size (0.9 percent for lesions less than 1 cm, 7.1 percent for tumors 1 to 5 cm, and 30.6 percent for lesions greater than 5 cm). This was related not only to the larger volume of skin involved, but also to the higher doses of radiation used to treat the tumors.
Necrosis of skin or soft tissue was noted in only 16 of 339 patients (4.7 percent); 2 patients had necrosis of soft tissue and bone, 1 had bone necrosis, and 1 had brain necrosis. This morbidity is substantially less than that suggested by Preston and Stern.
Similar results were obtained by Fitzpatrick et al. in 1166 skin cancers of the eyelid4 and in 361 patients with cancer of the lip,5 and by Petrovich et al.6 in 646 patients with various epithelial tumors of skin.
6 ReferencesCarlos A. Perez, M.D.
Mallinckrodt Institute of Radiology, St. Louis, MO 631081
Preston DS ,Stern RS . Nonmelanoma cancers of the skin. N Engl J Med 1992;327:1649-1662
Full Text | Web of Science | Medline2
Lovett RD ,Perez CA ,Shapiro SJ ,Garcia DM . External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 1990;19:235-242
Web of Science | Medline3
Perez CA ,Lovett RD ,Gerber R . Electron beam and x-rays in the treatment of epithelial skin cancer: dosimetric considerations and clinical results. Front Radiat Ther Oncol 1991;25:90-106
Web of Science | Medline4
Fitzpatrick PJ ,Thompson GA ,Easterbrook WM ,Gallie BL ,Payne DG . Basal and squamous cell carcinoma of the eyelids and their treatment by radiotherapy. Int J Radiat Oncol Biol Phys 1984;10:449-454
CrossRef | Web of Science | Medline5
Fitzpatrick PJ . Cancer of the lip. J Otolaryngol 1984;13:32-36
Web of Science | Medline6
Petrovich Z ,Kuisk H ,Langholz B , et al. Treatment results and patterns of failure in 646 patients with carcinoma of the eyelids, pinna, and nose. Am J Surg 1987;154:447-450
CrossRef | Web of Science | Medline
To the Editor:
In their review article on nonmelanoma skin cancers, Preston and Stern state, “There is no known precursor lesion for basal-cell carcinoma.”
The sebaceous nevus of Jadassohn, however, is a congenital hamartoma of sebaceous glands within which basal-cell carcinoma may develop. A 20 percent incidence of basal-cell carcinoma in untreated sebaceous nevi has been reported.1 The lesion generally presents at birth as a superficial plaque of varying size and shape that with time often becomes verrucous and nodular. The diagnosis is confirmed by biopsy, and once it is made, surgical excision is indicated.
1 ReferencesEdgar D. Altchek, M.D.
102 E. 78th St., New York, NY 100211
Mehregan AH ,Pinkus H . Life history of organoid nevi. Arch Dermatol 1986;91:574-588
CrossRef
Author/Editor Response
The authors reply:
To the Editor: As we noted in our article, “much of our information about treatment comes from partisans of competing approaches.” Furthermore, we cautioned about possible biases in open uncontrolled studies of one approach. The range of rates of recurrence noted by Dr. Perez in such uncontrolled open studies of radiotherapy, however, is within that given in our Table 4 (and elsewhere1,2). Dr. Perez's rate of complications (less than 2 percent) is in accord with our statement that such problems occur “infrequently.”
We used the phrase “patients under 50 years of age” as shorthand for patients with a life expectancy in excess of 25 years, long enough for the delayed adverse effects of ionizing radiation to develop. We stand by our statements that doses of superficial ionizing radiation such as those used to treat nonmelanoma cancer of the skin are accompanied by a risk of chronic radiation dermatitis and carcinogenesis occurring decades later. This problem is not new, but has been well recognized since Pierre Curie, who first described the use of ionizing radiation to treat cancer, and his wife Marie suffered from disabling chronic radiation dermatitis due to exposure to ionizing radiation similar to that used to treat skin cancer3. Probably because these long-term risks are so well recognized and young patients are only rarely treated at most institutions, we too are unaware of formal studies that have quantified this obvious risk. In certain circumstances, especially when preservation of vital structures is critical, radiotherapy may be the treatment of choice in younger patients. In older ones, radiotherapy is often appropriate.
As we also emphasized, cost and convenience should be considered in selecting treatment. As Dr. Perez notes, 12 to 30 radiotherapy treatments are usually required. These treatments typically cost from $2,000 to $7,500. Administering fewer of them increases the risk of a poor outcome1. In addition to its high cost, the greater inconvenience of radiotherapy as compared with other methods of treatment, which require one to three visits, should be considered. The high direct and indirect costs of radiotherapy are the principal reasons that we do not recommend this treatment more often for older patients.
We had used the word “precursor” in a narrower sense than Dr. Altchek. We were referring to a lesion arising in previously normal skin that displays cytologic atypia and can evolve into cancer. We agree that basal-cell carcinomas do arise with substantial frequency from nevus sebaceus, a congenital hamartoma of sebaceous glands.
3 ReferencesRobert S. Stern, M.D.
Diana S. Preston, M.D.
Beth Israel Hospital, Boston, MA 022151
Lovett RD ,Perez CA ,Shapiro SJ ,Garcia DM . External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 1990;19:235-242
Web of Science | Medline2
Petrovich Z ,Kuisk H ,Langholz B , et al. Treatment results and patterns of failure in 646 patients with carcinoma of the eyelids, pinna, and nose. Am J Surg 1987;154:447-450
CrossRef | Web of Science | Medline3
Pflaum R. Grand obsession: Madame Curie and her world. New York: Doubleday, 1989.
