Update: Solar UV Radiation, Vitamin D, and Skin Cancer Surveillance in Organ Transplant Recipients (OTRs).

Although great progress has been achieved during the last decades, the clinical management of organ transplant recipients (OTRs) remains a challenge. OTRs need in general lifelong immunosuppressive therapy that is associated with an increased risk to develop skin cancer and with an unfavorable clinical outcome of these malignancies. Skin cancer prevention measures, including regular full-body examinations, are therefore necessary in OTRs to detect and treat suspicious lesions at an early stage. The frequency of aftercare depends on the individual risk factors of the patient. Patients should apply consistent sun protection with sunscreens and clothing, as well as a monthly self-examination. On the other hand, the need of UVR avoidance increases the risk of vitamin D deficiency, which itself is associated with an increased risk for many diseases, including malignancies. OTRs should therefore be monitored for 25(OH)D status and/or should take vitamin D supplements. It has to be emphasized that an interdisciplinary approach, coordinated by the transplant center, that includes regular skin examinations by a dermatologist, is needed to ensure the best care for the OTRs.

Iodine Prophylaxis in the Case of Nuclear Accident.

BACKGROUND: On 26th April, 1986 the greatest accident of nuclear plant in Czernobyl occured and isotopes with high percentage of release were erupted: 33-Xe, 131-I, 132-Te, 134-Cs and 137-Cs. The radioactivity of the isotopes was very high - for instance: 33-Xe 6500 PBq, 131-I 1760 PBq. Rest of the 15 isotopes represented similar radioactivity with shorter percentage of release. The most exposed group of people were 237 liquidators, and 11600 people living around had to be evacuated when the limit dose for a person (5mSv) was crossed. Ionizing radiation on the molecular level produces high energy radicals, water radiolysis and ionization of the atoms leading to damage of the enzymes activity centers and receptors, cell membranes DNA, intracellular lysosomes, and especially important for ATP synthesis - mitochondria. These destructions lead to tissue and organs damage. OBJECTIVE: The aim of this article is the presentation of the protective property of iodine application in the case of nuclear accident. METHODS: In Poland at that time, effective iodine prophylaxis did not exist. In the face of such exposition, a special Governement Commission was appointed. When permissioned maximal dose for children and adolescents 50mSv appeared in some areas of the country, the Commission made a decision about obligatory administration of a single pharmacological dose of potassium iodide for all children and adolescents till age 16. No relevant recent patents were available for this WHO report. RESULTS: In this way, the dose of 131-I to thyroid for inhabitants in high, moderated, and low contaminated regions were reduced by about 45%. However, from 1987 to 1997 increase in prevalence of the differentiated thyroid cancer in adults in Polish population especially in women over 40 years old in the southern part of Poland was observed. CONCLUSION: Actually in European countries work 185 nuclear power plants and to 2045 another 100 is planned. In 1999, WHO issued recommendations on iodine prophylaxis in the case of nuclear accident.

Comparative statistical analysis of carcinogenic and non-carcinogenic effects of uranium in groundwater samples from different regions of Punjab, India.

LED flourimeter has been used for microanalysis of uranium concentration in groundwater samples collected from six districts of South West (SW), West (W) and North East (NE) Punjab, India. Average value of uranium content in water samples of SW Punjab is observed to be higher than WHO, USEPA recommended safe limit of 30µgl-1 as well as AERB proposed limit of 60µgl-1. Whereas, for W and NE region of Punjab, average level of uranium concentration was within AERB recommended limit of 60µgl-1. Average value observed in SW Punjab is around 3-4 times the value observed in W Punjab, whereas its value is more than 17 times the average value observed in NE region of Punjab. Statistical analysis of carcinogenic as well as non carcinogenic risks due to uranium have been evaluated for each studied district.

[Methotrexate-associated photosensitization]. / Photosensibilisierung durch Methotrexat.

BACKGROUND: Methotrexate (MTX), alongside fumaric acid esters, is the most commonly used drug in the systemic therapy of psoriasis in Germany. It is sometimes used in combination with topical therapy and/or phototherapy due to synergistic effects. CASE REPORT: Here we describe a case of phototoxic dermatitis during treatment with MTX. Other cutaneous side effects of MTX include so-called UV recall, radiation recall, and skin tumor formation.

The risk of skin cancer in psoriasis patients treated with UVB therapy.

Phototherapy is an effective and widely used treatment for generalised plaque psoriasis. Despite the mutagenic effects of UVB this type of therapy is still assumed to be a safe treatment option. We have performed a cross sectional study to assess the risk of skin cancer in the cohort of psoriasis patients treated with UVB. A total of 162 white patients (116 men and 46 women, mean ± standard deviation age 56.0 ± 13.5 years) were included in the study. All patients have previously been treated with UVB at least 100 times in the last 5 years. Eight patients (4.9%, 0.95 CI: 2.2-9.5%) out of the 162 included in the study had histopathologically verified skin cancer. We found that the risk of skin cancer in psoriasis patients treated with UVB correlated with the number of treatments (controlling for age) but not with the type of UVB lamp. How-ever, the overall risk of malignancy in the UVB-treated patients was not greater than in the general population.

Multifocal papillary thyroid carcinoma--a consensus report of the European Society of Endocrine Surgeons (ESES).

BACKGROUND: Multifocal papillary thyroid carcinoma (MPTC) has been reported in literature in 18-87 % of cases. This paper aims to review controversies in the molecular pathogenesis, prognosis, and management of MPTC. METHODS: A review of English-language literature focusing on MPTC was carried out, and analyzed in an evidence-based perspective. Results were discussed at the 2013 Workshop of the European Society of Endocrine Surgeons devoted to surgery of thyroid carcinoma. RESULTS: Literature reports no prospective randomized studies; thus, a relatively low level of evidence may be achieved. CONCLUSIONS: MPTC could be the result of either true multicentricity or intrathyroidal metastasis from a single malignant focus. Radiation and familial nonmedullary thyroid carcinoma are conditions at risk of MPTC development. The prognostic importance of multifocal tumor growth in PTC remains controversial. Prognosis might be impaired in clinical MPTC but less or none in MPTC <1 cm. MPTC can be diagnosed preoperatively by FNAB and US, with low sensitivity for MPTC <1 cm. Total or near-total thyroidectomy is indicated to reduce the risk of local recurrence. Prophylactic central node dissection should be considered in patients with total tumor diameter >1 cm, or in cases with high number of cancer foci. Completion thyroidectomy might be necessary when MPTC is diagnosed after less than near-total thyroidectomy. Radioactive iodine ablation should be considered in selected patients with MPTC at increased risk of recurrence or metastatic spread.

[Osteosarcoma of the prostate after radiotherapy]. / Osteosarkom der Prostata nach Strahlentherapie.

Osteosarcoma of the prostate is a rare finding. These tumours usually occur years after radiotherapy for prostate cancer. We report the case of a 74-year-old man with prostate cancer who had been treated with radiotherapy and androgen deprivation therapy. The man presented with urinary retention and his prostate was transurethrally resected. The histopathological investigation showed formations of a poorly differentiated osteosarcoma in the prostate. Because of serious comorbidities we decided to withhold chemotherapy considering its potential side effects. The man died a few months after the diagnosis of osteosarcoma in the prostate with the disease in a metastatic stage. In conclusion, osteosarcoma of the prostate is a rarely reported consequence of radiotherapy in patients with prostate cancer and is characterised by poor life expectancy.

An historical overview of radon and its progeny: applications and health effects.

Since its discovery by Dorn in 1900, studies of radon and its progeny have contributed to such diverse scientific fields as meteorology, geophysics, mineral exploration and radiation health effects. In addition to terrestrial scientific studies of radon, NASA missions in recent decades have yielded data on the behaviour of radon and its progeny on the Moon and on Mars. Radon has been used therapeutically for ∼100 y in the form of radon seeds for the irradiation of malignant tumours. It is, however, for its negative health effects that radon is better and more justifiably known. The causal role of radon and, in particular, its progeny in the elevated incidence of lung cancer in underground uranium miners was established in the 1950s. It is of historical interest to note that the fatal lung disease of silver miners in Saxony and Bohemia in the 16th century, was undoubtedly lung cancer caused by the high levels of radon in the mines. In recent decades there has been an ever-growing interest in the public health effects of exposure to radon in homes. Extensive radon epidemiological studies both of underground miners and of the general public in recent decades have quantified the lung cancer risks from radon exposure. Radon was classified in 1988 by International Agency for Research on Cancer as a human carcinogen and in 2009 the World Health Organization identified radon as the second cause of lung cancer globally after smoking. Radon control strategies are used by many governments to control and reduce the risk to public health from radon.

Effectiveness of skin cancer screening for individuals age 14 to 34 years.

BACKGROUND: Approximately 15 % of all cases of melanoma are diagnosed before age 35 years. In Germany, individuals ≥ 35 years are eligible for the national skin cancer screening program. The effectiveness of a population-based skin cancer screening in general and in particular for young adults is unclear. OBJECTIVES: Assessment of the effectiveness of a skin cancer screening program and of risk factors for detection of a melanoma/atypical nevus in the setting of a screening for the age group 14 to 34 years. METHODS: A total of 12,187 individuals age 14 to 34 years were screened in Saxony for skin cancer by a dermatologist in the program "Haut-Check 14-34 Jahre" of the AOK PLUS, a large German health insurance, between January and July 2009. Demographic, clinical and histopathological data and UV-exposure data were collected from each participant. Multivariate logistic regression models were used to assess risk factors for the detection of a (histopathologically confirmed) melanoma or atypical nevus. RESULTS: 2.8 % of the eligible individuals participated in the skin cancer screening program with women being more likely to do so. In 1 072 individuals (8.8 %) screening included at least one excision of a skin lesion leading to the diagnosis of melanoma in two participants, melanoma in situ in four persons, and atypical nevus in 641 persons. Use of tanning beds, higher age, number of nevi, and previous cutaneous excision were independent risk factors for the detection of a melanoma or atypical nevus. CONCLUSIONS: In 5.5 % of all cases skin cancer screening resulted in the excision of a malignant or atypical melanocytic lesion. It remains unclear what proportion of these cases would have been detected in routine care. The rate of excisions per newly diagnosed melanoma was 179 : 1. Further investigations are necessary to explore the reasons for this low diagnostic specificity. This study highlights the possibilities and limitations of routine data to evaluate screening programs and indicates the need to collect additional information on healthcare utilization behaviour.

Radio induced cancer risk during ERCP. Is it a real clinical problem? / Riesgo de cáncer por irradiación durante ERCP. ¿Es un problema clínico real?

Background: in recent years many factors have been shown to influence dose received by the patient during ERCP. Therefore it is necessary to update radio induced cancer risk. Objectives: to calculate lifetime attributable risk of cancer during ERCP. To compare the risk with the most common X-ray examinations. Design: descriptive study with 393 consecutive ERCP performed at one center. Equipment used was Philips BV pulsera. In each exploration demographic and anthropometric variables of the patient were collected. Dosimetric quantities were calculated from exposure parameters. Effective dose was estimated using specific conversion factors. Organ doses and radio induced cancer incidence was estimated. Results: dose area product was 0.82 mGym2 (IQR 0.4-1.5) with an average fluoroscopy time of 2 minutes and 45 seconds. Entrance surface dose was 30.7 mGy (IQR 15-60.8) and effective dose was 0.44 mSv (IQR 0.2-0.9). Multivariate analysis identified that difficult papillary cannulation (β0.4; p = 0.009), patient age (β-0.01; p = 0.001) and therapeutic applied (β= 0.89; p < 0.001) influenced dose-area product. The ERCP dose would be equivalent to the radiation received by twenty chest radiographs and would be about fourteen times smaller than a barium enema or twenty times less than that received during an abdominal CT. Lifetime attributable risk of cancer incidence was 4.08 and 16.81 per million procedures in diagnostic and therapeutic ERCP respectively. Conclusions: from the radiological point of view, ERCP is a safe technique that uses low exposure levels compared to other explorations commonly used in medicine. It implies a reasonably low risk of radio induced cancer (AU)

Occupational and diagnostic exposure to ionizing radiation and leukemia risk among German uranium miners.

Lung cancer is a well-known effect of radon exposure in uranium mines. However, little is known about the induction of leukemia by radiation exposure in mines. Moreover, miners usually have occupational medical checkup programs that include chest x-ray examinations. Therefore, the aim of the present study was to re-examine leukemia risk among miners, taking into account exposure to x rays for diagnostic purposes. The data used were from a previously analyzed individually matched case-control study of former uranium miners in East Germany with 377 cases and 980 controls. Additionally, data on x-ray examinations were taken from medical records for most of the subjects. Finally, the absorbed dose to red bone marrow was calculated considering both occupational and diagnostic exposures. Using conditional logistic regression models, a moderately but not statistically significant elevated risk was seen in the dose category above 200 mGy for the combined dose from both sources [odds ratio (OR) = 1.33, 90% confidence interval (CI): (0.82-2.14)]. Ignoring the dose accumulated in the recent 20 y, the risk in the highest dose category (>105 mGy) was higher [OR = 1.77, 90% CI: (1.06-2.95)]. Ignoring diagnostic exposure yielded similar results. For the highest dose category (absorbed dose lagged by 20 y) the risk was more than doubled [OR = 2.64, 90% CI: (1.60-4.35)].

[The risks of out of area missions: depleted uranium]. / I rischi delle missioni fuori area: l'uranio impoverito.

Depleted uranium (DU), a waste product of uranium enrichment, has several civilian and military applications. It was used as armor-piercing ammunition in international conflicts and was claimed to contribute to health problems, known as the Gulf War Syndrome and recently as the Balkan Syndrome. Leukaemia/Limphoma cases among UN soldiers in the Balkans have been related hypothetically to exposure to DU. The investigations published in the scientific literature give no support for this hypothesis. However future follow-up is necessary for evaluation of long-term risk.

[Thyroid function after external irradiation of the neck in patients with Hodgkin's disease--long-term observation]. / Czynnosc tarczycy po radioterapii okolicy szyi u pacjentów z choroba Hodgkina--dlugoletnia obserwacja.

INTRODUCTION: The modern therapy of Hodgkin's disease (HD): chemotherapy (CT) or/and radiotherapy (RT) gives a chance of a long time survival but it brings a possibility of early and late complications including thyroid gland function disorders (post-radiotherapy thyroiditis, thyroid hypofunction, Graves disease, thyroid nodules, thyroid cancer). AIM: Evaluation of thyroid gland function in patients with total HD remission status from 6 to 16 years after the treatment. MATERIAL AND METHODS: The study included 29 patients suffering from HD (9 women, 20 men, mean age 22.8 years), treated with CT (cycles MVPP and B-DOPA) and with RT (cervical region; 18-40 Gy) in their childhood. The patients were examined by palpation, ultrasound, fine-needle aspiration biopsy. The thyroid gland on the average 6 (1st examination) and 16 years (2nd examination) after the treatment as well as thyroid hormones (TSH, fT3, fT4), thyroglobulin (Tg) and anti-thyroid antibodies in blood serum were estimated. The results were analyzed statistically; the percentage of abnormal results of estimated hormones with reference range was calculated. RESULTS: There were no abnormalities in thyroid palpation examination in any patient. The mean thyroid volume in ultrasound in 2nd examination cor-responded to 66.3% of healthy individuals thyroid volume. In 8 patients thyroid nodules were found, in one thyroid papillary carcinoma was diagnosed. In one patient (3.4%) the features of subclinical thyroid hypofunction and in 17.2% the increased level of Tg in blood serum with normal thyroid hormone levels were found. In two patients (6.8%) the raised titre of a-TG and a-TPO was observed. CONCLUSIONS: 1. In majority of patients with HD after RT in cervical region in long term remission period the normal thyroid function was observed. 2. Due to thyroid cancer hazard even many years after radiotherapy regular morphological thyroid evaluation is necessary.

[Genesis under occupational exposure to toxic and radiation hazards].

The authors studied frequency, periods of development and morbidity structure of malignances among chronic uranium intoxication patients. tumors were diagnosed in 19.1% of the cases. Neoplasms developed in the presence of uranium intoxication symptoms in 57.8% of the patients, occurred after the occupational disease was ruled out in 42.2% of the cases. The oncologic morbidity structure was presented mostly by tumors of gastro-intestinal tract (33.3%) and respiratory system (20%).

A prospective study of thyroid nodular disease in children and adolescents in western Poland from 1996 to 2000 and the incidence of thyroid carcinoma relative to iodine deficiency and the Chernobyl disaster.

BACKGROUND: In Poland, where soil is deficient in iodine, supplementation of iodine was introduced in 1935, discontinued in 1980, and then re-introduced in 1997. One of the effects of inadequate iodine intake, prior to 1997, was an increase in the prevalence of thyroid nodular disease (TND) in children. Chernobyl, located in the neighbouring country of Ukraine, suffered a catastrophic nuclear explosion in April 1986. PROCEDURE: A total of 411 children with TND (an incidence of 7.53/100,000) were diagnosed and registered in western Poland between 1996 and 2000 and further evaluated as a population-based study. RESULTS: Based on the patient's clinical status, ultrasound examination, scintiscan, laboratory tests, cytology and the family history, many of the patients qualified for surgery and, as a result, histopathologic data were obtained from 155 of the 411 patients operated on to date (37.7% of all TND). Thyroid carcinoma was detected in 37 of the operated children, i.e. 23.9% or 9.0% of all children with TND with a median incidence of 0.68/100,000. Papillary carcinoma was the predominant histologic type (26-70.3%) compared to follicular carcinoma (10-27.0%) and medullary carcinoma (1-2.7%). Retrospective analysis of the figures for the 23 years (1972-1995) showed that in that period a total of 23 thyroid carcinomas were registered. However, only 12 of these were detected in the 20-year period between 1972 and 1991, none in the years 1992-1993 and, significantly, 11 from 1994 to 1995. CONCLUSIONS: Thyroid carcinoma appears to be an ongoing and increasing problem in the children and adolescents of our region, and it is developing more intensively when compared, both to other parts of Poland and to previous statistics (2000 vs. 1985; P<0.002). Iodine deficiency and radiation resulting from the Chernobyl disaster might be important risk factors in the development of thyroid carcinoma in the young population analysed in our region in the period since 1994. The high percentage of follicular carcinoma and follicular adenoma with an undetermined prognosis (19 out of 46) indicates that the long-term iodine deficiency in our region may be more significant in the pathogenesis of malignant transformation than has previously been postulated.

[Mucoepidermoid carcinoma of the salivary glands after high dosage radiotherapy]. / Mukoepidermoid-Karzinom der Speicheldrüsen nach hochdosierter Radioiodtherapie.

BACKGROUND: High-dose radioiodine therapy following total thyroidectomy is standard for patients suffering from differentiated thyroid carcinoma and contributes significantly to their favourable prognosis. Due to active iodine accumulation, high focal radiation doses are received by the salivary glands. PATIENTS/RESULT: Report on two patients, who received multiple high-dose radioiodine treatments because of a differentiated metastatic thyroid carcinoma. A few years later, they developed a mucoepidermoid carcinoma of the salivary glands. Due to the high cumulative radiation dose, radiation-induced secondary malignancies following radiation-induced sialadenitis appears likely, although no causal connection could be proven. CONCLUSION: Consistent protection of the salivary glands during radioiodine therapy as well as the follow-up of the many long-term survivors of differentiated thyroid carcinomas is desirable to further lower the salivary gland-related side effects and to detect secondary malignancies as early as possible.