Quiz

Dermatology

Multiple Lesions in Irradiated Skin

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Oncology

May 1, 2019

JAMA Oncology Clinical Challenge

Article Information and Disclosures

Megan Wetzel, MD, MPH¹;

Jae Y. Jung, MD, PhD²;

Timothy S. Brown, MD¹

Author Affiliations

¹Division of Dermatology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
²Norton Cancer Institute, Louisville, Kentucky

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A white man in his 20s presented with numerous pink and brown papules and plaques, some with ulceration, on the head and along the midline of the neck and spine (Figure). Medical history included medulloblastoma treated with irradiation of the brain and spine at age 2 years. He also received radiation therapy for a meningioma of the posterior fossa in adulthood. He was also treated for several seemingly similar lesions on the face and scalp and had a family history of similar cutaneous lesions reported in 2 brothers and 1 niece.

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D. Basal cell carcinoma

Basal cell carcinoma (BCC) is the most common cutaneous cancer in the United States and has an indolent growth pattern, though the lesions may become crusted and ulcerated. Although metastasis is rare, local invasion and destruction may occur with aggressive or chronic lesions. Thus, early identification and treatment is prudent. Risk factors include fair complexion; a history of intense, intermittent sun exposure; immunosuppression; and a positive family history. Radiation exposure may be especially carcinogenic in inducing BCC, and BCC is more likely than squamous cell carcinoma to develop following radiation exposure, with the greatest risk seen in patients who were younger than 10 years when exposed.¹ Furthermore, several genetic syndromes are associated with an increased risk of multiple BCCs, including basal cell nevus syndrome (BCNS).

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Article Information

Corresponding Author: Megan Wetzel, MD, MPH, Division of Dermatology, Department of Medicine, University of Louisville School of Medicine, 3810 Springhurst Blvd, Louisville, KY 40241 (wetzel.meg@gmail.com).

Published Online: January 17, 2019. doi:10.1001/jamaoncol.2018.5852

Conflict of Interest Disclosures: Dr Jung serves as consultant to Regeneron, Adgero, and Amgen, is a principal investigator for Regeneron, Merck, and Iderra, and is employed by the Norton Cancer Institute. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

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Kimonis VE, Goldstein AM, Pastakia B, et al. Clinical manifestations in 105 persons with nevoid basal cell carcinoma syndrome. Am J Med Genet. 1997;69(3):299-308. doi:10.1002/(SICI)1096-8628(19970331)69:3<299::AID-AJMG16>3.0.CO;2-M PubMed Google Scholar Crossref

Johnson RL, Rothman AL, Xie J, et al. Human homolog of patched, a candidate gene for the basal cell nevus syndrome. Science. 1996;272(5268):1668-1671. doi:10.1126/science.272.5268.1668 PubMed Google Scholar Crossref

Gorlin RJ. Nevoid basal cell carcinoma (Gorlin) syndrome. Genet Med. 2004;6(6):530-539. doi:10.1097/01.GIM.0000144188.15902.C4 PubMed Google Scholar Crossref

Jones EA, Sajid MI, Shenton A, Evans DG. Basal cell carcinomas in gorlin syndrome: a review of 202 patients. J Skin Cancer. 2011;2011:217378. doi:10.1155/2011/217378 PubMed Google Scholar Crossref

John AM, Schwartz RA. Basal cell naevus syndrome: an update on genetics and treatment. Br J Dermatol. 2016;174(1):68-76. doi:10.1111/bjd.14206 PubMed Google Scholar Crossref

Larsen AK, Mikkelsen DB, Hertz JM, Bygum A. Manifestations of Gorlin-Goltz syndrome. Dan Med J. 2014;61(5):A4829.PubMed Google Scholar

Multiple Lesions in Irradiated Skin

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Multiple Lesions in Irradiated Skin

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