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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

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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Leisenring  W, Friedman  DL, Flowers  MED, Schwartz  JL, Deeg  HJ.  Nonmelanoma skin and mucosal cancers after hematopoietic cell transplantation.  J Clin Oncol. 2006;24(7):1119-1126. doi:10.1200/JCO.2005.02.7052PubMedGoogle ScholarCrossref
2.
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-MPubMedGoogle ScholarCrossref
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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.272.5268.1668PubMedGoogle ScholarCrossref
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Gorlin  RJ.  Nevoid basal cell carcinoma (Gorlin) syndrome.  Genet Med. 2004;6(6):530-539. doi:10.1097/01.GIM.0000144188.15902.C4PubMedGoogle ScholarCrossref
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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:10.1155/2011/217378PubMedGoogle ScholarCrossref
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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.14206PubMedGoogle ScholarCrossref
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Larsen  AK, Mikkelsen  DB, Hertz  JM, Bygum  A.  Manifestations of Gorlin-Goltz syndrome.  Dan Med J. 2014;61(5):A4829.PubMedGoogle Scholar
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