Volume 10

Number 6 June, 1984

Port-wine stain treated with laser

normal epidermis and dermis without evidence of cellular atypia.

R E F E R E N C E S

1. Noe J, Barsley S, Greer D, et al: Portwine stains and the response to argon laser therapy: Successful treatment and the predictive role of color, age, and biopsy. J Plast Re- constr Surg 65: 130-136, 1980.

2. Gilchrest B, Rosen G, Noe J: Chilling portwine stains improves the response to argon laser therapy. J Plast Re- constr Surg 69:278-283, 1982.

3. Ratz J, Bailin P, Levine H: COs laser treatment of portwine stains: A preliminary report. J Dermatol Surg Oncol 8:1039-1044, 1982.

4. Apfelberg D, Kosek J, Maser M, et al: Histology of portwine stains following argon laser treatment. Br J Plast Surg 32:232-237, 1979.

5. Finley J, Barsley S, Greer D, et al: Healing of portwine stains after argon laser therapy. Arch Dermatol 117:486- 489, 1981.

Health effects associated with exposure to radioactively contaminated gold rings Mark S. Baptiste, M.S., Richard Rothenberg, M.D., Philip C. Nasca, Ph.D., Dwight T. Janerich, D.D.S., Charles D. Stutzman, M.D., Karim Rimawi, Ph.D., William O'Brien, M.S., and John Matuszek, Ph.D. Albany, NY, Atlanta, GA, and Buffalo, NY

This study was designed to assess the health risks associated with exposure to radioactively contaminated gold rings. A group of 135 exposed individuals, who were identified through a statewide jewelry screening program, were studied to determine the frequency of carcinoma and other skin problems on the ring finger. Severity of skin problems increased with increasing length of wear. Forty-one of the exposures were associated with mild to severe skin problems. Nine of the individuals studied were diagnosed as having histologically confirmed squamous cell carcinomas at the site of exposure. The incidence of skin cancer on the ring finger was eleven times that expected for men and forty-five times that expected for women. These data indicate that physicians who have patients with skin lesions of the ring finger should be aware of the possibility of exposure to a radioactive gold ring. (J AM ACAD DERMATOL 10:1019-1023, 1984.)

Accepted for publication Dec. 22, 1983.

Reprint requests to: Mark S. Baptiste, M.S., Director, Cancer Epidemiology Unit, Rm. 557, New York State Department of Health, Albany, NY 12237.

Mark S. Baptiste, M.S., is director, Cancer Epidemiology Unit, Cancer Control Section, Bureau of Chronic Disease Prevention, New York State Department of Health, Room 557, Tower Bldg., N.A. Rockefeller Empire State Plaza, Albany/5IS-474-2460; Richard Rothenberg, M.D., is director, Bureau of Chronic Disease Prevention, New York State Department of Health, Albany; Philip C. Nasca, Ph.D., is director, Cancer Control Section, Bureau of Chronic Disease Prevention, New York State Department of

Health, Albany; Dwight T. Janerich, D.D.S., is director, Division of Community Health and Epidemiology, New York State De- partment of Health, Albany; Charles D. Stutzman, M.D., is medi- cal epidemiologist, Cancer Branch, Chronic Diseases Division, Center for Environmental Health, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta; Karim Rimawi, Ph.D., is director, Bureau of Environmental Radiation, New York State Department of Health, Albany; William O'Brien, M.S., is associate radiological health specialist, New York State Department of Health, Buffalo; John Matuszek, Ph .D., is director, Radiological Sciences Institute, New York State Department of Health, Albany.

1019

1020 Baptiste et al

Journal of the American Academy of

Dermatology

Reports of health effects associated with radio- actively contaminated gold jewelry began to ap- pear in the 1960s. 1-'~ Skin lesions, including squamous cell carcinoma, occurred at areas of di- rect, long-term skin contact with radioactively contaminated rings. One articIe documented the use of spent radon gold seeds to make the contam- inated ring worn by a person with dermatitis, ~ but the source of contamination has not been estab- lished for most of the rings discovered thus far.

In 1968, the New York State Department of Health sent notices to New York State medical journals advising physicians to have jewelry tested for radioactivity i f they saw patients with unex- plained skin reactions. During the period from 1968 through January, 1981, eleven reports of persons exposed to radioactive rings came to the attention of the State Department of Health. Of the eleven persons concerned, four developed skin cancer at the site of exposure, and the other seven all had moderate to severe dermatitis on the ring finger. In February, 1981, the Department initi- ated a campaign to find and remove from circula- tion any jewelry with radioactive contamination and to assess the public health impact. A more detailed account of the historical aspects of the problem has been published elsewhere.* Approx- imately 160,000 items of jewelry have been screened. Although public media campaigns cov- ered the entire state, the greatest public response occurred in the western New York area.

As a result of these screening activities, the De- partment o f Health has identified I77 contam- inated jewelry items and 155 exposed persons. All but six of these items originated or were repaired in western New York State or nearby Pennsylva- nia. Anecdotal reports indicate that contaminated rings have also been found in other areas, includ- ing Connecticut, Texas, Arkansas, Toronto, Ohio, Florida, and Germany.

Besides screening for and removing contam- inated jewelry from circulation, the Department was charged with estimating the health risk asso- ciated with exposure. The health effects survey described below was designed to provide data for making this assessment.

*New York State Department of Health: Report to the Governor and Legislature: Radioactive gold jewelry. Albany, NY, September, 1982.

METHODS

The New York State Department of Health screening program has identified 155 persons exposed to jewelry contaminated with radioactive gold. The eleven ex- posed persons who had been identified by the depart- ment before the initiation of the screening program were excluded from analysis. Inclusion of these indi- viduals would bias the risk estimates since they came to attention because of the health problems being studied. Of the 155 persons identified by the screening program, fifteen were exposed to contaminated school pins and five to other types of jewelry not worn in direct contact with the skin. No health problems were associated with these items. These twenty items did not provide sig- nificant exposure and were excluded from the analysis. This analysis is thus limited to the 135 individuals ex- posed to contaminated gold rings.

The New York State Department of Health, in con- junction with the U.S. Department of Health and Human Services' Centers for Disease Control, con- ducted interviews to obtain information about the his- tory of the ring, duration of exposure, and selected sociodemographic characteristics. These factors, which included age, sex, and race, are associated with skin cancer risk and were controlled for in the risk estima- tion. Clinical data, including the occurrence of skin cancer, other skin disease, other cancer, general skin sensitivity indicators (e.g., color of eyes, hair, com- plexion, sensitivity to sunlight), and possible exposure to skin toxins or carcinogens were also collected. All skin cancers at the site of exposure were documented, with the patient's consent, through contact with the attending physician and/or through review of pertinent medical records. Less severe skin conditions were generally not treated by a physician, so that information on noncancerous conditions is based on patient re- sponse.

Five levels of health effects on the ring finger were identified: no disease, mild skin problem, moderate skin problem, severe skin problem, and skin cancer. Individuals were assigned to these categories on the basis of symptoms at the site of exposure to the ring. Persons with no symptoms were placed in the no dis- ease category. Persons with symptoms limited to erythema and/or pruritus were categorized as having a mild skin problem. The moderate skin problem cate- gory includes those with scaling, blistering, hy- perkeratosis, or hyperpigmentation. Persons with ul- ceration of the skin were classified in the severe skin problem group. The skin cancer group includes only cases confirmed through review of medical records. The average duration of exposure was calculated for each level of health effect.

Volume ! 0 Number 6 June, 1984

EXposure to radioactively c'ontaminated gold 1021

To estimate sex-specific standardized incidence ratios for carcinomas of the ring finger, it was neces- sary to calculate the "expected" incidence of these tumors in the exposed population. Data on skin cancer are not routineiy collected by the New York State Cancer Registry or other population-based registries. The best estimates of skin cancer incidence have been provided by Scotto et al, 6 who conducted a special survey of skin cancer in the United States during the years 1977 and 1978. Since the Scotto study excluded in situ forms of skin cancer, in situ cases in the present study were not included in the estimation of standard- ized incidence ratios.

The ring finger cancers observed among persons ex- posed to contaminated rings were all of the squamous cell type. Age-specific estimates of the expected num- bers of squamous cell carcinomas of the skin on the hand were calculated and compared with observed numbers to produce standardized incidence ratios for male and female patients in the study group. For each sex and age group (25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85+ years), the average annual incidence rate of squamous cell carcinoma reported by Scotto et aP was multiplied by the number of person-years of risk calculated for the corresponding sex/age stratum in the study group. These calculations produced the "ex- pected" number of squamous cell carcinomas of the skin for that age/sex group. This number was then multiplied by the proportion of squamous cell carci- nomas that occur on the hand (0.116 for male patients, 0.157 for female patients ~) to yield the "expected" number of squarnous cell carcinomas on the hand for each age/sex group. These were cumulated to produce the total expected number of squamous cell carcinomas on the hand for each sex.

Standardized incidence ratio estimates were calcu- lated by dividing the total observed number of invasive cancers for each sex by the corresponding expected number. The observed number of cancers in each sex group was assumed to be a Poisson variable, and confidence limits for the observed to expected ratios were calculated by using the tables published by Bailar and Ederer. v

RESULTS

Interviews were completed with 127 of the 135 individuals in the study group, for an overall re- sponse rate of 94%. Of the 127 interviews, 113 were face-to-face interviews conducted by a phy- sician and included an examination of the hands. Interviews with nine individuals were conducted by telephone. Surrogate intbrmation was obtained

Table I. Health effects associated with 135 exposures to contaminated gold rings

I Number I .yereent

None 85 63.0 Mild skin problem 13 9.6 Moderate skin problem 12 8.9 Severe skin problem 16 11.8 Squamous cell carcinoma 9 6.7

Total 135 100.0

Table l I . Mean duration of exposure by level of ring finger illness

Illness level

Average total duration of exposure

Mean I Standard (yr) N error of mean

None 5.0 85 1.04 Mild skin problem 7.3 13 2.61 Moderate skin problem 9.5 12 2.64 Severe skin problem 16.0 16 2.75 Squamous cell carcinoma 17.1 9 3.30

Total 7.8 135 0.91

for another five persons through personal inter- views conducted with next of kin. We were unable to contact four persons, and there were four re- fusals. In addition, information was entered twice on eight individuals who wore a ring on both hands to account for the separate duration of expo- sure for each hand. This resulted in 135 individual ring exposures.

Of the 135 exposures to contaminated rings, sixty-one (45.2%) were to men and seventy-four (54.8%) were to women. All of these individuals were white. On the average, the men wore their ring a total of 6.9 years compared with 8.5 years for women. The average age of the men was 61.3 years, whereas that of the women was 59.5 years. Of the 135 exposures, seventy-five (55.6%) were to school rings and sixty (44.4%) were to other types of rings.

Table I summarizes the frequency of health ef- fects. Of these exposures, fifty (37.0%)resulted in disease that is possibly related to wearing the ring. These included forty-one (30.4%) cases of mild, moderate, or severe skin problems of the ring finger, usually recurring with continued wear.

1022 Baptiste et al

Journal of the American Academy of

Dermatology

Cancer of the skin on the ring finger was diag- nosed in nine individuals (6.7%), including two cases of Bowen ' s disease, one in situ squamous cell carcinoma, and six invasive squamous cell carcinomas.

The average duration of exposure to the ring and each level of illness are shown in Table II. Individuals with no signs or symptoms had an av- erage duration of exposure of 5 years. The dura- tion of exposure increases through each level of skin problem to a maximum of 17.1 years for those with carcinoma. Although duration of expo- sure does appear to increase with level of illness, it should be noted that there are large standard errors associated with the mean values, due primarily to the presence of outliers in each group.

Other skin problems not occurring at the site of exposure were noted in slightly more than half of the study group. None of the individuals with car- cinoma on the ring finger had skin cancer at any other site. Seven skin cancers at sites other than the exposed finger were reported: one on the rib cage, two on the face, one on the back, one on the neck, and two at unspecified sites not on the hand. There was no skin cancer reported on any finger or hand that was not exposed to a contaminated ring.

The observed number of invasive squamous cell carcinomas on the ring finger was two in male and four in female patients. (The two cases of Bow- en's disease and one in situ carcinoma were excluded from this portion of the analysis because the Scotto et al survey 6 excluded in situ cases.) The corresponding expected numbers were 0. 181 and 0.089, respectively. A standardized incidence ratio estimate for squamous cell carcinoma on the hand of 11.05 was calculated for male patients (95% Confidence Interval = 1.34 - 39.89), and the standardized incidence ratio for female pa- tients was estimated at 44.94 (95% Confidence Interval = 12.25 - 114.95). This means that the incidence of skin cancer on the ring finger was eleven times that expected for men and forty-five times that expected for women. The confidence intervals indicate that the observed excess in cancer is statistically significant for both men and women.

DISCUSSION

The results of this study indicate that the wear- ing of radioactively contaminated gold rings is as- sociated with skin disease, which occurs at the site of direct contact. These effects range from mild skin problems to the development of cancer in nine persons who reported long-term exposure. The occurrence of nine site-specific skin cancers in only 135 exposed individuals is striking. Inci- dence of squamous cell carcinoma of the skin on the ring finger was estimated to be eleven times that expected for men and forty-five times that expected for women.

These estimates do not account for differences in radiation levels among the rings or differences in specific patterns of exposure to the rings. It is also possible that persons experiencing health problems were more likely to bring their rings in for testing. This would raise the proportion in the study group presenting with problems, thus creat- ing an upward bias in the standardized incidence ratios. On the other hand, the "expec ted" values were calculated on the basis of squamous cell car- cinoma on the hand. The site-specific risk for the ring finger may well be much higher. Finally, it should be noted that the data are clinical and not dose-related. It is expected that dosimetry testing, to determine the amount of site-specific radiation emitted by each ring, may help to better describe the precise relationship of radiation exposure to disease.

The effects on health of low-dose radiation are extremely difficult to quantify. 8 Few studies have shown as strong an association between cancer risk and radiation exposure as seen in this group exposed to radioactively contaminated gold rings. These data indicate that exposure to radioactively contaminated gold rings poses a serious health hazard. The size of the standardized incidence ratios is substantial. In addition, the graded- response relationship observed between length of wear and the severity of the condition suggests a causal relationship between this source of ionizing radiation and the health effects studied.

Physicians who have patients with skin lesions of the ring finger should be aware of the possibility of exposure to a radioactive gold ring. Appropriate

Volume 10 Number 6 June, 1984

Exposure to radioactively contaminated gold 1023

pub l i c hea l th agenc i e s shou ld be con tac t ed in such

cases to a r range for r a d i o l o g i c tes t ing of po ten-

t i a l ly c o n t a m i n a t e d j e w e l r y a n d r e m o v a l o f haz-

a rdous i t ems f rom c i r cu la t ion .

REFERENCES

1. Simon N, Harley J: Skin reactions from gold jewelry con- taminated with radon deposit. JAMA 200:166-167, 1967.

2. Gerwig T, Winer M: Radioactive jewelry as cause of cu- taneous tumor. JAMA 205:123-124, 1968.

3. Leone R: Radiodermatitis caused by a radioactive gold ring. JAMA 206:2113-2114, 1968.

4. Helm F: Squamous cell carcinoma due to radioactive ring. Arch Derrnatol 110:465-466, 1974.

5. Stearns F: The curious case of the radioactive ring. J AM ACAD DERMATOL 5:696-697, 1981.

6. Scotto J, Fears TR, Fraumeni JF Jr.: Incidence of non- melanoma skin cancer in the United States. U.S. De- partment of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Publication No. (NIH) 82-2433, December, 198I.

7. Bailar JC, Ederer F: Significance factors for the ratio of a Poisson variable to its expectation. Biometrics 20:639- 643, 1964.

8. Beebe GW: The atomic bomb survivors and the problem of low dose radiation effects. Am J Epidemiol 114:761- 783, 1981.

ABSTRACTS

Radiation-induced head and neck tumours: Is the skin as sensitive as the thyroid gland?

Van Daal W A , Goslings BM, Hermans J, et al: Eur J Cancer Clin Oncol 19:1081-1086, 1983

In a complex study, with plenty of loopholes for the statis- ticians, nevertheless, these epidemiologists found a disturb- ing increase in the incidence of both thyroid and skin cancer after a 30- to 40-year latency in a follow-up of x-ray therapy given for noncancer diseases of the head and neck. The au- thors suggest that less difference in susceptibility to induction of tumors by x-ray may exist between thyroid and skin than previously was presumed.

P.C.A.

Meningocoecal meningitis in a woman with inherited deficiency of the ninth component of complement

Fine DP, Gewurz H, Griffiss M, Lint TF: Clin Immunol Immunopathol 28:413-417, 1983

The inherited deficiencies of the terminal components of blood complement convey a susceptibility to disseminated

bacterial infection, typically with the genus Neisseria. Usu- ally Cq is excepted from this list because the few patients with isolated Cq deficiency reported have been healthy. This 17- year-old woman was devoid of Cq, rather than only deficient, and had a N. meningitidis septicemia with meningitis. An autosomal codominant type of inheritance was noted in this family. The customary exception of Cq from the list should not be employed clinically until better established.

P.C.A.

Pressure garments in the prevention and treatment of keloids

Ng C1, Lee ST, Wong K.L: Ann Acad Med Singapore 12(suppl 2):430-435, 1983

At Singapore General Hospital, over 3 years, 280 patients were treated with pressure garments in order to reduce the risk or size or nuisance of keloids or hypertrophic scars, all with- out additional surgery. In this simple study of efficacy, with- out pairings or placebo treatment, the results were very good. Instructions are offered for making these elastic contraptions.

P.C.A.