xrt study1
DESCRIPTION
You work at Data Imports, Inc., and the CEO knows you are pursuing your doctorate degree. He has asked you to perform a quantitative analysis on the data collected from the eight participants. Perform the following tasks to complete the analysis.TRANSCRIPT
CANCER RISKS AFTER RADIOTHERAPY FOR BENIGN
CONDITIONSHAZEM EL-GAMAL, MDRICHARD BENNETT, MD
MOHS MICROGRAPHIC SURGERY & DERMATOLOGIC SURGERY
SANTA MONICA • PASADENA • UCLA • USC • DREW/KING
WILHELM CONRAD RÖNTGEN(ROENTGEN)
• GERMAN PHYSICIST (1845-1923)
• PHYSICS INSTITUTE (WURZBURG, GERMANY)
• “DISCOVERED” X-RAYS IN NOVEMBER 1895
• WINNER NOBEL PRIZE PHYSICS 1901
HISTORY OF X-RAYS
• 1859 Plueber (Germany)-Vacuum Tube Fluoresced
• 1860 Hittorf (Germany)-Luminous Stream Detected by Magnet
• 1875 Wm. Crookes (English)-High Vacuum Tube; “Cathode Ray” - Apple Green Light
• 1893 Herbert Jackson (English)-Anode to Catch Cathode Stream
HISTORY OF X-RAYS (Cont.)
• 1893 H. Hertz (Germany) - Cathode Rays Through ??
• 1893 R. Leonard (Germany) - Showed Substances Fluoresced With Cathode Rays
• 1895 Roentgen (Germany) - Darkened Room, Put Hand between Chemical & Tube
EARLY X-RAY IMAGE
(Frau Roentgen’s Hand) c. 1895
FORMATION OF THE CATHODE STREAM AND X-RAYS
X-RAY TUBE EASILY OBTAINED
1898 BRITISH ADVERTISEMENT
EARLY X-RAY MACHINE
RADIOSENSITIVITYFrances Williams, MD
The Roentgen Rays in Medicine & SurgeryMacMillan, Co; New York 1901
Fat
Muscle
Bone
THOMAS A. EDISON1896 Fluoroscopic Exhibit
National Electric Light Association, NYC
SIDE EFFECTS OF X-RAY
• DERMATITIS (1896) “SUNBURN”
• “WARTS” (1898)• SQUAMOUS CELL
CARCINOMA →METASTASIS (1907)
• INTERNAL CANCER (1950)
ELECTROMAGNETIC SPECTRUM
PERCY BROWN, MD
AMERICAN MARTYRS TO SCIENCE THROUGH ROENTGEN RAYS
CHARLES C. THOMAS, SPRINGFIELD, 1936
• REPORTS 26 WORKERS IN X-RAY WHO DIED OF SCC, MOSTLY ON LEFT HAND THAT METASTASIZED– 16 MDS (7/16 IN LATE 30 OR 40 YRS OF AGE)
EARLY FLUOROSCOPE USING HAND TO FOCUS
EARLY FLUOROSCOPE USING FOREARM BONES TO FOCUS
SCC AFTER RADIOTHERAPY FOR ECZEMA
X-RAYS IN DERMATOLOGY
• 1898 FIRST REPORTED TO BE USEFUL IN ACNE
• 1899 SCHIFF & FRIEND, ↓ HAIR IN NEVUS
• 1902 DR. PUSEY PUBLISHES TEXTBOOK
• 1907 DR. MACKEE PUBLISHES TEXTBOOK
William A. Pusey, MD (1865-1940)
Professor DermatologyU. of Illinois Medical School
Introduced Radiotherapy to Dermatology
EARLY X-RAY TECHNIQUE
Wm. A. PuseyEarly Textbook by
Dermatologist Featuring Radiology,
1907
George M. MacKee, MD (1878-1955)
PROFESSOR DERMATOLOGY
NEW YORK SKIN & CANCER
MacKee’s Standard Textbook
Radiotherapy in Dermatology
4 Editions(1921, 1927, 1938, 1946)
Rose Hirschler, MD (1875-1940)
Professor DermatologyWomen’s Medical
School, Phil.
Began Radiotherapy Dept.
Died of Leukemia
SKIN PENETRATION BY X-RAYS
1903 BCC INNER CANTHUSTreated with X-ray
Rodent Ulcer
STUDY OVERVIEW
• 17,382 CHARTS REVIEWED FROM 1978-2003
• CASE GROUP– 432 PATIENTS FOUND THAT RECEIVED
RADIOTHERAPY FOR BENIGN CONDITIONS
• CONTROL GROUP– RANDOMLY SELECTED– AGE AND GENDER MATCHED 1:1 TO CASES
INDICATIONS FOR RADIOTHERAPY
Dermatologic Number/(%)Acne 357/(82.8)
Eczema 17/(3.9)
Tinea Capitis 9/(2.1)
Psoriasis 4/(0.9)
Dermatitis/NOS 4/(0.9)
Seborrheic Dermatitis 3/(0.7)
Hair Loss 2/(0.5)
Neurodermatitis 2/(0.5)
INDICATIONS FOR RADIOTHERAPY (Cont.)
Dermatologic (cont.) Number/(%)Yeast 1/(0.2)
Hyperhidrosis 1/(0.2)
Oily Skin 1/(0.2)
Keloid 1/(0.2)
Tinea Pedis 1/(0.2)
Impetigo 1/(0.2)
Hemangioma 1/(0.2)
Tinea Facei 1/(0.2)
INDICATIONS FOR RADIOTHERAPY (Cont.)
Dermatologic (cont.) Number/(%)Pruritis 1/(0.2)
Wart 1/(0.2)
Folliculitis 1/(0.2)
Erythema 1/(0.2)
Actinomycosis 1/(0.2)
INDICATIONS FOR RADIOTHERAPY (Cont.)
ENT Number/(%)Sinus Problems 6/(1.4)
Tonsils 2/(0.5)
Eustachian Tube 1/(0.2)
Asthma 1/(0.2)
Whooping Cough 1/(0.2)
INDICATIONS FOR RADIOTHERAPY (Cont.)
Orthopaedic Number/(%)Tendinitis 1/(0.2)
Ankylosing Spondylitis 1/(0.2)
GOLDSCHMIDT, H.
IONIZING RADIATION THERAPY IN DERMATOLOGY
ARCH DERMATOL 111:1511-1517, 1975
• SURVEY OF U.S. AND CANADIAN DERMATOLOGISTS
• 2,305 RESPONSES TABULATED
89.3
41.834.6
23.9
0102030405060708090
Percent (%)
BCC Acne Eczema PsoriasisIndications for Radiotherapy
DERMATOLOGISTS USING SUPERFICIAL X-RAY THERAPY (1975)
CANCER AND IONIZING RADIATION
CancerX-Rays
DATE INJURY REPORTED BY
1896 Dermatitis hands Grubbe
1896 Epilation Daniel
1902 CA in X-ray Ulcer Frieben
1911 Leukemia in 5 Radiation Jagic
Workers
1912 Anemia in 2 X-ray Workers Belere
1949 BCC in 5 yr old Child Scharnajel/Pack
1950 Thyroid Cancer in X-ray for Thymus Duffy/Fitzgerald
SCHARNAGEL, IM, PACK, GT
MULTIPLE BASAL CELL EPITHELIOMAS IN A 5 Y.O. CHILD
AM. J. DIS CHILD 77:647-651 (1949)
• BCCS DEVELOP IN PORT AREA FOR RADIATION TO THYMUS GLAND
DUFFY, BJ, JR., FITZGERALD, PJ
THYROID CANCER IN CHILDHOOD & ADOLESCENCE
CANCER 1018-1032 (1950)
• 10/28 CASES HAD HAD X-RAY FOR ENLARGED THYMUS GLAND IN INFANCY
Marion Sulzberger, MD (1895-1984)
PROFESSOR & CHAIRMAN
Dept. of DermatologyNYU School of Medicine
SULZBERGER, MB, BAER, RL, BOROTA, A
DO ROENTGEN-RAY TREATMENTS AS GIVEN BY SPECIALISTS PRODUCE CANCERS OR
OTHER SEQUELAE? ARCH DERM SYPH 65:639-655 (1952)
• REEXAMINED 1000 PATIENTS IRRADIATED AND 1000 NON-IRRADIATED PATIENTS
• NO SKIN CANCERS WITH 5-23 YEARS OF FOLLOW-UP
BCCs AFTER RADIOTHERAPY FOR ACNE
INCIDENCE ANGLES FOR X-RAY TREATMENT OF ACNE AND TINEA BARBAE
(MacKee Textbook 1946)
NMSCSTUDY INFORMATION
• 432 PATIENTS IRRADIATED FOR BENIGN MEDICAL CONDITIONS– 148 MEN– 284 WOMEN
• MEAN AGE 65 YEARS FOR CASES & CONTROLS
NMSCMean Number of NMSC in Cases & Controls
7.1
3.5
0.21 0.20
1
2
3
4
5
6
7
8
Number
Mean Number ofBCC (p <0.0001)
Mean Number ofSCC (p=0.22)
CasesControls
NMSCMean Age of First NMSC in Cases & Controls
53.9
60
5051525354555657585960
Age (yrs)
Mean Age at First NMSC(p-value <0.0001)
CasesControls
NMSCMean Number of NMSC in the Central Face
for Cases & Controls
1.63
1.2
00.20.40.60.8
11.21.41.61.8
Number of NMSC
Mean Number of NMSC inCentral Face
(p-value = 0.0001)
CasesControls
NMSCLocation of Presenting NMSC in Cases &
Controls
81.577.3
9.712.88.8 9.9
0102030405060708090
Percent (%)
Mid-face LateralFace
Other
(non-significant)
CasesControls
THYROID DISEASEOdds Ratio of Thyroid Cancer & Non-cancer
Thyroid Problems
17.62
2.3402468
1012141618
Odds Ratio (OR)
Thyroid Cancer (p-value = 0.000125)
Non-cancer Problems(p-value = 0.000075)
BREAST CANCER AND IONIZING RADIATION
Breast Cancer
Ionizing Radiation
MCGREGOR, DH, ET AL
ATOMIC BOMB SURVIVORS - HIROSHIMA, NAGASAKI
J. NATL. CANCER INST. 59:799-811 (1977)
• RELATIVE RISK ≈ AGE AND DOSE
• BUT AGE (10-19) >> DOSE
STUDY DOSE O/E
Atomic Bomb Japan 30 R 1.6
Postpartum Mastitis 380 R 4.5
Multiple Fluoroscopic Exams 70-100 R 0.9-1.7
Skin Hemangiomas 17-52 R 1.15-1.3
Hodgkins Disease
Tinea Capitis
Enlarged Thymus 70 R 3.5
X-RAYS → BREAST CANCER
BREAST CANCERStudy Information
• 244 WOMEN IRRADIATED FOR ACNE• 244 AGE MATCHED WOMEN
CONTROLS• MEAN YEARS F/U: 49 YRS• MEAN AGE:
– CASES: 66.2 YRS– CONTROLS: 65.8 YRS
BREAST CANCERStudy Information (cont.)
• Number of Breast Cancers– Cases: 36– Controls: 16– OR: 2.47 – P-value: 0.0033
36
16
0
5
10
15
20
25
30
35
40
Number
Cases Controls
STANDARD RADIOTHERAPY TECHNIQUE
(Goldschmidt 1994, J. Am. Acad. Derm. 30:173)
BREAST CANCEROdds Ratio of Breast Cancer vs. Age at
XRT
2.472.72
1.75
0
0.5
1
1.5
2
2.5
3
Odds Ratio (OR)
All Women(p=0.0033)
Age <20(p=0.0022)
Age>20(p=0.26)
BREAST CANCEROdds Ratio of Breast Cancer vs.
Number of Treatments
2.47
3.95
1.78
0
0.5
1
1.5
2
2.5
3
3.5
4
Odds Ratio (OR)
All Women(p=0.0033)
Number >=5(p=0.0029)
Number <5(p=0.36)
BREAST CANCEROdds Ratio of Breast Cancer vs. Year
of Treatment
2.47
3.35
0.66
0
0.5
1
1.5
2
2.5
3
3.5
Odds Ratio (OR)
All Women(p=0.0033)
Year of XRT<1950
(p=0.00014)
Year of XRT>=1950(p=0.77)
BREAST CANCEROdds Ratio of Breast Cancer vs.
Anatomic Location of Radiotherapy
2.472.28
3.99
0
0.5
1
1.5
2
2.5
3
3.5
4
Odds Ratio (OR)
All Women(p=0.0033)
Face Only(p=0.016)
Face + OtherSite (p=0.0093)
BREAST CANCEROdds Ratio of Breast Cancer
Multivariate Analysis
2.47
3.34
1.89
0
0.5
1
1.5
2
2.5
3
3.5
Odds Ratio (OR)
All Women(p=0.0033)
Age <20 &Year
XRT<1950(p=0.0004)
Age >20 &Year of XRT
>=1950(p=0.42)
BREAST CANCEROdds Ratio of Breast Cancer
Multivariate Analysis
2.47
4.1
00.5
11.5
22.5
33.5
44.5
Odds Ratio (OR)
All Women (p=0.0033)
Age <20 & YearXRT<1950 &
Treatment Number >=5(p=0.0066)
BREAST CANCERPrevalence of Breast Biopsies in Non-
cancer Cases and Controls
6.28
2.19
0
1
2
3
4
5
6
7
Prevalence (%)
Prevalence of Breast Biopsies in Non-cancer Cases & Controls
(OR = 2.98, p-value = 0.0511)
CasesControls
CONCLUSIONSNMSC
• PATIENTS THAT RECEIVED RADIOTHERAPY FOR BENIGN CONDITIONS:
– NO INCREASED RISK OF DEVELOPING SCC – DEVELOP A GREATER NUMBER OF BCCS– DEVELOP NMSC AT EARLIER AGE – DEVELOP GREATER PROPORTION OF NMSC IN
THE CENTRAL FACE
CONCLUSIONSTHYROID CANCER
• PATIENTS THAT RECEIVED RADIOTHERAPY FOR BENIGN CONDITIONS:
– INCREASED RISK (OR 17.6) FOR DEVELOPING THYROID CANCER
– INCREASED RISK (OR 2.34) FOR DEVELOPING NON-CANCER THYROID PROBLEMS
CONCLUSIONSBREAST CANCER
• WOMEN THAT RECEIVED RADIOTHERAPY FOR ACNE:
– INCREASED RISK (OR 2.47) FOR DEVELOPING BREAST CANCER
– BREAST CANCER RISK CORRELATED TO:• AGE AT RADIOTHERAPY (<20 YEARS)• NUMBER OF TREATMENTS (>=5)• RADIOTHERAPY YEAR (<1950)