Correspondence
References 1 Nigam PK, Saxena AK. Allergic contact dermatitis from henna. Contact Dermatitis 1988; 18: 55–56. 2 Abdulla KA, Davidson NM. A woman who collapsed after painting her soles. Lancet 1996; 348: 658. 3 Wells GC, Smith NP. Eosinophilic cellulites. Br J Dermatol 1979; 100: 101–109. 4 Lee S, Park J, Kim D, et al. Flame figures in molluscum contagiosum. Am J Dermatopathol 2004; 26: 441–442.
Clinico-epidemiological data on non-melanoma skin cancer in Greece: 5-year experience (2005–2009) in a tertiary referral center
Non-melanoma skin cancer (NMSC) is one of the most common forms of malignancy in humans. It is well recognized that the incidence of skin cancer has risen during the last decades due to a variety of reasons, such as increased intentional sun exposure, aging population, lifestyle trends, and better access to healthcare services. Basal cell carcinoma (BCC) is the most common form of cancer. Although it almost never metastasizes, it can be locally destructive if left untreated. Squamous cell carcinoma (SCC) can be more aggressive depending on site, age, and size of lesion. Overall mortality among patients with NMSC is estimated at 0.1%. Diagnosis of SCC, old age, and male gender are considered the most significant mortality risk factors.1 The rise of NMSC incidence notwithstanding, the overall mortality has dropped. This is probably due to earlier diagnosis and treatment because of advances in dermoscopy and easier access to health services.1,2 The incidence of NMSC in Greece appears to be high.3 Nevertheless, epidemiological data are lacking. The geo-
1.8 1.6 1.4
NMSC BCC SCC
5 Peters MS, Schroeter AL, Gleich GJ. Immunofluorescence identification of eosinophil granule major basic protein in the flame figures of Wells syndrome. Br J Dermatol 1983; 109: 141–148. 6 Watanabe H, Sueki H, Kitami A, et al. Flame figures associated with bullous pemphigoid. J Dermatol 1998; 25: 632–636.
graphic latitude of the country and its warm and sunny climate leads to heavy exposure to the carcinogenic ultraviolet radiation. On the other hand, the predominance of dark white skin phototypes seems to play a protective role. We conducted a retrospective study based on the records of the Second Academic Department of Dermatology-Venereology at ``Attikon'' General University Hospital, Athens, Greece. This is a tertiary referral center serving a mainly urban population of over one million people with referrals from neighboring rural areas of central and southern Greece as well. We documented clinical and epidemiological data of all histologically confirmed NMSC cases between January 2005 and December 2009. During this period, among 38,206 examined patients in total, 389 new cases of NMSC were diagnosed, i.e., 10.2 cases/1000 dermatology patients. The annual distribution of incidence rate is presented in Figure 1. The mean age of patients with BCC was 67.8 years (range 31–90 years), and that of patients with SCC was 73.9 years (range 47–90 years). The BCC–SCC ratio was 2.76 : 1, and the male–female ratio was 1.21 : 1. The most common site of appearance was the head (Fig. 2). The topographic distribution of NMSC on the head in men and women is depicted in Figures 3 and 4, respectively. Distribution
Upper Lower limbs: limbs: 6.7 3.9 Genitals: 1.0
1.2 1 0.8 0.6
Torso: 13.1
0.4 0.2
Neck: 2.8
0 2005
2006
2007
2008
2009
Head: 72.5
Figure 1 Annual incidence of NMSC, BCC, and SCC (2005–
2009) (new cases/dermatology patients reviewed 9 100). BCC, basal cell carcinoma; NMSC, non-melanoma skin cancer; SCC, squamous cell carcinoma ª 2013 The International Society of Dermatology
Figure 2 Predilection sites of non-melanoma skin cancer (%) International Journal of Dermatology 2014, 53, e240–e316
e307
e308
Correspondence
Ears: 6.8 Eyelids: 9.9
Forehead: 17.8 Temporal area: 6.2
Nose: 33.9
Parietal area: 4.3
Figure 3 Predilection sites of non-melanoma skin cancer at head (men,%)
Ears: 10.8 Forehead: 15.8 Eyelids: 14.2
Temporal area:10.0
Parietal area: 4.2
Nose: 25.8
Figure 4 Predilection sites of non-melanoma skin cancer at head (women,%)
Table 1 Distribution by melanoma skin cancer
histological
subtypes
of
non-
n (%) Basal cell carcinoma Ulcerated Nodular Multifocal superficial Infiltrative Metatypic Other Total Squamous cell carcinoma In situ (Bowen’s disease and actinic keratoses) Well differentiated Moderately differentiated Poorly differentiated Keratoacanthoma Squamous cell carcinoma/ keratoacanthoma (intermediate features) Large cell acanthoma Verrucous Total
International Journal of Dermatology 2014, 53, e240–e316
126 79 37 28 13 4 287
(43.9) (27.5) (12.9) (9.8) (4.5) (1.4)
14 34 30 5 5 12
(13.6) (33.0) (29.1) (4.9) (4.9) (11.7)
1 (0.9) 2 (1.9) 103
of cases according to histologic subtype is shown in Table 1. Comparing our results to another similar retrospective Greek study (1984–1995),3 we found that the incidence of NMSC among dermatologic patients in Athens, Greece, shows diminishing trends (14.5 vs. 10.2 cases/ 1000 dermatology patients), probably reflecting respective changes in true incidence. The BCC–SCC ratio increased from 1.2 : 1 to 2.76 : 1, while the male–female ratio remained pretty much stable (1.03 : 1 vs. 1.21 : 1). In both studies, the most common site of NMSC development was the head. Epidemiological studies on NMSC vary due to differences in registration practices, source of study population (general or hospital population), evidence of histological confirmation, etc. Nevertheless, it seems that the worldwide incidence of NMSC is on the rise. According to a systematic review of the literature, the highest rates are reported in Australia (>1000/100,000 person-years for BCC) and the lowest rates in certain parts of Africa (
References 1 Nigam PK, Saxena AK. Allergic contact dermatitis from henna. Contact Dermatitis 1988; 18: 55–56. 2 Abdulla KA, Davidson NM. A woman who collapsed after painting her soles. Lancet 1996; 348: 658. 3 Wells GC, Smith NP. Eosinophilic cellulites. Br J Dermatol 1979; 100: 101–109. 4 Lee S, Park J, Kim D, et al. Flame figures in molluscum contagiosum. Am J Dermatopathol 2004; 26: 441–442.
Clinico-epidemiological data on non-melanoma skin cancer in Greece: 5-year experience (2005–2009) in a tertiary referral center
Non-melanoma skin cancer (NMSC) is one of the most common forms of malignancy in humans. It is well recognized that the incidence of skin cancer has risen during the last decades due to a variety of reasons, such as increased intentional sun exposure, aging population, lifestyle trends, and better access to healthcare services. Basal cell carcinoma (BCC) is the most common form of cancer. Although it almost never metastasizes, it can be locally destructive if left untreated. Squamous cell carcinoma (SCC) can be more aggressive depending on site, age, and size of lesion. Overall mortality among patients with NMSC is estimated at 0.1%. Diagnosis of SCC, old age, and male gender are considered the most significant mortality risk factors.1 The rise of NMSC incidence notwithstanding, the overall mortality has dropped. This is probably due to earlier diagnosis and treatment because of advances in dermoscopy and easier access to health services.1,2 The incidence of NMSC in Greece appears to be high.3 Nevertheless, epidemiological data are lacking. The geo-
1.8 1.6 1.4
NMSC BCC SCC
5 Peters MS, Schroeter AL, Gleich GJ. Immunofluorescence identification of eosinophil granule major basic protein in the flame figures of Wells syndrome. Br J Dermatol 1983; 109: 141–148. 6 Watanabe H, Sueki H, Kitami A, et al. Flame figures associated with bullous pemphigoid. J Dermatol 1998; 25: 632–636.
graphic latitude of the country and its warm and sunny climate leads to heavy exposure to the carcinogenic ultraviolet radiation. On the other hand, the predominance of dark white skin phototypes seems to play a protective role. We conducted a retrospective study based on the records of the Second Academic Department of Dermatology-Venereology at ``Attikon'' General University Hospital, Athens, Greece. This is a tertiary referral center serving a mainly urban population of over one million people with referrals from neighboring rural areas of central and southern Greece as well. We documented clinical and epidemiological data of all histologically confirmed NMSC cases between January 2005 and December 2009. During this period, among 38,206 examined patients in total, 389 new cases of NMSC were diagnosed, i.e., 10.2 cases/1000 dermatology patients. The annual distribution of incidence rate is presented in Figure 1. The mean age of patients with BCC was 67.8 years (range 31–90 years), and that of patients with SCC was 73.9 years (range 47–90 years). The BCC–SCC ratio was 2.76 : 1, and the male–female ratio was 1.21 : 1. The most common site of appearance was the head (Fig. 2). The topographic distribution of NMSC on the head in men and women is depicted in Figures 3 and 4, respectively. Distribution
Upper Lower limbs: limbs: 6.7 3.9 Genitals: 1.0
1.2 1 0.8 0.6
Torso: 13.1
0.4 0.2
Neck: 2.8
0 2005
2006
2007
2008
2009
Head: 72.5
Figure 1 Annual incidence of NMSC, BCC, and SCC (2005–
2009) (new cases/dermatology patients reviewed 9 100). BCC, basal cell carcinoma; NMSC, non-melanoma skin cancer; SCC, squamous cell carcinoma ª 2013 The International Society of Dermatology
Figure 2 Predilection sites of non-melanoma skin cancer (%) International Journal of Dermatology 2014, 53, e240–e316
e307
e308
Correspondence
Ears: 6.8 Eyelids: 9.9
Forehead: 17.8 Temporal area: 6.2
Nose: 33.9
Parietal area: 4.3
Figure 3 Predilection sites of non-melanoma skin cancer at head (men,%)
Ears: 10.8 Forehead: 15.8 Eyelids: 14.2
Temporal area:10.0
Parietal area: 4.2
Nose: 25.8
Figure 4 Predilection sites of non-melanoma skin cancer at head (women,%)
Table 1 Distribution by melanoma skin cancer
histological
subtypes
of
non-
n (%) Basal cell carcinoma Ulcerated Nodular Multifocal superficial Infiltrative Metatypic Other Total Squamous cell carcinoma In situ (Bowen’s disease and actinic keratoses) Well differentiated Moderately differentiated Poorly differentiated Keratoacanthoma Squamous cell carcinoma/ keratoacanthoma (intermediate features) Large cell acanthoma Verrucous Total
International Journal of Dermatology 2014, 53, e240–e316
126 79 37 28 13 4 287
(43.9) (27.5) (12.9) (9.8) (4.5) (1.4)
14 34 30 5 5 12
(13.6) (33.0) (29.1) (4.9) (4.9) (11.7)
1 (0.9) 2 (1.9) 103
of cases according to histologic subtype is shown in Table 1. Comparing our results to another similar retrospective Greek study (1984–1995),3 we found that the incidence of NMSC among dermatologic patients in Athens, Greece, shows diminishing trends (14.5 vs. 10.2 cases/ 1000 dermatology patients), probably reflecting respective changes in true incidence. The BCC–SCC ratio increased from 1.2 : 1 to 2.76 : 1, while the male–female ratio remained pretty much stable (1.03 : 1 vs. 1.21 : 1). In both studies, the most common site of NMSC development was the head. Epidemiological studies on NMSC vary due to differences in registration practices, source of study population (general or hospital population), evidence of histological confirmation, etc. Nevertheless, it seems that the worldwide incidence of NMSC is on the rise. According to a systematic review of the literature, the highest rates are reported in Australia (>1000/100,000 person-years for BCC) and the lowest rates in certain parts of Africa (
