Background: Radiotherapy (RT) is a risk factor for nonmelanoma skin cancer (NMSC), specifically basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but whether features, histology, or recurrence of NMSC after RT resemble those observed in the general population is unknown.Methods: A retrospective review (1994–2017) was performed within the Adult Long-Term Follow-Up Program and Dermatology Service at Memorial Sloan Kettering Cancer Center. Demographics, clinical features, histology, treatment, and recurrence were collected for this patient cohort that was under close medical surveillance. Pathology images were reviewed when available.Results: A total of 946 survivors (mean age, 40 years [SD, 13]) were assessed for NMSC. The mean age at first cancer diagnosis was 16 years (range, 0–40 years [11]), and the most common diagnosis was Hodgkin lymphoma (34%; n=318). In 63 survivors, 281 primary in-field lesions occurred, of which 273 (97%) were BCC and 8 (3%) were SCC. Mean intervals from time of RT to BCC and SCC diagnosis were 24 years (range, 2–44 years) and 32 years (range, 14–46 years), respectively. The most common clinical presentation of BCC was macule (47%; n=67), and the most common histologic subtypes were superficial for BCC (48%; n=131) and in situ for SCC (55%; n=5). Mohs surgery predominated therapeutically (42%; n=117), the mean duration of follow-up after treatment was 6 years (range, 12 days–23 years), and the 5-year recurrence rate was 1% (n=1).Conclusions: Most NMSCs arising in sites of prior RT were of low-risk subtypes. Recurrence was similar to that observed in the general population. Current guidelines recommend surgical intervention for tumors arising in sites of prior RT because they are considered to be at high risk for recurrence. These findings suggest that an expanded role for less aggressive therapy may be appropriate, but further research is needed.

Urban children continue to be exposed to secondhand smoke (SHS), and this is particularly concerning for children with asthma. The objective of this study is to describe SHS exposure among urban children with asthma and assess SHS counseling delivered at primary care visits. We interviewed caregivers of 318 children (2-12 years) with persistent asthma at the time of a health care visit and reviewed medical records. We found that one third (32%) of children lived with a caregiver who smoked and that 15% lived with other smokers. Children whose caregivers smoked had the lowest prevalence of home smoking bans compared with homes with other smokers and no smokers (65% vs. 72% vs. 95%, respectively). Overall, 67% of caregivers received some SHS counseling. Providers most often counseled caregiver smokers; counseling occurred less frequently for caregivers in homes with other or no smokers. Further efforts to improve provider SHS counseling for all children with asthma are needed.

2-week old white male presented with a 13-day history of an asymptomatic rash on the left medial thigh. Physical examination demonstrated a well-nourished infant in no apparent distress with many 2-to 4-mm pink papules, pustules, and vesicles on an erythematous base in a blaschkolinear distribution on the left flank, left medial thigh, and extending to the left medial knee (Figure 1, A and B). A punch biopsy was performed on the left medial thigh for hematoxylin and eosin staining, which showed eosinophilic spongiosis, dyskeratotic keratinocytes, and superficial and mid-dermal perivascular inflammation with eosinophils (Figure 2, A and B; available at www.jpeds.com). Clinical and histopathologic findings were diagnostic of incontinentia pigmenti. Incontinentia pigmenti is a rare X-linked neurocutaneous genodermatosis characterized by a dominant loss-of-function mutation in the inhibitor of kappa light polypeptide gene enhancer in B cells, kinase gamma gene, resulting in increased cellular apoptosis. 1-4 Incontinentia pigmenti predominantly affects female infants and is usually lethal in males in utero. Rare cases of incontinentia pigmenti have been identified in male patients, for which 3 mechanisms of survival have been proposed: 47, XXY karyotype (Klinefelter syndrome), hypomorphic mutations, and somatic mosaicism. 5,6 Somatic mosaicism, resulting from a postzygotic mutation occurring during the blastocyst stage of embryogenesis leading to incomplete nuclear factor-kB inactivation, is the likely explanation for our patient as his cutaneous symptoms were relatively mild and no extracutaneous symptoms have been observed to date. 7 Furthermore, the family history was negative for incontinentia pigmenti, suggesting a de novo mutation. Dermatologic manifestations are generally the presenting sign of incontinentia pigmenti. Lesions follow Blaschko lines and are classically divided into vesicular, verrucous, hyperpigmented, and atrophic stages. The vesicular stage occurs in approximately 90% of cases, most often during the first 2 weeks of life. 8 The lesions present as superficial vesicles on an erythematous base in a linear distribution typically sparing the face. The verrucous stage occurs in approximately 70% of patients between 2 and 6 weeks of life. 8 Nearly all patients with incontinentia pigmenti experience the hyperpigmented stage between 12 and 26 weeks, with whorls and streaks of brown to gray pigmentation following the lines of Blaschko. These lesions do not typically correlate with the location of the prior stages and do not represent postinflammatory hyperpigmentation. The hyperpigmented stage can persist for years or decades. The atrophic stage appears in approximately 28% of patients as pale, hairless, atrophic patches. 8 Less commonly, it can appear as hypopigmented patches without atrophy. This stage is commonly permanent. 8 Some of the stages may occur concurrently with others or not at all. 7 Additionally, males tend to have a more localized disease, with unilateral presentation being a distinctive...

131 Background: Radiotherapy is a well-known risk factor for non-melanoma skin cancer (NMSC), but whether diagnosis, histologic features, or natural history of NMSC after radiotherapy resemble those observed in the general population is unknown. This study aims to describe clinical findings, histology, and management of NMSC on the skin of childhood cancer survivors previously treated with radiotherapy. Methods: A retrospective chart review (2000-2017) was performed including adult survivors of childhood cancer referred to the Adult Long-Term Follow-Up Program or the dermatology service at Memorial Sloan Kettering Cancer Center. Data was obtained from electronic medical records, including demographics, histologic subtype and treatment received for NMSC (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)). Clinical features were assessed with clinical images. Results: 960 (mean age 40 years, SD ± 13) patients were assessed for the diagnosis of BCC/SCC after radiotherapy for cancer. The mean age of cancer diagnosis was 15 years (range: birth-39 years). The most common primary diagnosis was Hodgkin lymphoma. 82 patients developed NMSC; 67 of these developed NMSC in the field of prior radiotherapy. 283 in-field lesions were counted, of which 275 were BCC and 8 were SCC. Of the 275 BCC, 261 (95%) were primary lesions and 14 (5%) were recurrent lesions. All SCC were primary lesions. Based on clinical images, 30% of BCC were clinically pigmented; the most common presentation was macule (46%). The mean intervals for BCC and SCC from time of radiotherapy to diagnosis of the first in-field lesion were 24 years (range, 2-44 years) and 32 years (range, 14-46 years), respectively. Histologically, superficial subtype was most prevalent in the BCC subgroup, comprising 47% of all cases. Mohs surgery was the most common therapy (43% of BCC cases; 37% of SCC cases). Conclusions: Among survivors of childhood and young adult cancer, BCC was the most prevalent NMSC. Most of BCC arising in sites of prior radiotherapy for cancer treatment were of low-risk histologic subtype and had low rates of recurrence. An expanded role for topical therapy may be appropriate, but further research is needed.

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