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Rheumatological diseases and cancer: the hidden variable of radiation exposure
  1. Eugenio Picano1,
  2. Richard Semelka2,
  3. James Ravenel3,
  4. Marco Matucci-Cerinic4
  1. 1Institute of Clinical Physiology, CNR, Pisa, Italy
  2. 2Department of Radiology, University of North Carolina, Chapel Hill, North Carolina, USA
  3. 3Department of Radiology and Radiologic Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4Division of Rheumatology AOUC, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
  1. Correspondence to Dr Marco Matucci-Cerinic, Division of Rheumatology AOUC, Department of Experimental and Clinical Medicine, University of Florence, Florence 50139, Italy; marco.matuccicerinic{at}

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Recently, several different meta-analyses have shown that rheumatological diseases—including systemic sclerosis (SSc), systemic lupus erythematosus, rheumatoid arthritis and psoriatic arthritis—are associated with an increased risk of cancer, in particular non-Hodgkin’s lymphoma, lung and liver cancer.1–6 Several hypotheses have been advanced to explain this finding, including immune dysregulation, biological therapy and exposure to common environmental risk factors.7 These data may suggest the inclusion of medical radiation as a potential, and verifiable, iatrogenic risk linking SSc and cancer. This malignant induction may be potentiated by the concomitant use of drugs, such as methotrexate and cyclophosphamide, or drugs such as paracetamol. In fact, these drugs are known to amplify the genotoxic effects of medical radiation. In addition, in some rheumatic diseases, the exposure to medical radiation is associated with an intrinsic higher vulnerability for DNA instability.

Frauenfelder et al8 present the prospective validation of a dedicated, 9-slice high resolution computed tomography (HRCT) protocol with reduced radiation dose for the detection of interstitial lung disease in SSc patients. This paper addresses clearly the fact that the dose reduction is becoming today a hot issue in clinics. Herein, we wish to draw the attention of the rheumatological community to the hypothesis that, in rheumatological patients, the use of medical radiation may pose an additional risk for cancer development, possibly potentiated by the concurrent use of antirheumatic drugs.

Medical radiation as a potential carcinogen

Medical radiation is suspected to contribute to the development of cancer. According to the linear no-threshold theory, all radiation poses some risk of cancer induction, although the magnitude of this risk remains unclear, particularly at very low doses. The average background exposure of a US citizen approximates 3.0 milliSievert (mSv, corresponding to the radiological dose equivalence of 150 chest X-rays) per person per year, as estimated in 2006.9 Doses of examinations commonly employed in rheumatology …

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