Superficial Radiotherapy of Warts: Treating 531 Warts
Therapeutic Radiology
Results of
Stanley H. Macht, M.D., F.A.C.R., and Jose M. Cordero, M.D. The fear of injurious effects has almost completely halted the use of radiotherapy in the cure of warts. Over a period of 24 years, the authors have treated 531 warts with both orthovoltage and superficial radiation equipment without any adverse effects. The selection of superficial or orthovoltage units was not dependent on the size of the lesion and was thought to be completely random. INDEX
TERM:
Skin, therapeutic radiology. Warts, therapeutic radiology
Radiology 122:231-232, January 1977
•
•
with a 250 kVp constant potential orthovoltage therapy unit calibrated at 100 kVp and no added filter, and 95 warts were treated with a 100 kVp superficial therapy unit with no added filter. The tube wall thickness of the orthovoltage unit without added filter had a HVL of 2.1 mm of AI. The superficial unit without filter had a HVL of 0.7 mm of AI. The warts were prepared by paring the horny tissue down as flat as possible with a sharp scalpel. Great care was used not to go so deep as to draw blood. Lead shielding was then placed as closely as possible around the base of the wart thus sharply screening the surrounding skin from irradiation. The patient was carefully draped with lead rubber aprons to protect against scattered radiation. A total dose of 1000 R (in air) was administered to the surface of the wart. The lesion was reexamined three weeks after the treatment, and at this time the wart was again denuded of dead tissue by careful paring. If there were no significant changes in wart size or appearance, an additional treatment of 500 R was given. The total maximum dose was 1500 R per lesion in 99 warts. A third dose of 500 R, bringing the total dose to 2000 R, was given in 60 warts that showed no response to the previous treatment. If no change was produced by the end of four to six weeks, the wart was considered refractory and no further radiation was given.
of plantar warts has almost disappeared from the speciality of radiology during recent years because of the fear of exposure to radiation and because of supposed radiation ulcers occasionally reported as the result of an over-treatment by some individuals many years ago. A search of the radiologic literature shows one paper by Reeves and Jackson (1). A second paper on this subject by Hazel and Bouchard (2) appeared in 1962. No other papers have been located in the radiologic literature since that time. Because of the paucity of reports on this long-used modality and because of the excellent results which can be obtained by using x rays to treat warts, a study was made to evaluate our results in treating 360 patients who had 531 warts. During the past 24 years all referred cases with verruca were treated with superficial x-ray therapy. The results of a follow-up study were coded, tabulated and analyzed through the hospital computer center. Four hundred and ninety-five questionnaires were sent out to patients that had been treated for warts. Three hundred and sixty were returned (72.7 %). On these 360 questionnaires, 103 patients indicated that they had more than one wart treated. A report of these findings is presented.
R
OENTGEN THERAPY
TECHNIQUE
Patients were divided according to ages as follows: (a) children up to 12 years of age; (b) 13 to 24 years; (c) 25 years or older. None of the patients had ever received x-ray therapy of warts prior to treatments administered in this hospital. Four hundred and thirty-six of the 531 warts were treated
Of the 436 warts treated with the orthovoltage unit, 140 were in patients under 12 years of age. Of these, 97.1 % were cured, 1.5 % were improved and 1.4 % showed no effect. In this group, 164 warts were in patients 13 to 24
Table I: Orthovoltage Unit Calibrated at 100 kV Without Added Filter. (Inherent Filtration HVL 2.1 mm Aluminum)
Table II: Superficial Unit at 100 kVp, (In herent Filtration HVL 0.7 mm Aluminum-No Added Filter)
Age (Years)
No. of Warts in Per Cent Age Group Cured
Up to 12
140
13-24
164 132
25 or older Total
97.1 90.9 79.2
RESULTS
Per Cent Per Cent Improved No Effect
1.5 6.1 12.5
Age (Years)
No. of Warts in Per Cent Age Group Cured
Per Cent Per Cent Improved No Effect
- - - - - - - - - - - - - - - - -o- -
1.4 3.0 8.3
Up to 12
27
13-24
32 36 95
25 or older Total
436
84.4 88.2
15.6
o
11.8
41.2
47.1
11.7
1 From the Department of Radiology, Washington County Hospital, Hagerstown, Md. Revised manuscript accepted for publication in July 1976. shan
231
232
STANLEY H. MACHT AND JOSE M. CORDERO
years of age and of these 90.90/0 were cured, 6.1 % were improved and 3% showed no effect. The remaining 132 warts were in patients over 25 years of age. The percentage of cures in these older individuals dropped to 79.2 %: 12.5 % were improved; and there was no effect 8.3% (TABLE I). Of the 95 warts treated with the superficial unit, 27 were in patients 12 years old or younger and of these 84.4 % were cured and 15.6% improved. Also in this group were 32 warts in patients from 13 to 24 years of age. Of these, 88.2 % were cured and 11.8 % failed to respond. Of the 36 warts in patients over 25 years old, 41.2 % were cured, 47. 1% were improved and 11.7% were not improved. In the total group of 531 warts in the study, 99 received 1500 Rand 60 received 2000 R before therapy was discontinued. Of the 99 warts requiring a second treatmert of 500 R, and of the 60 warts requiring a third treatment of 500 R in order to bring the total dosage to 2000 R, the results were as follows: 72.8% were cured, 12.2% were improved and 15.0% showed no effect. Follow-up of all 531 warts failed to show a single complication or adverse effect. Reeves and Jackson (1) reported 60 to 75 % of 80 patients cured and 12 to 14.8 % with no effect. They found no postradiation damage in any of their cases. Hazel and Bouchard (2) obtained 82.6% cure in a group of 75 patients and 8 % partial cure or improvement in this same group and a 9.4 % failure rate. No injuries were reported. Pendergrass and Hodes (3) in 1941 reported 208 patients with a cure rate of 98 % .
SUMMARY Comparison of the results between an orthovoltage
January 1977
therapy unit calibrated for superficial therapy at 100 kV and a superficial therapy unit calibrated at 100 kV showed that the average percentage of cures with the orthovoltage unit was 89 % in contrast to 70.3 % with the superficial unit. This is thought to be due to the heavier inherent filtration in the orthovoltage unit (HVL of 2.1 mm AI V5. 0.7 mmAI). In the younger age group with 363 warts, the rate of improvement was better than that in the 25 years or older group. In patients below 12 years of age improvement was even better as shown by the rate of 97 % . No adverse reactions or complications were seen or reported in any of these patients. From this study, one can state that x-ray therapy as administered under the above described parameters is still one of the most efficient, simple, safe and easily administered modes of therapy of warts. ACKNOWLEDGMENT: The authors wish to acknowledge with appreciation the assistance given by Nancy Bradfield, R. T. and William E. Myers of the Data Processing Center. Stanley H. Macht, M.D., F.A.C.R. Department of Radiology Washington County Hospital Association King and Antietam Streets Hagerstown, Maryland 21740
REFERENCES 1. Reeves RJ, Jackson MT: Roentgen therapy of plantar warts. Am J RoentgenoI76:977-978, Nov 1956 2. Hazel J, Bouchard J: The value of radiation therapy in the treatment of verrucae plantaris. J Canad Assoc RadioI13:70-71, Jun 1962 3. Pendergrass EP, Hodes PJ: Roentgen irradiation in treatment of inflammations. Am J RoentgenoI45:74-106, Jan 1941
Therapeutic Radiology
Results of
Stanley H. Macht, M.D., F.A.C.R., and Jose M. Cordero, M.D. The fear of injurious effects has almost completely halted the use of radiotherapy in the cure of warts. Over a period of 24 years, the authors have treated 531 warts with both orthovoltage and superficial radiation equipment without any adverse effects. The selection of superficial or orthovoltage units was not dependent on the size of the lesion and was thought to be completely random. INDEX
TERM:
Skin, therapeutic radiology. Warts, therapeutic radiology
Radiology 122:231-232, January 1977
•
•
with a 250 kVp constant potential orthovoltage therapy unit calibrated at 100 kVp and no added filter, and 95 warts were treated with a 100 kVp superficial therapy unit with no added filter. The tube wall thickness of the orthovoltage unit without added filter had a HVL of 2.1 mm of AI. The superficial unit without filter had a HVL of 0.7 mm of AI. The warts were prepared by paring the horny tissue down as flat as possible with a sharp scalpel. Great care was used not to go so deep as to draw blood. Lead shielding was then placed as closely as possible around the base of the wart thus sharply screening the surrounding skin from irradiation. The patient was carefully draped with lead rubber aprons to protect against scattered radiation. A total dose of 1000 R (in air) was administered to the surface of the wart. The lesion was reexamined three weeks after the treatment, and at this time the wart was again denuded of dead tissue by careful paring. If there were no significant changes in wart size or appearance, an additional treatment of 500 R was given. The total maximum dose was 1500 R per lesion in 99 warts. A third dose of 500 R, bringing the total dose to 2000 R, was given in 60 warts that showed no response to the previous treatment. If no change was produced by the end of four to six weeks, the wart was considered refractory and no further radiation was given.
of plantar warts has almost disappeared from the speciality of radiology during recent years because of the fear of exposure to radiation and because of supposed radiation ulcers occasionally reported as the result of an over-treatment by some individuals many years ago. A search of the radiologic literature shows one paper by Reeves and Jackson (1). A second paper on this subject by Hazel and Bouchard (2) appeared in 1962. No other papers have been located in the radiologic literature since that time. Because of the paucity of reports on this long-used modality and because of the excellent results which can be obtained by using x rays to treat warts, a study was made to evaluate our results in treating 360 patients who had 531 warts. During the past 24 years all referred cases with verruca were treated with superficial x-ray therapy. The results of a follow-up study were coded, tabulated and analyzed through the hospital computer center. Four hundred and ninety-five questionnaires were sent out to patients that had been treated for warts. Three hundred and sixty were returned (72.7 %). On these 360 questionnaires, 103 patients indicated that they had more than one wart treated. A report of these findings is presented.
R
OENTGEN THERAPY
TECHNIQUE
Patients were divided according to ages as follows: (a) children up to 12 years of age; (b) 13 to 24 years; (c) 25 years or older. None of the patients had ever received x-ray therapy of warts prior to treatments administered in this hospital. Four hundred and thirty-six of the 531 warts were treated
Of the 436 warts treated with the orthovoltage unit, 140 were in patients under 12 years of age. Of these, 97.1 % were cured, 1.5 % were improved and 1.4 % showed no effect. In this group, 164 warts were in patients 13 to 24
Table I: Orthovoltage Unit Calibrated at 100 kV Without Added Filter. (Inherent Filtration HVL 2.1 mm Aluminum)
Table II: Superficial Unit at 100 kVp, (In herent Filtration HVL 0.7 mm Aluminum-No Added Filter)
Age (Years)
No. of Warts in Per Cent Age Group Cured
Up to 12
140
13-24
164 132
25 or older Total
97.1 90.9 79.2
RESULTS
Per Cent Per Cent Improved No Effect
1.5 6.1 12.5
Age (Years)
No. of Warts in Per Cent Age Group Cured
Per Cent Per Cent Improved No Effect
- - - - - - - - - - - - - - - - -o- -
1.4 3.0 8.3
Up to 12
27
13-24
32 36 95
25 or older Total
436
84.4 88.2
15.6
o
11.8
41.2
47.1
11.7
1 From the Department of Radiology, Washington County Hospital, Hagerstown, Md. Revised manuscript accepted for publication in July 1976. shan
231
232
STANLEY H. MACHT AND JOSE M. CORDERO
years of age and of these 90.90/0 were cured, 6.1 % were improved and 3% showed no effect. The remaining 132 warts were in patients over 25 years of age. The percentage of cures in these older individuals dropped to 79.2 %: 12.5 % were improved; and there was no effect 8.3% (TABLE I). Of the 95 warts treated with the superficial unit, 27 were in patients 12 years old or younger and of these 84.4 % were cured and 15.6% improved. Also in this group were 32 warts in patients from 13 to 24 years of age. Of these, 88.2 % were cured and 11.8 % failed to respond. Of the 36 warts in patients over 25 years old, 41.2 % were cured, 47. 1% were improved and 11.7% were not improved. In the total group of 531 warts in the study, 99 received 1500 Rand 60 received 2000 R before therapy was discontinued. Of the 99 warts requiring a second treatmert of 500 R, and of the 60 warts requiring a third treatment of 500 R in order to bring the total dosage to 2000 R, the results were as follows: 72.8% were cured, 12.2% were improved and 15.0% showed no effect. Follow-up of all 531 warts failed to show a single complication or adverse effect. Reeves and Jackson (1) reported 60 to 75 % of 80 patients cured and 12 to 14.8 % with no effect. They found no postradiation damage in any of their cases. Hazel and Bouchard (2) obtained 82.6% cure in a group of 75 patients and 8 % partial cure or improvement in this same group and a 9.4 % failure rate. No injuries were reported. Pendergrass and Hodes (3) in 1941 reported 208 patients with a cure rate of 98 % .
SUMMARY Comparison of the results between an orthovoltage
January 1977
therapy unit calibrated for superficial therapy at 100 kV and a superficial therapy unit calibrated at 100 kV showed that the average percentage of cures with the orthovoltage unit was 89 % in contrast to 70.3 % with the superficial unit. This is thought to be due to the heavier inherent filtration in the orthovoltage unit (HVL of 2.1 mm AI V5. 0.7 mmAI). In the younger age group with 363 warts, the rate of improvement was better than that in the 25 years or older group. In patients below 12 years of age improvement was even better as shown by the rate of 97 % . No adverse reactions or complications were seen or reported in any of these patients. From this study, one can state that x-ray therapy as administered under the above described parameters is still one of the most efficient, simple, safe and easily administered modes of therapy of warts. ACKNOWLEDGMENT: The authors wish to acknowledge with appreciation the assistance given by Nancy Bradfield, R. T. and William E. Myers of the Data Processing Center. Stanley H. Macht, M.D., F.A.C.R. Department of Radiology Washington County Hospital Association King and Antietam Streets Hagerstown, Maryland 21740
REFERENCES 1. Reeves RJ, Jackson MT: Roentgen therapy of plantar warts. Am J RoentgenoI76:977-978, Nov 1956 2. Hazel J, Bouchard J: The value of radiation therapy in the treatment of verrucae plantaris. J Canad Assoc RadioI13:70-71, Jun 1962 3. Pendergrass EP, Hodes PJ: Roentgen irradiation in treatment of inflammations. Am J RoentgenoI45:74-106, Jan 1941
