Treatment of carcinoma of the skin with bone and/or cartilage involvement

A Systematic Review of Primary, Adjuvant, and Salvage Radiation Therapy for Cutaneous Squamous Cell Carcinoma

BACKGROUND

The gold standard of treatment for cutaneous squamous cell carcinoma (cSCC) is surgery radiation therapy (RT) is used selectively as definitive treatment for low-risk tumors or as adjuvant/salvage treatment for high-risk tumors. There is a lack of standardized studies evaluating the efficacy of RT in either clinical scenario.

OBJECTIVE

To determine the efficacy of primary and adjuvant/salvage RT for the treatment of cSCC.

MATERIALS AND METHODS

A systematic review of PubMed, Embase, Cochrane, and Web of Science was performed for studies that reported outcomes of cSCC treated with RT to the primary site alone. Outcomes included local control (LC), local recurrence (LR), nodal metastases (NM), distant metastases (DM), disease-specific death (DSD), and recurrence-free survival (RFS).

RESULTS

Forty-six studies with 4,141 tumors were included. Pooled LC and LR rates were 87.3% and 8.6%, respectively. The rates of NM, DM, DSD, and RFS were 4.8%, 3.5%, 5.3%, and 73.5%, respectively. Local recurrence was significantly higher for T3 and T4 tumors, with rates above 25.9%.

CONCLUSION

LR after RT to the primary site increased with increasing tumor stage, highlighting the importance of clear surgical margins for high-risk tumors. Prospective randomized studies characterizing outcomes by tumor stage for RT compared with surgery are needed to inform guidelines.

The role of radiotherapy for T4 non-melanoma skin carcinoma

INTRODUCTION

To review outcomes of patients treated with radiotherapy (RT) for T4 non-melanoma skin cancer (NMSC).

METHODS

A retrospective chart review was performed of 21 patients who received RT for T4 NMSC from 2004 to 2010. Outcomes of treatment efficacy, RT technique and patient morbidity were analysed. Twelve patients (57.1%) were treated definitively without prior treatment, five (23.8%) were recurrent lesions and four (19.1%) were treated postoperatively. Ten patients (47.6%) had evidence of bony erosion at presentation, and four (19.1%) had nodal disease. Intensity-modulated radiotherapy (IMRT), three-dimensional conformal RT and electron treatment were included RT techniques.

RESULTS

Median follow-up was 12 months (range, 5-48 months). Twelve patients (57.1%) following RT required no further treatment and had no disease recurrence. Three patients (14.3%) required salvage treatment and are disease-free following all treatment. Tumours treated initially or postoperatively had improved control rates following RT compared with recurrent lesions (58.3% and 100% vs. 20%). Sixty percent of patients treated with IMRT achieved local control following RT, and 80% were disease-free following surgical salvage treatment. Squamous cell carcinoma (SCC) histology, presence of bony erosion and/or nodal disease was associated with a higher incidence of disease recurrence.

CONCLUSIONS

Patients presenting with untreated lesions, smaller tumour volumes (<70 cm(3)) postoperatively, basal cell histology and absence of bone erosion or nodal disease have improved local control and outcomes. Basal cell carcinoma and SCC should be staged and treated as two separate disease entities. The use of IMRT for advanced skin cancer warrants further investigation.

High-dose-rate brachytherapy in a large squamous cell carcinoma of the hand

PURPOSE

High-dose-rate (192)Ir-based brachytherapy can be used as an exclusive treatment of large skin tumors when teletherapy or surgery is not feasible. A case of an extended inoperable skin epithelioma of the hand is reported; the lesion involved the first finger, the tenar, the palm, and the back.

METHODS AND MATERIALS

A detailed description of an individual case is reported. A customized mold was created for the patient, to administer a fractionated brachytherapy treatment in a reproducible way.

RESULTS

A total dose of 50Gy was administered in 10 fractions, after a time schedule of three fractions per week. The treatment was well tolerated and the acute effects (mainly, epitheliolysis) were resolved completely within a month after the treatment.

CONCLUSIONS

Nine months after the treatment, the malignant lesion completely disappeared and the cosmetic results are quite satisfactory. Therefore, we conclude that the treatment technique is well adaptable to any particular geometry and that the fractionation scheme has proven to be well tolerated and effective in tumor eradication.

Aggressive Squamous Carcinomas of the Scalp

BACKGROUND

Squamous cell carcinomas of the scalp sometimes exhibit unusually aggressive behavior.

OBJECTIVE

To describe a series of 11 cases of extraordinarily aggressive squamous cell carcinomas of the scalp.

METHODS

These cases were selected based on a number of criteria including their tendency to recur after Mohs surgery, their propensity to develop satellite lesions, their tendency to invade bone, and their tendency to metastasize to regional nodes and systemically. A chart review was performed for each patient.

RESULTS

Five of 11 patients have succumbed to their disease. Of note is that the patients all had significant long-standing alopecia or thinning of their hair with marked actinic damage. Initial biopsies of the tumors revealed them to be either moderate or well-differentiated. Four of 11 patients developed satellite lesions and experienced recurrences despite obtaining clear margins with Mohs micrographic surgery.

CONCLUSION

Squamous cell carcinomas of the scalp may metastasize and cause death. Thus, early diagnosis and treatment of these neoplasms is mandatory. In the setting of satellitosis, it is believed that it is best to perform a wide excision with margin control followed by split-thickness grafting and postoperative irradiation. The employment of radiation therapy, however, should be done with appropriate caution owing to the significant risk of osteoradionecrosis.

Radiotherapy management for squamous cell carcinoma of the nasal skin: the Princess Margaret Hospital experience

PURPOSE

To evaluate the outcome of radiotherapy (RT) for squamous cell carcinoma (SCC) of the nasal skin.

MATERIALS AND METHODS

The charts of 100 patients referred and treated with RT during 1982 to 1993 for SCC of nasal skin were reviewed. Most patients (81%) were treated with orthovoltage X-rays. In general, lesions </=2 cm were treated to 35 Gy in 5 fractions. For tumors 2-5 cm, 45 Gy in 10 fractions was commonly used. Lesions >5 cm or those associated with bone or cartilage invasion were typically treated to 50 Gy in 20 fractions. Six patients were lost to follow-up, leaving 94 patients assessable for local or regional failure analysis. Using the UICC staging system, the T stage at first presentation was as follows: T1, 60 patients; T2, 11 patients; T3, 0 patients, T4, 7 patients; TX, 16 patients. Only 1 patient had regional lymph node disease at presentation. Thirty-one patients were treated with surgery, followed by RT. Sixty-three patients were treated with primary RT.

RESULTS

The local relapse-free rate was 90% and 85% at 2 and 5 years, respectively. The actuarial 2 and 5-year overall survival rate was 75% and 51%, respectively. The cause-specific survival was 96% at both 2 and 5 years. No Radiation Therapy Oncology Group Grade 4 toxicities occurred. Univariate analysis could not identify any patient, tumor, or treatment factors that were statistically significant prognosticators.

CONCLUSION

RT for SCC of nasal skin achieves excellent outcome, is well tolerated, and should continue to be recommended in the management of this disease.

Adjuvant radiotherapy after excision of cutaneous squamous cell carcinoma

Most cutaneous squamous cell carcinomas (SCCs) of the trunk and extremities are small enough to be cured by simple surgical excision. Because the risk of metastasis of SCCs of the head and neck arising from mucosal surfaces is higher than the risk of metastasis of SCCs arising from cutaneous surfaces, it may be more appropriate to review case reports of the trunk and extremities separately from those of the head and neck when seeking prognostic indicators. A small group of advanced lesions, however, is more difficult to treat and has an increased risk of local recurrence or metastasis and a poorer prognosis. We describe a patient with high-risk cutaneous SCC who is disease-free 1 year after adjuvant radiotherapy subsequent to excision by Mohs micrographic surgery. This report discusses prognostic indicators of cutaneous SCC and suggests adjuvant modalities for the treatment of high-risk disease after surgical excision. Radiotherapy is a rational choice as adjuvant therapy for the treatment of high-risk cutaneous SCC after excision.

Radical radiotherapy for T4 carcinoma of the skin of the head and neck: a multivariate analysis

Sixty-seven patients with 68 stage T4 carcinomas of the skin of the head and neck were treated with radical radiotherapy at the University of Florida between October 1964 and November 1989. Thirty-three lesions were previously untreated and 35 were recurrent. Twenty-nine lesions were squamous cell carcinomas, 37 were basal cell carcinomas, and 2 were basosquamous carcinomas. Minimum follow-up was 2 years. The 5-year local control, local control including surgical salvage, and cause-specific survival probabilities were 53%, 74%, and 75%, respectively. Local control rates with radiotherapy alone were poorer in patients with recurrent lesions (41% vs. 67%, p = .07) or bone involvement (40% vs. 62%, p = .08). Results were analyzed by multivariate methods using local control, local control with surgical salvage, and cause-specific survival as endpoints. The parameters analyzed were histology; size of primary lesion; previous treatment (previously untreated vs. recurrent); involvement of bone, nerve, or cartilage; and skeletal muscle invasion. Three important prognostic factors were identified, each predictive of poorer ultimate local control and cause-specific survival rates: (a) bone involvement (p < .01); (b) recurrent lesions (p < .01); and (c) nerve involvement (p < .02). Radiotherapy alone can control advanced carcinomas of the skin of the head and neck, although lesions that have recurred after prior treatment and those with involvement of bone or nerve are associated with a lower likelihood of cure.

Squamous cell carcinoma of the skin (excluding lip and oral mucosa)

The striking impression obtained from reviewing the cancer literature is how difficult it is to analyze the data for answers to many important biologic, behavioral, prognostic, and therapeutic questions about squamous cell carcinoma of the skin. This article addresses current concepts, controversies, and management of cutaneous squamous cell carcinoma (excluding the lip and oral mucosa).

Basal cell carcinoma treated with radiation therapy

Between 1974 and 1989, 85 patients with 115 biopsy-proven basal cell carcinomas were treated with radiation therapy at the University Medical Center in Tucson. Either orthovoltage or megavoltage photons were used to deliver doses ranging from 2000 cGy in a single treatment to 7300 cGy in 35 fractions over 62 days. The median length of follow-up was 40 months. Kaplan-Meier estimates of the 5-year local control rates are presented by American Joint Committee on Cancer stage. The difference between the local control rates for both previously untreated and recurrent Stage I and II carcinomas (95% at 5 years) and Stage III and IV carcinomas (56% at 5 years) was statistically significant (P = 0.0001, by Mantel-Haensel test). Although recurrent basal cell carcinomas generally have a worse prognosis, the Kaplan-Meier estimate of the 5-year local control rate for recurrent Stage I and II carcinomas treated with radiation therapy was 95%. These results, along with a review of the literature, suggest two points: (1) high cure rates can be obtained when Stage I and II basal cell carcinomas are treated with radiation therapy and (2) radiation therapy is a relatively effective method for treating recurrent basal cell carcinomas, with cure rates surpassed only by Mohs micrographic surgery.