Customized double-shell immobilization device combined with VMAT radiation treatment of basosquamous cell carcinoma of the scalp.

Malignancies with a superficial involvement of the scalp/skull present technical challenges for radiation-treatment-planning, such as achieving skin coverage with the prescribed dose and with the desirable conformity, homogeneity, and lower brain dose. We report a radiotherapy treatment technique for a patient diagnosed with diffuse basosquamous cell carcinoma of the scalp and adjacent skull-bone. This study presents the plan's quality parameters, patient's dosimetry, and patient's outcome. The patient was treated using volume-modulated-arc therapy (VMAT) and a double-shell-bolus full-head device (DSBFD) designed for patient immobilization and better skin coverage. A VMAT plan was generated using an Eclipse treatment-planning system for a prescribed dose of 60 Gy in 30 fractions. The treatment plan was analyzed to determine the conformity index (CI), the homogeneity index (HI), the target-coverage, and the dose to the organs-at-risk (OARs). Skin-doses were measured using optically stimulated luminescence (OSL) dosimeters. Clinical follow-up was performed by the radiation oncologist during and after the course of radiotherapy. With regard to planning target volume (PTV) coverage, the V95 was 99%. The measured and calculated dose to the skin was in the range 100-108% of the prescribed dose. The mean brain-PTV dose was 711 cGy. The CI and HI were 1.09 and 1.08, respectively. The mean positioning accuracy for the patient over the course of treatment was within 2 mm. The measured accumulated skin dose and planning dose was agreed within 2%. Clinical examination of the patient 6 months after radiotherapy showed good response to the treatment and a 90% reduction in scarring. The DSBFD technique combined with RapidArc treatment was useful in terms of the target dose distribution and coverage. Daily patient alignment was found very precise, reproducible and less time-consuming.

Radiation-induced lichen sclerosus of the vulva : First report in the medical literature.

A 67-year-old woman presented with a firm plaque in the perineal region, 16 months after diagnosis of a high-grade basaloid squamous cell carcinoma of the vagina and treatment by external beam radiation therapy and vaginal cuff brachytherapy. The differential diagnosis included radiation-induced morphea, radiation dermatitis, or, possibly, radiation-induced lichen sclerosus. Biopsy findings, including special staining, confirmed the diagnosis of radiation-induced lichen sclerosus. To our knowledge, this is the first report of radiation-induced lichen sclerosus of the vulvar region.

Palliative combined treatment for unresectable cutaneous basosquamous cell carcinoma of the head and neck.

A case is presented of a patient with a skin basosquamous cell carcinoma of the frontal region infiltrating the cerebral tissue and with a widespread unresectable regional metastatic ulceration of the left parotid region. The patient underwent combined palliative treatment: surgical coverage of the ulceration by means of a pectoralis mayor flap transposition and radiotherapy. After 18 months of follow-up, no signs of tumour progression were noted, the patient is currently free from pain, no increase in trismus was seen, and a slight gain in weight was recorded. Unresectable cancer is mainly treated by concurrent chemoradiation; radiotherapy, however, is contraindicated in deep neoplastic ulcerations with exposure of large vessels. The data reported suggest that surgical coverage of an unresectable neoplastic ulcer is feasible, and combined with early administration of radiation permits a palliative approach in an otherwise untreatable condition.

Outcomes after radiotherapy for basaloid squamous cell carcinoma of the head and neck: a case-control study.

BACKGROUND: Basaloid squamous cell carcinoma (BSCC) is an uncommon, high-grade variant of squamous cell carcinoma (SCC) of the head and neck. Its poorer prognosis compared with common SCC remains controversial. The authors investigated the outcomes of patients with BSCC who received radiotherapy and compared them with the outcomes of patients with SCC. METHODS: From 1994 to 2004, 1007 patients received radiotherapy for head and neck carcinoma with lymph node involvement. The histologic types consisted of 51 BSCC, 431 poorly differentiated SCC (PSCC), and 525 well or moderately differentiated SCC (WMSCC). A case-control analysis was performed with BSCC matched against both PSCC and WMSCC to compare disease-control and survival rates. RESULTS: Patients with BSCC received treatment modalities similar to those received by patients with SCC: They received induction chemotherapy (12%) or concurrent chemotherapy (33%), and a median radiation dose of 70 Gray. Posttreatment viable tumor was present in 44%, 13%, and 28% of neck dissection specimens from patients with BSCC, PSCC, and WMSCC, respectively. The 5-year disease-free survival rates (63%, 77%, and 76%, respectively) and overall survival rates (85%, 70%, and 71%, respectively) demonstrated no statistically significant differences for BSCC, PSCC, or WMSCC, respectively. CONCLUSIONS: In this study, a poorer prognosis could not be demonstrated for irradiated patients with BSCC compared with either PSCC or WMSCC. All patients in this study had positive lymph node status, and the majority of patients (84%) had oropharyngeal cancer. The BSCC cohort did have a relatively high rate of viable tumor in their posttreatment neck dissections, and they had a relatively high rate of distant disease. On the basis of the high rate of lung metastases and the possibility of efficient salvage, the authors recommend obtaining a chest computed tomography scan during initial staging and follow-up.

Basaloid squamous cell carcinoma of the soft palate: case report.

Basaloid squamous cell carcinoma (BSCC) is a histologically distinct variant of squamous cell carcinoma. It occurs in various sites of the head and neck region and is believed to carry a dismal prognosis. The palate is a very rare site of BSCC development and only three cases have been reported in the international literature. In this report, we present a case of basaloid squamous cell carcinoma of the soft palate. The therapeutic strategy and histological findings are described in detail, including immunohistochemistry with the use of involucrin, an agent used for the first time for BSCC diagnosis. In addition, a brief review of the literature is presented.

Basaloid squamous carcinoma of the anal canal with an adenoid cystic pattern: histologic and immunohistochemical reappraisal of an unusual variant.

Two cases of a distinctive variety of basaloid squamous carcinoma (BSC) of the anal canal are described. Both occurred in female patients who presented with bleeding per rectum. Histologic evaluation of the tumors showed lobules and aggregates of medium-sized basaloid cells with distinctive peripheral palisading and focal areas of central, comedo-necrosis. Accompanying dysplasia of the overlying squamous mucosa was absent. However, the microscopic pattern was dominated by the presence of eosinophilic, hyaline, paucicellular basement membrane-like material around and within tumor nests. This appearance together with microcystic spaces simulated that of an adenoid cystic carcinoma. Immunohistochemistry of the tumors revealed the following profile: CK7, CK5/CK6, 34betaE12 positive, CK14 focally positive but CK20 negative. The following were all negative: EMA, CEA, smooth muscle and muscle-specific actin, calponin, and S-100. The tumor cells exhibited diffuse nuclear positivity with p63. The eosinophilic basement membrane hyaline material was positive for collagen type IV and also for laminin. BSC of the anal canal with an adenoid cystic pattern is an infrequently encountered and reported variant, although it is seen more often in the aerodigestive tract. There may be an increased propensity for BSC with an adenoid cystic pattern to metastasize to the liver, but the number of cases encountered are too small to be definitive. The histologic differential diagnosis is true salivary gland-type adenoid cystic carcinoma and basal cell adenocarcinoma. Immunohistochemistry and awareness of this unusual pattern of BSC will facilitate the correct diagnosis being reached.

Basaloid squamous cell carcinoma of the larynx: a case report.

Basaloid squamous cell carcinoma (SCC) is a very rare, high grade, and aggressive variant of SCC, with a predilection for the upper aerodigestive system. Treatment should include surgery of the primary tumor and dissection of the cervical lymph nodes, followed by radiotherapy. We present a 50-year-old man with basaloid SCC of the supraglottic larynx, which was initially misdiagnosed as SCC. Supraglottic laryngectomy with bilateral radical neck dissection was performed, and radiotherapy was applied postoperatively. During a follow-up of 26 months, no evidence for recurrence was found. Basaloid SCC should be considered in the differential diagnosis of upper aerodigestive system malignancies because it has a distinct prognostic significance compared to conventional SCC.

Cutaneous basosquamous carcinoma infiltrating cerebral tissue.

Basosquamous carcinoma of the skin is a rare malignancy with specific histopathological features of both basal cell carcinoma and squamous cell carcinoma. Some authors believe that basosquamous carcinoma is a variant of basal cell carcinoma, while others suggest that this tumour may behave more aggressively. We present a 44-year-old female patient who was diagnosed with a basosquamous carcinoma histopathologically. She had extensive ulcero-vegetative lesions, involving the anterior half of the scalp, the left orbit and the left side of the face. With this case we aim to emphasize the aggressive nature of basosquamous carcinoma and review the literature.

What is the current role of radiation therapy in the treatment of skin carcinomas?

AIMS AND BACKGROUND: In recent years several radiation therapy units have recorded a decline in the number of referrals for the treatment of skin carcinomas. This study aims to ascertain whether this decline has also affected the radiation therapy unit of Trieste and, if so, to consider the possible reasons. METHODS: We retrospectively reviewed all cases of non-melanoma skin cancer treated in our unit from January 1986 to December 1999. A database was created that would allow rapid and controlled data entry and a sufficiently simple query system. RESULTS: The total number of irradiated skin cancers was 2,219:1,863 basal cell carcinomas, 276 squamous cell carcinomas, and 80 basosquamous carcinomas. The distribution curves for the number of cases treated every year were similar: each of the three types showed a slow and gradual reduction in the number of patients referred for radiotherapy. CONCLUSIONS: For most authors surgery remains the treatment of choice for skin carcinomas. However, radiation therapy can also yield excellent results in terms of local control, cosmesis and functionality. In our view the indications for radiation therapy are poor general health, elderly age, the presence of diseases that are a contraindication for surgery, location of the tumor in the head region, and tumor size between 1 and 5 cm.

Invading basal cell carcinoma of the jaw: an under-evaluated complex entity.

Basal cell carcinoma (BCC) is a locally invasive neoplasm, rarely metastatic, yet capable of significant local destruction and disfigurement. Invasion into the bone is uncommon and only a few cases of invasion into facial bones, but never to the mandible or maxilla, have been described. We report three patients with BCC lesions invading their jaws, as a consequence of which either their mandible or maxilla had to be partially resected. This resulted in facial mutilation which required comprehensive multi-disciplinary therapy to restore function and esthetics. Such therapy requires a combination of modalities offered by both plastic and maxillofacial surgeons, as well as oral and dental rehabilitators.

Results of radiotherapy for epithelial skin cancer of the pinna: the Princess Margaret Hospital experience, 1982-1993.

PURPOSE: To assess the treatment outcome, late toxicity, and prognostic factors for radiotherapy (RT) of carcinoma of the pinna. METHODS AND MATERIALS: The charts of 313 patients treated between 01/82 and 12/93 were retrospectively reviewed. There were 334 lesions treated: 201 basal cell carcinoma (BCC), 122 squamous cell carcinoma (SCC), and 11 basosquamous carcinoma. RT was most commonly given by orthovoltage X-rays (278 lesions) or electrons (39 lesions). The most frequently used dose prescriptions were 35 Gy in 5 fractions (123 treatments with median field size = 4.9 cm(2)), 42. 5-45 Gy in 10 fractions (67 treatments with median field size = 10.5 cm(2)), and 50-65 Gy in 20-30 fractions (42 treatments with median field size = 81 cm(2)).2 cm. RESUL TS: The actuarial 2- and 5-year local control rates were 86.6% and 79.2 %. Multivariate analysis revealed two factors to be statistically signi ficant for increased local failure: tumor size > 2 cm (hazard ratio [HR] = 2.66, 95% confidence interval [CI] = 1.16-6.08), and a low biological effective dose (BED) (for each decrease of 5 BED units, HR = 1.76, 95% CI = 1.07-2.88). The 5-year actuarial rate of significant Grade 4 late toxicity was 7.3%. Factors statistically significant for this endpoint on univariate analysis were tumor size (p = 0.035), T-stage (p = 0.02), field size (p = 0.05), fraction size (p = 0.003), and BED (p = 0.05). CONCLUSIONS: RT is an eff ctive treatment option for epithelial skin cancer of the pinna. Large t umor size and low BED were independently statistically significantly ass ociated with increased local failure. Dose-fractionation schedules usin g fraction sizes < 4 Gy may reduce the risk of necrosis and ulceration, particularly for field sizes > 5 cm2.

The basaloid squamous cell carcinoma of the nasopharynx.

The basaloid squamous cell carcinoma (BSCC) is a very rare and widely unknown malignant tumour of the upper aerodigestive tract. It is considered a particular variant of squamous cell carcinoma (SCC), but much more aggressive. A relatively little number of cases and clinical reports has been published since its first description in 1986 by Wain et al. Only five basaloid squamous cell carcinomas with location in the nasopharynx, where it seems to have a different biological behaviour, are mentioned in the international literature. We present a new case of BSCC with this location, referring to the pathologic and clinical aspects and to the respective literature.

Basaloid squamous cell carcinoma of the larynx: report of two cases.

AIM: To present two patients with basaloid squamous cell carcinoma of the larynx, a rare, highly aggressive variant of the squamous cell carcinoma. METHODS: Surgical excision of the polypoid tumor of the anterior comissure of the larynx was performed in a 62 year-old male, and in the second case, total laryngectomy with radical dissection of the neck was performed in a 66 year-old male with supraglottic tumor of the larynx and enlarged lymph nodes of the neck. Histopathological analysis of biopsy specimens was performed on routine hematoxylin-eosin stained sections and on sections stained with antibodies to cytokeratin, epithelial membrane antigen, S-100 protein, neuron-specific enolase, and chromogranin. RESULTS: In both cases, the tumors were composed of moderately pleomorphic basaloid cells forming nests, cords, and cribriform patterns with foci of necrosis, squamous differentiation, and small cystic spaces containing mucin-like material. Surface mucosa showed squamous dysplasia. Cytokeratin and epithelial membrane antigen were positive. After surgery, both patients recieved radiotherapy and had no signs of tumor recurrence or metastases 12 and 15 months later, respectively. CONCLUSION: Basaloid squamous cell carcinoma has a potential for diagnostic confusion because of its basaloid and squamous component. It should be distinguished from adenoid cystic carcinoma that is much less aggressive.

Use of Mohs micrographic surgery to establish quantitative proof of heightened tumor spread in basal cell carcinoma recurrent following radiotherapy.

We compared 27 basal-cell carcinomas (BCCs) recurrent following radiotherapy and subsequently excised by Mohs micrographic surgery to a control group of BCCs recurrent following other treatment modalities and similarly excised. Mohs technique permitted precise, quantitative tumor assessment, obtained via a novel method utilizing three parameters: the number of surgical stages required for complete excision, the percentage increase between clinical preoperative tumor area and final postoperative defect area, and the presence of deep subcutaneous tissue invasion. Figures for the postradiation group were larger in all three categories, with the latter two revealing statistically significant differences versus the nonradiation group. This study gives strong, direct quantitative support to the clinical impression that BCC recurrent following radiotherapy is a uniquely aggressive, invasive subset of recurrent BCC.

Treatment results and patterns of failure in 646 patients with carcinoma of the eyelids, pinna, and nose.

From 1956 to 1978, 646 patients were treated with radiotherapy for carcinoma of the nose (350 patients, 54 percent), eyelids (159 patients, 25 percent), pinna (93 patients, 14 percent), and skin adjacent to the lip (44 patients, 7 percent). The histologic distribution was 72 percent basal cell carcinoma, 18 percent squamous cell carcinoma, and 10 percent mixed basal and squamous cell features. Tumors less than 2 cm in diameter were found in 602 patients (93 percent), whereas 44 patients (7 percent) had larger tumors. Tumor involvement of cartilage and bone was seen in 23 patients at the time of diagnosis. The 5, 10, and 20 year control rates were 99 percent, 98 percent, and 98 percent, respectively, for 502 tumors less than 2 cm in diameter. This compared favorably with control rates of 92 percent at 5 years and 79 percent at 10 years for tumors from 2 to 5 cm in diameter and 60 percent at 5 years and 53 percent at 8 years for 12 patients with massive tumors (p less than 0.0001). The histologic characteristics of the lesion had a strong influence on tumor control (p less than 0.02). Of the patients with cartilage or bone invasion, tumor was controlled in 19 (83 percent). Of these 19 patients, 11 had no evidence of disease for 3 years or more. Of all 646 patients treated, failure was seen in 60 (9 percent). It correlated well with the size of the lesion, being 7 percent for tumors of less than 2 cm and 50 percent for tumors of greater than 5 cm. Of the 60 patients in whom treatment failed, 48 (80 percent) had prior definitive therapy. Radiotherapy was an efficient modality to control operative failures; however, it was not as efficient at control in patients in whom previous radiotherapy failed. Operation was the treatment of choice to salvage patients in whom radiotherapy failed. Of the patients in whom retreatment failed, 10 were known to have died from skin cancer, and an additional 6 patients were presumed to have died from the cancer. This study has demonstrated a good control rate and good cosmetic results for small tumors of the eyelids, pinna, and nose. In addition, a good control rate was obtained in patients with cartilage and bone involvement. Treatment of massive tumors should involve planned operative resection with adjuvant radiotherapy.

Effects of urea treatment in combination with curettage in extensive periophthalmic malignancies.

46 patients with 47 cancers of the eyelids and the canthi, large or very large in their great majority, were treated with local urea injections in combination with thorough curettage. In 7 of the above patients, the caruncle and the conjunctiva were also affected. This treatment was effective in 100% of our cases. The full recovery of the skin which had been destroyed by the cancer, without any remnants of scar or other disfigurement, is a very remarkable phenomenon; the functional condition of the lids remained quite normal as well. So we can affirm that in extensive periophthalmic carcinomas, in which cure with conventional methods is very difficult or almost impossible, as in some reported cases, the afore-mentioned treatment gives the most beneficial results, without any of the disadvantages of these methods.

[A case of doubly differentiated epithelioma of the cervix (a mixed carcinoma) (author's transl)]. / A propos d'un cas d'épithélioma à double différenciation du col utérin.

Following a clinical case of doubly differentiated epithelioma of the cervix, we have reviewed the histological, epidemiological and clinico-pathological characteristics of this epithelioma. This lesion, which is particularly found in young patients, is often associated with pregnancy, and has a strong predilection for lymphatic spread. Finally, this tumour is very aggressive and seems to respond neither to radiotherapy nor to surgery.