Dermatology Association of Tallahassee
Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
Lyndsey Schimmel M.A.
CSN: DAT002
October 27, 2010
Situational Overview
Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologist’s in lower Alabama, South Georgia and the Panhandle, as well as our own general derms and local and regional physicians.
Many of our patients have multiple cancers at time of referral. Depending on the location, size, depth and aggressiveness of the individual tumor, juxtaposed to the patient’s age and health status we discuss Mohs vs. SRT as part of informed consent. We discuss radiation with all patients over 65 with the option of treatment either here in the office or by radiation oncology. We end up using it in about 10% of these patients over 65 who are referred for Mohs surgery. We have been doing this for 25+ years and recently calculated our 10-year cure rates, which compare very favorably to Mohs surgery.
Patient History
Patient is an 89-year-old white female who, over the course of the year, developed an erythematous scaly plaque on her forehead. It measured 52×45 mm. Two biopsies had been done, previous #1 showing well-differentiated SCC in situ and previous #2 showing well-differentiated Squamous Cell Carcinoma (SCC) in situ. These were about 3.5 cm apart and were in the midst of this large erythematous plaque of Squamous Cell Carcinoma (SCC) in situ.
Patient Prognosis & Management
The patient was referred in for Mohs surgery; but, after discussing the need for a large skin graft and an extensive surgery, the patient opted for superficial x-ray.
Treatment Parameters
The clinical lesion was circled and an appropriate shield was fashioned out of lead measuring 55×75 mm. Eye shielding and neck shielding were done. Using the Sensus SRT-100™ x-ray machine, a 10 cm cone was utilized to deliver 500 cGy directly at base with a PKV of 50, 10 mA, a time factor of 1.74 minutes, an SSD of 25 cm, 0 filtration, and a D ½ of 6.4 mm. This was repeated 7 times with 1 additional dose of 300 cGy for a total of 3,800 cGy to the area over a 2-week period.
Patient Outcome
The patient returned 2 weeks post treatment with a brisk moist desquamative reaction from the SRT treatment. She was followed clinically for a month and a half, during which time there were dressings (Arglaes) and lotions were used for healing. At post radiation day 44, the lesion had completely reepithelized. See photos. On post radiation day 106, there is minimal scarring and very slight erythema and no clinical evidence of disease. See photos below.