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: DAT003
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
The patient is an 86 year old male with history of multiple difficult skin cancers of the head and neck. The patient takes Aspirin and Plavix daily, has hypertension, and a history of bladder cancer.
Patient Prognosis & Management
The patient presented with a 2.0 x 3.2 cm, tender keratotic lesion on his left cheek. This was felt to be SK clinically but due to the presence of pain this area was biopsied to rule out SCC. The biopsy did prove this area to be a SCC in situ with no invasive component. There was also inflamed SK present in the submitted tissue. The patient returned in two weeks to discuss treatment options including Mohs surgery with a skin graft or Superficial x-ray, the patient opted for SRT. The clinically visible area of involvement was circled this measured 2.4 x 4.5 cm. A 7 mm area around this was delineated for treatment with SRT.
Treatment Parameters
The patient opted for superficial radiation treatment for this lesion. The clinical lesion was circled and an appropriate shield measuring 4.1 x 7.1 cm was fashioned out of lead sheet 0.762 mm thick. Eye shielding and neck shielding were done. Using the Sensus SRT-100™ x-ray machine, a 10 cm cone, 7 fractions of 500 cGy were delivered at 50 kv, 10 mA with a D ½ of 6.4 mm. The patient received a total of 3,500 cGy to the area over a two week period.
Patient Outcome
The patient tolerated the treatment with no side effects. The patient returned 2 weeks post op with a good erythematous reaction from the SRT treatment. This should give him a good chance of cure. See photos below.