Dermatology Association of Tallahassee
Armand B. Cognetta Jr., M.D.
Earl Stoddard M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT006
January 28, 2011
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 dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.
Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.
Patient History
The patient has a history of difficult skin cancers including 6 on her nose in the recent past. She has had numerous other skin cancers as well. She has a history of hypertension and diabetes.
Patient Management
The patient had 4 skin cancers on her nose 3 of which were treated with Mohs, 1 of which was treated with Superficial x-ray. On a follow-up visit 2 more skin cancers were found on her nose and treated with Mohs. See discussion below.
Treatment Parameters
The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this. The tumor depth was estimated to be <5 mm. A 0.762 mm thick lead shield was fashioned to include a 2 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Sensus RT machine with a 3 cm cone, 5 fractions of 700 cGy were delivered at 50 kv, 10 ma with a D1/2 of 5.8 mm. The patient received a total of 3500 cGy to the area over a two week period.
Clinical Photos
The patient presents with biopsy proven Nodular BCC labeled #1. There is a suspicious lesion on the right ala labeled #2 this was biopsied and found to be a Nodular BCC. A second suspicious lesion labeled #3, is identified inferior to site #1, this was biopsied and found to be a Nodular BCC. A third suspicious lesion labeled #4, is identified superior to site #1, this is biopsied and found to be a Nodular BCC.
Discussion
Sites 1,3 and 4 were along the midline nose and after Mohs were amenable to a midline closure with excellent cosmetic result seen on post op day 212. Site 2 on the alar rim, if approached with Mohs would have led to a defect which encroached on the alar rim. This would have required a full thickness skin graft or a bilobed flap; both of these options are complex and can result in a deformity (i.e) notching of the alar rim, pi-cushioning, or collapse of the ala with a valve effect. Superficial x-ray in this setting results in minimal scarring and deformity.
Mohs sites delineated with a Linear mark. The previous x-ray site is on the right tip of nose. The patient will complete a six week course of topical 5% imiquimod cream on her entire nose.
Patient Outcome
The patient tolerated the combination of Mohs Micrographic surgery and superficial x-ray treatments very well. The patient has been followed up long term with excellent cosmetic result.