[RADIATION THERAPY CASE STUDY]

Radiation Therapy Case Study - Squamous Cell Carcinoma

Vincent M. Lucas
Argosy University

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Introduction
For the past several months I have had the opportunity to observe a very
courageous attempt to save a mans limb through a battle with stage IV (T4N0M0)
squamous cell carcinoma or (SCC), I will use both terms throughout this paper, of
the left forearm with involvement of both radius and ulnar bones. To protect the
individuals identity he will be referred to as patient. Other considerations include
trauma or superimposed infection. The patients situation is disheartening; the
consensus of the orthopedic surgeon at Bone and Soft Tissue Conference was
amputation. I observed his therapy from his initial radiation oncology consultation.
This case study will include discussion of his consultation, describe simulation of
treatment, and discuss strategies and planning for treatment. To conclude, I will
discuss various squamous cell carcinomas and available treatment options currently
in place to treat the disease.

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Consultation
The patient is a 63-year-old Caucasian male recently diagnosed with a locally
advanced squamous cell carcinoma of the distal posterior left forearm. He has
undergone gross total resection of this with microscopic positive deep margins and
involvement of tendons. The goal of the consultation is to assess possible
postoperative radiation therapy as an option for treatment.
The patient reported having a pimple like lesion approximately two years
prior to consultation; it progressively got larger to the size of a dime at the core. At
this time he was seen by his primary physician in which a course of antibiotics was
prescribed; this had minimal effect and the lesion progressively worsened. The
patient admits to neglecting it somewhat before it increased in size to a point that
could no longer be tolerated. In such time it had increased to 9 to 9.5 cm in
diameter when a specialist was contacted and a resection was recommended. After
some axillary adenopathy was noted a CT scan was performed as well as a fine
needle aspiration of the left axillary lymph node; the result of which revealed
negative malignant cells and a polymorphous lymphoid infiltration consistent with
follicular lymphoid hyperplasia. He was then scheduled for surgery where a wide
local excision of the forearm was undertaken and a full thickness skin graft of the
forearm from the abdomen was completed. Pathological results showed the
squamous cell carcinoma to be approximately 6.9 x 6.0 x 1.1 cm in size even
though a 9 cm specimen was removed. The peripheral margin is free of tumor;
however, the deep margin is positive. Lymphovascular invasion was noted, but
there was no perineural invasion. The postoperative course was relatively
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unremarkable; although his graft did not completely take over the entire defect it
was covering approximately 70 percent of it. Due to the rate of growth and positive
margins with lympgovascular invasion the radiation therapy will be a course of
treatment.

It should be noted that the patient reports extensive solar exposure as a truck
driver. The exposure is a result of resting his left arm on the vehicle door while
traveling during daylight hours.
The patients social and family history is as follows: His father died at 67 of
lung cancer; he was a smoker. The patient is married and accompanied by his wife.
He is a truck driver doing long hauls in the San Antonio and Amarillo TX area. He is
a smoker of one pack per day for 30 years. He also drank six drinks per week,
stating he quit on July 12th 1996.
Simulation
After informed consent is obtained the treatment simulation for this patient
was fairly simple due to the inclusion of the whole forearm with the superior border
located just inferior to the elbow with the use of water bolus. This was accomplished
by positioning the patient in the prone position, head on a pillow, and left arm
submerged in a plastic rectangular container fill with water. To ensure reproducibility
his forearm was placed in the container while empty at which time his forearm and
hand was traced on the bottom of the container where it would be placed during
each subsequent treatment. Once positioning was deemed acceptable the container
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was filled to include the elbow, although not in the treatment field by filling to the
same the water level past the elbow ensured the same amount of bolus on any
given day of treatment. After positioning approval by the Radiation Oncologist
photos were taken to be placed in the treatment chart for reference data for the
therapists.
Treatment Planning
As noted in the simulation process, treatment planning was fairly simple due
to the absence of critical structures. The field borders in addition to the water bolus
insured uniformed dose distribution. The treatment plan required two oblique fields
for coverage and 200 cGy x 27 fractions to total 5400

cGy with an additional boost of 200 cGy x 6 fractions to total 1200 cGy. The left
axillary region was planned with AP/PA fields with a daily dose of 200 cGy x 25 to
total 5000 cGy.
Daily Administration of Treatments
The first day of treatment positioning was verified by taking orthogonal films
and overlaying them over CT scans taken during simulation to ensure accuracy
during treatment. Additional port films were completed on a biweekly basis to insure
consistent treatment. The patient was set-up daily with set-up specified from his
simulation. After patient positioning and prior to the addition of water SSDs were
taken to ensure simulation was reproduced. The treatment was provided with the
use of a Varian EX 2100 series Linac and Mosaiq record & verifies software. Due to
the use of a Varian EX series versus a IX or Trilogy series machine care was taken
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when imputing monitor units as input is manual on an EX series and prone to
operator error.
After his initial treatment the patient completed his first day teaching with
the oncology nursing staff. Although length of treatment, possible side effects, and
statistical outcomes were discussed with the radiation oncologist prior to treatment
all information is revisited in a Q&A session with nursing.
Assessment & Management of Treatment
Response to radiation treatment was positive with the previous graft removed
and the scheduling of a replacement graft after the conclusion of radiation
treatment. Throughout the course of treatment the patient tolerated the radiation
with no significant radiation related complications. There was the common issue of
mild fatigue however due to the location of the treatment and the management of
pain with a mild opiate it was not deemed a major side effect.

Follow-up
The patient completed his radiation treatments with a counseling session
attended by the radiation oncologist, radiation therapist, and nurse where he was
informed of results of the treatment and what to expect in the future. A follow up
visit was scheduled with the nurse practitioner of the radiation oncology
department four weeks after treatment with an additional phone interview two
weeks following the follow up visit.
Analysis of Disease

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Squamous cell carcinoma (SCC) is an unregulated growth of abnormal cells
arising in the squamous cells, which compose most of the skins upper layers, i.e.:
the epidermis. Squamous cell carcinomas often look like scaly red patches, open
sores, elevated growths with a central depression, or warts; they may crust or
bleed. They can result in disfigurement and in some instances lead to death if
allowed to grow (Skin Cancer Foundation, 2014).
Cancer of the skin is by far the most common of all types of cancer. According
to one estimate, about 3.5 million basal and squamous cell skin cancers are
diagnosed each year. About 8 out of 10 these are basal cell cancers. Squamous cell
cancers occur less often. The number of these cancers has been increasing for
many years. This is probably from a combination of better skin cancer detection,
people getting more sun exposure, and people living longer. Death from these
cancers is uncommon. Its thought that about 2,000 people die each year from nonmelanoma skin cancers, and that this rate has been dropping in recent years. Most
people who die are elderly and may not have seen a doctor until the cancer had
already grown quite large. Other people more likely to die of skin cancer are those
whose immune system is suppressed, such as those who have had organ
transplants. The exact number

of people who develop or die from squamous cell skin cancers each year is not
known for sure. Statistics of most other cancers are known because they are
reported to cancer registries, but squamous cell skin cancers are not reported
(American Cancer Society, 2014).

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SCC is mainly caused by cumulative ultraviolet (UV) exposure over the
course of a lifetime; daily year-round exposure to the suns UV light, intense
exposure in the summer months, and the UV produced by tanning beds all add to
the damage that can lead to SCC. SCCs may occur on all areas of the body
including the mucous membranes and genitals, but are most common in areas
frequently exposed to the sun, such as the rim of the ear, lower lip, face, balding
scalp, neck, hands, arms and legs. Often the skin in these areas reveals telltale
signs of sun damage, including wrinkles, pigment changes, freckles, age spots,
loss of elasticity, and broken blood vessels.
The risk factors involved in developing squamous cell carcinomas include but
are not limited to people who have fair skin, light hair, and blue, green, or gray
eyes. However, anyone with a history of substantial UV exposure is at significant
risk. Those whose occupations require long hours outdoors or who spend extensive
leisure or recreation time in direct sunlight are at increased risk. Anyone who has
had basal cell carcinoma is also more likely to develop SCC, as is anyone with an
inherited UV-sensitive condition, i.e.: xeroderma pigmentosum.
Squamous cell carcinomas are at least twice as frequent in men as in women,
partly because of more time spent in the sun. Most SCCs appear in people over 50,
but in recent years more and more young people in their 20s and 30sare being
diagnosed with the disease. The number of women under age 40 diagnosed with
SCC has especially increased in the last 30 years, and many experts attribute this to
their greater use of indoor tanning. More than 419,000 cases of skin cancer in the
US each year are

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linked to indoor tanning, and over 70 percent of tanning salon patrons is female.
The majority of skin cancers in African-Americans are squamous cell carcinomas,
usually arising on the sites of preexisting inflammatory skin conditions or burn
injuries. Though naturally dark-skinned people are less likely than fair-skinned
people to get skin cancer, it is still essential for them to practice sun protection. All
skin types are at risk of skin cancer. Recently, there has been a large increase in
new SCCs diagnosed in Latinos and other people of color. But skin injuries are
another important source. The cancer can arise in burns, scars, ulcers, longstanding sores, and sites previously exposed to X-rays or certain chemicals
(American Cancer Society, 2013).
Chronic infections and skin inflammation can also give rise to squamous cell
carcinoma. Furthermore, HIV and other immune deficiency diseases, chemotherapy,
anti-rejection drugs used in organ transplantation, and even excessive sun exposure
itself all weaken the immune system, making it harder to fight off disease and thus
increasing the risk of developing squamous cell carcinoma and other skin cancers.
Treatment Options
Squamous cell carcinomas if detected early and removed are almost always
curable and cause minimal damage. However, if left untreated they will penetrate
the deeper tissue and may become disfiguring. The prior stated lethality is due to
possible mets to local lymph nodes, distant tissues, and organs. Therefore, as
stated, any suspicious growth should be seen by a physician without delay. A tissue
sample (biopsy) will be examined under a microscope to arrive at a diagnosis. If
tumor cells are present, treatment is required.

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Fortunately, there are several effective ways to eradicate squamous cell carcinoma.
The choice of treatment is based on the tumors type, size, location, and depth of
penetration, as well as the patient's age and general health.
Excisional surgery involves a physician using a scalpel to remove the entire
growth, along with a surrounding border of apparently normal skin as a safety
margin. The excised tissue specimen is then sent to the laboratory for microscopic
examination to verify that all cancerous cells have been removed. A repeat excision
may be necessary on a subsequent occasion if evidence of skin cancer is found in
the specimen. The accepted cure rate for primary tumors with this technique is
about 92 percent. This rate drops to 77 percent for recurrent squamous cell
carcinomas.
Radiation therapy requires pre prescribed dose of X-ray beams directed at the
tumor, with no need for cutting or anesthesia. Destruction of the tumor usually
requires a series of treatments, administered several times a week for one to four
weeks, or sometimes daily for one month. Cure rates range widely, from about 85 to
95 percent, since the technique does not provide precise control in identifying and
removing residual cancer cells at the margins of the tumor. The technique can
involve long-term cosmetic problems and radiation risks, as well as multiple visits.
For these reasons, though this therapy limits damage to adjacent tissue, it is mainly
used for tumors that are hard to treat surgically, as well as patients for whom

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surgery is not advised, such as the elderly or those in poor health (American
Academy of Dermatology, .2015)

References
Skincancer.org: (November.2014) The Second Most Common Form of Skin
Cancer at http://www.skincancer.org/skin-cancer-information/squamous-cellcarcinoma. Retrieved November 19, 2014
American Cancer Society: (2/20/2014) Skin Cancer: Basal and Squamous
Cell at http://www.cancer.org/acs/groups/cid/documents/webcontent/003139pdf.pdf. Retrieved December 12, 2014
National Cancer Institute: (7/20/2012) PDQ Skin Cancer Treatment.
Bethesda, MD at
http://cancer.gov/cancertopics/pdq/treatment/skin/HealthProfessional. Retrieved
December 12, 2014.
American Academy of Dermatology: (November.2014) Skin Cancer at
https://www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer.
Retrieved December, 2014

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