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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 7  |  Page : 1660-1664

125I seeds implantation for an elderly patient of skin squamous cell carcinomas with ulcer guided by ultrasound


1 Graduate School of Hebei Medical University, Shijiazhuang, Hebei Province, China
2 Department of Oncology, The Hebei General Hospital, Shijiazhuang, Hebei Province, China

Date of Web Publication19-Dec-2018

Correspondence Address:
Hongtao Zhang
No. 348, Peace West Road, Xinhua District, Shijiazhuang, Hebei Province
China
Juan Wang
No. 348, Peace West Road, Xinhua District, Shijiazhuang, Hebei Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1032_17

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 > Abstract 


The skin squamous cell carcinoma (SCC) is a kind of malignancy of keratinocytes. SCC was originated within the epidermis or relevant appendages, which commonly occurred on sunlight exposure sites, such as the head and neck. This case report described an 85-year-old female patient with skin SCC at the right frontal, accompanied with skin ulcer. This patient suffered from indications that were not suitable for surgical resection, including old age, Alzheimer's disease (AD), lacunar infarction, hydropericardium, and some other concomitant diseases. In addition, the external beam radiotherapy was rejected by the relatives of this patient. Then, the patient received 125I seeds interstitial brachytherapy guided by bedside ultrasound. The tumor response was evaluated based on the response evaluation criteria in solid tumors version 1.1 criteria. Complete response was achieved 4 months after brachytherapy. No complications and recurrence were observed during 8-month follow-up. As the sole modality, the 125I seeds implantation could be a reasonable and safe alternative for treating skin SCC with ulcer, especially for the elderly patients.

Keywords: 125I seeds, aged, basal cell carcinoma, brachytherapy, nonmelanoma skin cancer


How to cite this article:
Liang Y, Di X, Liu Z, Zhao J, Wang Z, Zhao J, Sui A, Zhang H, Wang J. 125I seeds implantation for an elderly patient of skin squamous cell carcinomas with ulcer guided by ultrasound. J Can Res Ther 2018;14:1660-4

How to cite this URL:
Liang Y, Di X, Liu Z, Zhao J, Wang Z, Zhao J, Sui A, Zhang H, Wang J. 125I seeds implantation for an elderly patient of skin squamous cell carcinomas with ulcer guided by ultrasound. J Can Res Ther [serial online] 2018 [cited 2019 Jun 25];14:1660-4. Available from: http://www.cancerjournal.net/text.asp?2018/14/7/1660/247711




 > Introduction Top


Traditionally, skin cancers have been divided into two major groups: melanoma and nonmelanoma skin cancer (NMSC).[1] NMSC has accounted for one-third of all malignancies, of which, skin squamous cell carcinoma (SCC) has contributed to 20% of all NMSC, which was the second most common NMSC, only after basal-cell carcinoma.[2],[3] The pathogenesis of this disease attributed to both personal factors and environmental factors. The personal factors involved age, autoimmunity, and genetic abnormality,[4],[5],[6] and the exposure to ultraviolet radiation has been one of the greatest environmental factors.[7] Treatment regimens for NMSC have varied, including resection, radiotherapy, topical chemotherapy, immune response modifiers, photodynamic therapy, and some other approaches.[8] Surgical treatment has been considered as the first-line choice. However, if the lesion was located in the cosmetic sites such as the face, there were functional concerns about the surgical outcome or the patient showed contraindications for surgery, radiotherapy would be the alternative therapy.[9] There were various kinds of radiotherapy for treating malignancies including skin cancers, of which, the external beam radiotherapy (EBRT) has been the most common radiotherapy due to its standard fractionation. At present, brachytherapy showed some advantages over EBRT, including no need of dose build-up at the surface, rapid dose fall-off from the source to connective tissue in the subcutaneous layer, as well as the greater patient convenience and reduced cost.[8] The brachytherapy can be delivered with high-dose rate (HDR), medium-dose rate, and low-dose rate (LDR). HDR and LDR have been two common types of brachytherapy.[10] LDR can provide high doses of radiation for defined target volumes, which allowed relative sparing of critical adjacent structures.[11] As the representative of LDR, the 125I seeds can meet the treatment requirement and minimize radiation risk to surrounding normal tissues at the same time. Thus, this kind of brachytherapy has been rapidly applied in the treatment for malignancies.[12],[13] This case report described the application of 125I seeds implantation guided by ultrasound (US) for an elderly patient with skin SCC accompanied with ulcer.


 > Case Report Top


An 85-year old female patient was referred to our department in March 2017. She presented with a right frontal tumor for 6 months, accompanied with ulcer in the center for 4 months without a trauma. There was no history of malignancy in the family. The patient had a previous history of AD, and chief complaint was unavailable. Her families revealed that her normal life was not affected by this tumor. Physical examination showed a crater-like appearance with a hard texture [Figure 1]. The tumor volume was about 3.6 cm × 4.0 cm × 1.0 cm, and the ulcer was 2.5 cm × 1.5 cm, in the center of the tumor. The lesion was fixed to the overlying skin with clear boundary. Thus, the tumor was staged as T2N0M0 based on the tumor, lymph node, and metastasis system of the American Joint Committee on Cancer (2010).[14] The computerized tomographic (CT) scan showed low-density areas in the right frontal and pathology examination showed high-differentiated skin SCC [Figure 2]. For this patient because there were contraindications of resection and the relatives refused radiotherapy, the 125I seeds interstitial brachytherapy was planned.
Figure 1: The right frontal part lesion before treatment

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Figure 2: (a) A high-resolution version of this slide for use with the virtual microscope is available (H and E, ×100 [a]). (b) A high-resolution version of this slide for use with the virtual microscope is available (H and E, ×400 [b])

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The 125I seeds (type 6711, activity: 0.4 mCi; half-life: 59.4 days; half-value layer: 0.025 mm of lead; initial dose rate 7 cGy/h) were shaped as a cylindrical titanium package body, with the length and diameter of 4.5 mm and 0.8 mm, respectively. The preoperative plan and the postoperative real-time dose verification were completed with the brachytherapy treatment planning system (BTPS, Panther Brachy V5.0 TPS, Prowess Inc., USA). Preoperative CT imaging of the target area was obtained by a CT scanner with a slice thickness of 0.5 mm. The images were exported in digital imaging and communication in medicine format to TPS for preplan [Figure 3]. The clinical target volume (CTV) was defined as the gross tumor volume and its surrounding area was defined as 0.5 cm beyond the margins of the target. A prescribed dose of 120 Gy and radioactivity of 0.4 mCi were set for the CTV, which was calculated by the BTPS. During the operation, the needles were inserted into the basilar part of the tumor guided by the bedside US following local anesthesia with 1% lidocaine [Figure 3]. The distance between needles and seeds was 0.5 cm. A total of 24 seeds were implanted into the target, and 6 of the 24 seeds were implanted into the basal part of the ulcer according to preplan [Figure 4]. The postoperative real-time dose verification was performed: D90:122 Gy, V100:91.3%, V150:49.7% [Figure 5]. Then, the patient was hospitalized for 3 days and discharged, and then received a follow-up for 8 months [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]. The therapeutic evaluation was CR, according to the response evaluation criteria in solid tumors version 1.1 criteria,[15] and the ulceration was healed, without recording any toxicities. During this period, 16 seeds were brushed off and handled properly.
Figure 3: (a and b) The needles distribution during the operation

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Figure 4: (a and b) Preplan made by treatment planning system to determine the number, dose, and distribution of the radioactive seeds

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Figure 5: Dose-volume histogram of preplan and postplan calculated by treatment planning system

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Figure 6: Photo of the lesion 1 month after operation

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Figure 7: Photo of the lesion 2 months after operation

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Figure 8: Photo of the lesion 3 months after operation

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Figure 9: Photo of the lesion 6 months after operation

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Figure 10: Photo of the lesion 8 months after operation

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 > Discussion Top


The purposes of primary treatment for skin SCC consisted of curing the lesions and preserving functions and cosmesis. Surgery has been considered as the most convenient and effective mean for curing any invasive SCC.[12] However, the surgery was refused by the relatives of the patient. On the other hand, the National Comprehensive Cancer Network suggested that radiotherapy should only be applied in high-risk lesions with the diameter <2.0 cm, which were located in critical sites such as the forehead.[16] As one kind of radiotherapy, brachytherapy, especially the HDR brachytherapy, such as 192Ir, has showed its advantages in treating skin cancer. However, it also led to some early or late side effects.[17] The permanent 125I seeds implantation was selected in our case. The reason consisted of its safety and radiation protection. 125I seeds implantation has been an established technique and achieved better cancer control effects in prostate cancer compared to dose-escalated intensity-modulated radiation therapy.[18] This technology has been applied to other parts of the body in China.[14] However, it was worth exploring whether it could be an alternative therapy for elderly SCC patients intolerable to operation or EBRT.

125I seeds implantation showed some innovative advantages in this study. First, the 125I seeds implantation was guided under US instead of traditional real-time CT scans. This elderly patient in this study suffered from multi-system diseases who could not comply with CT scans. Therefore, we treated the patient with bedside implantation under the guidance of US. US guidance has been applied in the diagnosis and treat fields,[19],[20] and the American Brachytherapy Society mentioned that the US had played important roles in the treatment of skin cancer.[9] During the procedure, the difficulty of operation and nursing was decreased, in addition, the compliance and comfort of patients were also improved. It also raised the awareness on the US for clinicians. In this case, the US showed its advantages including low damage, easy-taking, convenience for use, at the same time, the relative position of the seeds in the target area could be presented. Second, the low-radioactivity 125I seeds implantation was applied in this study as a new attempt. The latest consensus considered that the tumor accompanying ulceration was an absolute contraindication of the 125I seeds implantation.[21] However, the energy of radioactivity would be decreased rapidly with increased distance to the source. In this study, the low-radioactivity seeds (0.4 mCi) were selected and implanted into the basilar part of the target. Thus, a higher minimum tumor dose can be guaranteed with less damage to normal tissues, especially to the skin. After a follow-up for 8-month, the tumor disappeared and the ulceration healed. This exploration confirmed a potential indication of the seeds implantation. In general, compared to surgery or EBRT, this kind of modality decreased the dependence on the medical facilities and made the treatment simpler and quicker with excellent and good cosmetic outcomes.

In brief, to the best of our knowledge, it has been the first case of the 125I seeds implantation for skin SCC accompanying ulcer. It was also less time-consuming for patients and staff than a full course of EBRT. It was possible for seeds implantation to be applied in treating SCC accompanying ulceration. In addition, long period of follow-up and the increased number of cases are recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Delishaj D, Rembielak A, Manfredi B, Ursino S, Pasqualetti F, Laliscia C, et al. Non-melanoma skin cancer treated with high-dose-rate brachytherapy: A review of literature. J Contemp Brachyther 2016;8:533-40.  Back to cited text no. 17
    
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Tian HY, Xu D, Liu JP, Mao WM, Chen LY, Yang C, et al. Contribution of ultrasound-guided fine-needle aspiration cell blocks of metastatic supraclavicular lymph nodes to the diagnosis of lung cancer.[J]. J Cancer Res Ther 2015;11 Suppl(8):C234.  Back to cited text no. 19
    
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Wang J, Zhang F, Guo J, Chai S, Zheng G, Zhang K, et al. Expert consensus workshop report: Guideline for three-dimensional printing template-assisted computed tomography-guided 125I seeds interstitial implantation brachytherapy. J Cancer Res Ther 2017;13:607-12.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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