Tomotherapy and Cetuximab for Unresectable SCC of the Skin
Tomotherapy and Cetuximab for Unresectable SCC of the Skin
On March 2012 we visited a 45-year-old Caucasian woman with a very extensive, untreated G1 cutaneous SCC infiltrating widely the lumbar region until bone. A physical examination showed a locally advanced lesions with necrotic and ulcerated areas involving the entire lumbar area until sacrum and buttocks. There was also a superinfection due to Pseudomonas Aeruginosa resistant to antibiotics. The patient referred functional limitation in movement, difficulty in walking, pain, and consequent serious relationship problems with a worse status of quality of life. The patient had G3 anemia due to the bleeding lesion, and performed red blood cells transfusion before to start the treatment. ECOG Performance Status was 2. A contrast-enhanced magnetic resonance (RM) of pelvis showed extensive skin thickening from the front region of the iliac spine up to posterior sacral region, involving the contralateral lumbar region. The lesion extended from the right of right iliac crest (where it is in contact with the lateral abdominal muscles and with the cortex of the iliac crest) until ipsilateral gluteal region, involving deep muscular tissue.
The patient's case was discussed by a multidisciplinary committee involving surgeons, radiotherapists and oncologists. The patient was treated with Cetuximab at the loading dose of 400 mg/m2, followed by weekly doses of 250 mg/m2, from 28 March 2012 to 13 March 2013. HT has been performed concomitant with the Cetuximab from 28 march 2012 to 19 May 2012, at the total dose of 60 Gy (2 Gy/fx).
Patient was immobilized in the prone position without application of bolus. Planning computed tomography (CT) images were acquired through the region of interest using a 3 mm slice thickness and transferred to the contouring workstation for TomoTherapy Hi · Art System®. Set up was based on fiducial markers and tattoo aligned with a room laser system before treatment.
The gross target volume (GTV) was considered as right gluteal region outlined based on the depth of involvement and the extent of disease. Clinical target volume (CTV) was created adding a margin of 3 mm at GTV. Doses to organs at risk (rectum, bladder, right and left femur, right and left kidney, pubis, bowel) were defined in accordance with dose constraints. Each therapy session was preceded by a MVCT in order to ensure the correct repositioning of the patient and to adjust the distribution of the irradiation dose according with the evolution of the tumor during therapy. The accepted tolerance at our institution was 5 mm. After a new CT scan for contouring, a new treatment plan was elaborated at 30 Gy according with volumetric reduction of lesion. The time of delivery (around 10 minutes for fractions) were well tolerated by the patients. At the end of the combined radio target therapy, Cetuximab treatment continued for the following 10 months.
The patient achieved complete response, confirmed at imaging evaluation, and the lesion reduced until disappear even after the suspension of the treatment (Figures 1 and 2). Toxicity resulted in G1 cutaneous rash and G2 toxicity to the nails according to typical toxicity profile of the anti-EGFR therapies, appeared 5 months after treatment. One month after therapy the Pseudomonas Aeruginosa superinfection totally disappeared as the G3 anemia.
(Enlarge Image)
Figure 1.
On left the lesion at baseline (March 2012) and on right the lesion at follow up (October 2013).
(Enlarge Image)
Figure 2.
TC imaging: A baseline TC (December 2011); B simulation TC (March 2012); C follow up (June 2013); D last follow up (February 2014).
Quality of life resulted significantly, dramatically improved with progressive reduction until discontinuation of anti-pain drugs. At follow up of 15 months there was no evidence of active disease, moreover she was able to get back a normal social life. Actually the ECOG Performance Status is 0 (zero).
Case Presentation
On March 2012 we visited a 45-year-old Caucasian woman with a very extensive, untreated G1 cutaneous SCC infiltrating widely the lumbar region until bone. A physical examination showed a locally advanced lesions with necrotic and ulcerated areas involving the entire lumbar area until sacrum and buttocks. There was also a superinfection due to Pseudomonas Aeruginosa resistant to antibiotics. The patient referred functional limitation in movement, difficulty in walking, pain, and consequent serious relationship problems with a worse status of quality of life. The patient had G3 anemia due to the bleeding lesion, and performed red blood cells transfusion before to start the treatment. ECOG Performance Status was 2. A contrast-enhanced magnetic resonance (RM) of pelvis showed extensive skin thickening from the front region of the iliac spine up to posterior sacral region, involving the contralateral lumbar region. The lesion extended from the right of right iliac crest (where it is in contact with the lateral abdominal muscles and with the cortex of the iliac crest) until ipsilateral gluteal region, involving deep muscular tissue.
The patient's case was discussed by a multidisciplinary committee involving surgeons, radiotherapists and oncologists. The patient was treated with Cetuximab at the loading dose of 400 mg/m2, followed by weekly doses of 250 mg/m2, from 28 March 2012 to 13 March 2013. HT has been performed concomitant with the Cetuximab from 28 march 2012 to 19 May 2012, at the total dose of 60 Gy (2 Gy/fx).
Patient was immobilized in the prone position without application of bolus. Planning computed tomography (CT) images were acquired through the region of interest using a 3 mm slice thickness and transferred to the contouring workstation for TomoTherapy Hi · Art System®. Set up was based on fiducial markers and tattoo aligned with a room laser system before treatment.
The gross target volume (GTV) was considered as right gluteal region outlined based on the depth of involvement and the extent of disease. Clinical target volume (CTV) was created adding a margin of 3 mm at GTV. Doses to organs at risk (rectum, bladder, right and left femur, right and left kidney, pubis, bowel) were defined in accordance with dose constraints. Each therapy session was preceded by a MVCT in order to ensure the correct repositioning of the patient and to adjust the distribution of the irradiation dose according with the evolution of the tumor during therapy. The accepted tolerance at our institution was 5 mm. After a new CT scan for contouring, a new treatment plan was elaborated at 30 Gy according with volumetric reduction of lesion. The time of delivery (around 10 minutes for fractions) were well tolerated by the patients. At the end of the combined radio target therapy, Cetuximab treatment continued for the following 10 months.
The patient achieved complete response, confirmed at imaging evaluation, and the lesion reduced until disappear even after the suspension of the treatment (Figures 1 and 2). Toxicity resulted in G1 cutaneous rash and G2 toxicity to the nails according to typical toxicity profile of the anti-EGFR therapies, appeared 5 months after treatment. One month after therapy the Pseudomonas Aeruginosa superinfection totally disappeared as the G3 anemia.
(Enlarge Image)
Figure 1.
On left the lesion at baseline (March 2012) and on right the lesion at follow up (October 2013).
(Enlarge Image)
Figure 2.
TC imaging: A baseline TC (December 2011); B simulation TC (March 2012); C follow up (June 2013); D last follow up (February 2014).
Quality of life resulted significantly, dramatically improved with progressive reduction until discontinuation of anti-pain drugs. At follow up of 15 months there was no evidence of active disease, moreover she was able to get back a normal social life. Actually the ECOG Performance Status is 0 (zero).
