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Recurrent basal cell carcinoma of the inner canthus of the left eye. Panel A shows a pre-treatment CT. Panel B shows a loss of substance and destruction of the inner canthus of the left eye, lacrimal apparatus and medial half of the lower left eyelid.
Source publication
Basal cell carcinoma (BCC) is the most common malignant periocular tumor. When periorbital invasion exists, orbital exenteration is necessary. A 73-year-old man with recurrent BCC of the inner canthus of the left eye with diffusion to the extrinsic muscles of the orbit and periorbital fat was treated with CyberKnife in stereotactic body radiation t...
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Introduction: Cutaneous squamous cell carcinoma (SCC) is the second most common skin neoplasia of the periorbital region, being more invasive and aggressive than basal cell carcinoma. In the periorbital area, SCC can potentially gain access to the orbital cavity, either directly or as a result of vascular, lymphatic or perineural spread.
Materials...
Citations
... Radiotherapy (RT) provides meaningful relief of symptoms and can result in at least temporary improvement in quality of life. [9][10][11] There are experiences in the literature that have documented complete relief of symptoms after radiotherapy. 6,12 In this systematic review, we evaluated the management strategies and in particular the role of RT in the treatment of OM, focusing on improvement of symptoms and patient quality of life. ...
Objectives
We search the current literature on data regarding the role of RT in OM treatment, focusing on improvement of symptoms and patient quality of life.
Methods
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations.
Results
From 340 citations, 60 papers were finally selected: 45 case reports and 15 case series. The case reports accounted for 47 patients. In 37/39 cases (95%) EBRT was done. Patients were mainly treated with 3DCRT, IMRT, and with SBRT. The most used RT regimens were 30 Gy in 10 fractions (23%) and 20–25 Gy in 5 fx (13%). No sever toxicity was reported. A median LC of 11 months (range 1–54 months) and a median OS of 12 months (range 1–54 months) were registered. Among the case series, a total of 457 patients were examined, 227 of whom underwent RT. The main used techniques were 3DCRT, CK, GK, SBRT, and BRT. RT doses could vary from 30 Gy/10 fractions to 60 Gy/30 fractions, 50 Gy/5 fractions, or 16.5–21 Gy in single fraction. No toxicity above G2 was reported. ORR could vary between 75 and 100%. Only two study provided information on response duration: a mean LC time of 22.8 months and a mean time to local progression of 5 months (range: 3–7). Regarding OS, the data were heterogeneous, ranging between 1 and 54 months.
Conclusions
RT for OM seems to be a safe and feasible option. More information on the RT ideal techniques and dose are still needed.
Advances in knowledge
This paper tried to sum up the few and fragmented data on the use of radiotherapy for orbital metastases: the possible option ranged from 3D- and 2D-CRT to SBRT, CK, and GK, with different possible fractionations (30Gy in 10 fractions, 60 Gy/30 fractions, 20-50 Gy/5 fractions, or 16.5-21 Gy in single fraction). Regardless of the chosen approach, almost all treated patients experienced a benefit after RT in terms of OM-related symptom intensity reduction and a good acute and late toxicity profile.
... Target size, site and shape are three different factors that can make radiation treatment difficult. However, new advances in RT techniques can satisfactorily treat even extremely complex skin targets [84][85][86]. Awareness of such therapeutic possibilities may call into question the "incurability" of a large proportion of LACSCCs that could still be amenable to curative-intent treatment. Indeed, there is an urgent need to improve the selection of patients with locally advanced CSCC who are likely to benefit from locoregional treatments and/or systemic cancer immunotherapy [87]. ...
Simple Summary
Nodal and distant metastases of cutaneous squamous cell carcinomas are very rare and lead to dismal prognoses. Immunotherapy is approved only for cutaneous squamous cell carcinoma patients not amenable to surgery or curative radiation therapy. Radiation therapy has a clear role as an adjuvant treatment for locally advanced disease. Radiation therapy may also have an important role in inoperable and metastatic disease. Oligometastatic disease is a condition that needs to be defined for this carcinoma. This review aims to offer to the readers a comprehensive overview of studies about the role of radiotherapy in the management of advanced or metastatic cutaneous squamous cell carcinomas, also assuming possible further developments in the light of the recent discoveries about tumor biology. The present paper has the merit of re-focusing great attention on the efficacy and cost-effectiveness of radiotherapy in these not yet properly explored scenarios.
Abstract
Radiation therapy (RT) is an effective therapeutic option for small localized cutaneous squamous cell carcinoma (cSCC) among patients who are not eligible for or refuse surgery. RT also has a defined role as an adjuvant treatment in cases of adverse features that predispose to tumor recurrence after local excision. Since the development of cSCC is often a late consequence of chronic sun exposure, its occurrence is more common among elderly patients whose comorbidities may contraindicate surgical procedures. These could be impeded not only by frail medical conditions but also by technical issues. Indeed, an aggressive locoregional behavior of cSCC may culminate in unresectability due to widespread invasion of neighboring tissues. Moreover, cSCC could develop distant metastases. Both locally advanced and metastatic cSCCs carry a poor prognosis. In these scenarios, recent discoveries of tumor molecular targets are promoting the use of promising systemic therapies, especially immunotherapy, over RT. However, the results from using immunotherapy and, even more so, of chemotherapy are still not optimal. By contrast, advances in radiation delivery equipment can safely treat even large and complex-shaped cSCC targets in challenging body sites. In addition, RT could also have a role in metastatic cSCC settings by enhancing the effectiveness of concomitant immunotherapy. The aim of this review is to summarize and comment on the body of literature about the use of radiotherapy for operable and inoperable locally advanced cSCCs and for metastatic ones in an attempt to define its current and future role.
... Radiotherapy is a well-established palliative therapeutic option for benign and malignant orbital lesions, as well as for periocular ones [11,12,32,[51][52][53]. In line with previous reports on choroidal metastases, we also found that radiotherapy significantly ameliorates clinical and functional status in patients with orbital metastases (p = 0.032), favoring nonsurgical lesion shrinkage and relief of mass effect [22,54]. ...
Background:
Orbital metastases often lead to severe functional impairment. The role of resection, orbital exenteration, and complementary treatments is still debated. We systematically reviewed the literature on orbital metastases.
Methods:
PubMed, Scopus, Web-of-Science, and Cochrane were searched upon PRISMA guidelines to identify studies on orbital metastases. Clinical characteristics, management strategies, and survival were analyzed.
Results:
We included 262 studies comprising 873 patients. Median age was 59 years. The most frequent primary tumors were breast (36.3%), melanoma (10.1%), and prostate (8.5%) cancers, with median time interval of 12 months (range, 0-420). The most common symptoms were proptosis (52.3%) and relative-afferent-pupillary-defect (38.7%). Most metastases showed a diffuse location within the orbit (19%), with preferential infiltration of orbital soft tissues (40.2%). In 47 cases (5.4%), tumors extended intracranially. Incisional biopsy (63.7%) was preferred over fine-needle aspiration (10.2%), with partial resection (16.6%) preferred over complete (9.5%). Orbital exenteration was pursued in 26 patients (3%). A total of 305 patients (39.4%) received chemotherapy, and 506 (58%) received orbital radiotherapy. Post-treatment symptom improvement was significantly superior after resection (p = 0.005) and orbital radiotherapy (p = 0.032). Mean follow-up was 14.3 months, and median overall survival was 6 months. Fifteen cases (1.7%) demonstrated recurrence with median local control of six months. Overall survival was statistically increased in patients with breast cancer (p < 0.001) and in patients undergoing resection (p = 0.024) but was not correlated with orbital location (p = 0.174), intracranial extension (p = 0.073), biopsy approach (p = 0.344), extent-of-resection (p = 0.429), or orbital exenteration (p = 0.153).
Conclusions:
Orbital metastases severely impair patient quality of life. Surgical resection safely provides symptom and survival benefit compared to biopsy, while orbital radiotherapy significantly improves symptoms compared to not receiving radiotherapy.
... Basal cell carcinoma (BCC) is the most frequent skin cancer in the world and accounts for 90% of all tumors on the eyelid with a slight male preponderance [1,2]. The most common periorbital site for BCC is the lower eyelid, followed by the internal or medial canthus, upper eyelid, and external or lateral canthus [3]. The most important predisposing factor described in the literature is prolonged exposure to sunlight, which explains why the tumor occurs more frequently on the lower eyelid [4]. ...
... Basal cell carcinoma (BCC) is the most frequent skin cancer in the world and accounts for 90% of all tumors on the eyelid with a slight male preponderance [1,2]. The most common periorbital site for BCC is the lower eyelid, followed by the internal or medial canthus, upper eyelid, and external or lateral canthus [3]. Intense exposure to ultraviolet (UV) radiation is one of the most important known risk factors of BCC [4,6]. ...
... After the treatment, the patient enjoyed rapid tumor regression, with prolonged complete remission and preserved visual function after 6 months. According to this study, this therapeutic modality is feasible and could be proposed for elderly patients who refuse brachytherapy, or for patients unfit for surgery [3]. ...
Basal cell carcinoma (BCC) is the most frequently occurring malignant periocular tumor. The aim of treatment remains surgery with negative margins. We report a case of 65-year-old woman who was diagnosed with BCC of internal canthus of the right eye, in October 2011. The patient was treated by surgical resection in 2 steps with reconstruction by a frontal flap. The treatment resulted in complete remission without any recurrence after ten years of surgery.
... 71 In case report of a 73-year-old man with recurrent BCC in the inner canthus extending to the orbit treated with CyberKnife stereotactic body radiation therapy the patient enjoyed rapid tumor regression, with complete remission after 6 months without toxicity. 72 Brachytherapy HDR Ir 192 can be used also in patients with BCC. 73 The side effects after external radiotherapy but also brachytherapy can be dry eye, secondary cataract, ectropion, cicatrization of the lacrimal duct, secondary neovascular glaucoma, radiation retinopathy and maculopathy, radiation optic neuropathy which can lead to blindness. ...
Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.
... After the treatment, the patient enjoyed rapid tumor regression, with complete remission after 6 months without toxicity. 38 ...
Basal cell carcinoma (BCC) is a common malignant tumor throughout the world. One of the known risk factors of BCC is intense exposure to ultraviolet radiation. More than 50% of BCCs of the eyelid initially occur on the lower lid. The gold standard of diagnosis of BCC is histopathology. Treatment options for BCC consist of surgery, vismodegib, radiotherapy and imiquimod. Surgical excision using Mohs micrographic surgery or wide surgical excision with frozen section margin control is the first consideration for treatment of periocular BCC. Eyelid reconstruction should be carefully considered as both function and esthetic outcome in patients are important after clear excision of tumors. Exenteration is considered in the case of extensive orbital invasion or high-risk aggressive tumors in order to reduce the rate of recurrence.
... The Cyberknife System permits to deliver this kind of dose distribution in different anatomic sites. 21 Patients treated in this study with SBRT for LpC with a minimum follow-up of 8 months present an optimal response in terms of PSA response (see Figures 4 and 5) with a median PSA nadir of 0.11 ng/mL. Although a longer follow-up is needed to confirm the results of SBRT in monotherapy or preboost modality for LpC, the data are encouraging and confirm the results obtained with HDR. ...
Stereotactic body radiotherapy (SBRT) can emulate high dose rate brachytherapy (HDR-BRT) dose fractionation. We report our preliminary results using SBRT in monotherapy or pre-external-beam radiotherapy (EBRT) boost in patients with localized prostate cancer (LpC). The primary end point was the evaluation of both acute and late toxicities; secondary end point was the observation of prostate-specific antigen (PSA) nadir.
Patients with LpC having prostate volume ≤90 cm(3) were enrolled in the present study. Patients were treated with SBRT alone or in combined modality (SBRT + EBRT). SBRT was performed using a CyberKnife System (Accuray Incorporated, Sunnyvale, California) and fiducial tracking system.
From February 2008 to July 2013, 21 patients for monotherapy (38 Gy/4 fractions) and 5 for combined modality (9.5 Gy/2 fractions plus 46 Gy/23 fractions EBRT) were enrolled. Androgen deprivation therapy (ADT) was administered in 16 of the 26 patients. The median pretreatment PSA was 9.4 (range, 4.5-14.3) ng/mL. All patients completed the planned therapy. Acute Grade 1 toxicity was observed in 18 patients, genitourinary (GU) in 12 / 26 patients, and gastrointestinal (GI) in 6 / 26 patients. Acute Grade 2 GU toxicity was reported in 1 / 26 patients, and Grade 2 GI toxicity was observed in 2 / 26 patients. The median PSA nadir was 0.15 (range, 0.02 = 1.4) ng/mL. Late toxicities were observed in 5 / 26 patients: Grade 1 GU (3 of 26), Grade 2 GU (1 of 26), and Grade 1 GI (1 of 26). Median follow-up was 21.5 (range, 8-65) months.
Our preliminary results of SBRT "simulating" HDR for LpC confirm a minimal toxicity and an optimal PSA response. The PSA nadirs appear comparable with HDR-BRT.
© The Author(s) 2015.
... In these instances stereotactic body radiotherapy (SBRT) is an alternative to BT because it allows to deliver high doses of external radiation similar to BT dose distribution [5] using multimodal imaging [6]. Modern external beams radiation therapy, such as stereotactic technique that is able to deliver high doses in targeted complex shapes. ...
External beam radiotherapy can be used to treat cutaneous squamous cell carcinomas (SCC). Acute skin toxicity is the most common adverse event. In this case study we report on an elderly patient with nasal root cutaneous SCC treated with stereotactic technique using a dedicated linear accelerator (CyberKnife system). Grade 3 skin toxicity was observed but it was resolved after 6 weeks. The use of stereotactic radiotherapy permitted a clinical remission of SCC with good cosmetic results.
... In a recent paper [2], we reported our experience with Stereotactic Body Radiation Therapy (SBRT) in a patient with recurrent and complicated NMSC using Cyberknife System (CKS). In fact, the CKS is a possible alternative to surgery and brachytherapy in patients with recurrent NMSC located in irregular anatomical areas close to critical organs (i.e. ...
To the Editor:
We have read with an interest the article of Olga Pons-Llanas et al. [1] published in the Journal about the use of electronic brachytherapy (EBT) in non-melanoma skin cancer (NMSC). However, we noticed the exclusion criteria for the following tumors: lesions with a diameter greater than 20 mm, invasion of more than 4 mm, irregular anatomic areas. Besides, there are limits linked to the use of circular collimators and the daily set-up position. NMSC often have irregular shapes and diameter longer than 2 cm; besides, in most cases, NMSC are recurrent and located in periorbital area (i.e. inner canthus). In these instances, both EBT and brachytherapy are difficult and/or inadequate to treat safely most of patients. Among the new technologies, stereotactic ablative radiation therapy could be a valid therapeutic option treating “difficult NMSC”.
In a recent paper [2], we reported our experience with Stereotactic Body Radiation Therapy (SBRT) in a patient with recurrent and complicated NMSC using Cyberknife System (CKS). In fact, the CKS is a possible alternative to surgery and brachytherapy in patients with recurrent NMSC located in irregular anatomical areas close to critical organs (i.e. eyes). The SBRT with image guided exceeds the limits of the set-up for relocation; the inverse planning allows to cover irregular volumes greater than 20 mm. The use of the photons X-6 MV permits to treat the lesions with invasion more than 4 mm.
Do Olga Pons-Llanas et al. have experience and/or data on the use of brachytherapy in “difficult areas”? In fact, in daily clinical practice many patients have “irregular and difficult” NMSC and it is important that Radiation Oncologists have more therapeutic options in these instances. We think that it is important for the authors to comment on these issues and perhaps reply within the context of this journal.
Basal cell carcinoma (BCC) is the most common malignancy in the face. Surgical removal and reconstruction is the first choice of treatment options for BCC, but it tends to be invasive and sometimes is accompanied by a drastic change in appearance. We report here a case of BCC in the eyelid of a patient who was successfully treated by gamma knife radiosurgery (GKRS). He was 88 years old at this time. The ulcer disappeared within 3 weeks after GKRS and was covered with normal epithelium. This is the first report to describe an eyelid BCC that was treated by GKRS.
