Case Study Topic

Title: Electron treatment of spindle cell carcinoma of the scalp and underlying skull.

This case involves a 73-year old gentleman who has a personal history of R vocal cord
carcinoma (1996 - treated with surgery then radiation therapy) and basal cell carcinoma to the
right forehead and left medial canthus (both excised in 2012 with deep margins). The new lesion
on his scalp was diagnosed as spindle cell carcinoma, which is an uncommon type of squamous
cell carcinoma known to be more aggressive. This lesion was also removed surgically. There
were several challenges presented with this case:
The patient has an anaphylactic allergy to all types of local anesthesia, so he had his
lesions removed under general anesthesia.
The patient is obese and had trouble lying on his stomach; however, the lesion is to the
back of his scalp, so he had to be simulated and treated in the prone position.
There was a pre-surgery CT scan that the radiation oncologist wanted fused with the
treatment planning CT, but the pre-surgery CT was done with the gantry tilted, so the
images were oblique, which made fusion difficult.
The patient is diabetic, so healing of the lesion after surgery was delayed.
The patient is on anti-coagulants for cardiovascular issues, so surgery was risky.
The patient has poor kidney function, so no contrast can be used during CT scans.
When the lesion was removed and biopsied, the outer margins (in the scalp) were
negative but the deep margin (bone of skull) was positive. The skull was burred but
negative margins were not obtained. Therefore, the radiation treatment needs to include
the bone of the skull underneath where the lesion was removed.
The area of the skull being treated is near the apex, where the curvature is severe.
There is a large, wide, irregularly-shaped divot in his scalp where the surgery was
done this area is .5 cm deep, making bolus difficult.
Difficulty determining where to put the calc point not in bone, but we do want dose
into the skull. We want to avoid dosing the brain.