Working Title

A Case Study for Post-Op Radiation Therapy of the Big Toe

Problem Statement
The problem is the paucity of literature about eccrine cancer radiotherapy of the big toe.

Purpose Statement
This study's purpose is to fill a gap in the literature about the role of radiotherapy and treatment
planning of eccrine cancers of the big toe.

Goals
The first goal is to compare two treatment techniques for radiation therapy treatment of the left
great toe.
The second goal is to provide a case study for the role of radiation therapy in the management
and treatment of eccrine cancers.

Summary

Sweat gland cancers are rare. They account for less than 0.01% of cutaneous

malignancies.1 They are divided into four categories: apocrine, eccrine, mixed origin and un-

classifiable.1 A subtype of eccrine neoplasm is aggressive digital papillary adenocarcinoma.2

This subtype can be aggressive, but delays in treatment are normal as it exhibits innocuous

clinical and histological features.2 This type of tumor usually presents in middle age males with

skin-colored nodules of the digits (usually fingers and thumbs).2 This type of eccrine tumor can

also mistakenly be diagnosed for metastatic adenocarcinoma.2 Likely prognostic factors are size,

histology, lymph involvement and distant metastasis with a 10-year disease free survival rate of

56% without lymph node involvement.1,3 This falls to 9% when there are positive lymph

nodes.1,3
 Fewer than 500 eccrine cancer cases exist in the literature.2 Since there is limited data and

cases, the best treatment regimen is still relatively unknown. Treatment for eccrine cancers is

usually wide surgical excision (at least 2 cm) along with regional node dissection if disease is

present.3,4 As this is a very rare type of cancer, treatment with radiation therapy is still debated as

the only evidence for adjuvant radiotherapy is based on case reports.4 Fractionation and dose

varies between 24 Gy in 12 fractions to 70 Gy in 35 fractions.4 Due to the low number of

evidence, there is no clear indication on post-surgery management of eccrine cancers. 4

In this case study, we will be contributing to the small amount of research about treating

eccrine cancer post operatively with radiation therapy. The treatment of the big toe with radiation

therapy is also an area where there is not much research. The patient is a 50-year-old female.

She had surgery to remove the primary tumor on her great toe with sentinel node biopsy. The

tumor was 4.5 cm with negative margins. The close margin of 0.5 mm and histology of digital

papillary adenocarcinoma warranted radiation therapy with custom bolus per the radiation

oncologist. The radiation oncologist prescribed a total dose of 60 Gy over 30 total fractions. Per

the initial consult notes, the goal is to decrease the odds for a local recurrence. We will compare

a VMAT (Volumetric Modulated Arc Therapy) treatment plan with a 3D conformal plan and

hypothesize that the VMAT plan provides better coverage and less dose to the other digits

because of the highly conformal nature of VMAT planning when compared to a simple 3D plan.

Resources

1.Kaseb H, Babiker HM. Eccrine Carcinoma. PubMed. Published 2022.

https://www.ncbi.nlm.nih.gov/books/NBK541042/

2.Brenn T. Malignant sweat gland tumors. Advances in anatomic pathology. 2015;22(4):242-

253. https://doi.org/10.1097/pap.0000000000000075
3.Chintamani, Sharma R, Badran R, Singhal V, Saxena S, Bansal A. Metastatic sweat gland
adenocarcinoma: a clinico-pathological dilemma. World Journal of Surgical Oncology.
2003;1(1):13. https://doi.org/10.1186/1477-7819-1-13
4.Fionda B, A Di Stefani, Lancellotta V, et al. The role of postoperative radiotherapy in eccrine
porocarcinoma: a multidisciplinary systematic review. DOAJ (DOAJ: Directory of Open Access
Journals). 2022;26(5):1695-1700. https://doi.org/10.26355/eurrev_202203_28238