Teaching CaseRadiation therapy for synchronous basal cell carcinoma and lentigo maligna of the nose: Response assessment by clinical examination and reflectance confocal microscopy
Introduction
Radiation therapy (RT) is a noninvasive treatment for a variety of skin cancers. Although surgery is often preferred for basal cell carcinoma (BCC) and lentigo maligna (LM), these conditions often affect patients that are medically inoperable, who decline surgery, or have lesions in challenging anatomic locations. Although nonsurgical treatments can be employed, close monitoring for disease recurrence and progression is of utmost importance. Typically, this is carried out by clinical examination, without adjunctive imaging. Reflectance confocal microscopy (RCM) is an emerging imaging technology that is proving useful to aid in the assessment of treatment response and disease recurrence (Fig 1). RCM has a high sensitivity (93%) and specificity (82%) for diagnosing LM (odds ratio = 60.8), and is Food and Drug Administration–approved for “review by physicians to assist in forming a clinical judgment.”1 Herein, we describe the case of a patient with a synchronously occurring BCC and LM of the nose, treated with definitive RT, and evaluated pre- and post-RT with RCM, which demonstrated complete response of the BCC and eventual recurrence of the LM.
Section snippets
Case report
An 83-year-old woman with a history significant for several nonmelanoma skin cancers and stage IV mantle cell lymphoma presented for management of a microinvasive LM of the nasal tip (Fig 2A). At initial consultation, mapping RCM using the handheld VivaScope 3000 (Caliber I.D. [formerly Lucid Inc], Rochester, NY) was performed and revealed areas of dendritic melanocytes and pagetoid cells diagnostic of melanoma as well as areas of polarized nuclei, tumor nests, and elongated blood vessels
Discussion
RT serves as a viable alternative for treatment of BCC and LM when the patient has comorbidities that limit surgery or when these lesions occur in areas where excision may result in significant cosmetic and/or functional deficit. One advantage of RT over surgery is the preservation of normal tissue within the radiation field. Treating the patient with a highly fractionated course allows for selective killing of tumor cells and sparing of normal tissues because normal cells are able to repair
Conclusion
Nonsurgical therapies are often appropriate alternatives for the treatment of complex superficial skin cancers, especially in the elderly. This case highlights both the promise and challenges associated with RT in this setting. It further underscores the potential role of RCM to facilitate mapping lesions before treatment as well as its longitudinal function in assessing response and monitoring for progression or recurrence in patients treated with radiation. Further studies on the use of RCM
Acknowledgments
The authors acknowledge L. Evan Michael MD PhD for providing images of the histology slides for the manuscript.
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Conflicts of interest: Dr Barker reports personal fees from RP Pharmaceuticals, grants and personal fees from Elekta, grants and nonfinancial support from American Society for Radiation Oncology, nonfinancial support from MASCC, and nonfinancial support from MesoScale Diagnostics outside the submitted work. The other authors declare that they have no relevant or material financial interests that relate to the case described in this article.