Locally advanced verrucous carcinoma of the oral cavity: treatment using customized mold HDR brachytherapy instead of hemi-maxillectomy

High-Dose-Rate Brachytherapy for Primary Treatment of Refractory Proliferative Verrucous Leukoplakia of the Hard Palate

Oral proliferative verrucous leukoplakia (PVL) is a rare, progressive form of leukoplakia with a high rate of malignant transformation. No therapies are known to lower the rate of malignant transformation and prevent a recurrence.

An 84-year-old patient with a years-long history of symptomatic PVL of the hard palate refractory to CO2 laser ablation presented to the radiation oncology clinic for consideration of non-surgical management. High dose rate brachytherapy was used to deliver 36 Gy in 12 fractions to the hard palate using an Ir-192 source with a custom-molded applicator.

By three months of follow-up, the patient had complete regression of the PVL and resolution of acute mucositis. With 18 months of follow-up, the patient remains disease- and symptom-free without toxicities of treatment.

High dose rate surface applicator brachytherapy is a feasible and potentially effective treatment for oral PVL, yielding durable control with low long-term toxicity.

Customized double-shell immobilization device combined with VMAT radiation treatment of basosquamous cell carcinoma of the scalp

Malignancies with a superficial involvement of the scalp/skull present technical challenges for radiation‐treatment‐planning, such as achieving skin coverage with the prescribed dose and with the desirable conformity, homogeneity, and lower brain dose. We report a radiotherapy treatment technique for a patient diagnosed with diffuse basosquamous cell carcinoma of the scalp and adjacent skull‐bone. This study presents the plan's quality parameters, patient's dosimetry, and patient's outcome. The patient was treated using volume‐modulated‐arc therapy (VMAT) and a double‐shell‐bolus full‐head device (DSBFD) designed for patient immobilization and better skin coverage. A VMAT plan was generated using an Eclipse treatment‐planning system for a prescribed dose of 60 Gy in 30 fractions. The treatment plan was analyzed to determine the conformity index (CI), the homogeneity index (HI), the target‐coverage, and the dose to the organs‐at‐risk (OARs). Skin‐doses were measured using optically stimulated luminescence (OSL) dosimeters. Clinical follow‐up was performed by the radiation oncologist during and after the course of radiotherapy. With regard to planning target volume (PTV) coverage, the V₉₅ was 99%. The measured and calculated dose to the skin was in the range 100–108% of the prescribed dose. The mean brain‐PTV dose was 711 cGy. The CI and HI were 1.09 and 1.08, respectively. The mean positioning accuracy for the patient over the course of treatment was within 2 mm. The measured accumulated skin dose and planning dose was agreed within 2%. Clinical examination of the patient 6 months after radiotherapy showed good response to the treatment and a 90% reduction in scarring. The DSBFD technique combined with RapidArc treatment was useful in terms of the target dose distribution and coverage. Daily patient alignment was found very precise, reproducible and less time‐consuming.

Oral verrucous carcinoma: From multifactorial etiology to diverse treatment regimens (Review)

Oral verrucous carcinoma (OVC) is a verrucous variant of oral squamous cell carcinoma (OSCC), which accounts for 2-12% of all oral carcinomas with a 5-year survival rate of only approximately 50%. Enormous effort has been dedicated to this cancer, and the past decades have witnessed significant advances in relevant diagnostic and therapeutic approaches. Currently, there exist three challenges from primary sub-fields of research and clinical practice of the cancer, namely multifactorial etiology, complex molecular mechanism, and deficient treatment. This study reviews the existing literature on the cancer, encompassing its etiology, clinical manifestations and pathology, molecular mechanism, diagnosis and differential diagnosis, and treatment. For improved treatment of OVC, multifactorial etiology analysis, incorporation of effective biomarkers for mechanism illustration, and integration of multidisciplinary modalities are expounded, in an attempt to resolve the challenges and to provide a useful guide for future research in the field.

Recurrent Bowen's disease of scalp treated with high dose rate surface mold brachytherapy: a case report and review of the literature

Our case is a 46-year-old female presenting to us with Bowen's disease of scalp since 5 years. Patient had failed topical therapy with 5% 5-florouracil, 0.1% tacrolimus and was intolerant to topical imiquimod. At presentation, she had 15 cm × 10 cm erythematous, hyperpigmented, crusted plaque with irregular border in the superior and lateral aspect of left side of scalp with extension in to forehead. Patient was treated with computed tomography based customized surface mold high dose rate brachytherapy with Iridium-192 to a dose of 35 Gy in 10 fractions (twice daily, 6 hours apart) over 5 days. Patient tolerated the treatment well and showed regression of the lesion with mild dermatitis at the end of treatment. Though dermatitis increased at 2 weeks, at 4 weeks post treatment there was near complete resolution of the lesion with adjacent alopecia. At 8 weeks after completion of the treatment, there was complete resolution of the lesion and patient was asymptomatic. Alopecia in the adjacent area has resolved and the skin pigmentation has begun. Patient is satisfied with both the disease control and the cosmetic outcome of the procedure. Our case report demonstrates successful application of surface mold high dose rate brachytherapy in the treatment of recurrent Bowen's disease of the scalp. Brachytherapy can play an important role in the management of recurrent malignant and premalignant diseases of the complex treatment sites like scalp and it's non-hesitant use should be encouraged in appropriately selected patients at the earliest.