ANTICANCER RESEARCH 34: 873-876 (2014)

Treatment of Periocular Basal Cell Carcinoma Using an Advanced Stereotactic Device

ANTONIO PONTORIERO, GIUSEPPE IATÌ, ALFREDO CONTI, FABIO MINUTOLI, ANTONIO BOTTARI, STEFANO PERGOLIZZI and COSTANTINO DE RENZIS

Department of Biomedical Sciences and Morphological and Functional Image - Section of Medical Imaging and Radiotherapy, School of Medicine, University of Messina, Messina, Italy

Abstract. Basal cell carcinoma (BCC) is the most common gland, conjunctiva and cornea). is a malignant periocular tumor. When periorbital invasion exists, therapeutic approach which permits an optimal dose orbital exenteration is necessary. A 73-year-old man with distribution even to a curved surface, but it is invasive when recurrent BCC of the inner canthus of the left eye with deeper targets have to be treated. Modern external-beam diffusion to the extrinsic muscles of the orbit and periorbital radiation therapies, such as those using stereotactic fat was treated with CyberKnife in stereotactic body techniques, are able to deliver high doses to complexly- (SBRT) modality. The treatment resulted in shaped targets. Cyberknife is a robotic device used to treat rapid tumor regression, with a complete remission after six both intracranial and extracranial targets. Here, we describe months without toxicities. To the best of our knowledge, this a patient with a locally advanced BCC of the medial canthus is the first report in the English literature describing a and lower eyelid treated with the Cyberknife system locally advanced BCC treated with SBRT alone. emulated brachytherapy dose distribution to the target.

Basal cell carcinoma (BCC) is the most common malignant Case Report periocular tumor, accounting for 90% of malignant eyelid lesions (1). The most frequent periocular site for BCC is the A 73-year-old Caucasian male had a diagnosis of BCC of the lower eyelid, followed by the medial canthus, upper eyelid, the inner canthus of the left eye in May 2009. Initial therapy and lateral canthus (2-3). was surgical resection. Pathological analysis confirmed a The goal of treatment is complete tumor removal in order nodular-type BCC, focally ulcerated, with disease in one of to prevent recurrence (4). The incidence of orbital invasion is the lateral margins. In January 2012, a local recurrence was approximately 2-4%, and risk factors include multiple observed and a physical examination revealed a loss of recurrences, large lesion size, aggressive histological substance with destruction of the eye’s inner canthus, subtype, medial canthus location, and advanced patient age lacrimal apparatus and medial half of the left lower eyelid. (4). In advanced cases (about 5.5%), the radical surgical A computed tomographic (CT) scan revealed pathological approach for periocular BCC (i.e. rectal muscle diffusion) is tissue along the edge of the left lower orbital, which invaded orbital exenteration (4-6). Radiation therapy is an organ- the periorbital fat; it had an intimate contact with the anterior sparing treatment. Using radiation, particular attention has to lower boundary and the extrinsic muscles of the eye (right be devoted to sparing organs at risk (lens, retina, lacrimal medial, inferior and oblique inferior). No bone infiltration was evident (Figure 1). In April 2012, the patient refused both surgical extentoration and brachytherapy, and for this reason in May 2012 he was admitted to our Department for Correspondence to: Professor Stefano Pergolizzi, School of stereotactic technique using Cyberknife (Accuray, Inc.), a Medicine, Department of Biomedical Sciences and Morphological robotic Linear Accelerator-based stereotactic device. The and Functional Image - Section of Medical Imaging and patient was placed supine on the treatment couch and Radiotherapy, University of Messina, A.O.U. G. Martino, Via immobilized with a custom-fitted thermoplastic mask; in Consolare Valeria 98100 Messina, Italy. Tel: +39 902217173, Fax: such position, a multislice CT scan (Siemens SOMATOM +39 902213192, e-mail: [email protected] Sensation 16) was performed. A total dose of 1.5 ml/kg of Key Words: Basal cell carcinoma, Cyberknife, stereotactic body contrast medium was infused using a pump in the cubital radiation therapy, periocular tumor. vein. The CT protocol was carried out according to

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CyberKnife-specific requirements: acquisition 16×0.75 mm, 120 kV, 320 mAs , rotation time 1 s, pitch 1.15; and reconstruction slice 1.5 mm, reconstruction increment 1.5 mm, filter reconstruction H31 (smooth), 512×512 matrix. The axial source images were transferred to the CyberKnife workstation for treatment planning. After the contouring of the tumor and critical volumes on the CT images, an inverse planning algorithm using a non-isocentric technique determined the optimal treatment planning. We utilized three collimators with different diameter: 7.5 mm, 12.5 mm and 15 mm. The volume of the tumor was 6 cc. The dose to the target was 40 Gy Figure 1. Recurrent basal cell carcinoma of the inner canthus of the left delivered in 10 sessions, prescribed to the 70% isodose line. eye. Panel A shows a pre-treatment CT. Panel B shows a loss of The maximal dose (Dmax) was 5714.29 cGy. The coverage of substance and destruction of the inner canthus of the left eye, lacrimal the target was 99.5%, the number of beams was 175, the apparatus and medial half of the lower left eyelid. conformality index 1.55, the homogeneity index 1.43 and the new conformality index 1.55. The number of total monitor units was 54705. The Dmax to critical organs was: 655 cGy to right optic nerve, 103 cGy to the right eye, 1,463 cGy to the right lens, 2,987 cGy to the left optic nerve, 432 cGy to the 2 Cook BE Jr. and Bartley GB: Treatment options and future optic chiasma and 1,034 cGy to the right lacrimal gland. prospects for the management of eyelid malignancies: An evidence-based update. Ophthalmology 108(11): 2088-2098, Figure 2 shows the isodose distribution and Figure 3 shows 2001. complete clinical remission in December 2012. 3 Cook BE Jr. and Bartley GB: Epidemiologic characteristics and clinical course of patients with malignant eyelid tumors in an Discussion incidence cohort in Olmsted County, Minnesota. Ophthalmology 106(4): 746-750, 1999. Here we report on a case which had some peculiar 4 Iuliano A, Uccello G., Diplomatico A, Tebaldi S and characteristics: an elderly patient, with recurrent BCC Bomnavolontà G: Risk factors for orbital exenteration in periocular basal cell carcinoma. Am J Ophthalmol 153(2): 238- involving both orbital extrinsic muscles and periorbital fat. All 241, 2012. these features lead to a poor prognosis with respect to 5 Howard GR, Nerad JA, Carter KD and Whitaker DC: Clinical conservative approaches. Using SBRT, we obtained clinical characteristics associated with orbital invasion of cutaneous long-term complete remission, preserving visual function. Few basal cell and squamous cell tumors of the eyelid. Am J reports describe SBRT in primary or recurrent head and neck Ophthalmol 113(2): 123-133, 1992. cancer (7-12) , and as far as we are aware, none describes 6 Nemet AY, Deckel Y, Martin PA, Kourt G, Chilov M, Sharma V locally advanced BCC which invades deeper structures or the and Benger R: Management of periocular basal and squamous cell carcinoma: A series of 485 cases. Am J Ophthalmol 142(2): orbit. Using , Kramkimal et al. reported eight 293-297, 2006. patients with BCC, and among these, one had locally 7 Siddiqui F, Patel M, Khan M, McLean S, Dragovic J, Jin JY, advanced disease of the right eye (13); in this case, a total dose Movsas B and Ryu S: Stereotactic body radiation therapy for of 66 Gy was delivered and a complete clinical remission was primary, recurrent, and metastatic tumors in the head-and-neck observed after eight months; as a late adverse event, a teary region. Int J Radiat Oncol Biol Phys 15 74(4): 1047-1053, 2009. eye was reported. We believe that our therapeutic approach is 8 Kawaguchi K, Sato K, Horie A, Iketani S, Yamada H, Nakatani feasible and could be proposed for elderly patients who refuse Y, Sato J and Hamada Y: Stereotactic may contribute to overall survival for patients with recurrent head and brachytherapy, or for frail patients not suitable for a surgical neck carcinoma. Radiant Oncol 5: 51, 2010. approach. We underline that this is the first case report on this 9 Kodani N, Yamazaki H, Tsubokura T, Shiomi H, Kobayashi K, issue using SBRT. Considering the actual worldwide Nishimura T, Aibe N, Ikeno H and Nishimura T: Stereotactic availability of stereotactic devices, it is important to report body radiation therapy for head and neck tumor: Disease control such a case so that more patients might be offered a and morbidity outcomes. J Radiat Res 52: 24-31, 2011. conservative approach with both esthetic and functional 10 Lim CM, Clump DA, Heron DE and Ferris RL: Stereotactic preservation. body radiotherapy (SBRT) for primary and recurrent head and neck tumors. Oral 49: 401-406, 2013. 11 Thariat J, Badoual C, Faure C, de Mones E, Butori C, Santini J, References Poissonnet G, Maingon P, Faivre S, Klijanienko J, Saint-Guily JL, Righini CA; Groupe Refcor (Réseau d’Expertise Français sur 1 Margo CE and Waltz K: Basal cell carcinoma of the eyelid and les Cancers ORL Rares): Basaloid squamous cell carcinomas of periocular skin. Surv Ophthalmol 38(2): 169-192, 1993. the head and neck. Bull Cancer 96(10): 989-1004, 2009.

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Figure 2. Non-isocentric treament planning with Multipan-CyberKnife emulating brachytherapy; dose distribution and dose−volume histogram are shown.

12 Vargo JA, Wegner RE, Heron DE, Ferris RL, Rwigema JC, Quinn A, Gigliotti P, Ohr J, Kubicek GJ and Burton S: Stereotactic body radiation therapy for locally recurrent, previously irradiated nonsquamous cell cancers of the head and neck. Head Neck 34(8): 1153-61, 2012. 13 Kramkimel N, Dendale R, Bolle S, Zefkili S, Fourquet A and Kirova YM: Management of advanced non-melanoma skin cancers using helical tomotherapy. J Eur Acad Dermatol Venereol Apr 6. [Epub ahead of print], 2013.

Figure 3. Complete clinical remission six months after the CyberKnife Received December 9, 2013 treatment. Panel A shows a post-treatment CT. Panel B shows the good Revised January 4, 2014 post-treatment esthetic result. Accepted January 7, 2014

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