ARTICLE
It is of great practical utility to assess which is the best therapeutic
choice in the management of basal and squamous cell skin carcinomas recurring
after different treatments. In fact the classical therapeutic modalities
of primary basal and squamous cell skin carcinomas yield, on the whole,
very high five-year cure-rates (evaluated about 91%), that are variable
in relation to the localization, and the size of the neoplasm [1-7]. On
the contrary, the cure-rates of the recurrent basal and squamous cell
skin carcinomas (RBSCSC) appear to be lower [3]. Such rates vary according
to the different studies on this topic. However, the literature data are
few and the results of the reported studies are not univocal. As a consequence,
reliable studies which provide further data about the cure-rates of the
treatment of RBSCSC, obtained with different therapeutic methods, appear
very useful.
With this aim, on the basis of the results of a preliminary study [8],
we have performed a retrospective review of 249 RBSCSC (after different
non radiological treatments), treated with radiotherapy in the period
1982-1999.
Material and methods
No patients with RBSCSC after a previous radiotherapy have been included
in our series, because of the well known technical contraindication of
treating again with radiotherapy an already irradiated area with full
total doses. The 229 patients treated represent 11.91% of the 1,941 cases
of primary malignant epithelial skin neoplasms irradiated at our Department
in the same period. The generalities of the patients studied and the modalities
of the treatment are listed in Tables
I to IV. Some patients had undergone
multiple modalities of treatment prior to radiotherapy (Table
III). In the case of an ill-defined lesion, the size of the irradiation
field was chosen so as to leave up to 1 cm of healthy skin around the
lesion, while for well outlined lesions or in the case of particular localizations
(i.e. eyelids) the choice was for a margin of 0.5 cm. In the patients
treated at alae nasi, lead rubber (1 mm Pb equivalent) shields
were inserted into the nostril, in order to protect the cartilage of the
septum. The same kind of shield was interposed between the scalp and the
ear during irradiation of the anterior surface of the ear (to prevent
alopecia and the possible retroauricolar skin reaction) and between pinna
and preauricular skin, when irradiating the posterior surface of the ear.
In the patients treated on the eyelids an appropriate eye shield to prevent
cataract formation was employed [10]. The follow-up was planned so as
to perform a first control one month from the end of the treatment, then
the patients were controlled every sixth months for 5 years and once a
year afterwards.
The data were processed by means of Excel 5.0 software (Microsoft Corporation,
1994). The cure-rate was evaluated according to the life table method
[11].
Results
The mean follow-up time was 41.663 months (range 1 to 287 months). In
Table V are summarized
the therapeutic results (Figs.
1 and 2). The five-year
cure-rate is 83.62%. The rate of re-recurrence is 8.03% at present. The
re-recurrences occurred in patients with recurrent basal cell carcinomas,
centrally in 5 cases and peripherally in 15 cases (Table
VI). Of these re-recurrent lesions: seven were treated with complete
remission [cryotherapy, 5-fluorouracil (5FU) ointment, surgical excision,
boost of contact x-ray therapy (CRT) + 5FU ointment]; two with control
(5FU ointment); one has relapsed after a further session of CRT, which
was possible since the recurrence was marginal; two were lost to follow-up
after surgery; six have had no response to the treatment with 5FU ointment;
two were sent for surgical counseling and then lost to follow-up.
The cosmetic results were evaluated as "good" in the cases characterized
by no visible radiation injury, as "acceptable" in the cases characterized
by mild skin atrophy and/or mild dyschromia, and as "not acceptable" in
those with severe skin atrophy and/or marked dyschromia and the presence
of numerous telangiectasias (Table
V). So far no complications nor sequelae to the radiological treatment
have been observed.
Discussion
Examining the 20 cases of re-recurrences of the series of patients studied,
it can be observed that 15 are marginal. This is probably to be put in
relation: 1. to the greatest sub-clinical extension of RBSCSC with respect
to the primary forms; and 2. to the proliferation of neoplastic cells,
horizontally and deeply, followed by a resurfacing at a certain distance
from the neoplasm as the result of the formation of the scar tissue after
the initial treatment. As a consequence, it is impossible to predict exactly
the safety margins in non-neoplastic tissue and then to perform irradiation
fields which encompass adequate portions of neoplasm-free tissue (Table
VI). This would explain the less than brilliant curative results
obtained by radiotherapy, as also by other therapeutical methods, in the
forms of RBSCSC with respect to the primary forms. In addition, it should
be mentioned that all re-recurrences have occurred in basal cell carcinomas:
however this could be explained by the prevalence of recurrent basal versus
squamous cell carcinomas in our series. We could not find any significative
correlation between re-recurrences and size of the lesions (Table
VI). Their prevalent location on the head or face is mainly related
to the fact that most lesions of our series were localized in these areas
(Table II). In a similar
way, the fact that all the re-recurrent lesions had been treated by means
of CRT may be explained by the employ of this technique in most of the
lesions (237 out of 249).
In any case, our results (five-year cure-rate
after the end of radiotherapy: 83.62%) are in agreement with the data
of the literature [2, 12]. The cosmetic results (evaluated as good or
acceptable in 92.62%) have to be judged as very favorable, as is the absence
of complications and sequelae.
The results obtained, also when compared to those from the literature
[3, 13], suggest two considerations about the choices in the treatment
of RBSCSC following non-radiological therapies: 1. dermatological radiotherapy
is a safe treatment and the most effective after Mohs surgery, given its
peculiar technical features that permit the treatment of extensive lesions
and the inclusion of large skin areas, with minimum loss of tissue. Such
advantages may result in the increased possibility of facing recurrent
lesions successfully; 2. dermatological radiotherapy is a first-line treatment
in those patients who cannot undergo extensive surgery for a variety of
different reasons (age, general health conditions, etc.).
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