Brachytherapy for Bowen's disease of the palm

A 70-year-old patient with an ulcer and lump on her hand visited Liou Ying Chi Mei Hospital in September 2020 (Fig. 1 (A)). The patient was unable to open her hand due to dermal inflammatory infiltrates. A biopsy confirmed nodular SCC. She was evaluated jointly by a radiation oncologist and a surgical oncologist. Considering the large lesion size, cosmetic and reconstructive issues, and the patient’s unwillingness, surgery was deferred. After discussion with the patient, treatment via radiotherapy was decided and informed consent was signed.

Images were acquired from the patient on a 16-slice CT scanner (Discovery CT590 RT, GE Medical Systems, Amersham, UK) with a thickness of 3.75 mm. Brachytherapy treatment planning was done using the Oncentra treatment planning system OTP V4.6.0.16 (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden). We prescribed 40 Gy in 8 fractions at a depth of 5 mm from the skin surface, using 4 catheters. The target size was 3 cm x 2.5 cm. Treatment was delivered using an Ir-192 source. For this patient, the maximum skin surface dose was 571.48 cGy/fraction. Treatment time was 15 minutes per fraction including treatment set-up time.

The patient tolerated the treatment well without any interruption. Figure 1 (B) shows the clinical picture on the first day of brachytherapy. During radiotherapy, increased discharge was noted at the site of ulceration (requiring regular dressing changes). The area appeared also erythematous and scabbing, with patchy moist desquamation (Figure 1 (C)). These effects were classified as Grade 2 toxicities. At two weeks after treatment (Figure 1 (D)), healthy granulation tissue with partial resolution of the lesion was observed along the adjacent area. Figure 1 (E) shows the site one month after brachytherapy. At 45 days post-brachytherapy, the lesion completely resolved (Figure 1 (F)). The treated skin was mildly pink with no ulceration, discharge, or skin atrophy. The patient was happy with the cosmesis and outcome.