Dermatology Association of Tallahassee
Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT009
May 11, 2011
Situational Overview
Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.
Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.
Patient History
This patient is an 85 year old male with history of multiple skin cancers. The patient is on Coumadin and has a pacemaker.
Patient Management
The patient presents with a biopsy proven Squamous Cell Carcinoma in situ on his Dorsal nose near tip, this is labeled P8. In addition to this he has two scaly crusty areas on either side of the original biopsy which are labeled 3A and 3B and are biopsied. Lesion 3A and 3B are found on frozen section to be SCC in situ. These lesions are inferior to a previous LN2 site marked with an X on the right bridge of nose, and a previous x-ray site marked with an X on the Left Ala. All three lesions P8, 3A, and 3B are included in one field.
Treatment Parameters
The clinical lesion as determined by the original biopsy P8 and frozen section biopsy 3A and 3B was identified and circled. An 8-10 mm border was drawn around this. The tumor depth was estimated to be <2 mm. A 0.762 mm thick lead shield was fashioned to include a 2.2 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Universal Superficial machine with a 3 cm cone, 7 fractions of 500 cGy were delivered at 80 kv, 5 ma with a D1/2 of 6.7 mm. The patient received a total of 3500 cGy to the area over a two week period.
Patient Outcome
