A 59-year-old Caucasian male presented with a 10-year history of a neglected slowly growing red lesion on the right anterior chest wall. Aside from tuberculosis treated in childhood and a remote right clavicle fracture he had no relevant past medical history, took no medications, and denied tobacco or alcohol consumption. He sought attention when the lesion’s growth rate increased and it began weeping serosanguinous fluid. He required transfusions for a presenting hemoglobin of 55 g/L. On examination there was a striking 20 x 15 cm non-odorous geographic lesion centered over the right chest wall, with heaped edges lying 3 cm proud of the normal skin contour and an ulcerated, weeping center (Fig. 1). It extended superiorly to the supraclavicular fossa, inferiorly below the inframammary fold, laterally to the anterior axillary line, and medially 5 cm beyond midline. In addition there was a 3 x 3 cm raised erythematous lesion suspicious for a satellite metastasis on the right forehead which had developed within the last year, and a long-standing unchanged 2 x 2 cm non-specific erythematous plaque on the left temple at the site of a remote chemical burn. Beyond chronic right shoulder achiness and motion restriction he denied pain, other local or constitutional symptoms and had an ECOG performance status of zero. CT from the chest to pelvis confirmed a large disc-shaped lesion invading the chest wall to a depth of 2 cm, destroying the right anterior manubrium and anteromedial right clavicle. There were calcified pulmonary nodules consistent with prior granulomatous disease, but no regional or distant lymphadenopathy and no visceral metastases. An incisional biopsy of the chest wall lesion confirmed moderately to poorly differentiated squamous cell carcinoma, and he was staged as pT4 cN0 cM1.
The size of the lesion was prohibitively large for either surgery or radiotherapy so he proceeded to palliative chemotherapy as follows: Cisplatin 55 mg/m2 and Docetaxel 55 mg/m2 every 3 weeks. He tolerated 12 cycles extremely well with only mild myelosuppression, oral mucositis and tinnitus. The chest lesion showed an early and sustained dramatic response to therapy (Fig. 2). The right forehead and left temple lesions remained stable. He went on to receive palliative radiotherapy to the chest lesion as follows: 5000 cGy in 20 fractions via 9 MeV electrons to a 15 x 15 cm field, and to the right forehead lesion as follows: 4500 cGy in 15 fractions via 9 MeV electrons to a 7 x 9 cm field. Both lesions showed further improvement. He sustained a significant progression-free interval: 16 months from the time of initiation of chemotherapy and 6 months from the time of radiotherapy completion, but then developed multiple in-field recurrent chest nodules (Fig. 3) which were re-treated with 3000 cGy in 10 fractions via 9 MeV electrons to a 7 x 14 cm field. The long-standing left temple lesion had also begun to progress, and because of this it was deemed to indeed be malignant and was treated with 3500 cGy in 5 fractions via 9 MeV electrons to a 4 cm diameter circular field. At the time of manuscript preparation, 21 months following the time of initiation of chemotherapy, he had developed new satellite metastases on the neck and left shoulder, but was doing well overall with an ECOG performance status of zero.
Case Two – Skin Cancer Removal