Large Scalp Lesion Research Articles

E025 A complex case of giant cell arteritis presenting with visual loss, tongue and scalp infarction and multiple cranial neuropathies

Abstract Background/Aims Giant cell arteritis (GCA) is the most common of the vasculitides. Visual loss due to vascular occlusion is a well recognised complication of GCA. It is important to remember that other ischaemic complications can occur, leading to atypical clinical features. We present a case of a patient with GCA who did not complain of headaches, but presented with at least five cranial neuropathies, including a right optic neuropathy, ischaemic ulceration of her tongue and a large area of scalp necrosis. Methods We present the results of our patient case review and literature search. Results An 82-year-old retired landlady who was an ex-smoker presented with haemoptysis and was diagnosed with non-small-cell lung cancer. She was treated with chemotherapy and radiotherapy in 2020, then had possible disease progression on CT thorax in 2021. She developed thigh pain, swallowing difficulties and decreased oral intake in 2021, and subsequently developed severe oral ulceration, dehydration and delirium and was admitted to the frailty unit. On examination she had a very large scalp lesion, oral lesions, and multiple cranial neuropathies (right optic neuropathy, right partial third nerve, right seventh nerve, recurrent laryngeal, and bilateral twelfth nerve palsies). Her anterior ischemic optic neuropathy meant she could only see hand movements with the right eye. Blood tests revealed anaemia of chronic disease and a CRP of over 200 mg/L. Ultrasound scan of the temporal arteries showed a halo sign confirming the diagnosis of GCA. CT angiography showed vertebral artery wall thickening and stenosis. She was treated with intravenous methylprednisolone followed by high dose oral prednisolone, and started on methotrexate. She improved symptomatically. The cranial neuropathies resolved and the area of scalp necrosis and ischemic tongue ulceration healed, but vision was not regained. Her inflammatory markers never normalised and she was subsequently started on tocilizumab, with the approval of her oncologist. Her ESR and CRP quickly fell to normal. It remains to be seen how biologic treatment may impact her malignancy. Conclusion This case highlights multiple atypical presenting features of GCA and the need for a high index of suspicion to treat early and avoid irreversible visual loss. A review of the literature reveals that cranial neuropathies secondary to ischemia can be the presenting feature in GCA and multiple cranial neuropathies can occur. This is the first case in the literature, that we are aware of, which involves this number of cranial neuropathies alongside extensive scalp and tongue infarction. These features have all resolved with treatment, with the exception of unilateral permanent visual loss. Disclosure J. Jade: None. V. Barradell: None. A. Coote: None.

Primary trans-calvarial lymphoma: A rare entity

Primary trans-calvarial lymphoma with both intracranial and extracranial extension is a scarcely described entity in published literature. Most often, these lesions are misdiagnosed as hematomas or meningiomas. We hereby report an interesting case of a 60-year-old female presenting with a large scalp mass. The diagnosis at the time of referral was an organized scalp hematoma. Magnetic resonance imaging of the brain revealed a large isointense enhancing mass lesion with transcalvarial extension involving the scalp as well as the meninges. Histopathology and immunohistochemistry confirmed a diagnosis of diffuse large B-cell lymphoma. Our case was unique in that the presentation was with a large scalp lesion with a reasonable meningeal component and invasion of the superior sagittal sinus without any associated focal neurological deficit.

Modulated Electron Radiation Therapy (MERT) for the Treatment of Large Scalp Lesions: A Dosimetric Feasibility Study

Curvature of the scalp and proximity to the brain makes the treatment of scalp tumors challenging. Practitioners often accept sub-optimal plans with modulated photons or matched electron fields in an attempt to cover the target and avoid unnecessary brain irradiation. The aim of this study is to evaluate the ability of modulated electron radiation therapy (MERT) to decrease radiation dose to the brain for large scalp targets. CT planning scans from 5 patients with skin cancers of the scalp measuring > 10 cm previously treated with volumetric modulated arc therapy (VMAT) to 5000 cGy in 20 fractions were unarchived in accordance with an institutional review board approved protocol. All cases were replanned with MERT. MERT cases were prescribed to the 90% isodose line and VMAT cases were normalized so 95% of the PTV received 5000 cGy. Using an in-house Monte Carlo (MC) based inverse treatment planning system, MERT treatment plans were calculated with the goal of covering the target and minimizing dose to the brain. Minimum planning target volume dose (PTVmin), dose to 95% (D95) of planning target volume (PTV), mean dose to the brain, and the percentage volume of the brain receiving 20 Gy (V20) were calculated. VMAT and MERT results were compared using Wilcoxon signed-rank tests. Plans were designed for delivery using a motorized electron multi-leaf collimator (eMLC) that attaches to the head of the linear accelerator. The eMLC has 27 pairs of tungsten leaves with a 0.56 cm width and 2 cm thickness. Treatment time for the MERT plans was estimated by multiplying the slowest leaf speed by the distance needed to travel from parking position to the center and then multiplying by the number of segments in the plan. The maximum dimension of the PTV ranged from 11-23 cm. The estimated treatment delivery time for the MERT plans ranged from 4-15 minutes. PTV coverage between VMAT vs MERT plans: mean PTVmin (3486 cGy vs 3393 cGy, p = 0.99) and mean D95 (5000 cGy vs 4804 cGy, p = 0.06) (see Table). Mean brain dose trended lower for MERT plans (1032 cGy vs 406 cGy, p = 0.06), as did V20 (16.9% vs 6.8%, p = 0.06). We successfully developed MERT treatment plans for 5 patients with large scalp lesions that were able to cover the PTV and show a trend for decreased dose to the brain when compared to the VMAT plans, while maintaining estimated treatment time ≤ 15 min. MERT technology may allow for improvement in conformity for shallow tumors, especially in the head and neck region, where sparing deeper radiosensitive tissues is critical.Digital Poster Abstract 1083; TablePatientVMAT PTVmin (cGy)MERT PTVmin (cGy)VMAT PTV D95 (cGy)MERT PTV D95 (cGy)VMAT Brain Mean Dose (cGy)MERT Brain Mean Dose (cGy)VMAT Brain V20 (%)MERT Brain V20 (%)144343145500047508003309.15.422606403050004830234997764.521.9323913799500048506102644.94.45443764220500048409041607.00.8536211770500047504982992.01.6Mean348633935004804103240616.96.8 Open table in a new tab

Tangential Volumetric Modulated Radiation Therapy Is Superior to Brachytherapy for Large Scalp Lesions: A Case Study in Lentigo Maligna

Tangential Volumetric Modulated Radiation Therapy Is Superior to Brachytherapy for Large Scalp Lesions: A Case Study in Lentigo Maligna

Dermatitis Artefacta: Facts for a Facial Plastic Surgeon

Objective: 1) To report a large scalp lesion secondary to dermatitis artefacta, requiring reconstruction. 2) To emphasize the need for a multidisciplinary approach involving dermatologist, psychiatrist, and facial plastic surgeon for optimizing outcome. 3) To highlight specific issues in the patient’s care in the perioperative period. Method: Case report of a 44-year-old white female patient who presented to our combined dermatology–facial plastic surgery clinic with a large lesion on her scalp and a known diagnosis of dermatitis artefacta. Results: The scalp lesion had gradually increased in size over 4 years. Prior to this she was being followed up by the dermatologists for this and other multiple, bizarre ulcerating areas on her face; the patient had associated depression. A diagnosis of dermatitis artefacta was made by the dermatologists and supported by the psychiatrists. She was treated with antibiotics for the excoriating lesions and local dressing for the scalp wound initially. Regional reconstruction of scalp was subsequently carried out to achieve closure of the scalp defect, with the active involvement of the dermatology and psychiatry teams. Conclusion: 1) Close monitoring is required postoperatively, as these patients can be passively noncompliant with treatment, inducing self-harm repeatedly because of lack of insight in causing skin damage. 2) Prompt discussion in a multidisciplinary setting with earlier input from facial plastic surgeons will potentially minimize the extent of reconstructive surgery required.

Treatment of extensive scalp lesions with segmental intensity-modulated photon therapy

To compare static electron therapy, electron arc therapy, and photon intensity-modulated radiation therapy (IMRT) for treatment of extensive scalp lesions and to examine the dosimetric accuracy of the techniques. A retrospective treatment-planning study was performed to evaluate the relative merits of static electron fields, arcing electron fields, and five-field photon IMRT. Thermoluminescent dosimeters (TLD) were used to verify the accuracy of the techniques. The required thickness of bolus was investigated, and an anthropomorphic phantom was also used to examine the effects of air gaps between the wax bolus used for the IMRT technique and the patient's scalp. Neither static nor arcing electron techniques were able to provide a reliable coverage of the planning target volume (PTV), owing to obliquity of the fields in relation to the scalp. The IMRT technique considerably improved PTV dose uniformity, though it irradiated a larger volume of brain. Either 0.5 cm or 1.0 cm of wax bolus was found to be suitable. Air gaps of up to 1 cm between the bolus and the patient's scalp were correctly handled by the treatment-planning system and had negligible influence on the dose to the scalp. Photon IMRT provides a feasible alternative to electron techniques for treatment of large scalp lesions, resulting in improved homogeneity of dose to the PTV but with a moderate increase in dose to the brain.

Nodular primary localized cutaneous amyloidosis: Immunohistochemical evaluation and treatment with the carbon dioxide laser

Nodular primary localized cutaneous amyloidosis is an uncommon disorder for which there is no consistently satisfactory treatment. The amyloid fibrils are thought to have an immunoglobulin light chain derivation and systemic involvement must be excluded in all cases. We report a patient with a large scalp lesion of nodular primary localized cutaneous amyloidosis whose immunohistochemical evaluation revealed lambda light chain deposits and who thus far has no apparent systemic involvement. The lesion was treated by the carbon dioxide (CO2) laser with excellent cosmetic results and minimal morbidity.