gms | German Medical Science

Objectives/Interrogation: Squamous cell carcinoma (SCC) is the commonest malignancy encountered on the hand and is generally treated by surgical resection. Here we present a case managed by primary radiotherapy, which subsequently recurred locally with deep subcutaneous dorsal to volar spread along tissue planes, in addition to a literature search on the efficacy of radiotherapy for SCC.

Methods: A case report is provided with retrospective data and clinical photographs. A structured search of the Medline database was performed to include terms related to radiotherapy, SCC and hands.

Case Report: A 92-year old male with multiple co-morbidities was offered primary radiotherapy for a biopsy-proven, well-differentiated SCC on the dorsum of the middle phalanx of the left ring finger as primary surgical excision would have necessitated amputation of the digit. Following radiotherapy, an ulcerated lesion developed at the site which was confirmed to be a recurrent SCC. Amputation was performed to include the 4th metacarpal head. Subsequent histology demonstrated, unusually, SCC present at not the dorsal but the volar excision margin, with evidence of the cancer having spread through bone and along the flexor sheath to the base of the finger.

Discussion: SCC is generally managed surgically. Surgical excision with pre-defined margins has an approximately 95% clearance rate, with a 2% local recurrence rate even when margins are confirmed as histologically clear by standard histopathological techniques. However in some cases, radiotherapy is used as a first-line modality, and upwards of 90% cure rates are reported. The use of radiotherapy as a secondary modality where SCC is recurrent or refractory to surgical management is common, although data on the efficacy of this approach is lacking; in particular, data does not appear to exist with respect to rates of subsequent recurrence. Radiotherapy has an important role in managing cutaneous SCC in the hand, and may often be the patient's choice when given the alternative of amputation. However, this report highlights the potential pitfall of local recurrence, as well as an unusual type of local extension of disease which important implications for achieving complete surgical clearance.