T.T. is a 46 year-old woman who underwent renal transplantation 20 years ago and has been on an immunosuppressive medication since the transplant. She started developing squamous cell skin cancers on her sun exposed arms and face 5 to 7 years ago. She continued to work at her convenient store, and had problems accessing care, allowing a lesion on her left dorsal hand at the junction of the index finger and thumb progress to a large size. Finally plastic surgery and dermatologic evaluation led to a recommendation for partial amputation given the large size of the tumor, and the challenges of surgery in a woman with immunosuppressive history, renal transplant, and heavy smoking throughout her life. The patient pleaded for a non-surgical option and was referred to radiation oncology. At the time of referral, she had foul-smelling purulence in the wound, severe pain, and no useful function of her index and middle finger.
Metronidazole powder was used on the wound and proper pain care immediately helped the management. Trial of radiation was offered in lieu of amputation, however the patient was well aware of the possible eventuality of amputation.
She is now three months out from the six-week treatment and as the pictures show, has almost a complete regression although there is a scab continuing to heal in the center of the original lesion. The odor and pain are gone as well, however she continues to have minimal use of the index and middle finger. She has a new lesion on her arm, which her surgeon suggested should be considered for radiation in her next treatment.
She was also informed about the recent randomized double blinded Australian Trial showing reduced development of skin cancers (23%) using 500 mg of nicotinamide or vitamin B3 twice a day in adult population with prior skin cancers.