Date of Visit: 02 May 2017
I had the pleasure of seeing Peter Higgins today in the Department of Radiation Oncology at Princess Margaret Hospital. I saw him in the Sarcoma Clinic. Peter is a very pleasant 72-year-old gentleman who has been recently diagnosed with angiosarcoma of the scalp, here for consideration of treatment for that.
Mr. Higgins presented to your hospital in early April with a 3-week history of right eye swelling and neck lymphadenopathy. Imaging revealed a preseptal right orbital thickening with involvement of the face and scalp. MR demonstrated that, and the CT of his neck revealed a 1.7 cm left level 2 lymph node and a right 1 cm neck node. There were also 2 osteolucent lesions in the scapula of uncertain etiology. The patient was admitted to the Dermatology Service, per my understanding, and a biopsy was performed of his scalp, which revealed angiosarcoma. He was then referred to us. Unfortunately, I am unable to open his imaging at this time. I am going by reports. I know that was treated with PREDNISONE, which reduced his swelling; however, today when I see him, his right eyelid is totally swollen shut.
On physical exam, in addition, the right eyelid swelling has involvement of this process in his right cheek, temple and forehead, and on the left his forehead and temple and cheek are also involved. His eyelid is edematous, but not clearly involved with tumor. He has a large lesion in the anterior left scalp. The remainder of his scalp is not clearly involved, although he has ample hair, which renders examination somewhat challenging. I am actually unable to open his eyelid at this time. He otherwise appears well and does not report being in any pain. He does have some blurred vision in his left eye. It is not clear if that is from secretions from the left eye.
Otherwise, this patient has a fairly unremarkable past medical history with hypertension and is treated for that with a medicine he cannot recall and a diuretic. He is not allergic to any medicines. He is self-employed, lives in Etobicoke, and does not smoke. He does drink alcohol frequently. I should say that further on his physical exam, he has a markedly enlarged right level 2 lymph node without any palpable lymphadenopathy elsewhere, including in his contralateral left neck.
Regarding the appropriate upfront treatment for this gentleman, I would like to have his pathology reviewed at Mount Sinai, but assuming that this is indeed angiosarcoma, which it appears to be, I think that he should either undergo treatment with upfront chemotherapy or upfront radiotherapy. I am actually uncertain as to whether these are the best for him and will consult and discuss him in a multidisciplinary setting with my colleagues in Medical Oncology, as well as with my colleagues in Head and Neck Radiation Oncology here at Princess Margaret.
I explained to him that if he were treated with radiotherapy, risks would include obviously dermatitis, mucositis, xerostomia and hair loss. There would be concern for injury to his eyes, including cataracts, which is a relatively minor injury, and that it can be easily surgically repaired, but there is also risk for corneal scarring and damage to his retina. Chemotherapy carries a partially overlapping risk of toxicities, and he will discuss that with the Medical Oncology Team, if and when he meets with them. I gave him a followup appointment in 1 week’s time, at which point I will discuss with him our planned course of action and consented for treatment if appropriate. I renewed his prescription for PREDNISONE today and also gave him RANITIDINE.
Sincerely,
Dr. David B. Shultz, MD, PhD