PMC4609426_01
Clinical images. Photographs of the patient at the time of initial presentation (a), after 4 months of vismodegib therapy (b), and at first follow-up, 2 months after completion of trimodality therapy (c).
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Physical examination was significant for a 7 cm by 5 cm right cheek mass with extensive vascularization and central ulceration (see Figure 1(a)). The patient was maintained on vismodegib until the initiation of radiation therapy, resulting in approximately 4 months of drug therapy in total that resulted in an objective clinical response of greater than 50% reduction in the size of the lesion (see Figure 1(b)). At 2-month follow-up after his surgery, he was doing very well, was clinically without evidence of disease, and had excellent facial cosmesis and functional capacity (see Figure 1(c)).
Radiographic images. Radiographic findings of facial bone computed tomography (CT) scan at time of initial presentation (a) and following 4 months of vismodegib therapy (b).
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Noncontrast facial bone computed tomography (CT) scan revealed a mass-like subcutaneous lesion abutting the anterior aspect of the right maxilla, maxillary sinus, and inferior orbital rim and base of nasal bone, measuring about 5.5 cm in length by 5 cm in width by 4.5 cm in anterior to posterior dimension (see Figure 2(a)). Prior to starting radiation therapy, he underwent repeat facial bone CT scan which revealed that the lesion had decreased in size to 2.7 cm in largest dimension (see Figure 2(b)).
Radiation therapy treatment plan. Axial (a) and sagittal (b) views of the radiation therapy treatment plan with target volumes and representative dose distributions: gross tumor volume (GTV) in red, clinical target volume (CTV) in blue, planning target volume (PTV) in cyan, and 45 Gy (blue), 47.5 Gy (light green), and 50 Gy (yellow) isodose lines.
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He was treated with a 0.5 cm daily skin bolus using 3-dimensional conformal radiation therapy (3DCRT) with a 4-field technique involving right anterior oblique, left anterior oblique, anterior superior oblique, and anterior inferior oblique field arrangements.  Figure 3 shows representative views and dose distributions of the radiation therapy plan on his CT simulation scan.  Table 1 relates target volumes to dose coverage and also shows representative doses to nearby critical structures.