PMC5856983_01
Left knee at presentation.
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On physical examination, a 9-cm exophytic, malodorous, ulcerated, and necrotic lesion was observed in the anteromedial aspect of the left proximal tibia (Fig 1). Both legs were slightly frog-legged (ie, both thighs slightly abducted and externally rotated), and the left knee was raised slightly higher than the right, using a small styrofoam square under the Vac-Loc (Fig 1).
A representative axial image from the radiation treatment plan (gross tumor volume in red; clinical target volume in yellow; planning target volume in orange; 54.0 Gy in dark blue; 48.6 Gy in green; and Bolus in blue).
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As seen on Figure 2, the gross tumor volume consisted of the tumor as seen in the simulation and diagnostic images.
Left knee at the end of treatment.
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Not surprisingly, the patient developed very limited areas of dry desquamation (Fig 3), consistent with acute grade 1 skin toxicity, based on the Radiation Therapy Oncology Group acute toxicity criteria.
Left knee at 1-month follow-up.
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Left knee at 6-month follow-up.
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There was no visible or palpable tumor at the site of the treatment (Fig 5).
Left groin and left knee at 1-year follow-up.
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Unfortunately, 1 year after completion of therapy, the patient presented with a rapidly enlarging, nontender, left inguinal lymph node and ulceration at the site of the original tumor (Fig 6).