**9.1 Remodeling of a skin tumor**

We present here the clinical evolution of a basal cell carcinoma (basalioma) located on the face of a 100-year-old patient (**Figure 8**).

#### **Figure 8.**

*The evolution of the remodeling of a basal cell carcinoma at the level of the right temple. Tumor before and during the application of local electron radiotherapy (flap applied to the irradiated area). After applying the first seven fractions of 2 Gy, the next 6 days were applied two daily fractions of 3 Gy (6 hours apart). The last 10 fractions of 2 Gy were applied until the total dose of 70 Gy was reached.*

*The Remodeling in Cancer Radiotherapy DOI: http://dx.doi.org/10.5772/intechopen.102732*

This case demonstrates the ability of "remodeling" at the level of this skin tumor and of the healthy peritumoral tissue, when the primary tumor is irradiated with a high total dose and fractionation that allows tumor control and does not produce side effects on these structures at high risk of the applied dose. In this case, the healing action was initiated and completed by the activity of macrophages and the stimulation of fibroblasts present at this level with a role in limiting side effects.

The action of fibroblasts contributed to the remodeling process with a favorable final result, in which not the slightest signs of scarring can be seen. Thus, it was possible to "remodel" at this level all the structures initially involved and disturbed through the tumor process. The skin, including the basal membrane, was completely restored, without the formation of a scar, acute skin side effects have been reduced.

#### **9.2 Remodeling of an orbital tumor**

The treatment of patients with advanced local orbital and facial cancer has been a much-debated topic in recent decades. At the end of the last decade, the complex treatment has included radical surgeries such as enucleation, reconstructive plastic surgery, chemotherapy, and radiation therapy. All these interventions were accompanied by accentuated side effects. New concepts could be developed due to advances in the diagnostic methods, tumor characterization, and the progress in the application of treatment (conservative surgery or high-dose radiotherapy) for cancer located in the orbit and the soft parts of the face.

We are going to present here the clinical evolution of an orbital advanced cancer and infiltration of the facial skin, in a 90-year-old patient, who presented in our department. This patient was treated with IMRT radiotherapy (intensity-modulated radiotherapy) with TOMOTHERAPY at the POLISANO Radiotherapy Center, Sibiu. Histopathological and immunohistochemical examination classified the lymphoma as a B-cells non-Hodgkin's lymphoma (NHL). The patient had two locations, one on the right orbita and the other suborbital and paranasal on the left side. Both locations were irradiated at the same time. A complete clinical remission was obtained for both locations.

The frequency of orbital tumors is low, representing only 0.1% in general and only 20% of all orbital diseases. The most common type of orbital tumor is non-Hodgkin's lymphoma. It generally manifests at the level of the ocular appendages, in 45–75% of cases being the extranodal lymphoma of the marginal area. Follicular lymphoma occurs in 15–30% of cases and diffuse B-cell lymphoma occurs in only 10% of cases. From a topographic point of view in 30–80% of cases, the conjunctiva is affected, in 10–50% the retrobulbar tissue, and in 10–55% the lacrimal gland. Radiotherapy is the method of choice in the treatment of orbital lymphomas. Multiple studies have reported satisfactory results by applying total doses between 24 and 46 Gy in standard fractionation with 1.8–2.0 Gy per fraction. The average total dose applied is 32 Gy.

The anatomy of the orbit and the extreme radio sensitivity of the various components of the orbit are a challenge for radiotherapy and radiotherapist. The orbital tumors occupy the space between the eyeball and the bony wall of the orbit. These include tumors of the eye that invade the orbit as well as ancillary structures such as sinuses, orbital bones, and the central nervous system.

#### *9.2.1 Radiotherapy of an orbital tumor*

The case of the 90-year-old patient demonstrates the capacity of "remodeling" that exists in healthy peritumoral tissues when the primary tumor is irradiated with a high total dose and fractionation that allows tumor control and does not produce side effects in organs and structures at high risk at the applied dose. In this case, the healing action was initiated and completed by the activity of macrophages and the stimulation of fibroblasts present at this level with a role in limiting side effects. The action of

fibroblasts contributed to the remodeling process with a favorable final result, in which not the slightest signs of scarring are seen. So, it was possible to "remodel" at this level all the structures initially involved in the tumor process: the patient's eyeball with the soft parts of the orbit and the facial skin. The skin is completely restored without the formation of a scar. Acute skin side effects have been reduced.

In the healing process, the role of macrophages is to remove damaged tumor cells by double-stranded damage to tumor DNA. In this case, the process of fibrosis at the level of the tumor bed was not noticed. The target volume had two components, namely the macroscopic tumor evaluated by imaging using a CT examination with and without a contrast agent and an MRI examination, also with and without a contrast agent. The irradiation plan was performed and subsequently applied at a TOMOTHERAPY machine (Polisano Center in Sibiu) developed under the instructions of Dr. Adrian Moga.

There is a wide spectrum of radiation tolerance between the various components of the orbital region. While the lens and the lacrimal gland are the most sensitive and their functionality is profoundly affected by doses above 10 Gy in standard fractionation, other structures such as the optic nerve tolerate doses up to 40–46 Gy.

The initiation of the radiological treatment was performed by performing a CT examination with the necessary means of contention. The irradiation plan with

#### **Figure 9.**

*Delineation of the macroscopic tumor masses by GTV (gross tumor volume) corresponding to the two tumor manifestations (right orbit and left suborbital and paranasal lesion). Irradiation plan with isodose distribution and volume dose histogram (DVH). The macroscopic tumor (GTV) obtains the maximum dose over the entire volume while the OR (organs at high risk of irradiation) such as the right and left eyeballs are underdosed, thus being protected to the maximum.*

### *The Remodeling in Cancer Radiotherapy DOI: http://dx.doi.org/10.5772/intechopen.102732*

the information on the applied doses and at the level of the so-called radiosensitive structures DVH (dose-volume histogram) are reproduced in **Figure 9**.

The response to radiotherapy of the 90-year-old patient with an orbital tumor, non-Hodgkin's lymphoma, manifested in the soft parts of the face and the right orbit, with the initial clinical situation until the complete response after radiotherapy is shown in **Figure 10**.

**Figure 10.**

*Left: Anatomical details at the level of the orbit and of the cheek. Right: Orbital tumor and invasion of the skin of the face (peritumoral infiltrative process and huge area of necrosis) before starting the radiation and after completion of radiation therapy with "Remodeling" ad integrum (preserved own eyeball).*
