Superficial Radiation Therapy “Radiation Therapy Update” Mark Steven Nestor, M.D., Ph.D Director Center for Cosmetic Enhancement, Center for Clinical and Cosmetic Research, Aventura Florida Voluntary Associate Professor Department of Dermatology and Cutaneous Surgery Department of Surgery, Division of Plastic Surgery University of Miami Miller School of Medicine

Disclosures           

Introduction  

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Epidemic of Non Melanoma Skin Cancer in the US and around the world Recent study in South Florida showed some of the highest incidences of NMSC*  466.5 per 100,000 people per year in the “commercial” (age 0 to 65) population  10,689.8 per 100,000 people per year in the Medicare age population  High ratio of SCC to BCC Dermatologists need to optimize treatment options *Nestor, MS, Zarraga, MB: The Incidence of Non Melanoma Skin Cancer and Actinic Keratosis in South Florida. J Clin Aesthet Dermatol. 5(4):20–24, 2012.

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Galderma: Consultant, Research Grants, Advisory Board IFC: Research Grants LaLumiere, LLC: Research Grants, Consultant, Advisory Board LEO Pharma: Advisory Board, Research Grants Sensus: Consultant, Advisory Board Sinclair: Research Grants, Consultant, Advisory Board Smith & Nephew : Advisory Board Strathspey Crown: Shareholder Thermi: Consultant, Advisory Board, Speaker

Introduction II Traditional treatment options for NMSC include:  Excision  Moh’s Micrographic Surgery  Electrodessication and Curettage  Cryosurgery  Topical therapy (5 FU, Iimiquimod, PDT)  Superficial Radiation Therapy (SRT)*  Historically, SRT has been one of the primary treatments for NMSC by dermatologists until approximately 1970.

Introduction III History of SRT in Dermatology

History of SRT in Dermatology

“Radiation Therapy” was born in the 1890’s and in 1899 first treatment of Basal Cell Carcinoma in Sweden. Brocq, in Paris began investigating RT for Dermatology and was responsible for “Radiotherapy in Skin Disease” by Belot in 1904. Over the next 20 years Dermatologists in Germany and throughout Europe and the US began using RT to treat a variety of skin problems including skin malignancies In 1921, George Miller MacKee published “X Rays and Radium in the Treatment of Disease of the Skin” for treatment of skin tumors in addition to Pyoderma, tinea, hypertrichosis, psoriasis. LP, nevi etc.

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Introduction III 

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Next 30 years was the “golden age” of SRT in dermatology  Most Dermatologists had training in residency an used SRT in office  Everything from Eczema to Acne was treated and sequelae began to appear In 1974 a comprehensive survey by the AAD “Task Force on Ionizing Radiation of the National Program for Dermatology”:  55.5% of dermatology offices had superficial x-ray and/or Grenz-ray  44.3% of dermatologists used them regularly.  Residency training in RT was considered good or adequate by 59.6%, and 18.3% received no practical training.

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Introduction IV

Introduction V

History of SRT in Dermatology

SRT in Dermatology: Back to the Future

During 1970’s Dermatologist slowly stopped using SRT and residency training in SRT declined:  No new equipment  Old XRT equipment was breaking down  No reasonable sources of new technology  Teaching departments did not replace equipment  Decreased Residency Training  No new devices  Teachers retired  Increase in cutaneous and Moh’s surgery  Better surgical training  Better cure rates?  Improved reimbursement  Radiation Oncologists took over RT treatment

Need for SRT in Dermatology:  Dramatic increase in NMSC  Comorbidities, anticoagulation in aging population  Increased larger tumors in difficult areas such as tibial and scalp  Perceived overutilization and decreased reimbursement of Moh’s  Need to make sure that Dermatology has access to all modalities  SRT offers high cure rate low morbidity and scaring

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Essentials of Radiation Oncology

Introduction VI

Treatment Modalities for Skin Cancer I

SRT in Dermatology: Back to the Future  No

need for Radiation Oncologists or Radiation Physicist  New Technology and Treatment paradigms  New computerized treatment systems for accuracy and safety  Physician extenders: PA, NP  New fractionation methodology  New indications for Dermatology: Keloids*

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Electron Beam : External direct radiation (range 6-20 MeV).  Need higher energies for equal efficacy  Maximum deposition near surface but affects deeper tissue so more acute and latent affects  Expensive equipment  Commonly used by Radiation Oncologists  Lower cure rates and increased morbidity vs. SRT

Essentials of Radiation Oncology

Essentials of Radiation Oncology

Treatment Modalities for Skin Cancer I Brachytherapy: Radiation source (isotopes) applied directly on tumor.  HDR brachytherapy lasts few minutes.  LDR brachytherapy source stays in place up to 24 hours  Effective and low side effects  Treatment restrictions (Bunker)  Need Radiation Oncologist  Consumables $80,000 per year 

Treatment Modalities for Skin Cancer II 

Electric Brachytherapy: New Devices  Penetrates the top surface layer of the skin, avoiding deep tissue damage which minimizes scarring  Energy is deposited in a uniform distribution and lower total doses, thus decrease in latent reactions.  Utilizes a miniature, consumable, non-isotopic 50 kV source  Applicator up to 50 mm  Collaboration with Radiation Oncologists and Radiation Physics  Excellent short term cure rates, few if any long term studies  Controversy over codes, T code not paid in all states

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Essentials of Radiation Oncology Treatment Modalities for Skin Cancer IV 

Superficial Radiation Therapy*: Low energy radiation beam (X-ray)  Penetrates the top surface layer of the skin, avoiding deep tissue damage which minimizes scarring  Energy is deposited in a uniform distribution and lower total doses, thus decrease in latent reactions.  Non consumable source up to 100Kv  Applicator up to 180 mm lesions (Keloid)  Most often used by office based Dermatologists, no need for Radiation Oncologists or Radiation Physics  High long term cure rates for primary BCC and SCC  Codes approved in all states

Literature Review

Introduction  

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Consider: Indications, Long Term Cure Rates and Cosmesis Challenging to compare the studies  BCC vs. SCC  Various treatment protocols  Different energy levels  Different number of fractions Compare to other treatment methods  Different RT  Electron Beam (Used by RT)  Brachytherapy (Traditional and Electronic)

History 

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Hernández-Machin, B et al: Office-based radiation therapy for cutaneous carcinoma: Evaluation of 710 treatments. Int J Derm, 46; 453-459,2007.

In its infancy, recurrence rates were high and long term sequelae was unfavorable.

SRT for NMSC

Retrospective Review I A retrospective study of 604 BCC and 106 SCC irradiated between 1971–96. The 5-year cure rates were 94.4% for BCC and 92.7% for SCC The recurrence rates for BCC and SCC were 11.5 and 16.5 per 1000 patientyears, respectively Tumor location on the nasolabial fold and tumor size ≥ 10 mm were independent predictors of increased BCC recurrence. SRT is effective treatment for BCC and SCC and should be considered as a first option.

X-rays were discovered by Wilhem Conrad Roentegen in November 1895. Seven months after Roentegen’s discovery, Victor Despeignes used radiotherapy to treat a patient with gastric carcinoma. At the same time, Dr. Emil Grubbe claimed to have been the first to treat cancer patients with x-rays in 1896. Dr. Thor Stenbeck and Dr. Tage Sjogren of Sweden reported successes with treating skin cancers by 1899.

Hodges PC. The life and times of Émil H. Grubbé. Chicago: University of Chicago Press; 1964. p. xi, 135. Eisenberg RL. Radiology: an illustrated history. St. Louis: Mosby Year Book; 1992. p. 481–510.

SRT for NMSC 

Superficial x-ray therapy has been successfully used to treat skin cancers for over a century.

Retrospective Review II   

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A retrospective analysis on 1715 histologically confirmed primary cutaneous BCC and SCC treated with SRT between 2000 and 2010. 712 BCC (631 nodular and 81 superficial), 994 were SCC (861 SCC in situ and 133 invasive SCC), and 9 features of both BCC and SCC Cumulative recurrence rates of all tumors at 2 and 5 years were 1.9% (1%-2.7%) and 5.0% (3.2%6.7%), respectively;  BCC were 2% (0.8%-3.3%) and 4.2% (1.9%-6.4%),  SCC were 1.8% (0.8%-2.8%) and 5.8% (2.9%-8.7%),  Male patients and greater than 2 cm increased recurrence. Energy: Approximately 3500, Fractions 5 - 8 Conclusion: SRT viable nonsurgical option for BCC and SCC Cognetta, AB, Howard, BM, et al: Superficial x-ray in the treatment of basal and squamous cell carcinomas: A viable option in select patients. J Am Acad Dermat, 67:6, 1235-4, 2012.

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Basal Cell Carcinoma A

40 year review of the literature in 1989 4,695 patients with BCC  Various Energy and Fractions  Average five year cure rate: 91.3%  Follow up 2-5 years  Pooled

Rowe DE, Carroll RJ, Day Jr CL. Long-term recurrence rates in previously untreated (primary) basal cell carcinomas: implications for patient follow-up. J Dermatol Surg Oncol. 1992, 18(7):549-554.

Basal Cell Carcinoma 454 BCC’s (6% recurrent) primarily on the head and neck, few on the trunk and extremities  Cure Rates 95% 

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5 mm margins and 10 mm margins for large BCC’s. Energy and Fractions: 6 to 48 Gy given in 1 to 12 fractions

Recurrence rate - 5% (7 year follow up) Side effects: Mild atrophy, telangiectasias and pigmentary changes  Cosmesis: Good

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Ashby MA, Smith J, Ainslie J, McEwan L. Treatment of nonmelanoma skin cancer at a large Australian center. Cancer. 1998 May 1;63(9):1863-71.

Basal Cell Carcinoma  

Retrospective study of 233 BCC’s, some recurrent, primarily on the face and scalp, few on the trunk and extremities Cure Rates Cure rate in untreated lesions - 94% Cure rate in recurrent lesions - 90% Multiple fractions (Average of 10) 60 Gy depending on size of the lesion Median follow-up time was 5.8 years

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Side Effects Long term - Soft tissue necrosis 2%, cartilaginous necrosis in 1 lesion, bone necrosis in 2 lesions

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92% good or excellent cosmetic result Local tumor control, cosmesis, and complications are related to the size of the primary lesion. 

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Locke J, Karimpour S, Young G, Lockett MA, Perez CA. Radiotherapy for epithelial skin cancer. Int J Radiat Oncol Biol Phys. 2001 Nov 1;51(3):748-55.

Basal Cell Carcinoma  862

primary BCC’s located on the face and scalp 680 cGy (3,400 cGy total)  Fractions: 5 fractions  Cure Rate  5 year cure rate for BCC’s 10 mm - 90.5%  Energy:

Silverman MK, Kopf AW, Gladstein AH, Bart RS, Grin CM, Leventstin MJ. Recurrence rates of treated basal cell carcinomas. Part 4: x-RAY THERAPY. J Dermatol Surg Oncol. 1992; 18(7):549-54.

Basal and Squamous Cell Carcinoma

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1267 lesions (1019 BCC and 245 SCC and 3 mixed) Energy: 45 -60 Gy Fractions: 9 - 10 5-Year Cure Rates - 94.8 % BCC and 90.4% SCC

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Side Effects

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2.4% of all tumors recurred at the margin of the irradiated field Hypopigmentation -72.7% Telangiectasias - 51.5% Erythema - 44.5% Hyperpigmentation - 23.4%

Schulte K.W., Lippold A., Auras C.,et al: Soft x-ray therapy for cutaneous basal cell and squamous cell carcinomas. J Am Acad Dermatol 2005; 53: 993-1001

Squamous Cell Carcinoma  Meta-analysis of 14 retrospective studies  Pooled 1018 primary SCCs  Various energies and fractions  Average local cure rate - 93.6%  Average local recurrence - 6.4%  

Age, tumor size correlated with risk of recurrence Follow up 2-5 years

Lansbury L, Bath-Hextall F, Perkins W, Stanton W, Leonardi-Bee J. Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies. BMJ. 2013 Nov 4;347:f6153.

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Cosmesis    

Difficult to assess and quantify Patients treated with radiotherapy had good to very good cosmetic results Optimal cosmetic results occur when the overall dosage is divided among a higher number of fractions Particularly favorable cosmesis on the nasal alar rim and perioral and periorbital areas 

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Cosmesis   

No retraction of the lip or ectropion of the eyelid

Most common cosmetically unfavorable side effects  

Hypopigmentation Increase in telangiectasias within long-standing treatment areas

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Cooper JS. Patients' perceptions of their cosmetic appearance more than ten years after radiotherapy for basal cell carcinoma. Radiat Med. 1988 Nov-Dec;6(6):285-8.

Cognetta AB, Howard BM, Heaton HP, Stoddard ER, Hong HG, Green WH. Superficial x-ray in the treatment of basal and squamous cell carcinomas: A viable option in select patients. J Am Acad Dermatol. 2012 Dec;67(6):123541

Superficial Radiation Therapy (SXRT) Versus Electron Beam Therapy (EBT)

Cosmesis       

They assessed the cosmetic and oncologic results in 26 patients after an average of 9.3 years follow up. Majority treated with 3 doses of radiation from a superficial 50 kVp unit. Cure rate - 96% Recurrence rate – 4% 81% of patient’s evaluated excellent or good cosmetic result 77% of rating physicians evaluated excellent or good cosmetic result The cosmetic result appears to remain stable over time  86% of patients at 13 years post treatment still rated an excellent or good cosmetic result. Childer BJ, Goldwyn RM, Ramos D, Chaffey J, Harris JR. Long-Term Results of Irradiation for Basal Cell Carcinoma of the Skin of the Nose. Plast Reconstr Surg. 1994 May;93(6):1169-73

Superficial Radiation Therapy Versus Electron Beam Therapy EBT can be used to treat broader areas EBT may be superior in delivering a homogenous dose in complex topographic treatment sites  EBT has established role in adjunctive therapy in tumors with perineural invasion, in the treatment of CTCL, merkel cell carcinoma, DFSP, and select melanomas of the head and neck  

Cognetta AB, Howard BM, Heaton HP, Stoddard ER, Hong HG, Green WH. Superficial x-ray in the treatment of basal and squamous cell carcinomas: a viable option in select patients. Journal of the American Academy of Dermatology. 2012 Dec;67(6):1235-41.

10 year evaluation after superficial XRT for BCC Of 47 elderly patients, 12 are alive with no recurrence Self rated on a scale consisting of: excellent, very good, good, mediocre, and poor.  6 of the 12 rated their cosmetic appearance as excellent  3 of 12 considered it very good  3 of 12 rated their cosmetic appearance as good Overall, patients appear to be pleased with the results

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SXRT energy source is light (rather than a charged particle)

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SXRT machines are smaller and less expensive and linear accelerator is not required

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The beam and delivered dose with SXRT have far less lateral edge beam drop-off in the umbra of the treatment site (may contribute to inferior cure rates of EBT)

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SXRT more cost-effective in terms of equipment and patient costs Cognetta AB, Howard BM, Heaton HP, Stoddard ER, Hong HG, Green WH. Superficial x-ray in the treatment of basal and squamous cell carcinomas: a viable option in select patients. Journal of the American Academy of Dermatology. 2012 Dec;67(6):1235-41.

Cure Rates According to External Beam Technique Size of the Carcinoma

Superficial XRT BCC Cure Rate

Electron Beam Therapy BCC Cure Rate

Superficial XRT SCC Cure Rate

Electron Beam Therapy SCC Cure Rate

< 1 cm

97% (69/71)

92% (11/12)

100% (12/12)

75% (3/4)

1 – 1.5 cm

93% (84/90)

73% (16/22)

91% (10/11)

70% (7/10)

> 5 cm

100% (4/4)

80% (4/5)

100% (1/1)

75% (3/4)

Mendenhall WM, Amdur RJ, Hinerman RW, Cognetta AB, Mendenhall NP. Radiotherapy for cutaneous squamous and basal cell carcinomas of the head and neck. Laryngoscope 2009;119:1994-9.

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Superficial Radiation Therapy Versus Electron Beam Therapy

Cure Rate Comparisons  Table below represents BCC local tumor control bymodality and size Modality 5 cm Not Specified Superficial 97% 93% 100% Electron Beam 92% 73% 80% Combination 100% 81% 83% Photons 100% 60% N/A  

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 Table below represents SCC local tumor control by modality and size Modality < 1cm 1.1 -5cm > 5cm Not Specified Superficial 100% 91% 100% Electron Beam 75% 70% 75% Combination 80% 73% 50% Photons 100% 75% 33% 

Lovett RD, Perez CA, Shapiro SJ, Garcia DM. External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 1990;19:235-42.

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Cosmesis  Superficial XRT  Favorable cosmesis, especially on the nose and perioral and periorbital areas  Most common long term side effects - hypopigmentation and telangiectasias  Electron Beam Therapy  Less favorable cosmesis  Most common long term side effects - alopecia and hyperpigmentation Cognetta AB, Howard BM, Heaton HP, Stoddard ER, Hong HG, Green WH. Superficial x-ray in the treatment of basal and squamous cell carcinomas: A viable option in select patients. J Am Acad Dermatol. 2012 Dec;67(6):1235-41 Ling SM, Roach M 3rd, Fu KK, Coleman C, Chan A, Singer M. Local control after the use of adjuvant electron beam intraoperative radiotherapy in patients with high-risk head and neck cancer: the UCSF experience. Cancer J Sci Am. 1996 Nov-Dec:2(6):321-9

Superficial X-Ray Therapy versus Electron Beam Therapy   

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Electron beam therapy may mutagenically alter cells in areas receiving less than a tumouricidal dose in the center of the field. EBT is also know as skin sparing which is beneficial in treating internal malignancies. To treat cutaneous malignancies, radiation oncologists apply a tissueequivalent material called a bolus to the skin to shift the efficacious portion of the beam higher towards the skin surface. If the skin-sparing nature is not compensated for in an appropriate way, more reoccurrences can be expected. Wolfe CM, Green WH, Hatfield HK, Shaker TJ, Baniahmad O, Cognetta AB. Multiple secondary cutaneous tumours following electron beam radiotherapy for cutaneous malignancies. Australas J Dermatol. 2012 Aug;53(3):233-8.

HDR Brachytherapy Placement of radioactive sources directly onto or into target tissues  Low Cure Rates seen with NMSC exceeding 2 mm in depth and greater than 2 cm in diameter.  Recurrence rates between 0% and 10% in ideal candidates  It requires expensive hardware such as various applicators and sophisticated HDR afterloading equipment.  It involves potential risks of radiation exposure to medical personnel.

Superficial X-Ray Therapy versus Electron Beam Therapy 

7 patients developed multiple secondary tumours arising within and immediately around the electron beam treatment sites.

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Electron beam therapy was the primary therapy for cutaneous malignancies or as adjunctive therapy for aggressive cutaneous malignancies.

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Squamous cell carcinoma was the predominant primary and secondary malignancy to develop. Wolfe CM, Green WH, Hatfield HK, Shaker TJ, Baniahmad O, Cognetta AB. Multiple secondary cutaneous tumours following electron beam radiotherapy for cutaneous malignancies. Australas J Dermatol. 2012 Aug;53(3):233-8.

Study

Site Studied

Lesion Type

Modality

Treatment Time

Dosage (cGy)/fractions

Follow-up (mo)

Recurrence Rate

Avril et al

Face

BCC (347)

LDH interstitial

165 h

5700-9600/1

48

8/95

Berridge and Morgan

Face

BCC (30/30)

LDR surface mold

168 h

6000-6500/1

120 (minimum)

Unknown

Conill et al

Eyelid

SCC (4/24) BCC (19/24)

LDR interstitial

54-55 h (total)

4000

43 (mean)

2/24

Conill et al

Lip

SCC (52/54) BCC (2/54) Other (10/370)

LDR interstitial

86 h

6000-6500/1

96 (mean)

2/54

Debois

Nose

Epiderm (60/370) BCC (300/370) Other (10/370)

HDR surface mold

48 h (total)

2400

>36

11/368

Guix et al

Face

SCC (34/136) BCC (102/136)

HDR surface mold (117/136) HDR Brock ap (19/136)

3-8 min/session

6000-6500/33-36 (4 cm)

60

3/136

0/5

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Alam M, Nanda S, Mittal BB, Kim NA, Yoo S. The use of brachytherapy in the treatment of nonmelanoma skin cancer: A review. J Am Acad Dermatol. 2011 Aug;65(2):377-88. *(Slide following)

Lee et al

Various

SCC (3/5) BCC (1/5) Bowen (1/5)

HDR surface patch

30 min- 1 h (total)

5000

8-20

Ozyar and Gurdalli

Scalp

BCC (1)

HDR surface mold

Not stated

4050/multiple

72

0

Rio et al

Face

SCC (88/97) BCC (9/97)

LDR interstitial

74-79 h

5000-6500

55 (median)

10/97

Rudoltz et al

Forearm, back of hand

SCC (1)

HDR surface mold

30 min/session

6000/30

7

Sedda et al

Various

SCC (37/53) BCC (16/53)

HDR surface resin

15 min-2 h/session

4000-6000/1-3

51 (mean)

0/53

Semrau et al

Scalp

SCC (1/1)

HDR surface mold

Not stated

6600/>33

24

0

0

Shields et al

Eyelid

BCC (2/8) Aden cystic (4/8) Conj mel (1/8) Met carc (1/8)

LDR plaque

96 h

5000/1

24 (BCC only)

0/2

Somanchi et al

Back of hand, fingers

SCC (25/25)

HDR surface mold

Not stated

4000-4500/8

60 (mean)

1/25

Svoboda et al

Various

Other (19/106) SCC (11/106) BCC (76/106)

HDR surface mold

Up to 5 min/session

1200-5000/1-15

9.6 (mean)

4/106

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Electronic Brachytherapy

Electronic Brachytherapy  122

patients with 171 NMSC lesions  40 Gy in eight fractions, delivered twice weekly  Followed up to 1 year  Cure rates 100%  Cosmesis good Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy. 2013 Mar-Apr;12(2):134-40

Electronic Brachytherapy  1,822

treated lesions from 2009 to 2014 in patients ranging in age from 52 to 104 years.  BCC (57%) or SCC (38%) less than 2cm in size (97%)  40 to 45Gy using mostly 8 fractions  Less than 1% recurrence but median follow-up only 4 to 16 months  Good cosmesis Bhatnagar A, et al:. High-dose Rate Electronic Brachytherapy: A Nonsurgical Treatment Alternative for Nonmelanoma Skin Cancer, J Clin Aesthet Dermatol. 2016;9(11):16–22

Keloid Recurrence Rates

Weighted Average Recurrence = 71.2 %

 Two

prospective, single-center, non-randomized, pilot studies.  20 patients were treated in each study: (1) 36.6 Gy in 6 fractions of 6.1 Gy, (2) 42 Gy in 6 fractions of 7 Gy.  At 1 year 90% response in group 1 and 95% in group 2  Good cosmesis Ballester-Sánchez R, et al:. Electronic brachytherapy for superficial and nodular basal cell carcinoma: a report of two prospective pilot trials using different doses J Contemp Brachytherapy. 2016 Feb; 8(1): 48–55

SRT for Recurrent Keloid Scars  Hypertrophic

and Keloid scars are common especially in certain ethnic populations  Symptomatic causing significant itching and pain  Treatments consist of topical preparations and injectables such as TAC and 5 FU but are not very successful  Surgical excision is effective but has a very high recurrence rate  Post operative treatment with SRT can significantly reduce recurrences

DNA / RNA Damage due to Ionizing Radiation

 Inability for cells to proliferate  Inability for cells to survive  Induction of mutations  apoptosis or malignancy

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Post-excision Radiation Of Auricular Keloids

Post-Excision Radiation & Keloids In a retrospective study of 80 keloidectomy patients treated with postoperative single-fraction 10Gy radiotherapy  

9% of keloids relapsed after 1 year 16% of keloids relapsed after 5 years

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Retrospective study of suturing lines of 60 keloidectomy patients (76 ear keloids) Treated 1-3 days post-operatively with 5 Gy/wk, 2545 Gy total dose, contact or superficial radiotherapy Mean follow-up 47.85 months 5 year relapse-free rate of 79.84% No pigmentation or telangiectasias Recalcati S et al. J Dermatol Treatment 2011; 22: 38-42

Ragoowansi R, Cornes PG, Moss AL, Glees JP. Plast Reconstruct Surg 2003; 111: 1853–9.

Superficial Radiation Therapy for the Prevention of Keloids After Surgery 

Relapse-Free Rate Following Post-Operative Radiotherapy (n=76)

A BED value of 30 Gy can be obtained with a single acute dose of 13 Gy two fractions of 8 Gy  three fractions of 6 Gy  a single dose of 27 Gy at low dose rate  

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BL

3 Years

Superficial Radiation Therapy (SRT) Post-Keloidectomy

a

c

Left Earlobe Keloid. Pre-excision

SRT 6 Gy on POD 1, 2, 3

b

d

The radiation treatment should be administered within 2 days after surgery Kal HB, Veen RE. Keloid Dose and Fractionation Schemes

SRT Ports for Large Keloid Excision Site Treatment

Post-excision

Suture removal at POD 7

12.7 cm diameter at 25 cm SSD

18 cm x 8 cm at 30 cm SSD

8

Superficial Radiation Therapy (SRT) Post-keloidectomy

Superficial Radiation Therapy for the Prevention of Keloids After Shave Excision Small study  5 month follow up  3 treatments after secondary intention healing 69 days after excision  No recurrence 

a

Chest keloid Pre-excision

b

1 month post-excision and SRT 6 Gy on POD 1, 2, 3

Keeling BH, et al . Keloid Removal with Shave Excision Followed by External Beam Radiation Derm Surgery 2015 Aug Vol 41 Num 8 989-992

Keloid Excision + Radiation: Fibrosarcoma 3.5 Years Later   

In 1963 a 23 yo woman received 22 Gy low energy (80 kV-rays) radiation after excision of keloids on her thigh 3 ½ years later a fibrosarcoma was found in that area Although keloidal tissue may have possibly underwent malignant transformation, the author noted that 3 ½ years may be too short for this to occur

Keloidectomy And E-beam Radiotherapy  Treated

91 keloids with by a combination of surgical excision and postoperative electron beam radiation 20 Gy: 5 Fractions (Ear: 16 Gy: 4 Fractions)

 44%

keloid recurrence rate (include symptoms)

Yamawaki S, Naitoh M, Ishiko T, Muneuchi G, Suzuki S. Ann Plast Surg. 2011;67(4):402-6

Biemans, RG. Arch Chir Neerl 1963; 15:175-185

Our Protocol

Radiation And Keloid Recurrence 

Treatment of earlobe keloids using the cobalt 60 teletherapy unit . Malaker K, Zaidi M, Franka MR. Ann Plast Surg2003; 52: 602–4. Forty-seven patients were treated with postoperative telecobalt external beam radiation and 87.2% had no recurrence at the 6-month follow-up visit.

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Keloids can be forced into remission with surgical excision and radiation, followed by adjuvant therapy. Yamawaki S, Naitoh M, Ishiko T, Muneuchi G, Suzuki S. Ann Plast Surg. 2011 Oct;67(4):402-6. The authors treated 91 keloids in total, with 51 keloids (56.0%) resolved completely by a combination of surgical excision and postoperative irradiation.

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Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy. Ragoowansi R, Cornes PG, Moss AL, Glees JP. Plast Reconstruct Surg 2003; 111: 1853–9. In a retrospective study of 80 patients treated with postoperative singlefraction radiotherapy, 9% of keloids relapsed after 1 year and 16% relapsed after 5 years.



The treatment of 783 keloid scars by iridium 192 interstitial irradiation after surgical excision . Escarmant P, Zimmermann S, Amar A, Ratoanina JL, Moris A, Azaloux H, et al. Int J Radiat Oncol Biol Phys 1993; 26: 245–51. There was a recurrence rate of 21% after at least 1 year follow-up in 783 treated keloids.



Biologically effective doses of postoperative radiotherapy in the prevention of keloids. Dose–effect relationship . Kal HB, Veen RE. Strahlenther Onkol 2005; 181: 717–23. In this review, a radiotherapy regimen resulting in a biologically effective dose of at least 30 Gy is recommended to be administered, starting within 2 days after surgery, to minimize keloid recurrence rates to less than 10%.

 Consult

with patient and review treatment options  If recurrent keloid by history recoment excision followed by SRT  Obtain referral for all procedures  Excise on day 0 and use SRT on POD 1, 2, 3 each 6 Gy  PO care use silicone gel

9

SRT for NMSC Clinical Paradigms 

SRT: Clinical Experience 



Patient Selection  Age  Medical Status  Co morbidities  Anticoagulation  Patient preference Tumor Selection  Type  Recurrence  Size  Location Other mitigating factors

SRT for NMSC

SRT for NMSC

Clinical Paradigms II

Our Clinical Experience I

Treatment algorithms  Energy  Margins  Fractionation  Schedule  Patient safety  Shielding  Comfort  Quality and regulatory compliance 

 Installed

June 2012  Room Preparation, installation and inspection  Training for myself and staff  I evaluate, PA’s treat  Approximately 500 NMSC to date with optimal fractionation protocols (approximately 10% of NMSC treated)  2 recurrences to date  Good to excellent cosmesis

SRT for NMSC Our Clinical Experience II

 Patient

comfort and safety paramount  Primary indications BCC and SCC Scalp, lower legs, nose Elderly with co morbidities  Average 15 fractions, 3 times a week

SRT: Clinical Examples

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Patient BW

Simulation and Treatment custom lead shield of 0.762mm thickness is used to form a molded, custom shield with a port to correlate with lesion size, including treatment margin  Additional shielding is used to protect sensitive, normal tissues (intranasal, intraoral, ear canal)  Total dose of radiation calculated based on applicator size and total fractionation dose and divided into an average of 15 fractionations either 3 or 5 times a week

Squamous Cell Carcinoma Left Nasal Ala

A

Energ y (kV)

Fractionations Per Week

Time Dose Fractionation (TDF)

Daily Fractionation Dose (cGy)

Number of Fractionations

Treatment Time Per Fractionation (min)

Total dose (cGy)

50

5

100

333.0

14

0.46

4662

Lesion Size (cm)

Treatment Margin (cm)

Field Size (cm)

Custom Shielding Size (cm)

0.6 x 0.8

0.5

2.0

1.8 x 1.6

Patient MS

Patient BW

Squamous Cell Carcinoma Mid Nose Tip

Squamous Cell Carcinoma Left Nasal Ala

Biopsy 8/20/12

Post Radiation #15 11/19/12

Energy (kV)

Fractionations Per Week

Time Dose Fractionation (TDF)

Daily Fractionation Dose (cGy)

Number of Fractionations

Treatment Time Per Fractionation (min)

Total dose (cGy)

50

5

100

318.6

15

0.44

4779

Post Radiation 1/8/13

Treatment Margin (cm)

Field Size (cm)

Custom Shielding Size (cm)

1.1 x 0.9

0.5

2.0

1.5 x 2.0

Patient MS

Patient DS

Squamous Cell Carcinoma Mid Nose Tip

Squamous Cell Carcinoma Right Nose Tip Ener gy (kV)

50

Biopsy 7/31/12

Lesion Size (cm)

Post Radiation #13 12/14/12

Post Radiation 2/6/13

Total dose Treatment Number of Daily Fractionati Time Dose (cGy) Time Per Fractionat Fractionation Fractionati ons Per Fractionation ons Dose ion Week (min) (cGy) (TDF) 5

99

318.6

15

0.44

4779

Lesion Size (cm)

Treatment Margin (cm)

Field Size (cm)

Custom Shielding Size (cm)

0.8 x 0.7

0.4

2.0

1.6 x 1.5

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Biopsy 12/18/12

Patient DS

Patient SR2

Squamous Cell Carcinoma Right Nose Tip

Squamous Cell Carcinoma Right Anterior Scalp Lateral

Post Radiation #13 1/23/13

Energy (kV)

Fractionations Per Week

Time Dose Fractionation (TDF)

Daily Fractionation Dose (cGy)

Number of Fractionations

Treatment Time Per Fractionation (min)

Total dose (cGy)

50

5

99

315.8

15

0.42

4737

Lesion Size (cm)

Treatment Margin (cm)

Field Size (cm)

Custom Shielding Size (cm)

2.2 x 1.8

1.0

5.0

4.2 x 3.9

Post Radiation 2/22/13

Patient SR2

Patient MAP

Squamous Cell Carcinoma Right Anterior Scalp Lateral

Squamous Cell Carcinoma Left Anterior Tibial Lateral Rx

Energ y (kV)

Fractionatio ns Per Week

Time Dose Fractionati on (TDF)

Daily Fractionation Dose (cGy)

Number of Fractionatio ns

Treatment Time Per Fractionation (min)

Total dose (cGy)

#1 #2

50 50

3 3

99 99

327.8 338.4

15 8

0.44 0.45

2294.6 2707.2

Rx

Biopsy 8/27/12

Post Radiation #14 9/27/12

Post Radiation 1/10/13

Lesion Size (cm)

Treatment Margin (cm)

Field Size (cm)

Custom Shielding Size (cm)

#1

1.8 x 1.6

1.0

4.0

3.2 x 3.2

#2

1.8 x 1.6

1.0

5.0

3.2 x 3.2

Note: The patient had two radiation prescriptions due to the fact that after the seventh treatment a 5cm applicator was used and new values needed to be calculated for total fractionation dose.

Patient MAP

Conclusions

Squamous Cell Carcinoma Left Anterior Tibial Lateral

   



Simulation 7/20/12

Post Radiation #14 8/24/12

Post Radiation 3/27/13



Historically, RT has been one of the primary treatments for NMSC by dermatologists but use has decreased over time and have been delegated to Radiation Oncologists Changing demographics, decreasing surgical reimbursements, increasing NMSC and new innovations in equipment and techniques bring SRT back to Dermatology Significant literature on benefits of SRT and more recent literature on eBT New fractionation methods improve therapeutic index with high cure rates and low acute and latent side effects especially in difficult treatment areas such as scalp and lower extremities without scaring Dramatic reduction in Keloid recurrences Computerized technology and the ability to use physician extenders allows for efficiency in an office base practice

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