Outcomes after radiotherapy for squamous cell carcinoma of the eyelid

Post-operative interventional radiotherapy (brachytherapy) in advanced ocular surface and eyelid tumors as an alternative to surgical retreatment

PURPOSE

The main purpose of treatment of advanced ocular surface and periocular malignant tumors is to eradicate the tumor while trying to preserve visual function and aesthetics. Our purpose is to describe the outcome of a retrospective case series of 10 patients with advanced ocular surface and periocular tumors treated surgically in first instance and then with postoperative interventional radiotherapy (IRT/Brachiterapy).

MATERIALS AND METHODS

We describe the clinicopathological features, treatments and outcome, in a retrospective case series of 10 patients with advanced tumors involving ocular surface (staging ≥ T2) and eyelids (staging ≥ T3), with involvement of periocular and/or orbit tissues. Patients were first surgically treated, most of them with incomplete excision, and then underwent a post-operative interventional radiotherapy (IRT/Brachytherapy) as an alternative to more invasive and disfiguring surgical retreatment. Tumor location, risk factors, staging, histological features, and follow-up timing were analyzed.

RESULTS

Three patients had advanced eyelid basal cell carcinomas, 2 patients were diagnosed with eyelid and conjunctival squamous cell carcinomas, 3 as sebaceous carcinomas, and 2 as primary conjunctival melanomas. The mean follow-up time from IRT to last clinical follow-up was 58.6 weeks, range 28.4-168 (median 43.65, IQR 28.9-72.9). Two patients - one with ocular surface SCC, the other with conjunctival melanoma - had a local recurrence 23.4 and 40,9 weeks after IRT, respectively. An overview of the current knowledge on adjuvant or post-operative IRT is also provided.

CONCLUSIONS

IRT can be considered an effective therapeutic option to avoid more invasive surgical retreatment in advanced tumors involving eyelids and ocular surface.

Implementing high-dose rate surface mould brachytherapy for carcinoma of eyelid: a practical approach and weekly review

Surface mould brachytherapy is a conformal radiotherapy technique that can deliver high dose to the target while sparing nearby normal structures, Here, we aim to describe the procedurals details for high-dose rate (HDR) surface mould brachytherapy in sebaceous carcinoma of eyelid in a 54-year old lady. She was hesitant for surgery and any form of invasive intervention like interstitial brachytherapy. So, she was treated with surface mould HDR brachytherapy to a total dose of 52 Gy in 13 fractions at a dose of 4 Gy per fraction delivered twice daily using Iridium-192 isotope with no acute side effects. She was evaluated on a weekly basis for any radiation side effects and now she is disease-free for 6 months post-treatment with only mild dry eye. A detailed step-by-step procedure of surface mould technique, simulation procedure, dose prescription, planning, plan evaluation and treatment has been described in this paper. Surface mould HDR brachytherapy can be safely used as organ preserving modality of treatment for eyelid carcinoma.

Novel MSH6 mutation predicted metastasis in eyelid and periocular squamous cell carcinoma

BACKGROUND

Our previous research revealed the relative local aggressiveness of eyelid and periocular squamous cell carcinoma (EPSCC), but its distinct genetic characteristics involved remain unknown.

OBJECTIVES

We conducted this study based on next-generation sequencing to identify the genetic distinctiveness of EPSCC and damaging mutations for possible etiology and poor prognosis.

METHODS

We performed sequencing using a 556-gene panel (smartonco) in 48 EPSCCs. Cox hazards model was applied to explore mutated genes that increase risk of metastasis and death. Pathogenesis of the mutations was predicted by sequence alignment algorithms.

RESULTS

The most commonly mutated genes were KMT2C (N=17, 35%), LRP1B (N=14, 29%), KMT2D (N=12, 25%), PTCH1(N=10, 21%) and TP53(N=10, 21%). DNA mismatch repair (MMR) genes (42%) like MSH6(19%) and MLH3(12%) were among the most frequently mutated genes. Cell cycle regulators including TP53(21%) and CDKN2A (10%) were less frequently mutated than in other squamous cell carcinomas (SCCs). Ultra violet exposure, MMR deficiency and aging were the main etiology. Of note, KMT2C has a deleterious mutation hotspot. Patients burdened with MSH6 mutation has a higher risk of overall metastasis (P=0.045, HR=5.165) and nodal metastasis (P=0.022, HR=14.038). Moreover, a hotspot mutation MSH6^E52A brought an even higher risk of nodal metastasis (P=0.011, HR=18.745).

CONCLUSIONS

EPSCCs displayed a unique mutation profile from cutaneous SCCs and mucosal SCCs. We have identified novel damaging mutations in epigenetic regulators like KMT2C boosted early onset of EPSCCs in addition to UVR, aging or MMR deficiency. And malfunction of MMR genes worsened prognosis.

Squamous cell carcinoma of the conjunctiva. Case report

Introduction

The prevalence of squamous cell carcinoma of the eyeball is low, and this is a rare condition. There are multiple therapeutic strategies for the treatment and depend on the degree of local involvement and extension of the tumor which, in turn, will have an impact on the patient's prognosis.

Presentation of case

We present a case of a patient with a mass of progressive growth on the left eyeball whit vision damage. The biopsy showed a squamous cell carcinoma of the conjunctiva, and imaging studies showed orbital invasion cT4bN0cM0, so surgery was indicated. The surgery was done with macroscopic margins of 5 mm. After resection, a radial free flap reconstruction was performed. Adjuvant treatment with radiotherapy was performed without complications. After six months, the patient manifested an improvement in his quality of life, and there is no evidence of relapse.

Discussion

The prevalence of squamous cell carcinoma of the conjunctiva is low. The most important risk factor is exposure to UV rays. Most are derived from conjunctival intraepithelial neoplasms. There are topical management protocols with chemotherapeutic agents and in patients with ocular or orbital invasion, enucleation and exanteration are the treatments of choice.

Conclusion

The squamous cell carcinoma of the conjunctive is rare. The management in the locally advanced tumors is surgical. The use of a radial free flap reconstruction is one of the reconstructive strategies to take into account, and the knowledge of additional strategies required to control the disease is important to ensure an optimal treatment.

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Squamous cell carcinoma is the most frequent tumor of the eyeball.

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The most important risk factor is the exposure to UV rays (damage in repairing DNA).

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There are topical management protocols with multiple chemotherapeutic agents.

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In patients with ocular or orbital invasion, the surgery is the GOLD standard of care.

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Adjuvant therapies are useful tools in the oncological management of these patients.

Challenging eyelid reconstruction in malignancies: Case reports

Eye is one of the most crucial organs in need of protection. The most important function of eyelids is designed to protect the eyeball. Despite their small and thin surface area, they are among the most sunlight-exposed area of skins, hence, it is prone to develop eyelid tumors. As the malignant tumors have the tendency of growing aggressively and have a high mortality, we have to meticulously remove the lesion along with its surrounding tissue, if needed, to ensure the clearance of tumor margin. To strike a suitable outcome between the cosmetic and function after tumor removal is a quite challenging task. Compromise on aesthetics and eyelids' indispensable function of protecting the eyes during management, may lead to unfavorable cosmetic deformity and loss of vision. Therefore, it is imperative that wise selection of appropriate techniques be discussed and managed accordingly. In this article, the authors reported two case scenarios of eyelid reconstruction which was performed to show the management of full-thickness defect after removal of the malignant neoplasms. Skin flaps and graft technique used to reconstruct the eyelid in each patient was different to emphasize that eyelid malignancies require an individualized management.

Clinical and pathological risk factors for worse stage and mortality of eyelid and periocular squamous cell carcinoma

BACKGROUND

The clinical and pathological risk factors for worse T stage and prognosis in eyelid and periocular squamous cell carcinomas (SCCs) remain unclear. P63 was reported to predict a worse prognosis in other SCCs; however, this correlation was not validated in eyelid and periocular SCCs.

METHODS

We reported on a retrospective case series of 85 consecutive patients with eyelid and periocular SCCs from 1995 to 2019. Cox proportional hazards regression models and logistic regression models were applied for risk factor analysis.

RESULTS

Thirty-nine (45.8%) patients were diagnosed with T4 SCCs. Four (5.1%) patients developed nodal metastasis, and five (6.4%) patients developed distant metastasis during the follow-up. 2-year and 5-year disease-specific survival rates were 95.3% and 86.4%, respectively. Poorly or moderately differentiated eyelid and periocular SCCs were associated with worse T stage (p=0.001; p=0.008). Poor differentiation was associated with a higher risk of recurrence (p=0.024). Disease-specific death was more common in patients with T4 stage SCCs (p=0.038, HR=9.05). P63 expression was more common in patients with T3c or worse stage (p=0.008, OR=3.77). P63 expression alone was associated with worse differentiation (p=0.029), higher risk of perineural invasion (p=0.042, OR=4.61) and metastasis (p=0.009, HR=3.99). P63 expression (p=0.012, HR=7.80), coexpression of P63 and Ki67 (p=0.007, HR=9.21) and distant metastasis (p=0.001, HR=11.23) were associated with disease-specific death.

CONCLUSION

Patients presented with more aggressive orbital invasion features and a higher rate of distant metastasis in this cohort. P63 and coexpression of Ki67 predicted a worse stage, differentiation and prognosis, including metastasis and death due to disease.

Proton Beam Therapy in the Treatment of Periorbital Malignancies

Purpose

Periorbital tumor location presents a significant challenge with 3-dimensional conformal radiation therapy or intensity modulated radiation therapy due to high tumor dose needed in the setting of close proximity to orbital structures with lower tolerance. Proton beam therapy (PBT) is felt to be an effective modality in such cases due to its sharp dose gradient.

Materials and Methods

We reviewed our institutional PBT registry and identified 17 patients with tumor epicenters within 2 cm of the eye and optic apparatus treated with passive scatter PBT with comparison volumetric arc therapy plans available. Maximum and mean doses to organs at risk of interest, including optic nerves, optic chiasm, lens, eye ball, pituitary, cochlea, lacrimal gland, and surrounding brain, were compared using the paired Wilcoxon signed rank test. Overall survival was determined using the Kaplan-Meier method.

Results

Median age was 67. Median follow-up was 19.7 months. Fourteen patients underwent upfront resection and received postoperative radiation and 3 received definitive radiation. One patient received elective neck radiation, 2 underwent reirradiation, and 3 had concurrent chemotherapy. There was a statistically significant reduction in mean dose to the optic nerves and chiasm, brain, pituitary gland, lacrimal glands, and cochlea as well as in the maximum dose to the optic nerves and chiasm, pituitary gland, lacrimal glands, and cochlea with PBT. The 18-month cumulative incidence of local failure was 19.1% and 1-year overall survival was 80.9%.

Conclusion

Proton beam therapy resulted in significant dose reductions to several periorbital and optic structures compared with volumetric arc therapy. Proton beam therapy appears to be the optimal radiation modality in such cases to minimize risk of toxicity to periorbital organs at risk.

Interstitial HDR Brachytherapy in the Treatment of Non-Melanocytic Skin Cancers around the Eye

BACKGROUND

Eyelid tumors are rare skin cancers, the most common of which is basal cell carcinoma characterized primarily by local growth. In addition to surgery, radiotherapy is among the basic methods of treatment. External beam radiotherapy is associated with the risk of complications within ocular structures, especially the lens. In the case of interstitial brachytherapy, it is possible to administer a high dose to the clinical target volume (CTV), while reducing it in the most sensitive structures.

METHODS

This paper presents the results of an analysis of 28 patients treated with interstitial high dose rate (HDR) brachytherapy for skin cancers of the upper and lower eyelid; medial and lateral canthus; and the cheek, nose and temples with the infiltration of ocular structures. The patients were treated according to two irradiation schedules: 49 Gy in 14 fractions of 3.5 Gy twice a day for 7 days of treatment, and 45 Gy in 5 Gy fractions twice a day for 5 days. The mean follow-up was 22 months (3-49 months).

RESULTS

two patients (6%) had a relapse: a local recurrence within the irradiated area in one of them, and metastases to lymph nodes in the other. The most common early complication was conjunctivitis (74%), and the most common late complication was dry eye syndrome (59%).

CONCLUSIONS

Interstitial HDR brachytherapy for skin cancers of the upper and lower eyelid; medial and lateral cants; and the cheek, nose and temples with infiltration of ocular structures is a highly effective, short and relatively low burden type of treatment.

Ocular Complications After Radiation Therapy: An Observational Study

Aim of the Study

The study aims to quantify the incidence of ocular complications in patients irradiated on the head and neck area in our medical center, stratified by type of neoplasm and radiation dose received.

Materials and Methods

From an existing database of patients radio-treated in our center, we selected 25 patients irradiated in the 2011-2018 period. The patients had been treated for orbital lymphoma, nasopharyngeal carcinoma and cranial base meningioma. The selected patients received an ophthalmologic evaluation which included a complete ophthalmological and orthoptic assessment.

Results

Our results showed a significantly higher incidence of DES (dry eye syndrome) and corneal complications for eyes receiving a Dmax higher than 40 Gy, as well as for cataract incidence in eyes that had received a Dmax to the lens higher than 5 Gy. We found an overall thinning of the RNFL (retinal nerve fiber layer) in eyes that had received a Dmax higher than 50 Gy, as well as a greater MD (mean deviation) from normal visual field values.

Conclusion

In conclusion, we can say that the study confirms the presence of a correlation between the received radiation dose and the onset of eye complications, despite the small sample.

Reirradiation for Recurrent Scalp Angiosarcoma: Dosimetric Advantage of PBT over VMAT and EBT

Purpose

Reirradiation in the scalp area can be challenging given the proximity to organs at risk (OARs), such as the eye and brain. Our aim is to evaluate the dosimetric differences of volumetric modulated arc therapy (VMAT) and electron beam therapy (EBT) compared with 3-dimensional proton beam therapy (PBT).

Patients and Methods

We evaluated a patient with recurrent angiosarcoma of the left temporal scalp after prior surgical resections and radiation therapy to 60 Gy in 30 fractions who needed reirradiation. We generated VMAT, EBT, and PBT plans using the Pinnacle Treatment Planning System (TPS). Both VMAT and EBT plans used a skin bolus, whereas no bolus was used for the proton plan. Doses to the OARs, including cochlea, eyes, lens, lacrimal glands, optic nerves, optic chiasm, pituitary gland, and underlying brain, were compared.

Results

The reirradiation treatment dose was 60 Gy(RBE). Target volume coverage was comparable in all plans. Compared with VMAT and EBT, the PBT plan showed reductions in mean and maximum doses to all OARs. Without the use of protons, several OARs would have exceeded dose tolerance utilizing VMAT or electrons. Dose reduction of up to 100% was achieved for central and contralateral OARs.

Conclusion

Compared with VMAT and EBT, PBT resulted in dose reductions to all OARs, while maintaining excellent target coverage. PBT showed a significant advantage in treating superficially located skin cancers, such as angiosarcoma, without the need for a bolus. PBT can be considered in the upfront treatment and certainly in the reirradiation setting.

Validation Study of the AJCC Cancer Staging Manual, Eighth Edition, Staging System for Eyelid and Periocular Squamous Cell Carcinoma

Importance

To our knowledge, there are no validation studies to date of the prognostic value of the AJCC Cancer Staging Manual, eighth edition (AJCC 8), criteria for eyelid and periocular squamous cell carcinoma.

Objective

To determine the association of tumor (T) category in AJCC 8 with local recurrence, nodal metastasis, distant metastasis, and disease-specific survival (DSS) for eyelid and periocular squamous cell carcinoma.

Design, Setting, and Participants

In this retrospective, single-center cohort study, 109 consecutive patients with eyelid and periocular squamous cell carcinoma treated from January 1999 to April 2018 were included. Patients with secondary involvement of the periocular region were excluded.

Main Outcomes and Measures

Local recurrence, nodal metastasis, distance metastasis, and DSS.

Results

Of the 109 included patients, 81 (74.3%) were male, and the median (range) age was 66 (40-91) years. At presentation, 43 patients (39.4%) had recurrent tumor, 4 (3.7%) had nodal metastasis, and 1 (0.9%) had distant metastasis. The median (range) follow-up was 23 (1-161) months. During follow-up, 11 patients (10.1%) developed local recurrence, 7 (6.4%) developed nodal metastasis, 2 (1.8%) developed distant metastasis, and 9 (8.3%) died of disease. The 5-year DSS rate was 87.7% (95% CI, 79.5-96.9). Chronic immunosuppression (hazard ratio, 47.24; 95% CI, 7.33-304.30; P < .001) and presentation with recurrent squamous cell carcinoma (hazard ratio, 5.22; 95% CI, 1.12-24.31; P = .04) were associated with local recurrence during follow-up. Of the 11 patients with local recurrence during follow-up, 7 (64%) had perineural invasion. T category was associated with nodal metastasis; clinical stage of T2c or worse at presentation was associated with higher risk of nodal metastasis and death of disease but not with a higher risk of local recurrence. Distant metastasis was associated with nodal metastasis at presentation (hazard ratio, 32.50; 95% CI, 1.97-536.40; P = .02) and during follow-up. A total of 33 patients (30.3%) had different T categories depending on whether disease was staged according to the seventh or eighth edition of the AJCC Cancer Staging Manual. Compared with AJCC 7, AJCC 8 showed a better predictive value in terms of local recurrence (T3, 17% vs 14%; T4, 11% vs 16%) and DSS.

Conclusions and Relevance

These findings suggest that T category in AJCC 8 is associated with nodal metastasis and DSS. Immunosuppression and presentation with recurrent disease are associated with increased risk of future local recurrence. Patients with tumors of clinical stage T2c or worse at presentation are at increased risk of nodal metastasis and worse DSS and should undergo surveillance for nodal metastasis. Future studies, ideally prospective in design, could provide greater confidence in these findings.

Mould-based surface high-dose-rate brachytherapy for eyelid carcinoma

Purpose

To evaluate toxicity and clinical outcomes in patients with eyelid tumour treated with contact high-dose-rate brachytherapy (HDR-BT).

Material and methods

Between April 2010 and August 2017, 10 consecutive patients with tumour of the eyelid underwent contact HDR-BT and custom-made surface mould. Every applicator was manually built using conventional thermoplastic material and standard plastic catheters. The median dose prescribed was 42 Gy (range, 30-48) with a median dose per fraction of 3.5 Gy (range, 2-4.5). The dose was delivered in a median of 12 fractions (range, 10-17) over a median of 16 days. In all cases, an ocular shield was placed to reduce the dose to the eye. Acute and late toxicity was evaluated according to RTOG toxicity criteria.

Results

We analyzed data of 9 of 10 patients (one patient was excluded because he did not give consent for investigation). The median age was 68 years (range, 31-88). According to the TNM-UICC staging system, 4, 1 and 4 patients were stage IA, IB and IC, respectively. Basal cell and sebaceous gland carcinomas were reported in 5 and 2 patients, respectively; other histological types were non-Hodgkin lymphoma and plasmacytoma. After a median follow-up of 51 months (range, 16-90), there was no evidence of local or distant recurrence. The treatment was very well tolerated. Most commonly acute reactions consisted of low grade (G1-G2) conjunctivitis and skin erythema. Only one patient required a temporary interruption of the treatment due to acute G2 conjunctivitis and G3 lid erythema. Only one G2 late toxicity was reported (corneal ulceration), without resulting in functional impairment or blindness.

Conclusions

Our results suggest that contact HDR-BT with a customized applicator is safe, effective and offers very good local control and can be considered for the treatment of eyelid tumours.

Outcomes of orbital malignancies treated with eye-sparing surgery and adjuvant particle radiotherapy: a retrospective study

Background

To report the clinical experience of eye sparing surgery (ESS) and adjuvant carbon-ion or proton radiotherapy (CIRT or PRT) for orbital malignancies.

Methods

An analysis of the retrospective data registry from the Shanghai Proton and Heavy Ion Center for patients with orbital tumors was conducted. The 2-year local progression-free, regional recurrence-free, distant metastasis-free, progression-free, and overall survival (LPFS, RRFS, DMFS, PFS, OS) rates as well as associated prognostic indicators were analyzed. Radiotherapy-induced acute and late toxicities were summarized.

Results

Between 7/2014 to 5/2018, 22 patients with orbital malignancies of various pathologies received ESS followed by CIRT (18), PRT (1), or PRT + CIRT boost (3). With a median follow-up of 20.25 (range 3.8–38.8) months, the 2-year OS, PFS, LPFS, RRFS, and DMFS rates were 100, 57.9, 92.9, 93.3, and 72.8%, respectively. No acute severe (i.e., ≥grade 3) toxicity was observed. Two patients experienced severe visual impairment as late toxicities.

Conclusion

With few observed acute and late toxicities, particle radiotherapy following ESS provided effective local control with infrequent severe toxicities for patients with orbital malignancies.

Management of a cutaneous squamous cell carcinoma overlying an AV fistula

Cutaneous squamous cell carcinoma (cSCC) currently affects over 700 000 patients per year in the USA alone, and its incidence continues to rise in recent years. A known risk factor for cSCC is chronic inflammation; a cSCC that develops at a site of chronic inflammation is known as Marjolin's ulcer. We present the case of a 76-year-old man with end-stage renal disease requiring chronic haemodialysis who developed an invasive cSCC at the cannulation site of an underlying arteriovenous (AV) fistula. In this instance, treatment with standard surgical excision or Mohs surgery would pose unique risks associated with injury to an otherwise functional AV fistula. Thus, the lesion was treated with electron beam radiation therapy, which offers a similar efficacy to surgery while minimising risk to the fistula. This resulted in a successful oncological outcome with no complications.

Utilization of a 3D printer to fabricate boluses used for electron therapy of skin lesions of the eye canthi

This work describes the use of 3D printing technology to create individualized boluses for patients treated with electron beam therapy for skin lesions of the eye canthi. It aimed to demonstrate the effectiveness of 3D-printed over manually fabricated paraffin boluses. The study involved 11 patients for whom the construction of individual boluses were required. CT scans of the fabricated 3D-printed boluses and paraffin boluses were acquired and superimposed onto patient CT scans to compare their fitting, bolus homogeneity, and underlying dose distribution. To quantify the level of matching, multiple metrics were utilized. Matching Level Index (ML) values ranged from 0 to 100%, where 100% indicated a perfect fit between the reference bolus (planned in treatment planning system) and 3D-printed and paraffin bolus. The average ML (± 1 SD) of the 3D-printed boluses was 95.1 ± 2.1%, compared to 46.0 ± 10.1% for the manually fabricated paraffin bolus. Correspondingly, mean doses were closer to the prescribed doses, and dose spreads were less for the dose distributions from the 3D-printed boluses, as compared to those for the manually fabricated paraffin boluses. It was concluded that 3D-printing technology is a viable method for fabricating boluses for small eye lesions and provides boluses superior to our boluses manually fabricated from paraffin sheets.

Intensity Modulated Proton Therapy Versus Intensity Modulated Photon Radiation Therapy for Oropharyngeal Cancer: First Comparative Results of Patient-Reported Outcomes

PURPOSE

We hypothesized that patients with oropharyngeal cancer treated with intensity modulated proton therapy (IMPT) would have lower symptom burdens, as measured by patient-reported outcome (PRO) surveys, than patients treated with intensity modulated photon therapy (IMRT).

METHODS AND MATERIALS

Patients were treated for oropharyngeal cancer from 2006 to 2015 through prospective registries with concurrent chemotherapy and IMPT or chemotherapy and IMRT and completed the MD Anderson Symptom Inventory for Head and Neck Cancer (MDASI-HN) module at various times before treatment (baseline), during treatment (acute phase), within the first 3 months after treatment (subacute phase), and afterward (chronic phase). Individual symptoms and the top 5 and top 11 most severe symptoms were summarized and compared between the radiation therapy modalities.

RESULTS

PRO data were collected and analyzed from 35 patients treated with chemotherapy and IMPT and from 46 treated with chemotherapy and IMRT. The baseline symptom burdens were similar between both groups. The overall top 5 symptoms were food taste problems (mean score 4.91 on a 0-10 scale), dry mouth (4.49), swallowing/chewing difficulties (4.26), lack of appetite (4.08), and fatigue (4.00). Among the top 11 symptoms, changes in taste and appetite during the subacute and chronic phases favored IMPT (all P<.048). No differences in symptom burden were detected between modalities during the acute and chronic phases by top-11 symptom scoring. During the subacute phase, the mean (±standard deviation) top 5 MDASI scores were 5.15 ± 2.66 for IMPT versus 6.58 ± 1.98 for IMRT (P=.013).

CONCLUSIONS

According to the MDASI-HN, symptom burden was lower among the IMPT patients than among the IMRT patients during the subacute recovery phase after treatment. A prospective randomized clinical trial is underway to define the value of IMPT for the management of head and neck tumors.

Brachytherapy in non melanoma skin cancer of eyelid: a systematic review

PURPOSE

Non melanoma skin cancers (NMSC) of eyelid are uncommon. Many treatments approach are available with surgery being considered as the gold standard. Radiotherapy is an effective alternative in patients unfit for surgery. Brachytherapy (BT) might be a better therapeutic option due high radiation dose concentration to the tumor and rapid dose fall-off resulting in normal tissues sparing. The aim of this review is to evaluate local control, toxicity, and functional cosmetic outcome of BT in NMSC of eyelid.

MATERIAL AND METHODS

A systematic search of the bibliographic databases PubMed, Scopus, and Cochrane Library from the earliest possible date through October 2015 was performed. Only studies published in English were included.

RESULTS

Six articles fulfilled the selection criteria and were included in our review. Due to high risk of bias, all studies were classified to provide a low level of evidence (according to Scottish Intercollegiate Guidelines Network Classification). No randomized controlled trials or case control studies were founded. Brachytherapy was well tolerated with acceptable toxicity and high local control rates (median: 95.2%). Functional and cosmetic outcome were reported in five study as acceptable good functional-cosmetic outcome (median: 100%).

CONCLUSIONS

To date, few evidences are available on the role of BT in eyelid NMSC, and they show satisfactory results in terms of local control and functional cosmetic outcome. Therefore, prospective controlled trials are justified.

A Multidisciplinary Orbit-Sparing Treatment Approach That Includes Proton Therapy for Epithelial Tumors of the Orbit and Ocular Adnexa

PURPOSE

Postoperative radiation is often indicated in the treatment of malignant epithelial tumors of the orbit and ocular adnexa. We present details of radiation technique and toxicity data after orbit-sparing surgery followed by adjuvant proton radiation therapy.

METHODS AND MATERIALS

Twenty patients underwent orbit-sparing surgery followed by proton therapy for newly diagnosed malignant epithelial tumors of the lacrimal gland (n=7), lacrimal sac/nasolacrimal duct (n=10), or eyelid (n=3). Tumor characteristics, treatment details, and visual outcomes were obtained from medical records. Acute and chronic toxicity were prospectively scored using Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

The median radiation dose was 60 Gy(RBE) (relative biological effectiveness; [range 50-70 Gy]); 11 patients received concurrent chemotherapy. Dose to ipsilateral anterior optic structures was reduced in 13 patients by having them gaze away from the target during treatment. At a median follow-up time of 27.1 months (range 2.6-77.2 months), no patient had experienced local recurrence; 1 had regional and 1 had distant recurrence. Three patients developed chronic grade 3 epiphora, and 3 developed grade 3 exposure keratopathy. Four patients experienced a decrease in visual acuity from baseline but maintained vision sufficient to perform all activities of daily living without difficulty. Patients with grade ≥3 chronic ocular toxicity had higher maximum dose to the ipsilateral cornea (median 46.3 Gy[RBE], range 36.6-52.7 Gy[RBE] vs median 37.4 Gy[RBE], range 9.0-47.3 Gy(RBE); P=.017).

CONCLUSIONS

Orbit-sparing surgery for epithelial tumors of the orbit and ocular adnexa followed by proton therapy successfully achieved disease control and was well tolerated. No patient required orbital exenteration or enucleation. Chronic grade 3 toxicity was associated with high maximum dose to the cornea. An eye-deviation technique can be used to limit the maximum corneal dose to <35 Gy(RBE).

Clinical and cosmetic outcomes in patients treated with high-dose-rate electronic brachytherapy for nonmelanoma skin cancer

PURPOSE

To retrospectively analyze clinical and cosmetic outcomes in patients treated for nonmelanoma skin cancer (NMSC) with high-dose-rate (HDR) electronic brachytherapy (EBT) using surface applicators.

METHODS AND MATERIALS

We identified 127 patients who had 154 NMSC lesions, 149 of which were basal cell carcinoma, treated with HDR EBT at our institution between July 2012 and March 2014. Lesions were treated to 40 Gy in 8 fractions. Local control, acute toxicity, late toxicity, and cosmetic outcomes were analyzed retrospectively. Acute and late toxicities were graded using the Common Terminology Criteria for Adverse Events, version 4.0. Cosmetic outcomes were graded using a standard scale based on the Radiation Therapy Oncology Group and European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema.

RESULTS

Median (range) follow-up from completion of treatment was 16.1 (3.4-34.8 months). The overall crude recurrence rate was 1.3% (n = 2). Grade 0 to 1 acute radiation dermatitis was observed in 52.6% of treated lesions (n = 81), grade 2 in 34.4% (n = 53), and grade 3 in 13.0% (n = 20). No acute toxicity greater than grade 3 was observed and all acute toxic events resolved after treatment. Grade 0 to 1 late toxicity was observed in 94.2% of cases (n = 145), and grade 2 in 5.8% (n = 9). No late toxicity greater than grade 2 was observed. Across the 152 controlled lesions, cosmetic results were excellent in 94.2% of treated lesions (n = 145), good in 3.3% (n = 5), fair in 0.7% (n = 1), and poor in 0.7% (n = 1).

CONCLUSIONS

HDR EBT confers promising local control, minimal toxicity, and excellent cosmesis in our institutional experience. It should be considered ideal for NMSC of the head and neck, particularly for basal cell carcinoma involving central facial locations where surgical cosmesis may be inferior.

Orbital carcinomas treated with adjuvant intensity-modulated radiation therapy

BACKGROUND

The purpose of this study was to assess outcomes of patients with orbital carcinomas treated with orbital exenteration and intensity-modulated radiation therapy (IMRT).

METHODS

Twenty-nine patients were treated with orbital exenteration and postoperative IMRT between 2002 through 2011; their medical records were retrospectively reviewed.

RESULTS

Adenoid cystic carcinoma represented the most common histology (41%) followed by squamous cell carcinoma (21%). Perineural invasion (PNI) was identified in 22 patients (76%). The median radiation dose was 60 Gy (range, 60-70). Seven patients (24%) received neck radiation. The median follow-up was 43 months (range, 5-102 months). Five-year local control, overall survival (OS), and disease-free survival rates were 83%, 60%, and 55%, respectively. PNI (p = .01) and especially involvement of a named nerve (p = .001) significantly correlated with worse OS.

CONCLUSION

Favorable disease control rates for orbital carcinomas are achievable with IMRT after orbital exenteration even for patients with advanced disease. Toxicity for the contralateral eye was minimal. © 2015 Wiley Periodicals, Inc. Head Neck 38: E580-E587, 2016.

Interstitial high-dose-rate brachytherapy in eyelid cancer

PURPOSE

To report the experience and the outcomes of interstitial high-dose-rate (HDR) brachytherapy (BT) of eyelid skin cancer at the Department of Radiotherapy of Hospital de Santa Maria in Lisbon.

METHODS AND MATERIALS

Seventeen patients (pts; mean age, 73.75 years) who underwent eyelid interstitial HDR BT with an (192)Ir source between January 2011 and February 2013 were analyzed. Lesions were basal (94%) and squamous (6%) cell carcinomas, on lower (88%) or upper (6%) eyelids, and on inner canthus (6%). T-stage was Tis (6%), T1 (46%), T2 (36%), and T3a (12%). The purpose of BT was radical (12%), adjuvant to surgery (71%), or salvage after surgery (18%). The BT implant and treatment planning were based on the Stepping Source Dosimetry System. The median total dose was 42.75 Gy (range, 32-50 Gy), with a median of 10 fractions (range, 9-11 fractions), twice daily, 6 h apart. The median V100 was 2.38 cm(3) (range, 0.83-5.59 cm(3)), and the median V150 was 1.05 cm(3) (range, 0.24-3.12 cm(3)).

RESULTS

At a median followup of 40 months (range, 7-43 months), the local control was 94.1%. There was one local recurrence and one non-related death. The BT was well tolerated. Madarosis was the most common late effect (65% of pts) and was related with higher values of V100 (p = 0.027). Cosmetic outcomes were good and excellent in 70% of pts.

CONCLUSIONS

Interstitial HDR BT is a feasible and safe technique for eyelid skin cancers, with good local control. Recurrent lesions and higher volumes receiving the prescribed dose were associated with worse outcomes.

Postoperative interstitial brachytherapy in eyelid cancer: long term results and assessment of Cosmesis After Interstitial Brachytherapy scale

Purpose

To analyse feasibility and safety of postoperative interstitial brachytherapy (IBRT) in patients of eyelid cancer treated primarily by surgical excision.

Material and methods

In this series, 8 patients with eyelid cancer were treated using postoperative interstitial brachytherapy. Patients were followed up for local control, cosmetic outcome, and acute and late toxicities. Cosmetic outcome was measured using a 6 point indigenous Cosmesis After Interstitial Brachytherapy (CAIB) scale.

Results

The patients were between 23-82 years (median: 71 years). There were 3 females and 5 males, and 3 patients had lesions in upper eyelid. Postoperative high-dose-rate brachytherapy was used in all with 2 catheters implanted in most of them (6 out of 8). Local control was calculated from end of treatment to last follow-up. At last follow-up, all patients remained locally controlled. Two patients had nodal recurrence 6 months after interstitial brachytherapy and were salvaged effectively by external beam radiotherapy. At last follow-up, 7 patients were loco-regionally controlled and one was lost to follow up. All patients had Radiation Therapy Oncology Group (RTOG) grade 1 acute toxicity and 2 had grade 1 Common Terminology Criteria for Adverse Events (CTCAE) version.3 late toxicities. The cosmesis score for the whole group ranged between 0-1 indicating excellent to very good cosmesis.

Conclusions

Postoperative high-dose-rate brachytherapy resulted in excellent disease control and cosmesis without significant acute or late toxicities. It is an effective modality for treatment of eyelid cancers in selected patients. Future prospective studies with the validation of CAIB scale would give us more insight to this effective yet often ignored modality of IBRT.

Interstitial brachytherapy for eyelid carcinoma. Outcome analysis in 60 patients

BACKGROUND

Eyelid cancer is a therapeutic challenge due to the cosmetic and functional implications of this anatomical region and the objectives of therapy are tumor control, functional and cosmetic outcome.

AIM

The present study was performed to analyze local control, toxicity, functional and cosmetic results in patients with eyelid carcinoma treated by interstitial brachytherapy.

MATERIAL AND METHODS

In this study 60 patients with eyelid carcinoma were treated by interstitial brachytherapy using iridium ((192)Ir) wires with a linear activity of 1.2-1.7 mCi/cm. The prescription dose was 51-70 Gy (mean 65 Gy, median 66 Gy).

RESULTS

Of the 60 patients 51 (85.0 %) had received no prior treatment, 4 (6.7 %) had received previous surgery with positive or close margins and 5 (8.3 %) had suffered local recurrence after surgery. Of the tumors 52 (86.7 %) were basal cell carcinoma, 7 (11.7 %) squamous cell carcinoma and 1 (1.7 %) Merkel cell carcinoma. Clinical stage of the 51 previously untreated tumors was 38 T1N0, 12 T2N0 and 1 T3N0. Mean follow-up was 92 months (range 6-253 months). Local control was maintained in 96.7 % of patients. Late effects higher than grade 2 were observed in 3.0 % of cases. Functional and cosmetic outcomes were optimal in 68.4 % of patients.

CONCLUSION

Interstitial brachytherapy for carcinoma of the eyelid can achieve local control, cosmetic and functional results comparable to those of surgery.

Results of radical radiotherapy for squamous cell carcinoma of the eyelid

PURPOSE

To analyze the results of radical radiotherapy by electron beams for squamous cell carcinoma (SCC) of the eyelid and to find the possible prognostic factors.

MATERIALS AND METHODS

Records of 38 patients with histologically confirmed SCC of the eyelid who underwent electron beam radiation therapy between 1964 and 2010 in our institution were retrospectively reviewed. Median tumor size was 15 mm (range, 3-40 mm). T stage was T1 in three, T2a in six, T2b in 14, and T3a in 15 patients. Four patients had nodal metastasis. Of the 38 patients, 14 had relapsed disease after prior treatment. Median radiation dose was 60.0 Gy (range, 45.0-70.4 Gy). Median follow-up was 72.5 months (range, 2.0-369 months).

RESULTS

5-year local relapse-free, nodal relapse-free, distant metastasis-free and relapse-free rates for all patients were 71.8%, 77.5%, 90.6% and 58.0%, respectively. In seven patients, lymph node metastases occurred in 11 faciocervical regions. The 5-year overall survival was 79.5%. T stage and radiation dose expressed in EQD2 Gy tended to have impacts on local control. Relapsed patients showed unfavorable local relapse-free rate, however this was without statistical significance. Of the 14 patients who died, 12 succumbed to concurrent diseases. Grade 3 or greater severe late morbidities (CTCAE ver4.0) were observed in nine patients. Due to the morbidities, two patients lost their vision.

CONCLUSION

Radical radiotherapy for SCC of the eyelid yielded good results and could be a treatment option. Whether radiation-dose escalation could improve local control in advanced T stages and relapsed patients needs further study.

Electron beam radiation for conjunctival squamous carcinoma

PURPOSE

To describe the authors' technique and preliminary results using electron beam radiation as rescue therapy for recalcitrant squamous cell carcinoma of the conjunctiva and cornea.

METHODS

A retrospective review comprised of an interventional case series of patients with pathologically confirmed diagnosis of squamous cell carcinoma of the conjunctiva and cornea, who had failed multiple standard treatments and underwent electron beam radiation therapy. Outcomes, radiation-related complications, and adverse effects were documented. Mortality and local control rates were calculated by the Kaplan-Meier survival probability method.

RESULTS

Eight patients met the inclusion criteria; of these, 6 (75%) were men and 2 (25%) were women, with ages ranging from 38 to 65 years (mean 50 years). One tumor (12.5%) was classified as T2N0M0, 6 (75%) were classified as T3N0M0, and one (12.5%) was classified as T4N0M0. Follow up from electron beam radiation therapy ranged from 3 to 72 months (mean 30.25 months). The most common side effect was erythema and edema of the eyelids with diffuse transient eyelash loss, seen in all patients. Tumor local control and regression after electron beam radiation therapy were noted in 6 patients (75%); recurrence was noted in 2. There was neither metastatic spread nor tumor-related deaths.

CONCLUSIONS

The authors report a small case series where local tumor control was achieved with electron beam radiation therapy for recalcitrant squamous cell carcinoma of the conjunctiva and cornea. This approach may be considered for patients who fail conventional therapy.

Non-surgical treatments of primary, non-melanoma eyelid malignancies: a review

The diagnosis and management of periocular cutaneous malignancies are essential components of an ophthalmologist's practice. Skin cancers comprise nearly one-third of newly diagnosed malignancies. Furthermore, the incidence of skin cancer appears to be increasing. Multiple treatment modalities exist for periocular cutaneous malignancy. Surgical extirpation, often with the combined expertise of a Mohs micrographic surgeon, is typically the first line therapy and is often curative in the periocular region, depending on a variety of factors, including tumour histology, specific location, depth of invasion and surgical technique. However, there are instances where a less invasive, non-surgical treatment option is warranted, including patients who are poor surgical risks or those with diffuse disease. The purpose of this article is to review the literature and describe the non-surgical treatment options, indications and efficacies for non-melanoma primary eyelid malignancies.