Electronic brachytherapy for superficial and nodular basal cell carcinoma: a report of two prospective pilot trials using different doses

Electronic brachytherapy for gynecological cancers - a systematic review

Background

The purpose of this manuscript is to provide an in-depth literature review of the management of endometrial and cervical cancers with electronic brachytherapy.

Materials and methods

An extensive literature search was performed and 9 articles were selected based on preset criteria.

Results

The reviewed studies provided dosimetric and clinical results. Patient populations were diverse and prescribed doses varied. When treatment plans were compared to those using cobalt 60 (⁶⁰Co) and iridium 192 (¹⁹²Ir) sources researchers found lower or equivalent doses in organs at risk while the doses at the applicator surface were significantly higher for electronic brachytherapy. In the eligible studies, a total of 72 patients received treatment with AxxentXoft vaginal applicator, 29 were treated with the Intrabeam vaginal applicator, and 8 with AxxentXoft cervical applicator.

Conclusions

All authors found that electronic brachytherapy was safe and well tolerated as higher mucosal doses did not present as adverse clinical effects. Electronic brachytherapy for gynecological cancers has the potential to achieve equivalent tumor control while minimizing bowel and urinary toxicity thus improving the quality of life. More clinical data is needed to stratify patients who would benefit the most.

The State of the Art of Radiotherapy for Non-melanoma Skin Cancer: A Review of the Literature

Due to the general aging population and the fashion trend of sun exposure, non-melanoma skin cancer (NMSC) is rising. The management of NMSC is difficult and necessitates a multidisciplinary team (i.e., pathologists, dermatologists, medical oncologists, surgeons, and radiation oncologists). When surgery is not an option or will cause unacceptably functional morbidity, radiation therapy (RT) may be a preferable tissue-preserving option. Whether used alone or in conjunction with other treatments, RT has been shown to be quite effective in terms of cosmetic results and local control. Contact hypofractionated RT, brachytherapy, and electronic brachytherapy are all promising new treatments. However, rigorous, randomized trials are missing, explaining the disparity in dose, fractionation, and technique recommendations. Therefore, it is essential that interdisciplinary teams better understand RT modalities, benefits, and drawbacks. Our review will provide the role and indications for RT in patients with NMSC.

Feasibility of electronic brachytherapy in cervix cancer-A dosimetric comparison of different brachytherapy techniques

INTRODUCTION

This study analyzes cases in which electronic brachytherapy (eBT) led to acceptable treatment plans in cervical cancer. Findings were compared with dosimetry values obtained in ¹⁹²Ir-based treatments according to the high-risk clinical target volume (HR-CTV) and the disease stage.

MATERIAL AND METHODS

We retrospectively analyzed 48 patients with cervical cancer from two centers. The patients were treated with ¹⁹²Ir based on MRI. It was possible to use interstitial needles via an Utrecht-type applicator. Dosimetry was simulated using eBT and the parameters D90 and D98 (HR-CTV) and D2cc, D1cc, and D0.1cc (bladder, rectum, and sigmoid colon) were evaluated. The Mann-Whitney U test was used for comparison. The overall cohort of patients was analyzed, as were the sub-cohorts based on stage (FIGO stages I+IIA, IIB and III-IV). Finally, the dosimetry of the eBT plans was evaluated, and the plans obtained were classified as "good", "acceptable", or "poor".

RESULTS

Statistically significant differences were found between the eBT and ¹⁹²Ir plans for D98 (HR-CTV), D1cc and D0.1cc (bladder), and D1cc and D0.1cc (sigmoid colon). A total of 31 cases (64.6%) were considered good, seven (14.6%) were considered acceptable, and 10 (20.8%) were considered poor. For volumes <30 cc, all the plans were good or acceptable; for volumes >30 cc, 54.3% were good, and 71.4% were good or acceptable. By stage, eBT plans for patients with stage IB-IIA disease were good in 100%, whereas those for patients with stage IIB were good in 70.6% and III-IV disease were good in 50%.

CONCLUSIONS

eBT provides appropriate dosimetry for treatment of cervical cancer in selected cases.

Radiotherapy in the Adjuvant and Advanced Setting of CSCC

Introduction

The use of radiotherapy for cutaneous squamous cell carcinoma (CSCC) has solid historical roots. It is used with patients who are not suitable for surgery, with patients with high-risk histological features in the adjuvant setting, and in palliative care.

Objectives

The aim of this article is to summarize and provide a radiation therapy overview on the indications, effectiveness, and potential adverse events of radiotherapy in the adjuvant and advanced setting of CSCC.

Methods

We performed a comprehensive literature review on PubMed, adopted as our biomedical literature database. Articles were selected based on their date of publication (in the last 30 years) and relevance.

Results

Radiotherapy (RT) can safely be used to manage non-surgical patients and high-risk patients in the advanced CSCC setting. The remarkable progress of delivery techniques has greatly improved the effectiveness and toxicity profile of RT treatments. From 2D techniques to intensity modulated radiation therapy (IMRT), and brachytherapy, all RT techniques have greatly advanced. To improve acute and chronic side effects, a deeper care has been used. As regards CSCC, several dose fractionations and schedules have been suggested, in line with the patient's age and medical conditions.

Conclusions

RT is a fundamental and constantly evolving therapeutic option in the treatment of CSCC, to minimize the risk of recurrence and metastases in the adjuvant setting and in the exclusive treatment for non-surgical patients. Patients' selection is crucial, together with and a collaborative team working approach among the specialists involved in disease management in the perspective of the best multidisciplinary assessment.

High-Dose-Rate Brachytherapy for the Treatment of Basal and Squamous Cell Carcinomas on Sensitive Areas of the Face: A Report of Clinical Outcomes and Acute and Subacute Toxicities

Purpose

Basal cell and cutaneous squamous cell carcinoma are common malignancies (keratinocyte carcinomas [KCs]). Surgical resection is the standard of care. Radiation using high-dose rate brachytherapy (HDR-BT) may serve as a superior alternative where surgical scars may be of cosmetic concern or in elderly patients with significant comorbidity. We aim to describe the clinical and cosmetic outcomes as well as posttreatment radiation toxicities associated with HDR-BT in patients who were treated for KCs of the face.

Methods and Materials

Patients with KCs treated with HDR-BT from 2015 to 2018 were included in the study. Patient medical records and clinical photos were reviewed at multiple time points: start of treatment, end of treatment, short-term (2 week) follow-up, 3-month follow-up, and if needed at 6 months. Radiation toxicity was graded using the Radiation Therapy Oncology Grading (RTOG) acute toxicity scale. Median (range) toxicity grades at follow-up intervals were calculated. Clinical outcomes including local recurrence were evaluated for all patients.

Results

The study included 19 patients and 20 KCs. The median radiation dose was 42 Gy (39-42 Gy) over 6 fractions. The median toxicity at completion of treatment was RTOG grade 2 (85% of patients). At short-term follow-up, 50% of patients (n = 10) improved to RTOG grade 1 (0-2). At 3 months, 70% of patients (n = 14) had RTOG grade 0, and by 6 months, 100% of patients (n = 18) had RTOG grade 0. No RTOG grade 3 or higher skin toxicity was observed. With a median follow-up of 7.2 months (range, 1.3-54.4 months), the local recurrence-free survival was 95%.

Conclusions

We demonstrate that HDR-BT can be used as definitive treatment of KCs of the face with excellent cosmetic outcomes and local control. Acute and subacute skin toxicities were most commonly RTOG grade 2 or less with resolution of patient's skin toxicity by 3 months.

The American Brachytherapy society consensus statement for skin brachytherapy

PURPOSE

Keratinocyte carcinoma (KC, previously nonmelanoma skin cancer) represents the most common cancer worldwide. While surgical treatment is commonly utilized, various radiation therapy techniques are available including external beam and brachytherapy. As such, the American Brachytherapy Society has created an updated consensus statement regarding the use of brachytherapy in the treatment of KCs.

METHODS

Physicians and physicists with expertise in skin cancer and brachytherapy created a consensus statement for appropriate patient selection, data, dosimetry, and utilization of skin brachytherapy and techniques based on a literature search and clinical experience.

RESULTS

Guidelines for patient selection, evaluation, and dose/fractionation schedules to optimize outcomes for patients with KC undergoing brachytherapy are presented. Studies of electronic brachytherapy are emerging, although limited long-term data or comparative data are available. Radionuclide-based brachytherapy represents an appropriate option for patients with small KCs with multiple techniques available.

CONCLUSIONS

Skin brachytherapy represents a standard of care option for appropriately selected patients with KC. Radionuclide-based brachytherapy represents a well-established technique; however, the current recommendation is that electronic brachytherapy be used for KC on prospective clinical trial or registry because of a paucity of mature data.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

[Alternative treatment options for periorbital basal cell carcinoma]

BACKGROUND

Latest developments as well as established procedures offer alternative treatment approaches to basal cell carcinoma (BCC) when micrographically controlled surgical removal is not a valid option.

OBJECTIVE

Alternative treatment options for periorbital BCC are presented.

METHODS

A literature search was carried out and a structured display and analysis of the results are given.

RESULTS

Micrographically controlled surgical removal represents the gold standard in treatment of BCC. When for various reasons surgical removal is not a valid option, other procedures are required. The alternative treatment options can be divided into three main groups: treatment options for locally advanced or metastasized BCC, topical approaches for small and superficial BCC and prophylactic measures. While radiotherapy and systemic therapy are suitable for locally advanced BCC and are discussed in a tumor board, small and superficial BCC can be treated by topical medication. In cases of a previous BCC history, a prophylactic treatment can be considered. Combinations of systemic treatment and also neoadjuvant or adjuvant approaches before and after surgery are promising options for a successful outcome, which can further improve the standard treatment for locally advanced BCC.

CONCLUSION

Alternative treatment options for periocular BCC are available; however, the use is only indicated when microscopically controlled excision with subsequent oculoplastic reconstruction is not possible. According to the national guidelines a prior presentation to a suitable tumor board is practically compulsory.

Current Role of Radiotherapy in Non-melanoma Skin Cancer

Non-melanoma skin cancer (NMSC) represents the most frequently diagnosed malignancy worldwide, most being cutaneous basal cell and squamous cell carcinoma. The global incidence of NMSC continues to increase as the global population ages. Numerous treatment options are available for NMSC patients, with radiotherapy an efficacious and tissue-preserving non-surgical option. External beam radiotherapy and brachytherapy are modalities with specific indications and advantages in treating NMSC. Where excision is not an option (medically/technically inoperable) or considered less ideal (e.g. cosmetic or functional outcome), radiotherapy offers an excellent alternative. Inoperable elderly and/or co-morbid patients of poor performance status can benefit from short-course hypofractionated radiotherapy, with very acceptable toxicity. Adjuvant radiotherapy in patients with unfavourable pathology can decrease the risk of local and regional recurrence and associated morbidity and mortality. Radiotherapy has advantages and disadvantages and it is important for clinicians to understand these. Managing patients with NMSC is carried out by clinicians from multiple disciplines but it is imperative that they are all aware of the role of radiotherapy in their patients in various clinical settings. Here we aim to discuss the role and indications for recommending radiotherapy in patients with NMSC.

Treatment of cervical cancer with electronic brachytherapy

PURPOSE

We report the first cervical cancer cases treated with interstitial electronic brachytherapy (eBT) at our hospital and compare them with plans made with high-dose-rate interstitial brachytherapy based on Ir192 (HDR-BT).

MATERIALS AND METHODS

Eight patients with cervical cancer were treated with the Axxent eBT device (Xoft, Inc.). Planning was with magnetic resonance imaging and computed tomography following the recommendations of the EMBRACE protocol. The dosimetry parameters of organs at risk (OAR) were evaluated for the bladder, rectum, and sigmoid colon (D2cc, D1cc, and D0.1cc). In addition, the V150 and V200 of irradiated tissue were compared for both eBT and HDR-BT. All patients received intensity-modulated external beam radiation therapy with a regimen of 23 sessions of 2 Gy followed by four sessions of 7 Gy of eBT performed over 2 weeks (two sessions followed by another two sessions a week later) following the EMBRACE recommendations. Each of the eight patients was followed to assess acute toxicity associated with treatment.

RESULTS

The doses reaching OAR for eBT plans were lower than for HDR-BT plans. As for acute toxicity associated with eBT, very few cases of mucositis were detected. No cases of rectal toxicity and one case with grade 1 urinary toxicity were detected. The results at 1 month are equally good, and no relapses have occurred to date.

CONCLUSIONS

The first results of treatment with the Axxent eBT device are promising, as no recurrences have been observed and toxicity is very low. eBT is a good alternative for treating cervical cancer in centers without access to conventional HDR.

Consensus Guidelines on the Use of Superficial Radiation Therapy for Treating Nonmelanoma Skin Cancers and Keloids

Background: The use of superficial radiation therapy (SRT) has experienced a renaissance for treating nonmelanoma skin cancers (NMSCs) and recurrent keloids; however, published treatment guidelines are lacking. Objective: The objective of this work was to provide consensus guidelines on the use of SRT for treating NMSC and recurrent keloids based on a review of the literature and expert opinion. Methods and Materials: A search of the medical literature was performed to obtain published information on the use of SRT for review. A group of qualified dermatologists convened to discuss their views on the use of SRT for the treatment of NMSCs and recurrent keloids. The various guidelines were considered to have consensus based on a supermajority two-thirds vote. The final consensus guidelines are thus based on the medical literature, when available, and expert opinions. Results: Agreement on consensus guidelines was reached for numerous aspects of SRT use, including appropriate tumor types for SRT; anatomical areas suitable for SRT; energy, fractions, and scheduling recommendations for SRT; use of SRT in the presence of comorbidities; safety factors; and treatment recommendations for recurrent keloids, based the literature and on both the opinions of the expert group and a survey of experienced users. Conclusion: Consensus was reached that SRT is a safe and effective treatment for basal cell and squamous cell carcinomas and should be considered as the first-line form of radiation treatment. Postsurgical treatment of keloid excision suture lines with SRT significantly reduces keloid recurrence rates.

Postoperative endometrial cancer treatments with electronic brachytherapy source

Purpose

This study is a dosimetric and acute toxicity comparison of endometrial cancer patients treated with either Axxent (Xoft, Inc., San José, CA, USA) electronic and interstitial brachytherapy versus interstitial high dose rate brachytherapy (HDRBT).

Materials and Methods

Between 2015 and 2017, 94 patients with postoperative endometrial cancer were treated in our centre with the Axxent electronic brachytherapy (eBT) system. The V150 and V200 are evaluated prospectively for each plan. The mean age of patients was 65.9 years (age range 33–84 years), with different tumour staging. Of the 94 patients, 37 received exclusive adjuvant brachytherapy (25 Gy in five sessions); the remaining patients received external beam radiotherapy (EBRT) with a regimen of 23 sessions of 2 Gy each to the entire pelvis, followed by eBT (15 Gy in three sessions). Additionally, the absorbed doses received by the organs at risk (OAR), urinary bladder, rectum and sigmoid colon were compared with HDRBT plans, evaluating D2cc, V50% and V35%. Median follow-up was done for each of the 94 patients to assess the toxicity of the treatment: vaginal mucosa toxicity, rectal and urinary toxicity; and results are presented for acute toxicity, toxicity at 1 month after the end of treatment and follow-up after 12 months for a portion of patients according to the Radiation Therapy Oncology Group (RTOG) toxicity criteria.

Results

The doses in OAR for eBT plans were lower than that for HDRBT plans, both Ir-192 and Co-60 plans, whose doses were similar. The dose in bladder with eBT was 63.8% of the prescribed dose for D2cc versus 70.1% for HDRBT Ir-192, for V50% was 7.2% versus 12.7% and for V35% was 15.2% versus 28.2%. In rectum the D2cc was 61.2% versus 68.4%, for V50% was 7.9% versus 14.3% and for V35% was 16.7% versus 32%. Results demonstrated lower doses to OAR in all eBT plans. Acute toxicity in eBT was very low in cases of mucositis, with only one case of toxicity greater than grade 1, rectal toxicity and urinary toxicity; results at 1 month are equally good, toxicity symptoms disappeared and no relapses have occurred to date.

Conclusions

The results of treatment with the Axxent eBT unit for 94 patients are very good, as no recurrence has been observed and the toxicity of the treatment is very low. The increase in V150 and V200 has not produced an increase in vaginal mucosa toxicity, and the doses in the OAR are lower than in the plans implemented for HDRBT with Ir-192 or Co-60. eBT is a good alternative to treat endometrial cancer in centres without conventional HDR availability. To date, there are limited published studies reporting on outcomes from patients treated with eBT.

GEC-ESTRO ACROP recommendations in skin brachytherapy

PURPOSE

The aim of this publication is to compile available literature data and expert experience regarding skin brachytherapy (BT) in order to produce general recommendations on behalf of the GEC-ESTRO Group.

METHODS

We have done an exhaustive review of published articles to look for general recommendations.

RESULTS

Randomized controlled trials, systemic reviews and meta-analysis are lacking in literature and there is wide variety of prescription techniques successfully used across the radiotherapy centers. BT can be delivered as superficial application (also called contact BT or plesiotherapy) or as interstitial for tumours thicker than 5 mm within any surface, including very irregular. In selected cases, particularly in tumours located within curved surfaces, BT can be advantageous modality from dosimetric and planning point of view when compared to external beam radiotherapy. The general rule in skin BT is that the smaller the target volume, the highest dose per fraction and the shortest overall length of treatment can be used.

CONCLUSION

Skin cancer incidence is rising worldwide. BT offers an effective non-invasive or minimally invasive and relative short treatment that particularly appeals to elder and frail population.

The feasibility of using ultrasound during follow-up for superficial non-melanoma skin cancers after electronic brachytherapy

Purpose

Non-melanoma skin cancers (NMSCs) can be treated with a number of modalities including surgery, topical chemotherapy, or radiotherapy. Amongst the radiotherapeutic options, electronic brachytherapy (eBT) is an appealing treatment as it is usually given in a few fractions, it leads to good outcomes, and is increasingly being used. However, currently no follow-up imaging is routinely used or recommended to evaluate treatment response of NMSC. We aimed to use ultrasound (US) in follow-up after eBT for superficial NMSC to assess its feasibility in detecting possible tumor response.

Material and methods

Fourteen patients were treated between 2013-2015 for a NMSC using eBT. US guidance was used for treatment planning prior to eBT initiation. After completion of eBT, patients were seen in follow-up for both clinical exam and a repeat US at 1 month to evaluate if tumor response was detectable.

Results

Of the 14 patients, 6 were male and 8 were female. The mean age was 71 years. With a median follow-up of 20.5 months, all patients had a complete response based on physical exam. Eleven patients appeared to have a complete response based on US obtained > 1 month after completing eBT. To date, there have been no local recurrences or progression, and all patients are alive.

Conclusions

US is an objective imaging modality that may be able to assess NMSC response after eBT. Based on follow-up imaging, further treatment or observation may be recommended. Although this study is hypothesis generating, larger studies with pathologic confirmation of recurrences would be needed to validate US use for follow-up, avoiding possible painful and scarring biopsies in case of low suspicion of recurrence.

Current status of brachytherapy in cancer treatment - short overview

Cancer incidence and mortality depend on a number of factors, including age, socio-economic status and geographical location, and its prevalence is growing around the world. Most of cancer treatments include external beam radiotherapy or brachytherapy. Brachytherapy, a type of radiotherapy with energy from radionuclides inserted directly into the tumor, is increasingly used in cancer treatment. For cervical and skin cancers, it has become a standard therapy for more than 100 years as well as an important part of the treatment guidelines for other malignancies, including head and neck, skin, breast, and prostate cancers. Compared to external beam radiotherapy, brachytherapy has the potential to deliver an ablative radiation dose over a short period of time directly to the altered tissue area with the advantage of a rapid fall-off in dose, and consequently, sparing of adjacent organs. As a result, the patient is able to complete the treatment earlier, and the risks of occurrence of another cancer are lower than in conventional radiotherapy treatment. Brachytherapy has increased its use as a radical or palliative treatment, and become more advanced with the spread of pulsed-dose-rate and high-dose-rate afterloading machines; the use of new 3D/4D planning systems has additionally improved the quality of the treatment. The aim of the present study was to present short summaries of current studies on brachytherapy for the most frequently diagnosed tumors. Data presented in this manuscript should help especially young physicians or physicists to explore and introduce brachytherapy in cancer treatments.

Hypofractionated radiation therapy for basal and squamous cell skin cancer: A meta-analysis

PURPOSE

To characterize the cosmetic outcomes and local recurrence (LR) rates of various hypofractionated radiation therapy (RT) regimens for skin basal and squamous cell cancers (BCCs/SCCs).

METHODS

A PICOS/PRISMA/MOOSE selection protocol was performed to identify 344 articles published between 1985-2016 evaluating patients with T1-2 N0 SCCs/BCCs treated with definitive RT. Biologically equivalent doses with α/β=3 (BED3s) were calculated. The primary endpoint was post-treatment cosmesis. Mixed effects regression models were used to estimate weighted linear relationships between BED3 and cosmetic outcomes.

RESULTS

A total of 21 studies were identified detailing the treatment of 9729 skin BCC/SCC patients, across seven countries, with external beam RT (n=9255) or brachytherapy (n=474). Median follow-up was 36months (range: 12-77). Median dose was 45Gy/11 fractions (interquartile range: 37.5Gy/6-55Gy/18) at 4Gy/fraction (interquartile range: 2.5-6Gy); most hypofractionated 18.75Gy/1. There was a trend to decreased "good" cosmesis with higher total dose: -3.4% "good" cosmesis/10Gy BED3, p=0.01. Similarly, there was a trend to increased "fair" cosmesis with higher dose: +3.8% "fair" cosmesis/10Gy BED3,p=0.006. At a BED3 of 100Gy, the expected rate of "good" cosmesis is 79% (95% confidence interval: 70%, 88%). Hypofractionated schedules produced similar cosmesis to conventionally fractionated schedules, at the same BED3. Fewer than 8% of patients experienced "poor" cosmesis, independent of dose or fractionation regimen.

CONCLUSION

Hypofractionated RT has favorable cosmesis for patients with skin BCCs/SCCs. We recommend clinicians consider these commonly-used regimens, which all have BED3 of ∼100Gy: 50Gy/15 fractions, 36.75Gy/7 fractions, or 35Gy/5 fractions, as they result in "good" cosmesis in 80% of patients.

Review: the reemergence of brachytherapy as treatment for non-melanoma skin cancer

Electronic brachytherapy (EBT) has seen a significant rise in use over the past few years in treating non-melanoma skin cancer (NMSC). However, the current literature in EBT remains scarce. Existing data on high-dose rate brachytherapy (HDR-BT) with surface applicators is often used to justify its efficacy and safety. In this review we study the two treatment modalities on their efficacy in treating NMSC and we explore the reasons behind the recent uprise in EBT. A literature review using PubMed was performed for articles published until January 2017 studying efficacy of HDR-BT and EBT for treating NMSC. HDR-BT demonstrated effective local control ranging from 96.2% to 100% up to 66 months of follow-up with acceptable cosmesis. For EBT, local control rates ranged from 90% to 100% with generally favorable tolerance and cosmesis outcome after roughly one year. While longer term data on EBT is needed, its short term efficacy shows promise as a possible alternative to surgery or other radiation therapy in a select group of patients.

Two years results of electronic brachytherapy for basal cell carcinoma

Purpose

The use of radiation therapy (RT) for non-melanoma skin cancer (NMSC) has been changing throughout the last century. Over the last decades, the use of radiotherapy has surged with the development of new techniques, applicators, and devices. In recent years, electronic brachytherapy (eBT) devices that use small x-ray sources have been introduced as alternative to radionuclide dependence. Nowadays, several devices have been incorporated, with a few series reported, and with a short follow-up, due to the recent introduction of these systems. The purpose of this work is to describe the clinical results of our series after two years follow-up with a specific eBT system.

Material and methods

This is a prospective single-center, non-randomized pilot study, to assess clinical results of electronic brachytherapy in basal cell carcinoma using the Esteya^® system. In 2014, 40 patients with 60 lesions were treated. Patient follow-up on a regular basis was performed for a period of two years.

Results

Twenty-six patients with 44 lesions achieved two years follow-up. A complete response was documented in 95.5% of cases. Toxicity was mild (G1 or G2) in all cases, caused by erythema, erosion, or alopecia. Cosmesis was excellent in 88.6% of cases, and good in the rest. Change in pigmentation was the most frequent cosmetic alteration.

Conclusions

This work is special, since the equipment’s treatment voltage was 69.5 kV, and this is the first prospective study with long term follow-up with Esteya^®. These preliminary report show excellent results with less toxicity and excellent cosmesis. While surgery has been the treatment of choice, certain patients might benefit from eBT treatment. These are elderly patients with comorbidities or undergoing anticoagulant treatment as well as those who simply refuse surgery or might have other contraindications.

Individualized 3D scanning and printing for non-melanoma skin cancer brachytherapy: a financial study for its integration into clinical workflow

Purpose

Skin cancer is the most common tumor in the population. There are different therapeutic modalities. Brachytherapy is one of the techniques used, in which it is necessary to build customized moulds for some patients. Currently, these moulds are made by hand using rudimentary techniques. We present a new procedure based on 3D printing and the analysis of the clinical workflow.

Material and methods

Moulds can be made either by hand or by automated 3D printing. For making moulds by hand, a patient’s alginate negative is created and, from that, the gypsum cast and customized moulds are made by hand from the patient’s negative template. The new process is based on 3D printing. The first step is to take a 3D scan of the surface of the patient and then, 3D modelling software is used to obtain an accurate anatomical reconstruction of the treatment area. We present the clinical workflow using 3D scanning and printing technology, comparing its costs with the usual custom handmade mould protocol.

Results

The time spent for the new process is 6.25 hours, in contrast to the time spent for the conventional process, which is 9.5 hours. We found a 34% reduction in time required to create a mould for brachytherapy treatment. The labor cost of the conventional process is 211.5 vs. 152.5 hours, so the reduction is 59 hours. There is also a 49.5% reduction in the financial costs, mostly due to lack of need of a computed tomography (CT) scan of the gypsum and the mould. 3D scanning and printing offers financial benefits and reduces the clinical workload.

Conclusions

As the present project demonstrates, through the application of 3D printing technologies, the costs and time spent during the process in the clinical workload in brachytherapy treatment are reduced. Overall, 3D printing is a promising technique for brachytherapy that might be well received in the community.

Does ultrasound measurement improve the accuracy of electronic brachytherapy in the treatment of superficial non-melanomatous skin cancer?

Purpose

Electronic brachytherapy (eBT) is a form of contact radiation therapy used for thin superficial non-melanomatous skin cancers (NMSCs). An accurate measurement of diameter and depth is important for eBT treatment planning. Therefore, we compared clinical measurements by an experienced physician to measurements obtained using ultrasound (US), an objective imaging modality, in order to determine if clinical measurements were accurate enough for adequate NMSC treatment.

Material and methods

Eighteen patients with 20 biopsy-proven NMSCs first had a clinical examination and then an US evaluation prior to starting eBT. One physician provided a clinical measurement for diameter and depth based on physical examination during radiation oncology consultation. The patients then had an US evaluation with a 14 or 18 MHz US unit, to determine both the diameter and depth measurements; eBT dose prescription was done using the US derived measurements. The clinical measurements and US measurements were compared using a t-test.

Results

Seventeen lesions were basal cell carcinoma and 3 lesions were squamous cell carcinoma. The most common location was the nose (10 lesions). The difference between the clinical and the US derived measurements for the second largest diameter was found to be statistically significant (p = 0.03), while the difference for the largest diameter of the lesions was not (p = 0.24). More importantly, the depth measurements obtained with US were also found to be significantly different from the clinical estimates (p = 0.02). All patients have had a complete response to therapy with a median follow-up of 24 months.

Conclusions

Statistically different measurements were obtained in 2 of 3 parameters used in choosing applicator size and prescription depth using an US assessment. The data presented suggests that US is a more objective modality than clinical judgment for determining superficial NMSC diameter and prescription depth for personalized eBT planning.

Electronic brachytherapy management of atypical fibroxanthoma: report of 8 lesions

Purpose

To evaluate the suitability of treating atypical fibroxanthoma (AFX), an uncommon skin malignancy, with electronic brachytherapy.

Material and methods

From Feb 2013 to Sep 2014, we were referred a total of 8 cases of AFX in 7 patients, all involving the scalp. All of them were treated with electronic brachytherapy 50 Kev radiations (Xoft Axxent^®, Fremont, California). All lesions received 40 Gy in two fractions per week with 5mm margins.

Results

At a median follow-up of 23.7 months, the local recurrence rate is 12.5%. The single lesion that failed was not debulked surgically prior to electronic brachytherapy.

Conclusions

To our knowledge, this is the first report in the literature on the use of radiation therapy as curative primary treatment for AFX. No contraindication to the use of radiations is found in the literature, with surgery being the sole treatment for AFX noted. Our recurrence rate is 0% for debulked lesions. Risk of recurrence is mitigated with surgical debulking prior to brachytherapy. Electronic brachytherapy appears to be a safe and effective treatment for debulked AFX. Multiple excisions, skin grafting, and wound care can be avoided in elderly patients by the use of electronic brachytherapy.

Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature

PURPOSE

The incidence of non-melanoma skin cancer (NMSC) has been increasing over the past 30 years. There are different treatment options and surgical excision is the most frequent treatment due to its low rates of recurrence. Radiotherapy is an effective alternative of surgery, and brachytherapy (BT) might be a better therapeutic option due to high radiation dose concentration to the tumor with rapid dose fall-off resulting in normal tissues sparing. The aim of this review was to evaluate the local control, toxicity, and cosmetic outcomes in NMSC treated with high-dose-rate BT (HDR-BT).

MATERIAL AND METHODS

In May 2016, a systematic search of bibliographic database of PubMed, Web of Science, Scopus, and Cochrane Library with a combination of key words of "skin cancer", "high dose rate brachytherapy", "squamous cell carcinoma", "basal cell carcinoma", and "non melanoma skin cancer" was performed. In this systematic review, we included randomized trials, non-randomized trials, prospective and retrospective studies in patients affected by NMSC treated with HDR-BT.

RESULTS

Our searches generated a total of 85 results, and through a process of screening, 10 publications were selected for the review. Brachytherapy was well tolerated with acceptable toxicity and high local control rates (median: 97%). Cosmetic outcome was reported in seven study and consisted in an excellent and good cosmetic results in 94.8% of cases.

CONCLUSIONS

Based on the review data, we can conclude that the treatment of NMSC with HDR-BT is effective with excellent and good cosmetics results, even in elderly patients. The hypofractionated course appears effective with very good local disease control. More data with large-scale randomized controlled trials are needed to assess the efficacy and safety of brachytherapy.

Skin surface brachytherapy: A survey of contemporary practice patterns

PURPOSE

The aim of this study was to define current patterns of care among radiation oncologists who use skin surface brachytherapy for the treatment of cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC) in academic and community settings.

METHODS AND MATERIALS

A 30-question electronic survey was administered to clinician members of the American Brachytherapy Society. The respondents were asked to provide details regarding their clinical practice and their approach to skin surface brachytherapy.

RESULTS

A total of 16 surveys were returned. Among the respondents, aggregate experience varied from 8 to 1800 cases. Most preferred brachytherapy over external beam radiation because of shorter treatment course, conformality of treatment for irregular or curved targets, and shallow dose deposition. Of the total, 60% of respondents routinely estimated lesion depth via ultrasound before initiating treatment. Treatment margin on gross disease varied widely (range, 3-15 mm; median, 5 mm). Hypofractionation was the preferred dose schedule. Prescribed doses ranged from 30 Gy in five fractions to 64 Gy in 32 fractions (EQD2, 40 Gy-65 Gy). There was a tendency to increase the number of fractions for larger targets, although some used the same fractionation regardless of anatomic location or lesion size. There was no consensus on dosimetric constraints, and some respondents reported cases of severe toxicity, particularly when treating the pretibial skin.

CONCLUSIONS

This pattern of care study suggests that skin brachytherapy can be a convenient and safe tool for treatment of BCC and cSCC. Prospective trials and the development of expert consensus guidelines would be beneficial for optimizing skin surface brachytherapy and reducing practice variation.

Novel simple templates for reproducible positioning of skin applicators in brachytherapy

PURPOSE

Esteya and Valencia surface applicators are designed to treat skin tumors using brachytherapy. In clinical practice, in order to avoid errors that may affect the treatment outcome, there are two issues that need to be carefully addressed. First, the selected applicator for the treatment should provide adequate margin for the target, and second, the applicator has to be precisely positioned before each treatment fraction. In this work, we describe the development and use of a new acrylic templates named Template La Fe-ITIC. They have been designed specifically to help the clinical user in the selection of the correct applicator, and to assist the medical staff in reproducing the positioning of the applicator. These templates are freely available upon request.

MATERIAL AND METHODS

Templates that were developed by University and Polytechnic Hospital La Fe (La Fe) and Hospital Clínica Benidorm (ITIC) in cooperation with Elekta, consist of a thin sheet made of transparent acrylic. For each applicator, a crosshair and two different circles are drawn on these templates: the inner one corresponds to the useful beam, while the outer one represents the external perimeter of the applicator. The outer circle contains slits that facilitate to draw a circle on the skin of the patient for exact positioning of the applicator. In addition, there are two perpendicular rulers to define the adequate margin. For each applicator size, a specific template was developed.

RESULTS

The templates have been used successfully in our institutions for more than 50 patients' brachytherapy treatments. They are currently being used for Esteya and Valencia applicators.

CONCLUSIONS

The template La Fe-ITIC is simple and practical. It improves both the set-up time and reproducibility. It helps to establish the adequate margins, an essential point in the clinical outcome.