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Table of Contents
CORRESPONDENCE
Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 233-234

High-dose-rate brachytherapy for the treatment of nonmelanoma skin cancer


1 Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Dermatology; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
3 College of Medicine; Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Date of Web Publication17-Dec-2019

Correspondence Address:
Dr. Cheng-Che Lan
Department of Dermatology, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, 100 Shih Chuan 1st Road, Kaohsiung 80708
Taiwan
Dr. Jen-Yang Tang
Department of Radiation Oncology, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, 100 Shih Chuan 1st Road, Kaohsiung 80708
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_50_18

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How to cite this article:
Huang YY, Lan CC, Tang JY. High-dose-rate brachytherapy for the treatment of nonmelanoma skin cancer. Dermatol Sin 2019;37:233-4

How to cite this URL:
Huang YY, Lan CC, Tang JY. High-dose-rate brachytherapy for the treatment of nonmelanoma skin cancer. Dermatol Sin [serial online] 2019 [cited 2020 Sep 25];37:233-4. Available from: http://www.dermsinica.org/text.asp?2019/37/4/233/273101



Dear Editor,

Cutaneous squamous cell carcinoma (cSCC) is the second most common nonmelanoma skin cancer (NMSC) in the world,[1] and its incidence continues to rise. Surgical excision remains the most popular treatment so far due to its low recurrence rate. However, 95% of these tumors grow on the face, a major sun-exposed area. In these cases, resection would leave major defects, leading to serious cosmetic concerns.

Recently, the Xoft® Axxent® Electronic Brachytherapy (eBx®) System® has been included as a therapeutic modality for treating NMSC located at esthetically sensitive anatomic regions.[2] This high-dose-rate brachytherapy (HDR-BT) device concentrates high doses of radiation on tumors, but spares nearby normal tissue via rapid dose fall-off effect, which yields low complication rate and better cosmetic outcomes.[3] In this report, we describe our experience of an elderly facial cSCC case treated with HDR-BT and proposed its role in the management of large NMSCs.

The patient was an 86-year-old male who came to our dermatology outpatient clinic in October 2015 due to a large ulcerative wound on the bridge of his nose for 10 years [Figure 1]a. He was previously diagnosed with squamous cell carcinoma, cT2N0M0, Stage I at the same site in 2005, during which he refused to accept treatment. The tumor had grown without therapy and HDRBT of 50 Gy/10 fx was then administered in 1 month's span, from November to December 2015. The tumor showed good response to irradiation (95% regression) with some residual lesions [Figure 1]b. We suggested Mohs surgery for eradication of tumor cells, but the patient kindly refused due to concerns about old age. After 3 months of relapse, local recurrences from residuals lesions were noted in March 2016.
Figure 1: (a) Squamous cell carcinoma over the nose root, (b) 1 month later after treatment with high-dose-rate brachytherapy (50 Gy/10 fx)

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After discussing with the patient, we decided to administer booster radiation, which led us to consider the safety accumulated dose for irradiation of recurrent facial skin cancer. With linear accelerator-based radiotherapy, conventional fractionation of 2 Gy per day is normally used and it has been suggested that cumulative dose to the recurrent skin lesion should be under 110 Gy for best results and cosmesis.[4] including the risk of radiation-induced secondary malignancy. Taking these into account, we administered two rounds of booster doses (each 10 Gy/2 fx) for the patient in April/May and December 2016, respectively, both of which yielded partial remission. We also suggested other treatment alternatives to the patient, including topical chemotherapeutic agents and immunotherapy. Pembrolizumab, a PD-1 targeting antibody, was hence suggested but declined due to the cost and potential side effects. As a result, tumor recurrence on the nose bridge with central crust and mild ulceration was noted again in January 2017. Thus, a high surface dose of 60 Gy/12 fx was given. For repeated recurrences, subsequent reirradiation with 10 Gy/2 fx and 20 Gy/4 fx (2 times each) in the same year failed in local tumor control. Despite the unsuccessful salvage therapy, the patient still resisted surgery.

From our experience in treating this patient, we conclude that even though HDR-BT is a safe and effective therapeutic modality for cSCCs located at difficult sites, its efficacy toward recurrent tumors is limited. As mentioned previously, the best therapeutic outcome is achieved when an accumulated BED of 110 Gy on skin surface is provided. Any higher cumulative dose does not benefit the patient and is instead associated with increased chance of skin defects. As seen in our case, subsequent irradiation showed lack of effect. Thus, HDR-BT cannot be used as monotherapy for treating high-risk NMSCs. Instead, surgical excision immediately following HDR-BT (within 3 months) is necessary to prevent recurrences. Despite these conclusions, further clinical trial supporting the combination of HDR-BT and surgery being more effective than standard surgery in the treatment of large NMSCs is still required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Parikh SA, Patel VA, Ratner D. Advances in the management of cutaneous squamous cell carcinoma. F1000Prime Rep 2014;6:70.  Back to cited text no. 1
    
2.
Delishaj D, Rembielak A, Manfredi B, Ursino S, Pasqualetti F, Laliscia C, et al. Non-melanoma skin cancer treated with high-dose-rate brachytherapy: A review of literature. J Contemp Brachytherapy 2016;8:533-40.  Back to cited text no. 2
    
3.
Skowronek J. Brachytherapy in the treatment of skin cancer: An overview. Adv Dermatol Allergol Postępy Dermatol Alergol 2015;32:362.  Back to cited text no. 3
    
4.
Chao CK, Gerber RM, Perez CA. Reirradiation of recurrent skin cancer of the face. A successful salvage modality. Cancer 1995;75:2351-5.  Back to cited text no. 4
    


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