Skin Care Patients (and an alternative to surgery)

eight fractions up to 12 fractions for the various protocols. The protocol that will deliver the best results for the specific lesion due to size, location, and histology, is prescribed by a Radiation Oncologist. “The treatments are typically painfree and well-tolerated with fast recovery times relative to protracted external beam radiotherapy (EBRT) during which schedules are frequently 20 to 30 daily fractions to 50 to 60Gy”. Licensed Radiation Physicists calculate and calibrate the precise prescription of radiation dose prescribed by the Radiation Oncologist. Licensed Radiation Therapists are the medical professionals that will interact, treat, and care for the patients in the dermatology clinic while they undergo the treatment protocol. A post-biopsy patient with a pathology report confirming the evidence of cancer can schedule a consultation and simulation to begin. From there, the medical team will develop a treatment plan to begin electronic brachytherapy radiation treatment. The patient can begin treatments within a week of consultation, in most cases, once insurance benefits have been processed. The treatments are delivered at least 36 hours apart for two treatments per week over a four-to-five-week period for most patients. In comparison to MOHS surgery, the most common toxicity between the two modalities is hypopigmentation. Radiation can cause mild side effects such as erythema, dry and moist desquamation (skin peeling), hypo and hyperpigmentation, and telangiectasia (dilated small blood vessels on the skin). The most common side effect is very comparable to phases of sunburn, ranging from mild to severe. Despite the skin changes the patient undergoes during electronic brachytherapy, “physicians rated cosmesis of the treatment sites as “excellent” or “good” in 98% of EBT-treated lesions”. Radiation related side effects are confined to the targeted area and do not extend to other anatomy of the body.

The consultation consists of extensive information about this modality shared with the patient. Question and answer session between the patient and the therapist comprises most of the time during this appointment. The essential goal is to assist the patient in making an informed decision on the treatment option that best suits them personally. Every patient is unique, as is their cancer journey. If the patient decides to continue with electronic brachytherapy to treat their cancer lesion, the next step is simulation. The simulation consists of deciding which standard surface applicator is adequate, flexi-shield cutout size and placement, if applicable, and prescribed fractionation. This is a process of measuring the skin cancer lesion and including a 5mm (about 0.2 in) margin to encompass any residual disease that is not visible to the naked eye. Photographs are taken and uploaded to the patient’s medical chart to document the precise location and setup for treatment. The information gathered is accessible by the Radiation Oncologist and physics team to create a radiation treatment plan.

Once the patient has undergone consultation and simulation, treatment appointments are scheduled appropriately. Treatments are routinely scheduled on a Monday/Wednesday or a Tuesday/Thursday regime over the four- or five-week duration. The information gathered in the simulation is utilized for treatment setup. The standard surface applicators range in size from 10mm, 20mm, 35mm, and 50mm diameter. Lesions up to four centimeters in diameter are treatable by the Xoft® Axxent® Electronic Brachytherapy System®. The typical dose depth is 3mm (about 0.12 in) for most lesions. This system has the capability of customizing up to a 5mm dose depth, if required for optimal coverage. The patient is positioned on an exam chair or table to perform the treatment. A Vac-Lok™ bag, a bean bag immobilization pillow, is used to stabilize the area of anatomy that will undergo treatment. The patient is encouraged to relax to minimize the amount of movement during treatment. The Xoft radiation controller is then positioned to accommodate the patients’ comfort while treatment is delivered. The standard surface applicator and flexi-shield cutout, if applicable, are placed flush on the lesion as determined from the simulation. The beam on time, actively administering radiation, varies from approximately three to eight minutes. Most appointments, the patient is checked in, treated, and out within 10 to 15 minutes. Once the treatment has concluded, the patient can continue their daily routine as usual. Showering, facial routine, and normal activities can resume without restriction in most instances. Exposure to direct sunlight should be limited and paired with protective apparel and sunscreen.

During the treatment process, typical maintenance of the radiation site is satisfied with Aquaphor Healing Ointment®. Aquaphor contains petroleum jelly and other ingredients that soothe the skin during all phases of radiation treatment. After the full treatment protocol is complete, the patient will schedule a six week follow up to allow the skin time to regenerate and heal. The dermatologist will visually examine the treatment site to ensure proper healing and rule out any recurrence. The follow up regime schedule is at six weeks, three months, six months, and then annually to monitor the area. The research gathered from proven treatment protocols dating back to 2010, demonstrates 40Gy distributed in eight or ten fractions has shown a local control rate of ~97 percent.

Patients diagnosed with basal or squamous cell carcinomas that are four centimeters or less in diameter are potential candidates for electronic brachytherapy. Common anatomy treated are ears, noses, cheeks, forehead, scalp, hands, arms, legs, and back. If you would like more information on this treatment modality for non-melanoma skin cancer, contact your dermatologist.

Stegman, Lauren D. MD, PhD, DABR. Electronic Brachytherapy for Nonmelanoma Skin Cancer. Oncology Times 39(9):p 38-39, May 10, 2017. | DOI: 10.1097/01.COT.0000516752.51518.13

Delishaj D, Rembielak A, Manfredi B, Ursino S, Pasqualetti F, Laliscia C, Orlandi F, Morganti R, Fabrini MG, Paiar F. Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature. J Contemp Brachytherapy. 2016 Dec;8(6):533-540. doi: 10.5114/jcb.2016.64112. Epub 2016 Dec 2. PMID: 28115960; PMCID: PMC5241375.

Patel R, Strimling R, Doggett S, Willoughby M, Miller K, Dardick L, Mafong E. Comparison of electronic brachytherapy and Mohs micrographic surgery for the treatment of early-stage non-melanoma skin cancer: a matched pair cohort study. J Contemp Brachytherapy. 2017 Aug;9(4):338-344. doi: 10.5114/jcb.2017.68480. Epub 2017 Jun 23. PMID: 28951753; PMCID: PMC5611452

Bhatnagar A, Patel R, Werschler WP, Ceilley RI, Strimling R. High-dose Rate Electronic Brachytherapy: A Nonsurgical Treatment Alternative for Nonmelanoma Skin Cancer. J Clin Aesthet Dermatol. 2016 Nov;9(11):16-22. Epub 2016 Nov 1. PMID: 28210385; PMCID: PMC5300713.

Patel R, Strimling R, Doggett S, Willoughby M, Miller K, Dardick L, Mafong E. Comparison of electronic brachytherapy and Mohs micrographic surgery for the treatment of early-stage non-melanoma skin cancer: a matched pair cohort study. J Contemp Brachytherapy. 2017 Aug;9(4):338-344. doi: 10.5114/jcb.2017.68480. Epub 2017 Jun 23. PMID: 28951753; PMCID: PMC5611452.