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Table of Contents 
THERAPEUTIC ROUND
Year : 2010  |  Volume : 55  |  Issue : 4  |  Page : 363-366
Plesiotherapy for non-melanoma skin cancer: Innovating to overcome!


1 Department of Radiation Oncology, AMRI Hospital, Kolkata, West Bengal, India
2 Department of Radiation Oncology, NRS Medical College, Kolkata, West Bengal, India
3 Department of Radiation Oncology, North Bengal Medical College, Siliguri, Darjeeling, West Bengal, India

Date of Web Publication4-Jan-2011

Correspondence Address:
Amitabh Ray
AMRI Hospital, Annexe Building, P-4&5, CIT scheme-LXXII, Block A, Gariahat Road, Kolkata 700029, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.74547

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   Abstract 

Background: The non-surgical management of non-melanoma skin cancers is an area requiring clinical investigation. Radiotherapy has a role in treatment for a defined subset of patients. Aims: The application of radiotherapy is subject to availability of proper equipment, non-availability of which precludes appropriate radiotherapy in most centers in third world countries. Materials and Methods: The introduction of innovations is needed to circumvent this. Plesiotherapy is such a mode of therapy for non-melanoma skin cancer. Results: In this paper we present successful management of a cohort of non-melanoma skin cancer patients with plesiotherapy using stepping source 192 Ir HDR source. Conclusions: Plesiothrapy is an effective mode of therapy for non-melanoma skin cancer.


Keywords: Plesiotherapy, non-melanoma skin cancer, HDR Brachytherapy


How to cite this article:
Ray A, Basu A, Deb A, Aich RK, Biswas LN, Pal J K. Plesiotherapy for non-melanoma skin cancer: Innovating to overcome!. Indian J Dermatol 2010;55:363-6

How to cite this URL:
Ray A, Basu A, Deb A, Aich RK, Biswas LN, Pal J K. Plesiotherapy for non-melanoma skin cancer: Innovating to overcome!. Indian J Dermatol [serial online] 2010 [cited 2019 Oct 21];55:363-6. Available from: http://www.e-ijd.org/text.asp?2010/55/4/363/74547



   Introduction Top


The incidence of skin cancer has been increasing over the past 30 years and is today the most common cancer worldwide. [1] Of the skin cancers, the nonmelanoma variety constitutes the majority (95%). [1] With an increase in incidence, a good evidence base is essential to make informed treatment decisions.

Radiotherapy is one of the commonly used modalities for treatment in nonmelanoma skin cancers. It is of two types: teletherapy ("tele" - from a distance) and brachytherapy ("brachy" is Greek for short distance). Plesiotherapy is a form of brachytherapy where the treatment of superficial lesions is done using customized radioactive molds. Radiotherapy of skin carcinomas has been done, generally, with low-energy X-rays (90 kV or less) or electrons of a linear accelerator. Some cases have been treated with interstitial brachytherapy with 192 Ir sources placed across the tumor volume or wax molds (plesiotherapy) with gamma ray emitters (Ra, Co, Au, Rn, Cs). The continuous technological advances produced in the field of brachytherapy have made possible the use of highly accurate after-loading equipment, with radioactive sources, usually 192 Ir, of few millimeters length and less than 1 mm diameter and high activity. This high-dose-rate (HDR) equipment is accompanied by programs of treatment planning and calculation of dose distribution incorporating sophisticated treatment optimization algorithms, which allow one to modify the dosimetry in order to obtain an individually adjusted dose distribution in each case.

The management of nonmelanoma skin cancers is fraught with inconsistency attributable to the poor evidence base for this most common human cancer. [2] Excisional surgery, curettage and cauterisation, radiotherapy, cryotherapy, photodynamic therapy, and imiquimod are the main treatments used.[3] The current standard of care is surgery as the results of randomized trials favor this modality. [4] The management of patients unsuitable for surgery remains an area of active investigation. In this study, we report the results of patients treated at a single center with plesiotherapy for nonmelanoma skin cancers. These patients were either deemed unsuitable or were unwilling for surgery.


   Materials and Methods Top


Patients attending the Radiation Oncology department were deemed suitable for the study if they1had localized nonmetastatic nonmelanoma skin cancer and had refused operation or were unsuitable for surgery. The surgical suitability was decided by a plastic surgeon jointly with the radiation oncologist and was dependant on age, site, previous treatment, and patient's preference. The performance status of the patient was required to be above 70% on the Karnofsky performance status scale. [Table 1] shows the details of patients in the study.
Table 1 :Patient characteristics


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Plesiotherapy was done using the stepping source HDR 192 Ir Microselectron (Nucletron BV). The patients were immobilized using thermoplastic molds. After preparation, a window was cut out in the area overlying the disease. A lead wire was used to indicate the target volume, which included the disease with 1.5 cm margin in all lateral directions. Flexible plastic catheters were now fixed to the thermoplastic mold using Paris system rules. This was done to ensure ease of optimization during planning. After fixation of catheters, orthogonal X-rays were taken and catheters were reconstructed from these. Using the lead wire as guide, target volume reconstruction was done. Dose points were created around the catheters and dose prescription was made. Following this, volumetric optimization was performed to make the prescription isodose conform to the target volume. Dose prescription was made at 90% isodose. Dose upto 110% was allowed within the target volume. The usual depth of treatment was 0.5 cm in smaller tumors (less than 2 cm) and 0.75 cm in larger tumors. The total prescribed dose was 4500 cGy delivered in twice daily fractions of 500 cGy each at least 6 h apart for nine fractions. Treatment was completed in 5 days; the first day was utilized for planning and a single fraction was delivered in the evening.

Following the completion of treatment, patients were followed up at weekly intervals for the first month, monthly intervals for the first 3 months and at 3-month intervals up to the first year. Then they were examined every 4 months till the end of the second year. Following this, patients have been kept on 6-month follow-ups for at least 5 years.


   Results Top


Eleven patients were treated with plesiotherapy over the course of 2 years. The median age of presentation was 72 years with 70% of patients being male. Nine patients presented with basal cell carcinoma, one patient presented with squamous cell carcinoma, and one patient presented with basi-squamous carcinoma. Two patients presented in the postoperative period, one with positive margins after surgery and another with recurrence after previous surgical management. Six patients had a maximum tumor size of less than 1 cm, four patients had a tumor size between 1 and 2 cm, while one patient had a 2.5 cm tumor pretreatment. Five patients were treated with radiotherapy as they had refused surgical management. The rest were medically unfit for undergoing surgery, with pre-existing cardiac morbidity being the most common factor precluding surgery.

All patients responded very well to treatment. Moist desquamation occurred in all the patients with peak at around 2 weeks after the completion of therapy [Figure 1]. This was expected considering the accelerated mode of radiotherapy delivery that was used in the study. All the patients showed complete response to treatment at around 3 months. None of the patients have failed locally so far [[Figure 2]a-c]. One patient failed regionally and was managed with external beam radiotherapy.
Figure 1 :Treatment procedure for plesiotherapy

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Figure 2 :(a) Pretreatment noduloulcerative lesion with bleeding; (b) post-treatment at 6 months; (c) post-treatment lesion at 2 years

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The median follow- up for this study is 13 months (3-26 months). The most severe late complication was the development of radiation-induced dyspigmentation, which was uniformly seen throughout the entire study group. Three of the patients also showed telengiectasia in the irradiated area.


   Discussion Top


Nonmelanoma skin cancer is the most common of all cancers worldwide. [1] The lower incidence of skin cancers in countries like India is attributable to skin pigments, which are considered to be protective. [5] It is usually a disease of old age, [6] a fact borne out in this study.

The availability of radiotherapy in Third World countries like India is limited to telecobalt and LDR or HDR brachytherapy equipment for most centers. [7] Linear accelerators with the electron beam therapy facility and low-energy X-rays are not available in most centers including ours. The innovation tried out in this study was to circumvent this problem. We aimed at achieving surface treatment in a small area with minimal dose being delivered to deeper tissues. The smallest field size achievable with Theratron 780E telecobalt machine is 4 Χ 4 cm. Although smaller field sizes are possible with newer machines and blocks, the penumbra associated with telecobalt machines makes treatment of such small areas impractical. Delivering dose to smaller areas meant possibility of safely utilizing higher dose per fraction and hence decreasing the total treatment time. This was successfully achieved in the study.

The treatment of nonmelanoma skin cancers is primarily done with surgery. One randomized controlled trial of 347 patients compared surgical excision with frozen section margin control versus radiotherapy in primary basal cell carcinoma of the face less than 40 mm in diameter. At 4 years significantly more persistent tumors and recurrences had occurred in the radiotherapy group than in the surgery group (odds ratio 0.09, 95% confidence interval 0.01-0.67). Cosmetic outcome favored surgery. After radiotherapy, more than 65% of the patients developed dyspigmentation and telangiectasia, and skin atrophy affected 41%. [3]

For patients who are not candidates for surgery, the options are radiotherapy, cryotherapy, photodynamic therapy, and imiquimod. The literature is not very clear regarding the optimal nonsurgical modality of treatment. Traditional indications of radiotherapy have included treatment of lesions in eyelid, nose, and external ear for cosmetic reasons, medically inoperable cases and older age. In the postoperative setting, radiotherapy is offered when perineural or lymphovascular invasion is seen on histopathology or positive margins reported are not addressed with revision surgery. [8] Data published from Massachusetts General Hospital and MD Anderson Cancer Center have demonstrated that with orthovoltage/megavoltage radiation, hypofractionated treatment regimens with high dose per fraction and lower number of fractions give excellent results with acceptable toxicity for smaller (<2 cm) tumors. Moreover, photon margins of up to 1 cm and electron margins of 1-1.5 cm laterally and treatment depth of 5 mm below the expected tumor depth are recommended for < 2 cm tumors.

One study of 93 patients compared radiotherapy with cryotherapy for low-risk primary BCC. Significantly more recurrences occurred in the cryotherapy group than in the radiotherapy group at 1 year - 39% (17/44) versus 4% (2/49). Cosmetic results were not significantly different. The degree of pain and discomfort from the treated areas was the same in both groups. Hypopigmentation was more common than hyperpigmentation with both modes of treatment (81% in the radiotherapy group and 88% in the cryotherapy group). Seven patients treated with radiotherapy developed some radiation telangiectasia. [9]

Photodynamic therapy (PDT) has been compared with cryotherapy in one study. The recurrence rate at 2 years was lower in the PDT group with better cosmesis, although more patients indicated pain and discomfort during and after treatment with photodynamic therapy than with cryotherapy. [10]

In this study we were able to use stepping source HDR 192 Ir (Microselectron) for plesiotherapy with minimal resource and manpower investment. By objective assessment, cosmesis was definitely poor with all patients developing dyspigmentation [Figure 2], which was expected considering the fractionation schedule employed, although it was subjectively acceptable to the patients undergoing the treatment. None of the patients have had disease recurrence at site of plesiotherapy. No other troublesome complications have emerged so far.

The only patient who failed regionally was a patient of squamous cell carcinoma. He developed regional metastasis to the level 1b neck node on the left side and was subsequently treated with external beam radiotherapy.

In the course of conducting the study, it was realized that an optimal utilization of available resources was required for the delivery of quality radiotherapy. The mere absence of one modality should make us take cognizance of the full range of operations the available equipment is capable of. The successful management of this cohort of patients shows the importance of innovation in radiation oncology, particularly in Third World countries and low-resource centers.


   Conclusion Top


The nonsurgical management of nonmelanoma skin cancers is an area needing further research to decide on an optimal treatment modality.

Radiotherapy is associated with significant long-term cosmetic defects, and the evidence for curettage and cautery, cryotherapy, photodynamic therapy, and imiquimod is inconclusive at present. In this setting, it seems reasonable to offer radiotherapy to a defined subset of patients. The treatment should be tailored to spare deeper tissues and must be able to treat small areas with precision. Electron beam therapy and low-energy X-rays are ideal but not widely available in our country. HDR brachytherapy using flexible catheters can be combined with thermoplastic immobilization masks to fashion plesiotherapy applicators. Such innovations not only expand the applicability of available resources, but also help provide optimal healthcare to patients.

 
   References Top

1.Preston D, Stern R. Nonmelanoma cancers of the skin. N Engl J Med 1992;327:1649-62.  Back to cited text no. 1
    
2.Bath-Hextall F, Bong J, Perkins W, Williams H. Interventions for basal cell carcinoma of the skin: systematic review Br Med J 2004;329;705-9   Back to cited text no. 2
    
3.Price P, Sikora K, editors. Treatment of Cancer. London: Arnold; 2002. p. 1107-25.  Back to cited text no. 3
    
4.Avril M, Auperin A, Margulis A, Gerbaulet A, Duvillard P, Benhamou E, et al. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. Br J Cancer 1997;76:100-6.  Back to cited text no. 4
    
5. Yamaguchi Y, Beer JZ, Hearing VJ. Melanin mediated apoptosis of epidermal cells damaged by ultraviolet radiation: factors influencing the incidence of skin cancer. Arch Dermatol Res 2008;300:43-50.  Back to cited text no. 5
    
6.Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust 2006;184:6-10.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Yarnold J. A view from far - Letter from Europe. J Can Res Ther 2005;1:9-11.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Veness MJ. The important role of radiotherapy in patients with non-melanoma skin cancer and other cutaneous entities. J Med Imaging Radiat Oncol 2008;52:278-86.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Hall V, Leppard B, McGill J, Kesseler M, White J, Goodwin P. Treatment of basal-cell carcinoma: comparison of radiotherapy and cryotherapy. Clin Radiol 1986;37:33-4.  Back to cited text no. 9
    
10.Wang I, Bendsoe N, Klinterberg C, Enejder A, Andersson-Engels S, Svanberg S, et al. Photodynamic therapy vs. cryosurgery of basal cell carcinomas: results of a phase III clinical trial. Br J Dermatol 2001;144:832-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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