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The Dermatology Digest - Superficial Radiation Therapy Clinical Benefits and Studies

Not all treatment modalities for non-melanoma skin cancer are the same. In Part 2 of this video series, Dr. Mark Nestor discusses studies that demonstrate the clinical benefits of SRT, including cure rate, cosmesis, and consensus guidelines.

About This Series

In this 3-part educational series, Dr. Mark Nestor reviews the core concepts and treatment modalities in NMSC, provides a literature review of the clinical benefits of SRT, and presents and discusses patient cases.

Treating Non-Melanoma Skin Cancer

Drexel University College of Medicine study suggests all organ transplant recipients should receive total-body screenings for skin cancer

Michael E. Jones; Cherrell Hardy, BSN, RN; and Julie Ridgway, BSN, RN

Jones Keloids Paper - July 2016 Advances in Skin & Wound Care

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Earl Stoddard M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm

CSN: DAT004
January 28, 2011

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to a local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs to choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

The patient is a 78-year-old female who presented with a subtle crusty lesion on the right upper lip. She has a history of asthma and hypertension. She was referred to us for Mohs Micrographic surgery, but she wishes to avoid surgery if possible. She has had multiple skin cancers in the past.

Patient Management

The lesion on the right upper lip was biopsied and found to be a Squamous Cell Carcinoma (SCC) in situ that was amenable to SRT. The options of Mohs surgery or SRT were discussed with the patient. The patient opted for superficial radiation therapy for this lesion.

Treatment Parameters

The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this.

Patient Outcome

The patient tolerated the treatment with no side effects. The patient returned 2 weeks post-op with a good erythematous reaction from the SRT treatment. This should give her a good chance of cure.

Comment: The patient could have benefited from further fractionation for cosmesis (i.e) 300 cGy x15 or 250cGy x20, but due to her age and frailty this fractionation schedule worked well. The patient passed away 8 months after the treatment was finished from other causes.

Click here to download a PDF of this case study.

Dermatology Association of Tallahassee

CSN: DAT001
September 06, 2010

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Panhandle, as well as our own general dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral. Depending on the location, size, depth, and aggressiveness of the individual tumor, juxtaposed to the patient’s age and health status we discuss Mohs vs SRT as part of informed consent. We discuss radiation with all patients over 65 with the option of treatment either here in the office or by radiation oncology. We end up using it in about 10% of these patients over 65 who are referred for Mohs surgery. We have been doing this successfully for 25+ years and recently calculated our 10- year cure rates, which compare very favorably to Mohs surgery.

Patient History

The patient is a 103-year-old white female who lived independently and drove until two years ago. She still is quite independent and lives in an assisted living home. She has had a history of multiple skin cancers over the last 25 years, including some difficult and aggressive squamous cells on her face.

Patient Prognosis & Management

The patient presented with a pink crusted papule on her nasal tip, which would not heal. A biopsy showed this to be a superficial and nodular basal cell estimated depth less than 3 mm. She was given the option of observation or treatment and opted for treatment with superficial x-ray, which she had opted for in the past for other facial skin cancers with success.

Treatment Plan

The patient opted for superficial radiation treatment for this lesion. The lesion was circled and an appropriate shield size 1.6 cm was fashioned out of lead sheet 0.762 mm thick. Using the 3 cm cone, 5 fractions of 700 cGy were delivered at 60 kV, 10 ma with a D . of 9.6 mm. The patient received a total of 3,500 cGy to the area over a two week period.

Basal Cell Carcinoma (BCC) of the Nose in a 103 Year Old Female

Patient Outcome

The patient tolerated the treatment with no side effects. The patient returned two weeks post-op with a good erythematous reaction from the SRT treatment. This should give her a good chance of cure (see photos below).

Patient Quote

“I am very thankful for this x-ray treatment. I just don’t know what I would do if I had to have surgery on my nose.”

Click here to download a PDF of this case study

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Earl Stoddard M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm

CSN: DAT006
January 28, 2011

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

The patient has a history of difficult skin cancers including 6 on her nose in the recent past. She has had numerous other skin cancers as well. She has a history of hypertension and diabetes.

Patient Management

The patient had 4 skin cancers on her nose 3 of which were treated with Mohs, 1 of which was treated with Superficial x-ray. On a follow-up visit 2 more skin cancers were found on her nose and treated with Mohs. See discussion below.

Treatment Parameters

The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this. The tumor depth was estimated to be <5 mm. A 0.762 mm thick lead shield was fashioned to include a 2 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Sensus RT machine with a 3 cm cone, 5 fractions of 700 cGy were delivered at 50 kv, 10 ma with a D1/2 of 5.8 mm. The patient received a total of 3500 cGy to the area over a two week period.

Clinical Photos

The patient presents with biopsy proven Nodular BCC labeled #1. There is a suspicious lesion on the right ala labeled #2 this was biopsied and found to be a Nodular BCC. A second suspicious lesion labeled #3, is identified inferior to site #1, this was biopsied and found to be a Nodular BCC. A third suspicious lesion labeled #4, is identified superior to site #1, this is biopsied and found to be a Nodular BCC.

Discussion

Sites 1,3 and 4 were along the midline nose and after Mohs were amenable to a midline closure with excellent cosmetic result seen on post op day 212. Site 2 on the alar rim, if approached with Mohs would have led to a defect which encroached on the alar rim. This would have required a full thickness skin graft or a bilobed flap; both of these options are complex and can result in a deformity (i.e) notching of the alar rim, pi-cushioning, or collapse of the ala with a valve effect. Superficial x-ray in this setting results in minimal scarring and deformity.

Mohs sites delineated with a Linear mark. The previous x-ray site is on the right tip of nose. The patient will complete a six week course of topical 5% imiquimod cream on her entire nose.

Patient Outcome

The patient tolerated the combination of Mohs Micrographic surgery and superficial x-ray treatments very well. The patient has been followed up long term with excellent cosmetic result.

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT009
May 11, 2011

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

This patient is an 85 year old male with history of multiple skin cancers. The patient is on Coumadin and has a pacemaker.

Patient Management

The patient presents with a biopsy proven Squamous Cell Carcinoma in situ on his Dorsal nose near tip, this is labeled P8. In addition to this he has two scaly crusty areas on either side of the original biopsy which are labeled 3A and 3B and are biopsied. Lesion 3A and 3B are found on frozen section to be SCC in situ. These lesions are inferior to a previous LN2 site marked with an X on the right bridge of nose, and a previous x-ray site marked with an X on the Left Ala. All three lesions P8, 3A, and 3B are included in one field.

Treatment Parameters

The clinical lesion as determined by the original biopsy P8 and frozen section biopsy 3A and 3B was identified and circled. An 8-10 mm border was drawn around this. The tumor depth was estimated to be <2 mm. A 0.762 mm thick lead shield was fashioned to include a 2.2 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Universal Superficial machine with a 3 cm cone, 7 fractions of 500 cGy were delivered at 80 kv, 5 ma with a D1/2 of 6.7 mm. The patient received a total of 3500 cGy to the area over a two week period.

Patient Outcome

Superficial Radiation of Previously Irradiated Nose | Sensus Healthcare

Click here to download a PDF of this case study.

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT008
May 11, 2011

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

At the time of treatment the patient was a 76 year old male with personal history of skin cancer. The patient takes one baby asprin daily.

Patient Management

The patient presents with a 4×5 mm pearly pink papule on the right nose tip. The patient states it has been there for a few weeks. The lesion was biopsied and found to be a BCC. The options of Mohs Micrographic surgery or SRT were discussed with the patient. The patient would like to proceed with SRT.

Treatment Parameters

The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this. The tumor depth was estimated to be <5 mm. A 0.762 mm thick lead shield was fashioned to include a 1.3 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Universal Superficial X-ray machine with a 3 cm cone, 5 fractions of 700 cGy were delivered at 80 kv, 5 ma with a D1/2 of 6.7 mm. The patient received a total of 3500 cGy to the area over a two week period.

Patient Outcome

12 Years Post-Op Basal Cell Carcinoma on Nose Tip Treated with SRT

Click here to download a PDF of this case study.

Basal cell carcinoma on the Nose Treated with SRT:

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT007
May 11, 2011

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to a local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

The patient is a 74-year-old female with a personal history of Basal Cell Carcinoma, Hypertension, and breast cancer with Mastectomy in 1992. She takes asprin daily.

Patient Management

The patient presented with a biopsy-proven 4×4 mm BCC located on her right nose tip. This is a predominately superficial BCC with a depth of less than 2 mm. The options of Mohs Micrographic surgery or SRT are discussed with the patient and her husband. The patient would like to proceed with SRT.

Treatment Parameters

The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this. The tumor depth was estimated to be

Patient Outcome

BCC-on-the-Nose-Treated-with-SRT

Click here to download a PDF of this case study to see basal cell carcinoma n the nose treated with SRT.

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
Lyndsey Schimmel M.A.

CSN: DAT003
October 27, 2010

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologist’s in lower Alabama, South Georgia and the Panhandle, as well as our own general derms and local and regional physicians.

Many of our patients have multiple cancers at time of referral. Depending on the location, size, depth and aggressiveness of the individual tumor, juxtaposed to the patient’s age and health status we discuss Mohs vs SRT as part of informed consent. We discuss radiation with all patients over 65 with the option of treatment either here in the office or by radiation oncology. We end up using it in about 10% of these patients over 65 who are referred for Mohs surgery. We have been doing this for 25+ years and recently calculated our 10-year cure rates, which compare very favorably to Mohs surgery.

Patient History

The patient is an 86 year old male with history of multiple difficult skin cancers of the head and neck. The patient takes Aspirin and Plavix daily, has hypertension, and a history of bladder cancer.

Patient Prognosis & Management

The patient presented with a 2.0 x 3.2 cm, tender keratotic lesion on his left cheek. This was felt to be SK clinically but due to the presence of pain this area was biopsied to rule out SCC. The biopsy did prove this area to be a SCC in situ with no invasive component. There was also inflamed SK present in the submitted tissue. The patient returned in two weeks to discuss treatment options including Mohs surgery with a skin graft or Superficial x-ray, the patient opted for SRT. The clinically visible area of involvement was circled this measured 2.4 x 4.5 cm. A 7 mm area around this was delineated for treatment with SRT.

Treatment Parameters

The patient opted for superficial radiation treatment for this lesion. The clinical lesion was circled and an appropriate shield measuring 4.1 x 7.1 cm was fashioned out of lead sheet 0.762 mm thick. Eye shielding and neck shielding were done. Using the Sensus SRT-100™ x-ray machine, a 10 cm cone, 7 fractions of 500 cGy were delivered at 50 kv, 10 mA with a D ½ of 6.4 mm. The patient received a total of 3,500 cGy to the area over a two week period.

Large-SCC-in-SITU-on-the-Face

Patient Outcome

The patient tolerated the treatment with no side effects. The patient returned 2 weeks post op with a good erythematous reaction from the SRT treatment. This should give him a good chance of cure. See photos below.

Patient Quote

“I really like the x-ray treatment; it was painless and easier on me than surgery and a skin graft. I am very happy with the results.”

Click here to download a PDF of this case study.

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
Lyndsey Schimmel M.A.

CSN: DAT002
October 27, 2010

Situational Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologist’s in lower Alabama, South Georgia and the Panhandle, as well as our own general derms and local and regional physicians.

Many of our patients have multiple cancers at time of referral. Depending on the location, size, depth and aggressiveness of the individual tumor, juxtaposed to the patient’s age and health status we discuss Mohs vs. SRT as part of informed consent. We discuss radiation with all patients over 65 with the option of treatment either here in the office or by radiation oncology. We end up using it in about 10% of these patients over 65 who are referred for Mohs surgery. We have been doing this for 25+ years and recently calculated our 10-year cure rates, which compare very favorably to Mohs surgery.

Patient History

Patient is an 89-year-old white female who, over the course of the year, developed an erythematous scaly plaque on her forehead. It measured 52×45 mm. Two biopsies had been done, previous #1 showing well-differentiated SCC in situ and previous #2 showing well-differentiated Squamous Cell Carcinoma (SCC) in situ. These were about 3.5 cm apart and were in the midst of this large erythematous plaque of Squamous Cell Carcinoma (SCC) in situ.

Patient Prognosis & Management

The patient was referred in for Mohs surgery; but, after discussing the need for a large skin graft and an extensive surgery, the patient opted for superficial x-ray.

Treatment Parameters

The clinical lesion was circled and an appropriate shield was fashioned out of lead measuring 55×75 mm. Eye shielding and neck shielding were done. Using the Sensus SRT-100™ x-ray machine, a 10 cm cone was utilized to deliver 500 cGy directly at base with a PKV of 50, 10 mA, a time factor of 1.74 minutes, an SSD of 25 cm, 0 filtration, and a D ½ of 6.4 mm. This was repeated 7 times with 1 additional dose of 300 cGy for a total of 3,800 cGy to the area over a 2-week period.

Large-SCC-in-SITU-of-teh-Forehead

Patient Outcome

The patient returned 2 weeks post treatment with a brisk moist desquamative reaction from the SRT treatment. She was followed clinically for a month and a half, during which time there were dressings (Arglaes) and lotions were used for healing. At post radiation day 44, the lesion had completely reepithelized. See photos. On post radiation day 106, there is minimal scarring and very slight erythema and no clinical evidence of disease. See photos below.

Click here to download a PDF of this case study.

Dermatology Association of Tallahassee

Armand B. Cognetta Jr., M.D.
Earl Stoddard M.D.
Molly Warthan M.D.
Jerry Edwards REMT-P, HT (ASCP)cm
CSN: DAT005
January 28, 2011

Institutional Overview

Dermatology Associates is a seven-person dermatology group with two Mohs surgeons, a fellow, an in-house plastic surgeon, and a dermatopathologist. We care for patients referred to us from about a 100-mile radius by dermatologists in lower Alabama, South Georgia, and the Florida Panhandle, as well as our own dermatologists and local and regional physicians.

Many of our patients have multiple cancers at the time of referral for Mohs Micrographic surgery. Depending on the location, size, depth, and aggressiveness of the individual tumor, and factoring in the patient’s age, health status, coagulation status, and what we term frailty index, we discuss Mohs surgery versus superficial radiation therapy (SRT) as part of the informed consent in patients over the age of 65. During this discussion of radiation, we offer treatment in our office of the SRT-100 or referral to local radiation oncologist. Approximately 10% of patients over the age of 65 referred for Mohs choose SRT. We have been providing this option for 25+ years and recently calculated our ten-year cure rates which compare very favorably to Mohs Micrographic surgery.

Patient History

The patient is a 95 year old male with a personal history of Melanoma, Basal and Squamous Cell Carcinoma. He is on Imuran for Myasthenia Gravis and takes a maintenance dose of Aspirin for heart disease.

The patient had a previous skin cancer treated successfully with superficial radiation on his left nose-cheek sulcus.

Patient Management

The patient presents with a 6×6 mm pearly lesion on the right upper forehead which was found to be a Basal Cell Carcinoma. Various options were discussed including wide local excision, Mohs Micrographic surgery, and superficial RT. The patient opted for superficial radiation therapy for this lesion.

Treatment Parameters

The clinical lesion was identified and circled. Then an 8-10 mm border was drawn around this. The tumor depth was estimated to be <5 mm. A 0.762 mm thick lead shield was fashioned to include a 2.4 cm field and placed over the lesion and extended field. Eye shielding and thyroid shielding were done. Using the Sensus RT machine with a 3 cm cone, 5 fractions of 700 cGy were delivered at 50 kv, 10 ma with a D1/2 of 5.8 mm. The patient received a total of 3500 cGy to the area over a two week period.

BCC-on-the-Forehead

Patient Outcome

The patient tolerated the treatment with no side effects. The patient has some mild redness and erythema on the day of final x-ray. This should give him a good chance of cure. (see photos below)

Comment: The patient has a very good cosmetic result and more importantly, at 95 years old he was able to avoid surgery.

Click here to download a PDF of this case study.

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