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SRT Effectively Addresses NMSC, Keloids

Superficial radiation therapy (SRT) greatly reduces keloid recurrence rates and, for keratinocytic skin cancers, provides short-term cure rates similar to those in previous SRT research and of surgical options including Mohs surgery, Brian Berman, MD, PhD, told Dermatology Times®.Using ultrasound-based image guidance may improve nonmelanoma skin cancer (NMSC) out- comes, added Berman, Professor Emeritus of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine and codirector of the Center for Clinical and Cos- metic Research in Aventura, both in Florida. Berman presented on SRT for keloid treatment as part of a conference track on dermatology updates for the therapy along with new and emerging medicines to treat skin cancers at the Music City Scale Symposium 16th Annual Meeting, August 18-22, 2021, in Nashville, Tennessee.1

VISUALIZING SKIN CANCERS

He pointed to a recent review of 2917 invasive and in situ keratinocytic carcinomas treated with image-guided SRT (IGSRT) which showed an overall control rate of 99.3% at patients’ last follow-up.2 Based on these results, authors led by Lio Yu, MD, suggested considering IGSRT as a first-line option for keratinocytic tumors in suitable early-stage patients. Yu is a radiation oncologist at Laserderm Dermatology in Smithtown, New York. “These results, while observed with approximately 55% of patients having follow-up for 12 months or more, appear at this time to be at least consistent with the results of standard surgical and nonsurgical modalities used to treat NMSC,” wrote the study authors.

Performing 22-MHz ultrasound imaging before SRT (SRT-100 Vision; Sensus Health- care) facilitates visualizing tumor depth up to 6 mm, said Berman, a consultant and investigator with Sensus. “Once you know the depth of the tumor, you can correlate it with percentage depth dose tables,” he said. Whereas the study’s 99.3% tumor control rate “at last follow-up” is a rather broad statement in his view, Berman said control rates were equally impressive when one considers only tumors with at least 1 year of follow-up (n = 1639, also 99.3%), and only invasive BCC and squamous cell carcinoma (n = 1242, 99.2%).

In fact, said Berman, the study’s 99% control rate is higher than the 90% to 96% rates reported in most SRT studies,3,4 and on par with results of Mohs surgery.5 “It’s not counterintuitive that if you can visualize the tumor, then you know where to aim the beam and how deep the beam needs to go,” he added. “[And] maybe you’re going to get a higher cure rate than what’s been in the literature, which has very robust data supporting the effectiveness of SRT on NMSC.”

“Having said that, I am not advocating using SRT for all nonmelanoma skin cancers in all patients,” he cautioned. “Surgery is the standard of care for nonmelanoma skin cancers.”

However, he said, SRT is well suited for patients who resist or cannot undergo surgery. In his experience practicing in Florida, Berman reported that patients who have undergone previous skin cancer excisions may reject additional scarring surgeries. Additionally, elderly patients with other comorbidities—Berman explained that, generally, relevant comorbidities increase with age—or those on anticoagulants may benefit by avoiding surgery, he noted.

David J. Goldberg, MD, JD, director of Skin Laser & Surgery Specialists; director of cos- metic dermatology and clinical research with the Schweiger Dermatology Group; clinical professor of dermatology and past director of Mohs surgery and laser research at Icahn School of Medicine at Mount Sinai, and adjunct professor of law at Fordham University School of Law, in New York, New York, also noted positive outcomes for this therapy. “Having an SRT unit added to my busy Mohs surgery office has greatly added to our ability to treat many more patients with nonmelanoma skin cancer,” he said. “Each technique has its benefits. With an increasingly older population of patients who are not good surgical candidates, SRT provides high cure rates for many people. Similarly, for a younger, cosmetically concerned patient base, SRT can lead to elegant cosmetic results with a high cure rate.”

The IGSRT study’s retrospective nature requires interpreting results cautiously, Berman said. However, he added, long-term prospective skin cancer studies are very difficult to perform. The 99% cure rate remains impressive, in his view. “If there’s a recurrence 3 years later, let’s say, in the margin where the port didn’t catch the original tumor, you’re not handcuffed from using surgery at that point,” he said.

PREVENTING KELOID RECURRENCE

Keloids commonly occur in high-visibility locations such as the face and earlobes. “When a patient comes to me with a keloid, I try to talk them out of surgery,” Berman said. Without adjunctive therapy such as SRT, recurrence rates are high, Berman added. In unpublished research, he reviewed 13 studies incorporating 343 patients and calculated a weighted-average postkeloidectomy recurrence rate of 71.2%.9,10“Very often, I’ll say, ‘You have a small keloid. If I were able to take away the burning, itching, and tenderness and get it softer and maybe a little flatter, would that be sufficient?’ And I hope they say yes, because there are other modalities to treat an existing keloid without cutting it out,” Berman said. With a referral-based practice, though, his patients typically want surgery because conservative treatments have failed.Berman explains to patients that postsurgical SRT offers a noninvasive tool for reducing recurrence risk. Separate studies show that this treatment reduces postsurgical recurrence rates to 3.0% and 10.4%, respectively.11,12 “Dropping the recurrence rate from 7 out of 10 to 1 out of 10, with at least 1 year of follow-up, is very helpful to the clinician to be able to hold out hope to patients,” he said.13

Radiation therapy is believed to prevent keloid recurrence by reducing fibroblast proliferation, arresting the cell cycle, and inducing apoptosis.13 Although these mechanisms delay healing in normal skin, they are tailor-made for preventing keloids with their excessive scarring and for destroying malignant, abnormal cells in nonmelanoma skin tumors arising from bro- blast or keratinocyte hyperproliferation, accord- ing to Berman.

“The mechanisms are consistent, but there are different reasons why we’d use it for keloids vs a tumor,” he said. The SRT-100 is FDA 510(k) cleared for treating NMSC and keloids. Berman said colleagues have told him that they bought the machine for NMSC but now use it more often for postsurgical keloid recurrences.Patients may worry about radiation therapy and carcinogenesis, Berman said. “I appreciate that. But I explain to them the historical safety of SRT, and the fact that it only goes a few milli- meters deep at most into the skin, [meaning] it’s truly super cial radiation therapy.”

Moreover, a 10-year retrospective analysis of 264 excised keloids, of which most received sub- sequent external-beam radiation or high dose- rate interstitial brachytherapy, showed no development of malignancy.14 Similarly, a search of Medline and PubMed between 1901 and March 2009 uncovered only 5 cases of carcinogenesis associated with, but not likely caused by, postkeloidectomy radiation therapy, Berman said. The cancers included BCC, thyroid cancer, breast cancer, and fibrosarcoma.

“Intuitively, it doesn’t make sense that radiation therapy induced the development of BCC because we use radiation therapy to treat BCC,” Berman said. Breast cancers originate at deeper levels than SRT penetrates, and the noted thyroid cancer did not develop in the treated area, he added. The single fibrosarcoma investigators found was probably a fibrosarcoma before surgery, authors allowed. These tumors typically take a decade to develop, Berman explained, whereas study follow-up periods generally are considerably shorter.

Pacemakers implanted in the treatment area are a contraindication for SRT, in his opinion. Regarding adverse effects, Berman said he warns patients about the potential for postradiation pigmentary changes, most often hyperpigmentation. In a chart review of 96 excised keloids followed for at least 1 year on which he was lead author, 56% of subjects experienced hyperpigmentation. Usually transient, he said, less than 5% of patients experienced persistent hyperpigmentation.

Because of the safety and efficacy of SRT, Berman suggested that more dermatologists con- sider o ering this therapy. “It’s part of our armamentarium to treat a patient who has disfiguring keloids that have an impact physically, cosmetically, and psychologically,” he said. In appropriately selected patients with keratinocytic skin cancers, results are commensurate with the standard of care, he added.

DisclosuresBerman is a consultant and investigator for Sensus. Goldberg reports no relevant nancial interests.

References1 Berman B. Super cial radiation therapy for keloids. Presented at: Music City SCALE Symposium for Cosmetic Advances and Laser Education 16th Annual Meeting; August 18-22, 2021; Nashville, Tennessee.2 Yu L, Oh C, Shea CR. The treatment of non-melanoma skin cancer with image- guided super cial radiation therapy: an analysis of 2917 invasive and in situ keratinocytic carcinoma lesions. Oncol Ther. 2021;9(1):153-166. doi:10.1007/ s40487-021-00138-43 Hernández-Machin B, Borrego L, Gil-García M, Hernández BH. Of ce-based radi- ation therapy for cutaneous carcinoma: evaluation of 710 treatments. Int J Der- matol. 2007;46(5):453-459. doi:10.1111/j.1365-4632.2006.03108.x4 Cognetta AB, Howard BM, Heaton HP, Stoddard ER, Hong HG, Green WH. Super- cial x-ray in the treatment of basal and squamous cell carcinomas: a via-
ble option in select patients. J Am Acad Dermatol. 2012;67(6):1235-1241. doi:10.1016/j.jaad.2012.06.0015 Tolkachjov SN, Brodland DG, Coldiron BM, et al. Understanding Mohs micro- graphic surgery: a review and practical guide for the nondermatologist. Mayo Clin Proc. 2017;92(8):1261-1271. doi:10.1016/j.mayocp.2017.04.0096 Rodriguez JM, Deutsch GP. The treatment of periocular basal cell carcinomas by radiotherapy. Br J Ophthalmol. 1992;76(4):195-197. doi:10.1136/bjo.76.4.1957  Grossi Marconi D, da Costa Resende B, Rauber E, et al. Head and neck non-mela- noma skin cancer treated by super cial x-ray therapy: an analysis of 1021 cases. PLoS One. 2016;11(7):e0156544. doi:10.1371/journal.pone.01565448  Lawrence WT. In search of the optimal treatment of keloids: report of a series and a review of the literature. Ann Plast Surg. 1991;27(2):164-178. doi:10.1097/00000637-199108000-000129  Shaffer JJ, Taylor SC, Cook-Bolden F. Keloidal scars: a review with a critical look at therapeutic options. J Am Acad Dermatol. 2002;46(2 Suppl Understand- ing):S63-S97. doi:10.1067/mjd.2002.12078810  Berman B, Nestor MS, Gold MH, Goldberg DJ, Fox J, Schmieder G. Low rate of keloid recurrences following treatment of keloidectomy sites with a biologically effective dose 30 of super cial radiation. SKIN The Journal of Cutaneous Medi- cine. 2018;2(6):402-403. doi:10.25251/skin.2.6.711  Berman B, Nestor MS, Gold MH, Goldberg DJ, Weiss ET, Raymond I. A retro- spective registry study evaluating the long-term ef cacy and safety of super - cial radiation therapy following excision of keloid scars. J Clin Aesthet Dermatol. 2020;13(10):12-16.12  Liu X, Liu JZ, Zhang E, et al. Impaired wound healing after local soft x-ray irra- diation in rat skin: time course study of pathology, proliferation, cell cycle, and apoptosis. J Trauma. 2005;59(3):682-690.13  Hoang D, Reznik R, Orgel M, Li Q, Mirhadi A, Kulber DA. Surgical excision and adjuvant brachytherapy vs external beam radiation for the effective treat- ment of keloids: 10-year institutional retrospective analysis. Aesthet Surg J. 2017;37(2):212-225. doi:10.1093/asj/sjw12414  Ogawa R, Yoshitatsu S, Yoshida K, Miyashita T. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg. 2009;124(4):1196-1201. doi:10.1097/PRS.0b013e3181b5a3ae

05/14/2019

Mike Masterson, a correspondent for the Arkansas Democrat Gazette, wrote an article in 2019 detailing how the SRT-100 machine was an integral part of curing his non-melanoma skin cancer. Since his successful treatment he has been an advocate for any Arkansas dermatologists to adopt SRT as a part of their non-melanoma skin cancer treatment protocol. Masterson goes on to praise the The Dermatology Office on Linwood Drive in Paragould and Helms Dermatology on West Main Street in Russellville for being the first two practices in the state of Arkansas to begin using SRT machines. 

"For me and others who've experienced this 21st century treatment, it's definitely a gift to have an effective choice beyond what otherwise often involves surgery, bleeding and stitches. There's also no anesthesia, risk of infection or scarring involved. In short, there's no need to undergo the trauma involved with reconstructive plastic surgery if you can get to this machine," said Masterson.

Read the full article by Mike Masterson here.

Mid-Atlantic Skin operates under the direction of George K. Verghese, MD, one of the nation’s premier dermatologists. Along with his dedicated and professional team, Dr. Verghese provides excellent, comprehensive skin care.

Dr. Verghese is a fellow of the American College of Mohs Surgery and the American Academy of Dermatology. He is board certified in dermatology. In addition to his private practice, he is an Assistant Clinical Professor of Dermatology at Howard University College of Medicine and former Mohs surgeon for the Veterans Affairs Medical Center in Washington, DC.

A native of Southern Maryland and graduate of St. Mary’s Ryken High School, Dr. Verghese earned his undergraduate degree in biology from Georgetown University and earned his medical degree from Howard University College of Medicine. He also completed his residency in dermatology at Howard University Hospital. Thereafter, he completed a fellowship in Mohs Micrographic Surgery at the Northwestern Skin Cancer Institute.

Read what Mid Atlantic Skin has to say about SRT:

"SRT  treatments have revolutionized the way that we offer patient solutions regarding skin cancer diagnosis.

Mid Atlantic Skin is thrilled about acquiring our second SRT-100 device and Sensus's 500th worldwide offering skin cancer superficial radiation therapy to our Southern Maryland patient community.

Patients desire options and many are surprised to learn that a non-surgical option for skin cancer is available; especially if the patient comes from another dermatology practice without SRT. In our experience, this innovation demonstrates excellent patient outcomes and we highly recommend Sensus as a preferred partner."

Dr. Steven K. Grekin, D.O. is the founder and Medical Director of The Grekin Skin Institute, a dermatological practice providing care within many segments of the medical market in Michigan. His primary mission is to help his patients put their best face forward by delivering extraordinary care and medical treatment.

Having completed his undergraduate studies at the University of Michigan in Gerontology and his medical degree from Des Moines University, Dr. Grekin was privileged to study under the tutelage of world leaders in dermatology and gerontology. Following his studies, Dr. Grekin spent many years as a lead researcher at the International Skin Rejuvenation Institute in Paris and Quebec, providing state-of-the-art skin techniques to patients of all ages. His time abroad led him to understand the secrets to younger, smoother, more radiant skin—secrets he brings to his patients in America.

Guided by cutting-edge principles of modern dermatology and the highest quality medical care, Dr. Grekin offers his patients an elegant, intelligent program distinguished by its unique flexibility in providing patients a choice when it comes to their healthcare. That’s why the Grekin Skin Institute offers Superficial Radiation Therapy with the SRT-100™, a painless, safe and highly effective non-surgical option for skin cancer treatment and keloid removal.

“Every patient deserves to know their options for treating skin cancer and keloids. At the Grekin Skin Institute, my patients are thrilled to have a non-surgical choice. Safe and effective, SRT allows me to treat areas that are surgically difficult or don’t heal well. My patients are exceedingly pleased with the cure rate and cosmetic results.” – Steven K. Grekin, D.O.

Dr. Grekin has been an advocate for SRT since introducing it to his practice, as he is committed to restoring every skin type to its youthful, natural best. Dr. Grekin has drawn on the powers of science, nature, and art to overcome these challenges and fulfill society's demand for healthier skin. The SRT-100™ has truly been a game-changer, serving not only a very important medical role in the treatment of NMSC but also a very important cosmetic role in the treatment of keloids.

Discover how Senus Healthcare and its non-surgical skin cancer solution are helping dermatologists and radiation oncologists improve outcomes for their skin cancer and keloid patients.

More About Dr. Steven K. Grekin

In addition to founding The Grekin Skin Institute, Dr. Grekin has provided the inspiration and leadership as Chief Executive Officer for Bedside Medical Group offering a new standard in dermatological care for the elderly. Constantly seeking new solutions, he has created a new standard of care by taking these services to the bedside for the senior market and is expanding the operations in other markets nationally.

When he founded Bedside, many of the nursing home patients had not been examined by a dermatologist for several years and there was a real unmet need. Additionally, a procedure, such as Moh's surgery, that is simple for a young healthy person may be a lot harder for someone who is very frail. With SRT services available, Dr. Grekin has been able to provide patients with a safe and effective option that eliminates the risks for post-surgical infections and complications.

Whether he is delivering the latest dermatological services at his patients' bedside or at his practice, Dr. Grekin always seeks to raise awareness of skin cancer and to motivate people to have any suspicious spots checked.

See him on Fox2 Detroit as he explains the importance of skin screenings.

Daniel J. Ladd, Jr., DO is the Medical Director and Founder of Tru-Skin Dermatology in Austin, Texas and the 2018 President-Elect of the AOCD. He earned his BA from the University of Texas at Austin and received his medical degree from Des Moines University in 1999. He completed his Dermatology residency at the Northeast Regional Medical Center in Kirksville, Missouri in conjunction with the Dermatology Institute of North Texas in 2004. In addition to general dermatology and cosmetic dermatology, Dr. Ladd is board certified in Mohs micrographic surgery.

He is a member in good standing of the American Academy of Dermatology, American Osteopathic College of Dermatology, the American Society of Dermatologic Surgeons and the American Society of Cosmetic Dermatology and Aesthetic Surgery, as well as a Member of the American Society of Mohs Surgery. Dr. Ladd is a lifetime member of the Skin Cancer Foundation’s Amonette Circle, an elite group of the country’s foremost dermatologists and Mohs surgeons who have made a commitment to skin cancer education and prevention.

Dr. Ladd has been an advocate for SRT since introducing it into his practice. Here are his top five favorite things about Sensus Healthcare’s SRT:

  • SRT offers variety to patients as well as less invasive options
  • SRT is the newest, cutting edge technology
  • Auxiliary revenue for the practice
  • Ability to develop deeper relationships with patients due to the frequency of care
  • Practice growth  

 

Michael H. Gold, M.D., FAAD

Founder and Medical Director of Gold Skin Care Center, Advanced Aesthetics Medical Spa, The Laser & Rejuvenation Center, and Tennessee Clinical Research Center: Clinical Assistant Professor, Vanderbilt University School of Nursing, Nashville, TN.

As a dermatologist, we are constantly faced with skin cancers and with keloids in our practices. We have many options to deal with these lesions and since incorporating the Sensus SRT into our practice, now we truly have options that we never had before.  Non-melanoma skin cancers are, as we all know, rising dramatically in number.  We have surgical techniques at our disposal to deal with many of them but we also have patients who do not want surgery, or have what we call “surgical fatigue.” These patients are looking for other methods for dealing with them. We can now offer these patients SRT. With SRT we are not only destroying the skin cancers, but we are also giving cosmetic results that have been very satisfactory for our patients.  Skin cancers on the scalp, on the nose, and on the legs are our most common indications for SRT, but one can use it virtually anywhere.  Some of our most satisfied patients thought they would be left scarred and miserable, and now they are cancer-free thanks to SRT.

In 1990, I introduced the concept of silicone gel sheeting into dermatology.  Our research showed its effectiveness and how we could incorporate it into known treatment options to reduce hypertrophic scars and keloids. Over this period of time, we all agree that treating hypertrophic scars with silicone, works quite well.  Our difficulty has always been keloids. No matter what we have done, recurrences and recurrence rates, with larger and more painful lesions, have always been high.  With the advent of SRT, we now have a treatment modality that actually is doing something that we have never been able to do before.  With a surgical procedure and then fractional superficial radiation over a three-day period we, are reducing the recurrence rates to levels we have never seen before which is between 1-10% and that is truly remarkable.

In our office, we have begun to recommend SRT to most every keloid patient that we see.  Again, a surgical procedure is performed by us or one of our referral plastic surgeons. We then perform SRT for three consecutive days after the surgical procedure.  It has truly been a game-changer and something that, we think should be employed by those who deal with these difficult skin lesions.

We present one of our patients, who had some of the worst keloids we had seen in our clinical practice. When you look at his neck and try to decide what to do, you know immediately that a surgical procedure is going to be needed.  You also should realize that based on the size that is seen, that the risk of recurrence following surgery alone is very high.  With the help of a talented plastic surgeon, surgery was performed and SRT was employed for three days after the surgery.  We are now almost 6 months out and there are no signs of recurrence.  We have basically given him his life back. He is extremely happy and so are we.

This is not an unusual outcome for our keloid patients and it won’t be an abnormal outcome for your patients either. SRT is a game-changer and surely has been for our skin cancer and keloid patients since incorporating this into our practice.

Michael H. Gold - Physician Spotlight | Sensus Healthcare

More About Dr. Michael H. Gold

Dr. Michael H. Gold is the founder and medical director of Gold Skin Care Center, Advanced Aesthetics Medical Spa, The Laser & Rejuvenation Center, and Tennessee Clinical Research Center in Nashville, TN. He is a board-certified dermatologist and dermatologic surgeon and oversees the various facets of the center's operations — a combination of medical and surgical dermatology, cosmetic dermatology, aesthetic services and research endeavors, which began in 1990.

Dr. Gold has earned worldwide recognition for providing patients with leading-edge technological advances in dermatology and aesthetic skincare. He plays an integral role in the development of new pharmaceutical products and medical devices through his clinical research.  He presents the results regularly at national and international dermatology and cosmetic meetings.

Dr. Gold has authored over 300 published scientific articles, 35 textbook chapters, and has edited two textbooks on Photodynamic Therapy. He serves on most major dermatology journal boards and is the current Editor-in-Chief of the Journal of Cosmetic Dermatology. In addition, Dr. Gold helped establish the Tennessee Society for Laser Medicine and Surgery (TSLMS), a group of health care providers interested in the distribution of information and proper training for those in the cosmetic arena. The TSLMS puts on an annual meeting known as SCALE, or Symposium for Cosmetic Advances & Laser Education. It is one of the leading U.S. dermatologic and aesthetic meetings.

Dr. Gold also helped start two international groups: the Dermatologic Aesthetic Surgery International League (DASIL), which aims to create a global community for the open exchange of knowledge and innovation by physicians specializing in Dermatologic and Aesthetic Surgery.  It has become one of the most prominent and important international dermatology groups. It showcases meetings all over the world; and 5-Continent-Congress (5CC), is one of the world’s leading conferences on Dermatologic and Aesthetic Surgery, where he is the current President of the Congress.

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