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 Table of Contents  
CASE STUDY
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 124-127

High-dose rate surface mold brachytherapy in a case of squamous cell carcinoma of lower eyelid: A case report from a rural cancer center of Maharashtra


1 Department of Radiotherapy and Oncology, Rural Medical College of PIMS, Loni, Ahmadnagar, Maharashtra, India
2 Department of Medical Physics, Rural Medical College of PIMS, Loni, Ahmadnagar, Maharashtra, India
3 Departments of Radiotherapy and Oncology, Rural Medical College of PIMS, Loni, Ahmadnagar, Maharashtra, India

Date of Web Publication9-Sep-2019

Correspondence Address:
Dr. Vandana Shailendra Jain
Department of Radiotherapy and Oncology, Rural Medical College of PIMS, Loni, Ahmadnagar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_10_19

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  Abstract 


Squamous cell carcinoma (SCC) of skin is an uncontrolled growth of cells of epithelium commonly seen in males in fifth to sixth decade of life. Risk factors include fair skin, blonde hair, exposure to sunlight (ultraviolet B), immunosuppression, human papillomavirus, and genetics. Surface mold brachytherapy (SMB) is a well-established treatment for early stage head and neck cancers involving accessible sites. It has evolved from the radium era to low-dose rate and now to high-dose rate intensity-modulated interventional brachytherapy. We present a 50-year-old male patient with squamous carcinoma of the left lower eyelid and was operated for the same. Histopathology was well-differentiated SCC with all positive margins. The patient was then treated by SMB and evaluated for toxicity, local control, and survival.

Keywords: High-dose rate brachytherapy, lower eyelid malignancies, surface mold brachytherapy


How to cite this article:
Jain VS, Kushwah V, Chaitali P W, Mukund B S. High-dose rate surface mold brachytherapy in a case of squamous cell carcinoma of lower eyelid: A case report from a rural cancer center of Maharashtra. J Radiat Cancer Res 2019;10:124-7

How to cite this URL:
Jain VS, Kushwah V, Chaitali P W, Mukund B S. High-dose rate surface mold brachytherapy in a case of squamous cell carcinoma of lower eyelid: A case report from a rural cancer center of Maharashtra. J Radiat Cancer Res [serial online] 2019 [cited 2019 Nov 18];10:124-7. Available from: http://www.journalrcr.org/text.asp?2019/10/2/124/266115




  Introduction Top


Skin cancers of the eyelid account for 5%−10% of all skin cancers. Basal cell carcinoma (BCC) is the most common eyelid tumor reported in western population and accounts for 90% of all eyelid malignancies.[1] It most frequently occurs in the lower eyelid (50%−66%) and medial canthus (25%−30%). Surgical excision, Mohs micrographic surgery, cryosurgery, and radiotherapy have all been reported to achieve 5 years' cure rates of 90% or higher in BCC.[2],[3] Squamous cell carcinoma (SCC) accounts for <5% of eyelid malignancies. Surface mold therapy was introduced at the beginning of the 20th century to treat skin lesions following the discovery of radium.[4] Radioactive mold became one of the established modalities to treat skin cancer along with superficial and orthovoltage X-rays.[5] The development of after loading techniques and in particular high-dose rate (HDR) remote after loader overcame the issues associated with personal radiation protection. HDR surface mold brachytherapy (SMB) was first introduced by Joslin.[6],[7] Depending on the site, histology and adjuvant or primary treatment patients are treated with a dose of 300–500 cGy per fraction twice a week for a total dose ranging from 1600 to 5000 cGy (4–13 fractions).[8]


  Case Report Top


A 50-year-old male patient presented to our department postoperatively for oncological management. He underwent an excisional biopsy of a swelling over the left lower eyelid on September 2015 at the ophthalmology department of our institute [Figure 1] and [Figure 2]. Histopathology was suggestive of well-differentiated SCC with all positive margins. The patient was advised re-excision with plastic reconstruction but refused the same and was then planned for adjuvant treatment by HDR brachytherapy with surface mold technique.
Figure 1: Swelling over left lower eyelid

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Figure 2: Immediate post of photo September 2015

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Scar with 1.5 cm margin was considered as the clinical target volume. The area, over which the surface mold was to be prepared, was marked over the skin. The mold by perforated thermoplastic sheet to immobilize the head during each fraction and to keep SMB applicator in place was made, and the mold assembly area was cut as shown in [Figure 3]. Scar being adjacent to eyeball, cornea, and lens the mold was prepared with extra care with wax strips. Two plastic needles were mounted over the mold at 7 mm distance [Figure 3]. As per the necessity, adhesive tape was used to fix the mold in position for comfortable fitting during treatment. TPS planning was done on Brachyvision (Eclipse brachytherapy planning 8.1.20, Varian medical systems). Step distance of source was 5 mm; total treatment length was 3 and 2.5 cm in 1st and 2nd needles. The dose was prescribed at 4 mm depth. The total dose delivered was 40 Gy in 10 fractions, twice weekly over 5 weeks' duration. Homogeneous dose distribution was achieved at the desired depth of eyelid with an adequate margin as shown in transverse and coronal plan [Figure 4] and [Figure 5]. The patient was instructed to look up at the time of brachytherapy treatment, so as to increase the distance of lens and cornea from mold (dose area). The mold with catheters in situ was to be connected to the treatment machine during radiation treatment.
Figure 3: Photo showing surface mold applicator with two tubes in position before radiation treatment

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Figure 4: Isodose curve showing dose distribution in coronal plane

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Figure 5: Isodose curve showing dose distribution in transverse plane

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During and on completion of the treatment, the patient was regularly followed in the department and with the ophthalmologist and was prescribed eye drops and topical steroid ointments [Figure 6]. The radiation-related toxicities were classified according to the Radiation Therapy Oncology Group grading system. The first review was done at 6 weeks from completion, then at every 3 months, till 2 years, and then 6 monthly. On follow-up, the clinical and ophthalmological examination was undertaken, and further investigations were done only if required clinically. Pre- and post-radiotherapy visual evaluation and cosmetic outcome were done. The last follow-up was on March 2019 with no evidence of any local or distant failure [Figure 7].
Figure 6: Photograph of patient after 10th fraction (40 Gy) of surface mold brachytherapy on November 2015

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Figure 7: Photograph of patient on the last follow-up on March 2019

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  Results and Discussion Top


With custom-made surface mold, the dose distribution was uniform over the surface of the skin and at 5 mm depth in the desired surface volume to be treated. The treatment tolerance was excellent, and the patient was disease free at the 40th month follow-up [Figure 7].

SCCs of the skin are uncommon in Indian population. It arises from the keratinocytes. BCC and SCC of the skin account for 90% of skin cancers. Of this 90%, approximately 5%–10% arise in the eyelid region. Surgery is the primary treatment for most of the skin carcinomas with good results. Skin carcinomas located on the nose, eyelid, ear, and any other face region surgical excision might be difficult due to cosmetic reasons. Cosmetic surgeries with good margins require anesthesia with high risk for patient life. This is particularly the issue in the elderly and frail patients. However, in the presence of certain high-risk factors, adjuvant radiotherapy is indicated postoperatively.[9],[10]

Radiotherapy treatment for nonmelenomatous skin cancers as primary or adjuvant therapy can be delivered by orthovoltage X-rays, Electron beam, HDR SMB, and interstitial brachytherapy.

Electron-beam therapy is preferred in the treatment of skin carcinomas. HDR SMB offers an alternative radiotherapy modality to electrons for the treatment of superficial tumors. The HDR mold, due to its flexibility, is able to conform well to the skin area and the dose can be delivered uniformly at depth when treating curved surfaces as well. The electron cones, on the other hand, are rigid and as a result, there can be appreciable variations in the treatment source to skin distance across the treatment area. Obliquity effects for electrons[8],[11] when incident on curved surfaces can further contribute to the dose inhomogeneity at depth. With electron-beam therapy, there are air gaps between the patient surface and electron cone specifically over curved surfaces.

SMB is a well-established treatment for the surface tumors of the head and neck region and used since many decades. In the series reported by Budrukkar et al.[12],[13] for skin malignancies 5 years' local control rate was 92%. Only one out of 14 patients, recurrence was observed after 8 months, and the tumor was located over the nose. Similarly, in another series, reported by Maroñas et al.[14] all five patients who had recurred (of total 48) the tumor was located over the nose. The dose schedule used by both the authors was 3–4 Gy per fraction twice daily; 6 h apart, the total dose varies from 38.5 Gy to 52.5 Gy in 11–15 fractions over 1–2 weeks' time.

Similar reports by Musmacher et al.[15] and Sabbas et al.[8] for the treatment of skin malignancies by SMB shows good results, but the dose schedule used by them was 4–5 Gy per fraction twice weekly for 4–5 weeks (total dose 40–50 Gy in 10–12 fractions over 4–5 weeks). They noticed less acute reactions and late toxicities.

The advantage of spreading dose over 4–6 weeks as per conventional plans can be achieved with SMB as compared to interstitial brachytherapy in which placement of needles/wires/applicators is required, and dose is delivered by twice daily fractionation schedule over 1 week time, till then applicators remain in place. For eyelid tumors, interstitial brachytherapy has also been used by Manghani and Khan[9] with acute and late toxicities even corneal ulcers were also reported. Advantages of SMB over interstitial brachytherapy are dose can be very well spread over a time, so that reactions are less and trauma of keeping catheters over a week time can be avoided.


  Conclusion Top


Radiotherapy is a highly effective treatment of skin carcinomas of the face and body. The surface mold used in conjunction with HDR brachytherapy makes it possible to deliver a uniform dose distribution at the desired depth and area; treating only the surface and sparing deeper structures. Local control is excellent with minimal complications. Various advantages of SMB are easy conformability of the treatment surface; dose fall-off is faster and accurate reproducibility during each treatment. Short treatment time (few minutes) once molds preparation and treatment planning is done. Treatment delivery is on outpatient department basis.

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.

Acknowledgment

We would like to thank Mr. Pawar Vijay and Datir Bhaskar (Clerk) for providing technical support for taking out hospital records from medical record section of the Institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cook BE Jr., Bartley GB. Treatment options and future prospects for the management of eyelid malignancies: An evidence-based update. Ophthalmology 2001;108:2088-98.  Back to cited text no. 1
    
2.
Mohs FE. Micrographic surgery for the microscopically controlled excision of eyelid cancers. Arch Ophthalmol 1986;104:901-9.  Back to cited text no. 2
    
3.
Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database: Periocular squamous cell carcinoma. Ophthalmology 2004;111:617-23.  Back to cited text no. 3
    
4.
Meredith W, Massey J. Fundamental Physics of Radiology. Bristol: Wright; 1977.  Back to cited text no. 4
    
5.
Ashby MA, Pacella JA, de Groot R, Ainslie J. Use of a radon mould technique for skin cancer: Results from the peter MacCallum cancer institute (1975-1984). Br J Radiol 1989;62:608-12.  Back to cited text no. 5
    
6.
Joslin CA, Liversage WE, Ramsey NW. High dose-rate treatment moulds by afterloading techniques. Br J Radiol 1969;42:108-12.  Back to cited text no. 6
    
7.
Joslin CA, Flynn A. High dose-rate brachytherapy in the treatment of skin tumors. In: Joslin CA, Flynn A, Hall EJ, editors. Principles and Practice of Brachytherapy Using After Loading Systems. London: Oxford University Press; 2001. p. 393-9.  Back to cited text no. 7
    
8.
Sabbas AM, Kulidzhanov FG, Presser J, Hayes MK, Nori D. HDR brachytherapy with surface applicators: Technical considerations and dosimetry. Technol Cancer Res Treat 2004;3:259-67.  Back to cited text no. 8
    
9.
Manghani J, Khan K. A study of role of brachytherapy IR192 in treatment of eyelid tumors. Int J Med Res Rev 2016;4:1318-22.  Back to cited text no. 9
    
10.
Kalaghchi B, Esmati E, Ghalehtaki R, Gomar M, Jaberi R, Gholami S, et al. High-dose-rate brachytherapy in treatment of non-melanoma skin cancer of head and neck region: Preliminary results of a prospective single institution study. J Contemp Brachytherapy 2018;10:115-22.  Back to cited text no. 10
    
11.
Biggs PJ. The effect of beam angulation on central axis per cent depth dose for 4-29 MeV electrons. Phys Med Biol 1984;29:1089-96.  Back to cited text no. 11
    
12.
Budrukkar A, Dasgupta A, Pandit P, Laskar SG, Murthy V, Upreti RR, et al. Clinical outcomes with high-dose-rate surface mould brachytherapy for intra-oral and skin malignancies involving head and neck region. J Contemp Brachytherapy 2017;9:242-50.  Back to cited text no. 12
    
13.
Kovács G. Modern head and neck brachytherapy: From radium towards intensity modulated interventional brachytherapy. J Contemp Brachytherapy 2015;6:404-16.  Back to cited text no. 13
    
14.
Maroñas M, Guinot JL, Arribas L, Carrascosa M, Tortajada MI, Carmona R, et al. Treatment of facial cutaneous carcinoma with high-dose rate contact brachytherapy with customized molds. Brachytherapy 2011;10:221-7.  Back to cited text no. 14
    
15.
Musmacher J, Ghaly M, Satchwill K, High dose rate brachytherapy with surface applicators: Treatment for nonmelanomatous skin cancer. J Clin Oncol 2016;12:Suppl. 15543.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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