non-melanoma skin cancer treated with electronic brachytherapy: results at two years

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Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy: Results at Two Years Ajay Bhatnagar MD, MBA Cancer Treatment Services Arizona Casa Grande, AZ University of Pittsburgh, School of Medicine Pittsburgh, PA

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Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy: Results at Two Years. Ajay Bhatnagar MD, MBA Cancer Treatment Services Arizona Casa Grande, AZ University of Pittsburgh, School of Medicine Pittsburgh, PA. Disclosure. I have received research funding from - PowerPoint PPT Presentation

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Page 1: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy: Results at Two Years

Ajay Bhatnagar MD, MBA

Cancer Treatment Services ArizonaCasa Grande, AZ

University of Pittsburgh, School of MedicinePittsburgh, PA

Page 2: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Disclosure

• I have received research funding from Xoft — a subsidiary of iCAD, Inc., Sunnyvale, CA, as the Principal Investigator for this study.

Page 3: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Background• Non-melanoma skin cancer (NMSC) is the most common malignancy in

the US • Affects 2 to 3 million people each year1

• High dose rate (HDR) brachytherapy using surface applicators has shown efficacy in the treatment of NMSC

• An electronic brachytherapy (EBT) system permits treatment of NMSC without the use of a radioactive isotope• Xoft Axxent® eBx® system

• A miniature, electronic, HDR, low energy X-ray tube produces X-rays of 50 keV maximum energy1 Rogers HW, Martin A. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010;146:283-287.

Page 4: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Ir-192 HDR Surface Applicator vs. Xoft eBx Surface Applicator

Page 5: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Dose Profile of Xoft 35mm Surface Applicator vs. Ir-192 Liepzig Applicator

For 10 sources over the 80% field width (per AAPM TG25)• Flatness (Mean and S.D.): 3.2 % +/- 1.2%• Symmetry (Mean and S.D.): 4.2 % +/- 2.1%

Superior Dose Profile with Xoft Applicator• Potential to decrease margins compared to Ir-192

Page 6: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Study Purpose

• The objective of this IRB approved study was to assess adverse effects, cosmesis, and recurrence rates up to two years following HDR electronic brachytherapy for the treatment of non-melanoma skin cancer.

Page 7: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Methods• July 2009 – February 2012, 122 patients with 171 NMSC tumors were

treated with eBx using surface applicators• All received same dose fractionation

• 5.0 Gy x 8 fractions = 40.0 Gy, 2 fractions per week• Prescription depth

– Empirically 3 mm for most lesions– Determined by CT only for thick lesions

• Surface applicator size (10, 20, 35, and 50 mm) was selected to allow for complete coverage of target lesion with acceptable margin

• Patient care included• Petrolatum ointment during treatment• Aloe vera gel through 1 month post-treatment

• Adverse Events Assessment: NCI CTCAEv4 criteria• Cosmesis Assessment: RTOG scale

Page 8: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Treatment setup for patient with facial lesion showing a) thermoplastic mask cut out around lesion; b) surface applicator in contact with skin; c) shielding and applicator setup; and d) electronic brachytherapy controller to the right of the patient.

a

c d

b

Page 9: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Results

• Mean Follow up 11 months (range 1-38 months)• No Recurrences to Date

PATIENT CHARACTERISTICS

N Subjects N Lesions 122 Subjects 171 Lesions

Mean Age (Range) 73 Years (49-97)

Gender 63% Male 37% Female

Ethnicity 97% Caucasian non-Hispanic

Page 10: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Tumor CharacteristicsTYPE (N=171 LESIONS) n % Basal Cell Carcinoma (BCC) 91 53% Squamous Cell Carcinoma (SCC) 70 41% Merkle Cell Carcinoma (MCC) 2 1% Cutaneous T-cell Lymphoma (CTCL) 3 2% Basal-Squamous Cell Carcinoma 1 1%

STAGE (N=171 LESIONS) n % Tis 10 6% T1 138 81% T2 4 2% Recurrence 15 9% Not available 4 2%

Page 11: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Tumor CharacteristicsLESION LOCATION (N=171 LESIONS) n %

Nose 49 29%

Face (forehead, temple, eyelid, glabella, sideburn, cheek, lip, chin) 50 29%

Ear 22 13%

Extremity 24 14%

Scalp 14 8%

Torso 12 7%

Page 12: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Tumor Characteristics

TUMOR SIZE (N=171 LESIONS) n %

≤ 1CM 101 59%

> 1 CM TO ≤ 2CM 61 36%

> 2 CM TO ≤ 3CM 6 3%

>3 CM TO ≤ 4CM 2 1%

>4 CM TO ≤ 5 CM 1 1%

Page 13: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Number of Lesions Treated by Applicator Size and Dose Depth

Applicator Size

Prescription Dose Depth

1 mm 3 mm 4 mm* 5 mm§ 7 mm TOTAL

10 mm 2 64 1 9 0 76

20 mm 0 39 2 20 1 62

35 mm 0 5 2 22 0 29

50 mm 0 1 1 1 1 4

TOTAL 2 109 6 52 2 171* Includes prescription dose depths of 4.0 mm to 4.1 mm§ Includes prescription dose depths of 4.75 mm to 5.6 mm

Page 14: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Treatment Time and Dose Depth by Histopathology

Histopathology (N=171 Lesions) n

Treatment Time: mean

(range)Basal Cell Carcinoma 91 5.6 (4-8.2) minSquamous Cell Carcinoma 70 5.8 (3.9-12.5) minMerkle Cell Carcinoma 2 5.8 (4.6-6.9) minCutaneous T-cell Lymphoma 3 8.4 (5.7-13.8) minBasal-Squamous Cell Carcinoma 1 5.2 (5.2-5.2) minNot available 4 7.3 (4.5-11.2) min

Page 15: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Adverse Events: Late6 MONTHS (N=52 LESIONS) n % Hypopigmentation 4 8% Alopecia 2 4% Hyperpigmentation 1 2% Atrophy 1 2%1 YEAR (N=58 LESIONS) n % Hypopigmentation 5 9% Alopecia 2 3%2 YEARS (N=30 LESIONS) n % Hypopigmentation 4 13% Alopecia 1 3%

• All Hypopigmentation was Grade 1 (mild)• No Grade 3 or higher Adverse Events

Page 16: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Cosmesis

Percent of Lesions withGood or ExcellentCosmesis

1 3 12Post-Treatment Visit Month

6 24N=122 N=81 N=52 N=55 N=29

100 ––

80 ––

60 ––

40 ––

20 ––

0 –

75%

89% 92% 95% 93%

• No Patients with Fair or Poor Cosmesis

Page 17: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

CASE EXAMPLES

Page 18: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma on right cheek Treated with 40 Gy to a 5 mm depth

Pre-treatment Fraction 7

1 Mo 3 Mo

6 Mo 2 Yr

Page 19: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Basal cell carcinoma on chin Treated with 40 Gy to a 3 mm depth

Pre-treatment

2 Yr

Page 20: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Basal cell carcinoma on right nostril and nasal bridge Treated with 40 Gy to a 5 mm depth

Pre-treatment

2 Yr

Page 21: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma on left armTreated with 40 Gy to a 5 mm depth

Pre-treatment2 Yr

Page 22: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Basal cell carcinoma on left tip of noseTreated with 40 Gy to a 3 mm depth

Pre-treatment

23 Mo

Page 23: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Basal cell carcinoma on right tip of noseTreated with 40 Gy to a 5 mm depth

Pre-treatment22 Mo

Page 24: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma below left eyeTreated with 40 Gy to a 3 mm depth

Pre-treatment

20 Mo

Page 25: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma on left cheek Treated with 40 Gy to a 5 mm depth

Pre-treatment

1 Yr

Page 26: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma on right antihelixTreated with 40 Gy to a 3 mm depth

Pre-treatment

1 Yr

Page 27: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Basal cell carcinoma on right upper eyelidTreated with 40 Gy to a 3 mm depth

Pre-treatment

6 Mo

Page 28: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Squamous cell carcinoma on left postauricular scalpTreated with 40 Gy to a 5 mm depth

Pre-treatment

3 Mo

Page 29: Non-Melanoma Skin Cancer Treated with Electronic Brachytherapy:  Results at Two Years

Conclusions• As of date, treatment of non-melanoma skin cancer with HDR

electronic brachytherapy using surface applicators was effective and convenient comparable to Ir-192 HDR brachytherapy• Cosmesis was good to excellent up to 2 years post-treatment • Toxicities were acceptable• No recurrences to date, but longer follow up is being collected

• Brachytherapy (electronic or traditional) is an ideal modality for patients (especially elderly patients) with NMSC given the excellent results and convenient schedule

• We (Radiation Oncology) need to take a more prominent role in the treatment of NMSC