Figure 8. Saggital View of Treatment Plan

Patient developed grade 2 reactions during radiotherapy and grade 3 reactions after 1 week of completion of radiotherapy. Reactions settled post 3 weeks of brachytherapy. Post one month he was operated for hydrocoele. Now the patient has been five years of follow up with no evidence of disease, no significant late effects and excellent organ preservation.

Brachytherapy is the most conformal form of radiotherapy with sharp dose fall off and minimal dose to adjacent structures. Superficial brachytherapy is a useful non-invasive technique for treatment of superficial malignancies. It also gives good cosmesis, good control rates and also organ preservation resulting in better functional outcomes. We reviewed our institutional experience with this technique and reporting three different types of cases out of ten cases.

Surgery is often considered the primary treatment for NMSCs (non-melanoma skin cancers), but often this may not be the best option, due to tumor location (and thus, cosmetic outcomes) or patient comorbidities. Mohs microsurgery has certain limitations with high chances of failure if tumor shows multicentricity, disconnected foci, or satellite lesions [2]. External beam radiotherapy is a useful technique where patient status, comorbidities or tumor location precludes resection, but it can have an impact on adjacent normal structures, resulting in toxicity or cosmetic changes, located within the radiation field. There is evidence suggesting similar rates of local control, late toxicity and cosmetic effects with brachytherapy as compared with EBRT. Delishaj et al. noted in their literature review of ten studies of non melanoma skin cancers treated by HDR brachytherapy. They used the RTOG/EORTC toxicity grading criteria to grade cosmesis into excellent, good, fair and poor category. Patients had excellent cosmetic results in 62% of cases, good results in 26% and poor results in 5.5% [16]. Many of the studies are small and often retrospective, hence GECESTRO’s have given grade B recommendation for the technique (moderate/strong evidence for efficacy but with limitedclinical benefit - generally recommended) [17]. The largest study was performed by Gauden et al. where they prospectively followed 200 patients with 236 skin lesions treated with 36 Gy in 12 fractions using surface brachytherapy. Patients were evaluated regularly for toxicity and cosmetic results, and the LC was 98% (232/236) with a median follow-up of seven months. Four patients developed local recurrences and were salvaged with surgery. Moderate toxicity was noted and 88% of the patients had good/excellent cosmesis. Treatment was completed by all patients and LC was comparable to EBRT patients [10]. Various other retrospective studies have shown similar results with LC varying from 83.3% to as much as 100%. The papers reported variable levels of follow-up, cosmetic results and toxicities [13-18]. In a study by Rio et al. 97 skincarcinomas (88 BCC, 9 SCC) of the nose, periorbital areas, divided in two groups, 40 previously untreated patients (group 1) and 57 patients who had undergone surgery (group 2) were retrospectively analysed. The local control was 92.5% in group 1 and 88% in group 2 (median follow-up 55 months). The average dose was 55 Gy (range: 50–65 Gy) in group 1 and 52 Gy (range: 50–60 Gy) in group 2. Brachytherapy provided good local control and cosmetic results for facial, peri-orificial skin carcinomas that pose problems of surgical reconstruction [19]. Our case 1 and 3 reported control rate of 100% at 2years with good cosmesis. We found no significant toxicities and treatment was well tolerated.

In primary breast cancer role of interstitial brachytherapy is well established [20] but in metastatic case setting role of surface brachytherapy is very less explored. Inerstitial Brachytherapy in metastatic disease has been widely used for spinal metastasis and liver metastasis. Gordon Mao et al summarized the results of various primary and metastatic spinal tumors treated by various brachytherapy modalities and reported recurrence rates of 18-27% across various studies [21]. Case 2 was a post treated carcinoma breast with solitary chest wall recurrence. Control rate was 100% at three months and six months. At seven months patient developed metastatic lung and liver disease but local site was well controlled.

Our case 3 deals with early stage carcinoma penis. Carcinoma penis brachytherapy is well explored. Penile brachytherapy is challenging due to applicator placement reproducibility, immobilization, and the need to treat to appropriate depth although adhering to skin constraints. Interstitial techniques have been mainly used to achieve adequate dose coverage at depth although coupling the applicators to the target site [22]. Hugh et al described a custom mould for treating superficial tumors delivering 40Gy in 10 fractions [22]. In a metanalysis by Shakir Hasan et al total of 2178 males, median age 61 years, were included. 1505 patients in surgery group, and 673 patients in brachytherapy group. Penectomy was associated with a higher 5-year LC rate of 84% compared with 79% with brachytherapy, odds ratio = 1.45 (1.09–1.92, p = 0.009). The 5-year OS with surgery was 76% compared with 73% with brachytherapy, odds ratio = 1.17 (0.95–1.44, p = 0.128). The organ preservation rate for brachytherapy treatment was 74%. Among the surgery patients in a Stage I/II subset, the 5-year OS and LC was 80% (n = 659) and 86% (n = 390), respectively. Of the 209 early stage patients who received brachytherapy, the 5-year OS was 79% and LC was 84%. Chi-square testing demonstrated no difference for either OS or LC for early stage disease [23].

In our case 3 the maximum acute toxicity was grade 3, with no urethral stricture or any late toxicity.It was well controlled at 2 years with 100% local control and no recurrence at 5 years with good organ function.

In conclusion, surface mould brachytherapy is a safe, effective modality for treatment of skin malignancies especially involving challenging sites like nose, eyes, etc. Brachytherapy is overall well tolerated, with no grade 4-5 acute or late toxicities. This treatment is a good alternative option for those patients unwilling or unable to undergo surgery for their superficial malignancies and also can be the primary modality for carefully selected cases. Brachtherapy in metastatic cancers need to be explored more in terms of patient selection and optimal dosing. Brachytherapy is an established alternative in superficial penile tumors with good local control and organ preservation.

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Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors haveconfirmed that this study did not involve animal subjects or tissue.

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