Skin / Melanoma
HDR surface brachy for facial and pinna BCC/SCC: high LC across retrospective and prospective single-institution series, heterogeneous dose/fractionation, no randomised comparator vs EBRT or surgery.
HDR brachytherapy with custom-made surface molds for facial skin carcinomas
ForFacial BCC/SCC, primary or post-surgical recurrence, node-negative
TL;DR5y actuarial LC 98% overall (99% primary, 87% recurrent) in 136 facial BCC/SCC treated with HDR Ir-192 surface molds, no severe late complications.
The RT read is geometry plus fractionation: a custom PMMA mold held dose at 5 mm depth within 5% of prescription over curved facial surfaces, with 180 cGy fractions to 6000-6500 cGy and no severe late effects. Whether that conformality keeps its late-toxicity profile with fewer, larger fractions was not tested here.
In node-negative BCC/SCC on curved facial skin (nose, eyelid, ear) where an electron or orthovoltage field fits poorly, this supports HDR surface-mold brachytherapy as a conformal RT option; it does not inform hypofractionated mold schedules or deeply invasive lesions. The longer read
A custom PMMA mold held dose at 5 mm depth within 5% of prescription over curved facial anatomy with a sharp edge gradient, giving 99% 5y LC in primaries and no severe late effects at 180 cGy per fraction. It supports molds for non-flat sites; transfer to short-course schedules is untested.
14 details
Prospective single-institution series, 136 consecutive pts treated 1992-1997 in Barcelona. Minimum follow-up 12 mo; median follow-up not reported.
Pathologically confirmed facial BCC (102) or SCC (34), 73 primary and 63 recurrent after prior local therapy. Gross tumor left in place in most; margins positive in 128. No nodal or distant disease on CT head/neck and chest X-ray.
HDR Ir-192 via 117 custom PMMA molds (3-7 parallel catheters, 5 mm bolus layer) or 19 Brock applicators. 6000-6500 cGy in 33-36 fx of 180 cGy at 5 mm depth; lesions ≥4 cm boosted 1800 cGy/10 fx after a 3-wk rest to 7500-8000 cGy. Eye shielded with a 5 mm lead sheet in the mold.
All pts complete responders; 3 local recurrences (1/73 primary, 2/63 recurrent). 5y actuarial LC 98% overall, 99% primary, 87% recurrent; no regional or distant failure.
| Group | N | Local recurrences | 5y actuarial LC |
|---|---|---|---|
| All pts | 136 | 3 | 98% |
| Primary tumors | 73 | 1 | 99% |
| Recurrent tumors | 63 | 2 | 87% |
| Previously untreated >4 cm | 16 | 1 | 91% |
| Timepoint | Good/excellent cosmesis |
|---|---|
| 2 wk | 38% |
| 3 mo | 92% |
| 6 mo | 98% |
Erythema G1 in 117 and G2 in 19; 14 (10%) had G1 ulceration at 6 wk, all healed by 4 mo. Good/excellent cosmesis 98% at 6 mo; no severe late complications.
Primary-tumor LC of 99% sits alongside the 95% superficial X-ray result in the Lovett EBRT series and above Lovett's 77% with electrons. Daly's Ir-192 interstitial implants reached 96% LC but with 18% severe late effects, the toxicity gap the mold approach is designed to close.
Dose per fraction (180 cGy) far from modern short-course skin brachy, so the late-effect profile may not transfer. Recurrent-tumor LC timepoint reported inconsistently (5y vs 4y), and cosmesis was graded by the treating team.
The contribution is technical: a reproducible, afterloaded surface applicator that conforms to non-flat facial anatomy with a sharp edge gradient. It shows high control with conventional fractionation but does not settle how it compares head-to-head with superficial X-ray, electrons, or Mohs.
Single-arm single-institution series without a comparator; follow-up minimum only 12 mo with median unreported; comparisons rest on historic EBRT and implant series.
- Does late cosmesis hold with hypofractionated HDR mold schedules?
- Head-to-head vs superficial X-ray or electrons on curved facial sites
- Durability of control beyond 5 years in recurrent lesions
📚 Sources · 📄 1 paper
Fractionated HDR brachytherapy moulds for carcinoma of the pinna
ForSuperficial BCC/SCC of the pinna, no cartilage invasion
TL;DR13 pts with superficial pinna carcinoma treated with HDR moulds, 45 Gy/8 fx: complete resolution in all, no recurrences at minimum 18 mo f/u.
The transferable parameter is ultrasound-guided mould height: measuring tumour depth (0.84 mm in one case) lets the 80% isodose cover disease while leaving cartilage outside, which electrons cannot do for lesions thinner than 12 mm. Full-thickness cases needed a sandwich mould at reduced dose (42.5 Gy), so cartilage sparing is the selection criterion.
In superficial BCC or SCC confined to pinna skin without cartilage invasion on ultrasound, this supports an HDR surface mould as a cartilage-sparing RT option; it does not address lesions requiring full-thickness pinna irradiation. The longer read
The transferable parameter is ultrasound-guided mould height: measuring tumour depth (0.84 mm in one case) lets the 80% isodose cover disease while leaving cartilage outside, which electrons cannot do for lesions thinner than 12 mm. Full-thickness cases needed a sandwich mould at reduced dose (42.5 Gy).
13 details
Retrospective single-institution series of 13 pts treated at the Christie Hospital up to July 1996. Technique description with three illustrative cases.
9 BCC, 3 SCC, 1 intraepidermal carcinoma. Lesion confined to pinna skin; dermal ultrasound confirmed cartilage not invaded in all but one.
HDR microselectron with single stepping iridium source via custom vacuum-formed mould. 45 Gy in 8 fx over 5 days prescribed to the surface, mould height set so tumour depth lies within the 80% isodose. Sandwich mould case reduced to 42.5 Gy.
Complete tumour resolution in all pts, barely perceptible scar. No recurrences and no late complications over minimum 18 mo f/u.
Moderate cutaneous erythema limited to the high-dose area, settled by the 6 wk visit. No discernible reaction on the contralateral pinna skin.
Authors position moulds against electrons (poor fall-off for thin lesions, cartilage necrosis risk), 30 kVp X-rays (dose inhomogeneity on curved surfaces, limited availability) and surgery (amputation or excision with graft). No head-to-head data.
Outcomes reported as a blanket statement without per-pt f/u, actuarial LC, or a validated cosmesis scale. Late cartilage toxicity can emerge beyond 18 mo, and the LQ-based BED rationale assumes complete repair between fractions.
The contribution is technique, not efficacy: ultrasound depth measurement plus tunable source height makes the plan conformal to sub-millimetre tumour thickness. Whether a higher late-tissue BED is tolerated because of the small volume is asserted, not shown.
Single-institution case series of 13 selected pts, no comparator, 18 mo minimum f/u too short for late cartilage effects; outcomes descriptive only.
- Late cartilage toxicity beyond 18 months
- Local control vs surgery or electrons in matched pts
📚 Sources · 📄 1 paper
Skin surface brachytherapy practice-pattern survey
ForBCC and cSCC treated with skin surface brachytherapy
TL;DR16 ABS respondents: gross-disease margin 3-15mm (median 5mm), doses 30 Gy/5fx to 64 Gy/32fx (EQD2 40-65 Gy), no consensus on dosimetric constraints.
The transferable read is pretibial dosing: 10 respondents (63%) dropped to 2-3 Gy per fraction there, and eight reported severe toxicity on the lower extremity. With max skin dose ranging 125-150% and fractionation cut points spanning 2-5 cm, a reader building a skin HDR program has a variance map, not a constraint set.
For a BCC or cSCC on the pretibial skin, this survey supports treating site as a reason for gentler fractionation; it does not inform lesions deeper than 3 mm or with perineural invasion, which respondents steered away from brachytherapy. The longer read
The transferable read is pretibial dosing: 10 respondents (63%) dropped to 2-3 Gy per fraction there, and eight reported severe lower-extremity toxicity. Max skin dose 125-150% and fractionation cut points of 2-5 cm mean a skin HDR program must set and audit its own constraints.
12 details
30-question electronic survey sent to ~400 American Brachytherapy Society clinician members. 16 fully completed surveys analyzed; one incomplete survey excluded. Nearly all US respondents, one from Spain.
Radiation oncologists using skin surface brachytherapy for cSCC and BCC. Practice settings spanned academic, hospital-based and private; aggregate experience ranged 8 to 1800 cases.
Hypofractionation preferred; clinical-scenario doses ranged 30 Gy in 5 fractions to 64 Gy in 32 fractions (EQD2 40 Gy-65 Gy). Median max prescription depth 5 mm; shielded applicators most common, custom molds for large or curved areas. Respondents avoided daily schedules when hypofractionating.
Margin on gross disease 3-15mm, median 5mm. Max skin dose 125-150% (median 135%) of prescription; CTV coverage 90-100% (median 95%). No consensus on dosimetric constraints.
| Parameter | All respondents | >100 cases in career |
|---|---|---|
| Max dose at skin surface | 13 (81%) | 7 (78%) |
| Min dose to CTV | 8 (50%) | 3 (33%) |
| Depth of 90% isodose line | 6 (38%) | 3 (33%) |
| Min dose to skin surface | 5 (31%) | 4 (44%) |
| V150 | 4 (25%) | 2 (22%) |
| D95 | 2 (13%) | 1 (11%) |
Eight respondents described severe acute and late toxicity on the lower extremity, especially pretibial skin. Three referred non-healing in-field ulcers for hyperbaric oxygen.
The cited prior literature (Guix custom-mold HDR, Paravati electronic brachytherapy, van Hezewijk hypofractionated electrons) reports single-series outcomes. This survey adds no outcomes; it documents how widely dose, margin and constraints vary across practices using the technique.
Several key tables carry ambiguous row-value pairing in the source, and the scenario table (Table 4) was not captured. Toxicity is anecdotal recall with no denominators.
The useful output is the spread itself: margins, skin-dose ceilings and the lesion-size threshold for gentler fractionation all vary several-fold. Prospective trials and expert consensus are what the authors call for, and this survey cannot substitute for either.
Practice survey of 16 self-selected respondents; no efficacy or toxicity endpoints measured, so the authors' 'convenient and safe' conclusion is not testable from this design.
- Which dosimetric constraints predict late skin toxicity?
- Optimal fractionation for pretibial and lower-extremity lesions
- Brachytherapy vs electrons or orthovoltage for cosmesis
📚 Sources · 📄 1 paper
CT-based flap brachytherapy for facial non-melanoma skin cancers
ForT1 facial BCC/SCC (area H/M), elderly, surgery-unfit or refusing
TL;DR1-yr KM local control 92% after HDR flap brachy 40 Gy/8 fx twice weekly for T1 facial BCC/SCC; no chronic G≥3 toxicity.
The dosimetry is the transferable part: median V100 85% and D90 92% with catheters 5 mm off the skin, against tumors up to 7 mm thick, so deep-margin coverage is the weak point. Three of 4 recurrences were nose, eyelid and lip, the irregular sites the flap is meant to solve.
In an elderly pt with T1 BCC or SCC of the nose, eyelid or temple who declines or cannot tolerate Mohs, this supports CT-planned flap HDR 40 Gy/8 fx as a reasonable option; it does not address pts fit for surgery or lesions thicker than 7 mm. The longer read
The dosimetry is the transferable part: median V100 85% and D90 92% with catheters 5 mm off the skin, against tumors up to 7 mm thick, so deep-margin coverage is the weak point. Three of 4 recurrences were nose, eyelid and lip, the irregular sites the flap is meant to solve.
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Single-institution retrospective review, January 2007 to December 2018. 50 pts, 53 lesions, minimum 6 mo follow-up, median follow-up 15 mo (range 6-27). LC by Kaplan-Meier.
Histologically confirmed BCC or SCC, AJCC 8th T1, all NCCN high-risk by area H or area M location. Median age 80; selected by a multidisciplinary dermatology clinic, mostly for inability to tolerate or refusal of surgery.
40 Gy in 8 fractions twice weekly (BED 60 Gy, α/β 10) via Ir-192 HDR catheter flap, CT-planned in BrachyVision. CTV = visible tumor + 5 mm, PTV = CTV with no margin; 5 mm spacers protected the nasal mucosa, globe and gingiva.
1-yr LC 92%, 4 local recurrences, 3 in nose/eyelid/lip. 49 lesions (92%) had good/excellent cosmesis with complete remission.
| Toxicity | n (%) |
|---|---|
| Acute G1 (erythema) | 32 (60%) |
| Acute G2 | 19 (35%) |
| Acute G3 (moist desquamation) | 3 (5%) |
| Chronic G1 at 6 mo | 5 (10%) |
| Chronic G1 hypopigmentation at 12 mo | 2 (4%) |
| Chronic G2 telangiectasia at 12 mo | 2 (4%) |
Acute G1 60%, G2 35%, G3 5%, all after fraction 5. Chronic G2 telangiectasia in 2 pts (4%) at 12 mo, no chronic G≥3, no toxicity-related hospitalization.
Local control falls inside the 87%-100% range of prior retrospective HDR surface-mold series. The only randomized surgery-vs-RT trial in facial BCC cited by the authors found 4-yr failure 7.5% vs 0.7% favoring surgery, though RT there was mostly interstitial brachy, not surface HDR.
Median V100 85% falls short of the ≥95% PTV coverage goal, and depth was assessed mostly by palpation. Abstract and body disagree on acute toxicity grade, and the Discussion understates chronic G2 events.
The flap's value is conformity on irregular surfaces where surface molds and electrons struggle, yet recurrences clustered in exactly those sites. BCC and SCC got identical dose and margins, consistent with NCCN, the 2020 ASTRO guideline and the 2019 ABS consensus, so histology-specific dosing is still untested.
Single-arm retrospective series, surgery-unfit/refusing pts, 15-mo median f/u; no comparator vs Mohs or EBRT. Consistent with prior HDR surface-mold series.
- Durability of local control and late cosmesis beyond 2 years
- Histology-specific dose or margin for BCC vs SCC
- Surface HDR brachytherapy vs Mohs or EBRT head to head
📚 Sources · 📄 1 paper
Surface mould brachytherapy for skin cancers: British Columbia Cancer experience
ForElderly pts with superficial skin cancers (mostly H&N BCC/SCC)
TL;DR2-yr LC 84.9%, CR 96.8%, no G3+ toxicity with CT-planned Ir-192 HDR surface mould in 65 mostly head-and-neck skin lesions.
The planning detail is the transferable part: prescription at 0.5 cm with no PTV left median V100 at 73.7% and surface dose 126.5%. LC was 88.9% with V90 >95% vs 76.9% below (p=0.85), a hint that coverage matters, but too few events to set a V90 target.
In elderly, surgically unsuitable pts with superficial head-and-neck BCC or SCC, this supports CT-planned surface mould HDR as a non-invasive option; it does not extend to lesions deeper than 5 mm, which the authors steer toward interstitial techniques. The longer read
Prescription at 0.5 cm with no PTV gave median V100 73.7% and surface dose 126.5%. LC 88.9% with V90 >95% vs 76.9% below (p=0.85) suggests coverage matters, but five recurrences cannot define a V90 target or justify a margin.
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Retrospective review of all Ir-192 HDR surface mould cases at one BC Cancer center, 2010-2017, 65 lesions in 59 pts. Median follow-up 8 months.
Median age 82 (45-97). BCC 54%, SCC 31%, plus melanoma, lentigo maligna, Merkel cell, cutaneous NHL and one keloid. Mostly head and neck (forehead/temple, nose, scalp, cheek/lip); 7 lesions palliative-intent.
Individualized Aquaplast + superflab mould, catheters ~1 cm apart, CT-based planning in BrachyVision. Most common 40 Gy/10 fx (48.2%); range 15 Gy/3 to 60 Gy/30 fx. Prescribed at 0.5 cm depth, CTV from clinical wire with no PTV expansion.
2-yr LC 84.9%, 2-yr PFS 71.5%, 2-yr OS 77.6%; CR 96.8% at 2-4 mo. Of 20 deaths, only two were from the skin malignancy. No dosimetric or histologic factor reached significance on univariate analysis.
| Endpoint | Estimate |
|---|---|
| 2-yr local control | 84.9% |
| 2-yr PFS | 71.5% |
| 2-yr OS | 77.6% |
| Complete response (2-4 mo) | 96.8% (61 lesions) |
| Local recurrence | 5 pts |
| Variable | Group | 2-yr LC (%) | p |
|---|---|---|---|
| V90 | <95% vs >95% | 76.9 vs 88.9 | 0.85 |
| Median target dose | <100% vs >100% | 75 vs 88.2 | 0.94 |
| Histology | BCC vs SCC | 70 vs 88.2 | 0.94 |
No G3-5 acute or late toxicity. Acute G2 dermatitis 32% and ulceration 8%; one late G2 necrosis (2%) appearing around 10 months.
The authors place their LC within the brachytherapy literature range of 83.3% to 100% and against EBRT LC of 87-100% and Mohs at 95-99%. Gauden et al. reported LC 98% with 36 Gy/12 fx, but at similarly short follow-up and largely in a post-resection margin-positive setting. GEC-ESTRO grades the technique B.
Histology and intent are pooled (keloid, lymphoma, melanoma, palliative lesions). Toxicity was graded retrospectively from records and photographs, and cosmesis was not scored. Internal inconsistencies (median age 82 vs 83, follow-up 8 vs 9 mo, sex counts summing to 65 of 59 pts) lower confidence in the tabulated data.
The series shows the technique is deliverable and tolerable in a very old cohort, which is the realistic use case. It does not settle the durability of control, the right prescription depth or margin, or whether coverage metrics predict recurrence.
Retrospective single-institution series, n=59, mixed histology and intent; 2-yr estimates drawn from a median 8 mo follow-up with no comparator arm.
- Durability of local control beyond one year of follow-up
- Does V90 coverage above 95% predict local control?
- Role of a PTV margin in surface mould brachytherapy
