International Journal of Radiology & Radiation Therapy Case Series Open Access Lesion-based radiotherapy of the ears, lips and eyelids for skin cancer Abstract Volume 8 Issue 1 - 2021 Purpose: This study is a retrospective audit of radiotherapy (RT) for skin cancer of the ear, Anthony Tanous,1 David Tighe,1 Julie Bartley,2 eyelid, and lip in Sydney, Australia. The growth of referrals to a tertiary radiation oncology 3 4 service over a specific time period were also assessed. Gavin Gottschalk, Tanya Gilmour, Nicholas Lotz,5 Gerald B. Fogarty2 Materials and methods: The records of patients who received RT to the external ear, 1Faculty of Medicine, University of New South Wales, Australia eyelid or lip between January 1 2007 and April 30 2020 were reviewed. Patient, tumour, 2Genesis Care, Mater Hospital, Australia treatment and outcome factors were recorded. 3Chatswood Dermatology Centre, Australia 4North Shore Dermatology & Specialist Skin Cancer Centre, Results: 147 patients with a mean age of 73 years (range: 33-96) were identified as eligible Australia for inclusion. 165 lesions were treated and 18 patients had multiple treatment events. Of 5North Shore Cosmetic Surgery, Level 1, Australia all the treated lesions, 81 were basal cell carcinoma (49.2%), 65 cutaneous squamous cell carcinoma (39.4%), 7 lentigo maligna (LM) (4.2%), 2 sebaceous carcinoma (1.2%), 2 Correspondence: Prof Gerald Fogarty, Radiation Oncology, merkel cell carcinoma (1.2%), 4 Bowen’s disease (2.4%), 2 actinic change (1.2%) and 2 Mater Sydney, Crows Nest, NSW Australia, keloid treatments (1.2%). The mean follow-up was 42 weeks. Definitive RT, that is, RT Ph +61 2 9458 8050, Fax +61 2 9929 2687, given as primary treatment rather than post operatively, was given in 108 cases. There were Email five cases of BCC recurrence and three cases of cSCC recurrence within 3 - 61 months. Received: March 24, 2021 | Published: April 07, 2021 These were successfully salvaged in six cases (75%). Late side effects were seen in 26 patients with abnormal cosmetic results being the most common late effect (6/26; 23.1%). Conclusion: Lesion-based RT for skin cancer of the ear, eyelid, and lip can be delivered safely and is effective. Definitive RT may be preferable to surgery especially when tissue loss may lead to poor functional and cosmetic outcomes. Keywords: radiotherapy, pinna, ear, eyelid, lip, skin cancer, Australia Introduction Skin cancer is common in Australia and is increasing in incidence. Amongst skin malignancies, keratinocytic cancer is the most common.1 Keratinocytic cancers include basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). Surgery is often used but always involves tissue sacrifice, which may impact functional and cosmetic outcomes, especially in the head and neck region (Figure 1).2 Radiotherapy (RT) can be given in the post-operative scenario (PORT) when high risk features, such as positive margins or perineural invasion (PNI), are seen, or as definitive treatment when RT is given as the sole treatment. Definitive RT offers comparable cure rates,3 conserves tissue, and may provide better functional and cosmetic outcomes in select sites. Case B. Photo is taken from behind to compare the operated right ear (broad arrow) with the unoperated left ear (thin arrow). The right ear had Figure 1 Three cases following surgery of the external ear for skin cancers. had a lesion removed from the mid pinna with primary closure resulting in Tissue sacrifice associated with surgery has led to inferior cosmetic outcomes. significant deformity of the pinna. Case A. Photo is taken from behind to compare the operated left ear with the unoperated right ear. The left ear (broad arrow) had had a lesion removed from the mid pinna with primary closure and needed post opertaive radiotherapy (PORT) or adjuvant RT due to a positive margin. Note the smaller size of the Case C. This left ear had had a lesion removed from the upper and middle operated pinna (broad arrow) versus the right unoperated pinna (thin arrow). pinna with amputation of the top part of the pinna (broad arrow). Submit Manuscript | http://medcraveonline.com Int J Radiol Radiat Ther. 2021;8(1):32‒42. 32 ©2021 Tanous et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Lesion-based radiotherapy of the ears, lips and eyelids for skin cancer ©2021 Tanous et al. 33 Difficult anatomical sites for surgery include the external ear, The lip and the eyelid were described using upper and lower, with eyelid and lip. These organs are important for adequate function as the inner canthus included as an anatomical part of the eyelid for this well as for cosmesis. External ears help to concentrate sound but are study. also needed as support for earrings, glasses, hearing aids and, in these Treatment factors included radiotherapy modality and role, dosage, COVID times, face masks. Definitive RT enables tissue conservation fractionation, radiotherapy start and completion dates, any unplanned in these sites. This is a retrospective audit of one radiation oncologist’s breaks, and field size. The role of radiotherapy was defined as either (RO) work (GBF) and aims to provide modern Australian retrospective radical or palliative; radical was further defined into definitive or data on lesion-based definitive RT of the ears, lips and eyelids. adjuvant. Field size was measured either during planning by the Methods prescribing RO or retrospectively by the research team using a scale and images. Outcome factors (when documented) included acute side Ethics approval effects based on the Common Terminology Criteria of Adverse Effects V5 (CTCAE-V5), late side effects, recurrence, salvage therapy, St Vincent’s Hospital Human Research Ethics Committee provided cosmetic outcome, and length of post-treatment follow-up. Acute side ethical approval on 12 December 2019 (ETH13048). effects were defined as occurring between 0-3 months post RT, and Patient selection late side effects were defined as occurring at least six months post RT.5 Local recurrence was defined as recurrence within the previous Patients were included in this retrospective, single clinician audit treatment field. if they were aged over 18 years and had a skin cancer of the ear, eyelids and/or lips that was planned for RT treatment in Sydney Radiotherapy process between January 2007 and April 2020. Patient factors, tumour factors, Initially, each patient was assessed for RT suitability. Assessment treatment factors and outcomes data were collected by assessing factors included lesion history, RT history, and the availability to individual medical records. The recorded patient factors included attend the clinic for fractionation. The RO examined the patient to date of birth and age at simulation, gender, post-code of residency determine the extent of the lesion and the areas requiring treatment. at treatment, referring practitioner and immunosuppression status. If RT was deemed suitable, informed consent was obtained and the Immunosuppression status was defined as patients on long-term patient proceeded to RT planning. Here, the patient was immobilised corticosteroids, or long-term chemotherapy such as methotrexate; in a comfortable and reproducible position. A mask was used for chronic blood disorders such as lupus and leukaemia; those with linear accelerator-based treatments. organ transplants on immune suppressive drugs, and human immunodeficiency virus infection (HIV). Different treatment modalities were employed and depended upon machine availability and the nature of the lesion. The most Tumour clinical factors were tumour size, depth, location, and common treatment modalities were electron beam radiation (usually a history of previous treatment to the lesion prior to RT. Tumour 6 megavolts (MeV) and 9 MeV), megavoltage photon beam radiation histological factors were available if there was a biopsy prior to referral (MV), and superficial x-ray radiation therapy (SXRT) using the which allowed the histological type to be accessed. In patients who 100kV beam of a Xstrahl 300 machine (Xstrahl Ltd, Surrey, UK). underwent an excisional biopsy, more data was available including The superficial machine was especially practical in older patients who histological depth, differentiation, presence of adverse factors such could not tolerate a mask (Figure 3). as PNI, close or positive margins, and lymph-vascular space invasion (LVSI). When using megavoltage electrons of these energies, tissue equivalent material called “bolus” or ‘build up’ is used to ensure that The external ear was broken into three parts: the pinna (consisting the right dose reaches the target, or to ‘soak up’ any dose that may be of the helix, anti-helix, lobulus, tragus, and the scapha)4, the conchal heading for normal tissue (Figure 4). bowl, and the external auditory meatus (EAM) (Figure 2). Figure 3 Superficial x-ray radiation therapy (SXRT) with a Xstrahl 300 machine was often used, especially in older patients who could not tolerate a mask. This patient had SXRT treatment to bilateral biopsy-proven BCC of the pinnas. Figure 2 Normal anatomy of the ear. The pinna is defined by the short arrows, the conchal bowl by the long horizontal arrow, and the external auditory meatus by the long vertical arrow. Figure 3A Treating the right pinna. Citation: Tanous A, Tighe D, Bartley J, et al. Lesion-based radiotherapy of the ears, lips and eyelids for skin cancer. Int J Radiol Radiat Ther. 2021;8(1):32‒42. DOI: 10.15406/ijrrt.2021.08.00292 Copyright: Lesion-based radiotherapy of the ears, lips and eyelids for skin cancer ©2021 Tanous et al. 34 Figure 4 Use of bolus for megavoltage electrons to achieve adequate dose to the lesion. Figure 3B Treating the right pinna close up. Note the pink material (bolus) used to ensure sufficient dose to the edge of the pinna.