A radiation oncology approach for using definitive radiotherapy with volumetric modulated arc therapy (VMAT) for skin field cancerisation (SFC)

"Resection of skin cancer with graft or flap repair may be referred for local postoperative radiotherapy (PORT) to ensure local control." PORT needs to be delivered in a certain time frame after surgery, but this may impact on graft and flap survival. The purpose of this article is to pass on some experience our multidisciplinary team has acquired in order to assist in the management of these cases. Specifically, pertinent issues in patient assessment (history and examination), indications for PORT, the differences between a graft and a flap, and technical considerations in the prescription of radiotherapy to these are covered, accompanied by illustrative cases with appropriate photographs and diagrams. The principal findings are that a conservative approach may need to be taken to ensure graft and flap survival, with PORT reserved for a role in salvage. Other interesting cases cover the lack of acute radiation side effects in flaps; the tendency of acute radiation skin toxicity to move with gravity, and transplanted skin may have a different radiation sensitivity to that of its new environment. We hope that this article will be of use for the multidisciplinary skin oncology team. Further research is needed to validate and confirm our findings.

Section: Assessing the Patient Historymentioning

confidence: 99%

Experiences when irradiating grafts and flaps for skin cancer

Dwyer¹,

Haddad²,

Fogarty³

2020

“…Skin patients are often different from tradition RT patients. 35 They have chronic conditions that cause more morbidity than mortality. They can have comorbidities that promote skin cancer (e.g.…”

Section: The Skin Patientsmentioning

confidence: 99%

Experiences in growing a skin radiation therapy practice

Fogarty¹,

Christie²,

Wong³

et al. 2020

The successful treatment of skin disease decreases morbidity and mortality. Radiation therapy (RT) can cure skin disease and conserves tissue, possibly delivering better quality of life post treatment and so a superior survivorship. Modern RT delivers better dose conformality and homogeneity, and more is known about the radiobiology of skin and its diseases, enabling treatment personalisation. Skin, however, can be viewed in RT departments as not a serious subspecialty, even in Australia where the incidence of skin cancer is highest. Radiation oncology leaders are needed to carve out a niche for RT amongst a crowded field of skin carers. This article based on the cumulative experience of a group of Australian skin radiation oncologists (ROs), details how this may be achieved. First, focus is placed on growing a high-quality service. The RO needs to understand how patient, tumour and treatment factors impact the skin RT prescription. The particular nuances around skin RT planning, including immobilisation, simulation, contouring and the advantages and disadvantages of each RT modality in skin, are important to know. How skin reacts to RT when the skin is the target and the importance of fractionation is essential knowledge. Second, the RO needs to understand the needs of the skin stakeholders. These include those in the department who look to them for leadership. It includes those outside the department, that is, patients and other skin carers who could be future colleagues and even referrers. Third, the RO needs to use much needed research as a way to bring the disparate skin caring community together through completing high-quality research to guide therapy and post-treatment care.

“…9 New radiation techniques have been developed, especially volumetric modulated arc therapy (VMAT) which is a further evolution of intensity modulated radiotherapy (IMRT). [10][11][12] VMAT allows definitive radiation treatment of large convex fields (e.g. scalp, forehead, cheeks, forearms and legs).…”

Section: Introductionmentioning

confidence: 99%

Volumetric modulated arc therapy (VMAT) for extensive skin field cancerisation (ESFC) – exploring the limits of treatment volumes with a case series of backs

Wong¹,

Christie²,

Hellyer³

et al. 2020

Skin field cancerisation arises from prolonged sun exposure and increases with age. Multiple areas of the skin can be involved resulting in poor quality of life and cosmesis and even death. The long-term efficacy of traditional treatments such as topical creams is disappointing. Volumetric modulated arc therapy (VMAT) is a relatively new radiation technique that allows the definitive treatment of large convex fields. Extra dose can also be delivered simultaneously using a boost technique to proven areas of macroscopic invasive disease. In what we believe is the first publication of its kind, we present a retrospective case series of 15 patients with 21 areas treated with VMAT to the back. Treatment is feasible but areas of skin cancerisation over 800 cm2 should not be treated in one course but broken into smaller fields separated by adequate breaks. Care should be taken when treating large areas of the spine as pancytopenia may result and routine blood counts between treatment courses should be considered. More research is warranted to confirm the dose and efficacy outcomes, but this technique may represent a new therapeutic option for patients with extensive skin field cancerisation of the back.