Skin CA

[deleted4401]

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Almost never treated it at UPMC during residency (60 sunny days a year). Now, I treat it all the time. Have 4 scalp cancers on treatment and usually get 1-2 a month.

What do you guys do for run of the mill sun related scalp/face cancer? I usually do 55/20 Gy and it seems to do the trick without too much acute toxicity, but had some bad moist desquamation recently. But, for these old guys, just think 33 trips is too much.

We also have the equipment to do brachytherapy. Anyone use those molds? What sort of dose do you use? Is there a thickness of cancer that limits you from using it?

S

 

[medgator]

Treated a fair amount in residency with orthovoltage which worked brilliantly. Unfortunately, don't have that option anymore. I have typically used 60-66/30-33 for any head area for the most part out of concern for toxicity. I have hypofx slightly to 55/20 in some cases where I had to but have noticed anecdotally more toxicity with this so I have used it less for head and neck skin. That being said I know a lof of people who use 55/20 in H+N skin and swear by it. Seems like you are right in line with it. I dont use brachy for skin so no experience there.

I'll do 55/20-22 Fx if cosmesis and toxicity isn't too big of a concern. If I am hitting a big area of cartilage though, I do make them come in for 32 Fx (64 Gy as per NCCN). I will also do the protracted regimens for those difficult CA referrals we get on the anterior shin.

 

[Palex80]

We often give 45-48/15-16fx. Cosmetic results are fine, especially if you are treating small fields.
However, we do have two orthovoltage machines here, which deliver 10-200kV and we use them quite often instead of electrons. Some say, that cosmetic results with orthovoltage can be better than with electrons and permit you higher dose/fraction, because you are treating very superficially with the high doses, while with electrons you generally "overshoot" (unless you use a big bolus), thus limiting healing from deeper skin layers. But that's just a theory... 😕

We want to use brachytherapy with molds and are in the process of trying to commission the equipment. I find them quite helpful for treating scalp or the entire circumference of an extremity.
They look like that:

 

[Tanner]

It really depends on the size of your lesion and location:

Smaller lesions- 33-39 / 3-5fx
Medium lesions: 40-54 Gy / 10-20fx
Large lesions: 60 Gy / 30fx

If the lesion is over very thin or delicate skin, then I tend to fractionate, but I normally hypofractionate as best as possible. Most of my skin cancer patients are old and I prefer to finish their course as quickly as possible.