R. Ballester-Sánchez

Efficacy and safety of electronic brachytherapy for superficial and nodular basal cell carcinoma

Purpose Surface electronic brachytherapy (EBT) is an alternative radiotherapy solution to external beam electron radiotherapy and high-dose-rate radionuclide-based brachytherapy. In fact, it is also an alternative solution to surgery for a subgroup of patients. The objective of this work is to confirm the clinical efficacy, toxicity and cosmesis of a new EBT system, namely Esteya® in the treatment of nodular and superficial basal cell carcinoma (BCC). Material and methods This is a prospective single-center, non-randomized pilot study to assess the efficacy and safety of EBT in nodular and superficial BCC using the Esteya® system. The study was conducted from June 2014 to February 2015. The follow up time was 6 months for all cases. Results Twenty patients with 23 lesions were included. A complete response was documented in all lesions (100%). A low level of toxicity was observed after the 4th fraction in all cases. Erythema was the most frequent adverse event. Cosmesis was excellent, with more than 60% of cases without skin alteration and with subtle changes in the rest. Conclusions Electronic brachytherapy with Esteya® appears to be an effective, simple, safe, and comfortable treatment for nodular and superficial BCC associated with excellent cosmesis. It could be a good choice for elderly patients, patients with contraindications for surgery (due to comorbidities or anticoagulant drugs) or patients where surgery would result in a more disfiguring outcome. A longer follow-up and more studies are needed to confirm these preliminary results.

Tratamiento de la pustulosis palmo-plantar con ustekinumab

patient was admitted and treated with oseltamivir. During her stay in hospital, several deep, bilateral genital ulcers with necrotic-looking borders were noticed. Several swab specimens were obtained for standard culture, Neisseria gonorrhoeae culture, and PCR testing for Chlamydia trachomatis, herpes simplex virus types 1 and 2, and samples were taken for serology. Empirical treatment was initiated with ceftriaxone (single dose), oral acyclovir, and amoxicillin-clavulanic acid. The ulcers, however, continued to deteriorate and it was decided to debride the area. In view of the worsening condition of the patient, and the negative results for the viral cultures, the PCR tests, and serology for syphilis and human immunodeficiency virus (HIV), her physicians decided to request dermatologic evaluation. At the time of this evaluation, there was marked vulvar edema and the posterior region of the right labia minora had been resected, leaving an ulcerated area with a clean base. On the left side of the vulva, there was a 1.5-cm exudative ulcer with a fibrinous base. The lesions were painful and accompanied by bilateral enlarged inguinal lymph nodes of less than 1 cm. Topical treatment with absorbent dressings and fusidic acid was prescribed. The ulcers improved and began to heal within a few days; 3 weeks later, they had healed completely. Serology was negative for HIV I and II, syphilis, and cytomegalovirus. Epstein-Barr virus serology was negative for immunoglobulin (Ig) M antibodies and positive for IgG antibodies. No antinuclear antibodies were detected. The differential diagnosis we considered included other causes of acute genital ulcer such as sexually transmitted diseases, lesions caused by trauma, complex aphthosis, and ulcerative lesions associated with autoimmune diseases or inflammatory bowel disease.4--6 In our case, the final diagnosis was ulcus vulvae acutum in association with H1N1 influenza A virus infection, although we cannot rule out the possibility that the drugs taken by the patient during her illness contributed to the aggressive course of the disease and the necrotic appearance of the lesions. There have been several reports of acute genital ulcers associated with influenza virus infection in the last 3 years, but it is not known whether this association is due to new mutations of the virus or to the concomitant ingestion of drugs. Prospective studies will help to determine whether the prevalence and course of ulcus vulvae acutum in patients with influenza differ depending on whether they receive oseltamivir or purely symptomatic treatment. Familiarity with this disease in emergency and dermatology departments will improve the management of these patients and prevent unnecessary interventions.

Electronic brachytherapy for superficial and nodular basal cell carcinoma: a report of two prospective pilot trials using different doses.

Purpose Basal cell carcinoma (BCC) is a very common cancer in the Caucasian population. Treatment aims to eradicate the tumor with the lowest possible functional and aesthetic impact. Electronic brachytherapy (EBT) is a treatment technique currently emerging. This study aims to show the outcomes of two consecutive prospective pilot clinical trials using different radiation doses of EBT with Esteya® EB system for the treatment of superficial and nodular basal cell carcinoma. Material and methods Two prospective, single-center, non-randomized, pilot studies were conducted. Twenty patients were treated in each study with different doses. The first group (1) was treated with 36.6 Gy in 6 fractions of 6.1 Gy, and the second group (2) with 42 Gy in 6 fractions of 7 Gy. Cure rate, acute toxicity, and late toxicity related to cosmesis were analyzed in the two treatment groups. Results In group 1, a complete response in 90% of cases was observed at the first year of follow-up, whereas in group 2, the complete response was 95%. The differences with reference to acute toxicity and the cosmetic results between the two treatment groups were not statistically significant. Conclusions Our initial experience with Esteya® EB system to treat superficial and nodular BCC shows that a dose of 36.6 Gy and 42 Gy delivered in 6 fraction of 7 Gy achieves a 90% and 95% clinical cure rate at 1 year, respectively. Both groups had a tolerable toxicity and a very good cosmesis. The role of EBT in the treatment of BCC is still to be defined. It will probably become an established option for selected patients in the near future.

Análisis retrospectivo del papel de la fototerapia en la enfermedad injerto contra huésped crónica cutánea. Revisión de la literatura

INTRODUCTION AND OBJECTIVES Cutaneous chronic graft-vs-host disease (GVHD) is a common complication of hematopoietic stem cell transplantation. Phototherapy is a therapeutic option for patients with skin involvement and for those who require high doses of corticosteroids. We analyze the cases treated in our department and review the literature. MATERIAL AND METHODS All patients with GVHD treated with phototherapy in the dermatology department of Hospital Universitario y Politécnico la Fe in Valencia, Spain between March 2011 and October 2014 were identified. Data were gathered retrospectively. RESULTS There were 16 patients: 10 treated with psoralen-UV-A and 6 with narrowband-UV-B. Complete response was achieved in 9 patients and partial response in 7; 2 patients with partial responses relapsed after treatment. Ten patients were able to decrease their dose of corticosteroids during treatment, and a further 3 decreased the number of other immunosuppressant drugs. No serious adverse effects occurred. CONCLUSIONS Phototherapy is a good therapeutic option for patients with chronic GVHD with extensive cutaneous involvement, as well as for those who fail to respond to topical treatment or who have become steroid-dependent. The main benefits are that, as the treatment targets the skin, it reduces corticosteroid requirements and has a good safety profile. Treatment must be individualized and, in our experience, both the initial dose and the maximum dose per session can be lower than for other diseases.

Two years results of electronic brachytherapy for basal cell carcinoma

Purpose The use of radiation therapy (RT) for non-melanoma skin cancer (NMSC) has been changing throughout the last century. Over the last decades, the use of radiotherapy has surged with the development of new techniques, applicators, and devices. In recent years, electronic brachytherapy (eBT) devices that use small x-ray sources have been introduced as alternative to radionuclide dependence. Nowadays, several devices have been incorporated, with a few series reported, and with a short follow-up, due to the recent introduction of these systems. The purpose of this work is to describe the clinical results of our series after two years follow-up with a specific eBT system. Material and methods This is a prospective single-center, non-randomized pilot study, to assess clinical results of electronic brachytherapy in basal cell carcinoma using the Esteya® system. In 2014, 40 patients with 60 lesions were treated. Patient follow-up on a regular basis was performed for a period of two years. Results Twenty-six patients with 44 lesions achieved two years follow-up. A complete response was documented in 95.5% of cases. Toxicity was mild (G1 or G2) in all cases, caused by erythema, erosion, or alopecia. Cosmesis was excellent in 88.6% of cases, and good in the rest. Change in pigmentation was the most frequent cosmetic alteration. Conclusions This work is special, since the equipment’s treatment voltage was 69.5 kV, and this is the first prospective study with long term follow-up with Esteya®. These preliminary report show excellent results with less toxicity and excellent cosmesis. While surgery has been the treatment of choice, certain patients might benefit from eBT treatment. These are elderly patients with comorbidities or undergoing anticoagulant treatment as well as those who simply refuse surgery or might have other contraindications.

In reply to the Letter to the Editor titled: "Comments on: Clinical implementation of a new electronic brachytherapy system for skin brachytherapy".

To the Editor: We have read with an interest the letter to the Editor titled “New technologies for non-melanoma skin cancer”. In this letter, the authors comment on our article [1] about the clinical implementation of a new system for skin brachytherapy (Esteya® electronic brachytherapy by Elekta, Stockholm, Sweden) and they asked for a reply to their letter. We would like to thank the authors for their interest in our publication and would like to respond to their letter. First of all we need to clarify that in our study we chose to exclude irregularly shaped lesions, lesions with a diameter > 2 cm, and lesions with a depth larger than 4 mm because of the design of the radiation therapy system that was used. Lesions included in our work using the specific features of the Esteya® device, in fact represent the vast majority of non-melanoma skin cancer primary presentations. The Esteya® electronic brachytherapy system (E-eBT) is delivered with a set of applicators up to 3 cm in diameter. When treating non-melanoma skin cancer, typically a margin of 0.5 cm is added to the GTV. Consequently, the maximum diameter of lesions to be treated is 2 cm. The system has a dose-gradient of about 8% per mm, therefore with lesions deeper than 0.4 cm, the overdose at the first skin layers will exceed 130% and this might impact cosmetic outcome. This is the reason we limited inclusion to lesions with a depth of 4 mm or less. Finally, E-eBT applicators are designed with a flat surface to allow full contact with the skin. Avoiding air gaps between applicator and skin is a prerequisite because of the significant impact of air gaps on the dose to the lesion. Nowadays, we have the possibility to use a new set of more precise applicators for treatment of lesions in difficult areas. When we say that irregular areas are not suitable for EBT, we only mean those locations that, despite applying some pressure, are not entirely in contact with the applicator. These cases should be treated with other types of brachytherapy/radiotherapy. In our experience there are only a few locations where one cannot get a flat surface by applying mild pressure. Only larger lesions in areas with angled surfaces result in bone or cartilage, for example impeding/preventing a flat surface being obtained; this can be on the inner canthus of the eye, or for example on the pinna, and on the peri-alar nose groove. We have, however, successfully treated several “difficult cases” of BCC located on for example the nasal tip, retroauricular region, and scalp with E-eBT. It is our experience that the vast majority of NMSC lesions can be treated with the Esteya® electronic brachytherapy system. We disagree with the authors of the letter stating that “NMSC often have irregular shapes and a diameter longer than 2 cm”, and “most cases of NMSC are recurrent and located in the periorbital area (i.e. inner canthus)”. In fact, most NMSC are small, usually less than 20 mm, and the majority of lesions are located on the face, especially on the nose. Both surgery and radiation therapy are very effective and recurrence is usually found in less than 10% of cases. There is, however, a bias of patients submitted to radiotherapy since only difficult cases and lesions that have failed other treatments are referred. Better communication and cooperation between dermatology and RT services will improve referral and benefit both patients and care givers. For the less frequent appearing lesions with dimensions and shapes that are outside of the range included in our study, other radiotherapy treatment solutions besides Esteya® electronic brachytherapy are available such as brachytherapy moulds, isotope based brachytherapy with interstitial-or flap applicators, and treatment with electrons. We have read with great interest the article of Pontoriero et al. [2] that the authors of the letter to the Editor referred to. In this article, Pontoriero et al. reported their experience treating a deeply invasive lesion on the inner canthus of the eye with the Cyberknife system. Although in their case report the patient seems to have a good clinical outcome, we do have some concerns with promoting this technology in general for skin cancer treatment around the eye based on this single case. We consider the risk of intrafraction-movement as high because of very long treatment time associated with the large number of beams. In addition, there are challenges associated with the dose build up in the first layers of the skin beam, the inverse planning calculation algorithm on the first fractions of millimeter of the skin, and the use of a bolus. Also, protecting the eye from radiation damage is not easy. In our opinion, more robust research is needed to prove this technique as safe and beneficial when other therapies, such as interstitial brachytherapy with more substantial evidences are available. That new sophisticated techniques such as “Cyber Knife®” – as Dr. Pontoriero described in his letter – or particulate radiation, as a proton beam therapy, etc., could be used in selected cases, complying properly the goals for treatment of theses tumors. But on the other hand, even when it is desirable, a good knowledge on the part of radiation oncologist specialist of the full potential of these new techniques is required. The cost and complexity of these techniques, together with the necessary investment in human resources to fit the goal of these treatments, as well as short follow up of every single case referred, become, at least in our opinion, the accurate approach as a non-elective treatment for non-melanoma skin cancer. In our practice, this type of lesions on the inner canthus use to be treated with an HDR interstitial implant, with catheters just subcutaneous, and the eyes protected with a lead sheet. Although it is small invasive procedure, in our hospitals we prefer it to IMRT because of the robustness, simplicity, eye protection, dose gradient through normal tissue, and guarantee of full coverage of the lesion. In our group, we have accumulated over years a great experience treating successfully this kind of difficult tumors with this approach. We want to express our gratitude to both the letter authors and the Journal Editor, to have the opportunity to include this discussion.