Clinical investigation
Skin
Interstitial brachytherapy of periorificial skin carcinomas of the face: A retrospective study of 97 cases

Presented at the 46th Annual Meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO), October 3–7, 2004, Atlanta, GA.
https://doi.org/10.1016/j.ijrobp.2005.03.027Get rights and content

Purpose: To analyze outcomes after interstitial brachytherapy of facial periorificial skin carcinomas.

Patients and Methods: We performed a retrospective analysis of 97 skin carcinomas (88 basal cell carcinomas, 9 squamous cell carcinomas) of the nose, periorbital areas, and ears from 40 previously untreated patients (Group 1) and 57 patients who had undergone surgery (Group 2). The average dose was 55 Gy (range, 50–65 Gy) in Group 1 and 52 Gy (range, 50–60 Gy) in Group 2 (mean implantation times: 79 and 74 hours, respectively). We calculated survival rates and assessed functional and cosmetic results de visu.

Results: Median age was 71 years (range, 17–97 years). There were 29 T1, 8 T2, 1 T3, and 2 Tx tumors in Group 1. Tumors were <2 cm in Group 2. Local control was 92.5% in Group 1 and 88% in Group 2 (median follow-up, 55 months; range, 6–132 months). Five-year disease-free survival was better in Group 1 (91%; range, 75–97) than in Group 2 (80%; range, 62–90; p = 0.23). Of the 34 patients whose results were reassessed, 8 presented with pruritus or epiphora; 1 Group 2 patient had an impaired eyelid aperture. Cosmetic results were better in Group 1 than in Group 2 with, respectively, 72% (8/11) vs. 52% (12/23) good results and 28 (3/11) vs. 43% (10/23) fair results.

Conclusions: Brachytherapy provided a high level of local control and good cosmetic results for facial periorificial skin carcinomas that pose problems of surgical reconstruction. Results were better for untreated tumors than for incompletely excised tumors or tumors recurring after surgery.

Introduction

Epithelial skin cancer is a common cancer, on a par with breast and colon cancer (1). Its incidence is steadily increasing in Western countries. However, if suitable treatment is instigated early, it is often curable. The importance of early treatment and the regular increase in life expectancy make screening and treatment essential, including of elderly patients.

Epithelial skin cancer incidence is directly linked to the duration and intensity of exposure to the sun. Skin carcinomas develop in exposed body zones. More than 75% of cases involve the face (2) and primarily the periorificial zones, i.e., the lower eyelids, inner canthus, nasal bridge, nostrils, tip and lateral sides of the nose, and pinna. These zones derive from the fusion zones of facial embryonic buds (3), which are expansion zones that favor carcinoma infiltration. On the other hand, although carcinomas of the lips are periorificial tumors, they are of mucosal origin.

Surgery is the standard treatment of periorificial zone tumors of the face (4). These zones belong to cosmetic subunits that are subject to global reconstruction rules governing the nasal, suborbital, and facial mask zones (5, 6). Reconstruction is thus delicate, imposing a static (cosmetic) as well as a dynamic (functional) element. Cosmetic and functional results still need to be evaluated fully. An alternative to surgery is low dose–rate interstitial brachytherapy with 192Ir wire implants, which preserves the initial anatomic structure. A single randomized prospective trial (7) has compared radiation therapy with surgery but did not distinguish interstitial brachytherapy from external radiotherapy nor periorificial from flat-zone tumors.

The aim of this retrospective study was to examine outcomes after interstitial brachytherapy of patients with carcinomas of periorificial zones of the face. We looked at the results for two groups of patients: previously untreated patients treated by brachytherapy, and surgically treated patients who underwent brachytherapy after one or several incomplete surgical excisions or tumor recurrence. For these patients previously treated, brachytherapy was indicated to preserve anatomic structures.

Section snippets

Methods and materials

From February 1992 to February 2002, 97 skin carcinomas of facial periorificial zones were treated at the Centre Regional de Lutte Contre le Cancer (CRLCC) Nantes-Atlantique by low dose–rate interstitial brachytherapy. This was performed in the operating theater under aseptic conditions and local anesthesia. We used either the plastic double-gain technique (8) with afterloading of 192Ir wires (Technique A), or the single plastic tube technique (9) with immediate loading of 192Ir wires

Patient and tumor characteristics

The mean age of the 97 patients with periorificial face tumors was 71 years (range, 17 to 97 years). The male:female sex ratio was 1.7:1. Tumors were distributed as follows: 59% (57/97) in the nose, 28% (27/97) in the periorbital region, and 13% (13/97) in the pinna. Overall, 40 patients received brachytherapy as first-line therapy (Group 1) and 57 after surgery (Group 2). In Group 2, 20 patients were treated after incomplete microscopic excision and 37 after macroscopic recurrence. The

Discussion

Our results confirm the efficacy of first-line interstitial brachytherapy for the treatment of T1–2 periorificial skin carcinomas. The local control rate (92.5%) was similar to that found in other retrospective studies of ionizing radiation treatment of facial BCC (91.6–99%) (13, 14, 15, 16). The risk of local recurrence was higher among patients who had previously undergone surgery compared with those who had not (12% vs. 7.5%), in line with the 12% to 18% rate reported by others (17, 18, 19,

Conclusion

The choice of treatment of periorificial tumors of the face depends on the characteristics of the tumor (location, size, depth of invasion, and histologic subtype) and on patient preference. Low dose–rate interstitial brachytherapy is a conservative treatment that provides good local control and excellent cosmetic and functional results. It is an alternative to surgery in the treatment of small, Class T1–2 N0 carcinomas. However, randomized prospective studies comparing interstitial

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