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Can Modern Radiotherapy be used for Extensive Skin Field Cancerisation: An

Update on Current Treatment Options

Article · April 2018

DOI: 10.26717/BJSTR.2018.04.000998

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 Volume 4- Issue 1: 2018
DOI: 10.26717/BJSTR.2018.04.000998
Gerald Fogarty. Biomed J Sci & Tech Res

ISSN: 2574-1241

Review Article Open Access

Can Modern Radiotherapy be used for Extensive

Skin Field Cancerisation: An Update on
Current Treatment Options
Fogarty GB1, David Christie2, Lynda J Spelman3*, Madeleine J Supranowicz3 and Robert J Sinclair3
1
Genesis Cancer Care, St Vincent’s Hospital, Australia
2
Genesis Cancer Care, Australia
3
Specialist Connect Services, Australia
Received: April 10, 2018; Published: April 25, 2018
*Corresponding author: Lynda J Spelman, Specialist Connect Services, Brisbane, Australia, Email:

Abstract

The use of Radiotherapy (RT) for skin cancer by dermatologists has decreased since the latter half of last century for many reasons. Driven
by clinical need, radiation oncologists, radiation biologists and physicists, have progressed RT in many ways over the course of the last fifty
years. The creation of multidisciplinary meetings for clinicians involved in skin cancer has put the specialisties of dermatology and radiation
oncology in touch. With better modalities and techniques, is there a new role for RT in skin cancer?. A particular scenario is the treatment
of Extensive Skin Field Cancerisation (ESFC), where in situ disease can cause significant symptoms and can lead to invasive disease. Current
dermatologic and traditional radiation treatments have been disappointing, especially for large convex surfaces of sun-exposed areas such as
scalps. These therapies all suffer from a top down problem. To give enough treatment to fully sterilize in situ disease in deep skin appendages,
unacceptable side effects can be suffered in the more superficial layers, sometimes leading to a lack of compliance. This review explains recent
advances in RT that allow a more homogenous RT dose through the skin treatment volume. Trials need to be performed with modern RT
in ESFC. The review also attempts to set some meaningful definitions that can be used for trials. Hopefully these efforts will lead to better
oncological, functional, and cosmetic outcomes for patient suffering from ESFC.

Keywords: Skin Cancer; Squamous Cell Carcinoma; Bowens Disease; Radiotherapy; Volumetric Modulated arc Therapy; Review; Field
Cancerisation

Abbreviations: RT: Radiotherapy; RCT: Randomised Controlled Trials; ESFC: Extensive Skin Field Cancerisation; IEC: Intraepidermal carcinoma; AK:
Actinic Keratosis; EBRT: External Beam Radiotherapy; GTV: Gross Tumour Volume; BT: Brachytherapy; Clinical Target Volume; CTV: Clinical Target
Volume

Introduction
Radiotherapy (RT) for skin cancer was a common treatment
administered by dermatologists until the 1980s. Better surgical and
topical treatments, coupled with increasing radiation regulatory
requirements, led to a decline in the use of RT by dermatologists.
RT has continued to evolve in the treatment of other cancers. Driven
by radiation oncologists, radiation biologists and physicists, RT has
progressed in many ways. High quality Randomised Controlled
Trials (RCT) has led to an increase in the indications for RT in
many tumour types. The creation of multidisciplinary meetings
for clinicians involved in skin cancer has put the specialities of
dermatology and radiation oncology in touch. This has led to
dermatologists asking whether there is a new role for modern RT in
the treatment of skin cancer. A particular scenario is the treatment
of Extensive Skin Field Cancerisation (ESFC). Patients can suffer Figure 1: A: ESFC on arms in sun-exposed areas.
B: Following modern radiotherapy.
with ESFC caused by chronic ultraviolet radiation exposure (Figure
Source: Provided by G Fogarty for this article.
1).

Cite this article: Fogarty GB, Christie D, Spelman LJ, Supranowicz MJ, Sinclair RS. Can Modern Radiotherapy be used for Extensive Skin Field
Cancerisation: An Updateon Current Treatment Options. Biomed J Sci &Tech Res 4(1)- 2018. BJSTR.MS.ID.000998.
DOI: 10.26717/BJSTR.2018.04.000998. 1/8
Gerald Fogarty. Biomed J Sci & Tech Res Volume 4- Issue 1: 2018

Actinic Keratosis (AK), Bowen’s disease or Intraepidermal surface mould. The homogeneity of the surface dose depends on the
carcinoma (IEC) are found in ESFC from which new invasive distance of the sources from each other, and the distance of the skin
Cutaneous Squamous Cell Carcinoma (cSCC) can arise[1]. This to the sources (called “standoff”). Surface moulds contain catheters
disease can cause significant morbidity and poor quality of life, along which a high dose rate source travels under computer
with itch, flaking skin and poor cosmesis. Patients often have control. The energy of the radiation emitted from the source and
comorbidities that preclude other treatments, especially surgery the source standoff distance will also determine the dose at depth
if complex closure is required. Patients may also decline surgery in the skin. Increasing the thickness of standoff will create a more
because of fear of a poor functional or cosmetic outcome with the homogenous dose in the skin but will increase significantly the
tissue loss that surgery entails. Current dermatologic treatments time taken to deliver treatment. Increasing the standoff thickness
have been disappointing, especially for larger convex surfaces of will also increase dose to deeper structures [7]. This is a top down
sun-exposed areas such as scalps. Recurrence at twelve months is problem. The top down problem implies that the therapeutic effect
common [2-4]. Not all therapies are readily available. Application of the treatment is focused at the epidermis and decreases in
can be painful. Skin reaction, sometimes a necessary measure efficacy with depth.
of efficacy, can be unsightly, painful and require significant care
including dressings.

Figure 3: A representation of a brachytherapy mould

where the brachytherapy catheters are kept in a pattern
Figure 2: Photomicrograph showing a cross section of by the mould, usually separated by equal spacing. The
cancerous skin with H&E stain. Skin appendages shown mould is made of a water-equivalent material called bolus
by the red arrows to indicate the depth that must be or build up. Bolus between the brachytherapy catheters
treated. Lack of treatment penetration to the depth of and the skin that attenuates the radiation. The thickness of
the appendages may be the cause of future in-field field this bolus is called the standoff distance. This enables the
recurrences. Therapies with a top down problem will dose cloud, by the time it gets to the skin, to have a
not sterilise the adnexal structures without potential homogeneous wave front. See the thin red line.
unacceptable side effects being suffered in the more Source: Provided by G Fogarty for this article.
superficial layers-see text. Traditional modalities of EBRT for skin cancer have included
Source: Figure provided courtesy of Prof Richard Scolyer. beams of either photons or electrons. EBRT comes from a point
Compliance can be difficult if application depends on the source (Figure 4). A machine that has a stationary point source
patient [5]. Cryotherapy can cause hypopigmentation and scarring. is ideal for treating small areas of the skin close to sensitive
These therapies all suffer from a similar problem. The deepest structures, especially areas concave to the beam front (e.g. inner
appendages on male scalp have been shown to be 4.5mm depicted canthus, nasal-alar groove) of Figure4. Superficial radiotherapy
in Figure 2[6]. To deliver enough treatment to fully sterilize in-situ (SXRT) is ideal in treating a lesion that is concave to the beam e.g.
disease deep in skin appendages, unacceptable side effects can inner canthus, nasal-alar groove, with little exposure of underlying
occur in the more superficial layers, leading to a lack of compliance organs at risk. However, the short SXRT SSD means the field size
and cure. This review describes recent advances in RT that allow a is limited to 8cm at skin surface so SXRT can only effectively treat
more homogenous RT dose through the target treatment volume. lesions less than 6 cm in diameter. SXRT was the treatment often
RT trials with these advances in ESFC are now on going and will delivered by dermatologists. EBRT beams can consist of either
hopefully lead to better oncological, functional, and cosmetic photons or electrons; both are generated by linear accelerators
results. using megavoltage energies. The advantage of electrons over SXRT
is that electrons can treat a greater area of skin. Electrons have a
Traditional RT Modalities also suffer from the Top better depth dose curve meaning that the top down problem is not
downProblem as great. There are however several disadvantages with electrons.
Traditional modalities of radiotherapy treatment can be broadly Electrons need a layer of tissue-equivalent material called bolus to
divided into two types. Teletherapy or External Beam Radiotherapy bring the maximum dose onto the skin. The use of bolus increases
(EBRT), involves radiation created outside the patient and beamed the set-up time and the uncertainty of treatment. Electron beams
into the target from a source relatively distant. Brachytherapy (BT) have a wider penumbra and so need a bigger field, meaning more
involves the use of radioactive sources that are laid onto or into the normal tissue will be irradiated.
target. BT for skin (Figure 3) is delivered via a specially constructed

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Figure 4: A: This cartoon shows schematically a fixed point source of radiation with a short sourceto-surface distance (SSD)
e.g. a superficial X ray machine (SXRT).
B: For lesions that are convex tothe beam, however, there can be significant under dosing of the target leading to treatment failure
atthe periphery and overdosing of deeper organs, increasing the risk of side effects.
C: This is anothertop down problem. Compromise can include using machines with a longer SSD so that the beamprofile is flatter
when incident on the lesion. A machine with a longer SSD than an SXRT machine isthe linear accelerator, which can emit electrons.
Electrons are ideal irradiating larger fields of skinto a more homogeneous dose. Electrons, however are complex.
Source: Provided by G Fogarty for this article.

Figure 5: Electron beams are most useful when a flat surface is treated with a beam perpendicular to the surface. In this
diagram the 90% isodose line (green), which is the line that used to calculate the prescription, straddles the skin surface. Note
the wires are marking the field. One can see a significant dose drop-off towards the subcutis, meaning less subcutaneous dose,
an advantage of electrons.
Source: Provided by G Fogarty for this article.

Electron beams are best treating a flat field that is perpendicular

to the direction of the beam (Figure 5). The skin that is to be treated
can be modified to make it flat. For example, noses can be taped
flat to one side when treating the nasal ala. One can tape the ears
forward to treat the postero-medial surface of the pinna (Figure
6). One can also use bolus material to make the field as flat as
possible, for example, filling a conchal bowl. Electron dosimetry
can be difficult when treating in homogeneities, for example, the
nose with air tissue interfaces such as in the nostril. The treatment
Figure 6: Electron beams are more useful if there is a flat
field. The skin surface can be modified to make it flat. For staffs need to pack the nostril so it absorbs dose in the same way as
example, one can tape the ears forward in order to treat a solid organ. This packing takes time, is uncomfortable especially
the posteromedial surface of the pinna. Note the inner towards the end of treatment when side effects like mucositis are
dotted area which denotes GTV and the outer dotted area common and decreases reproducibility of the set-up from day to
denotes the planning Target Volume (PTV). The PTV is day.To treat larger skin areas, several electron fields may need to
larger for electron beams than for SXRT as electrons have be junctioned together. The dose of radiation in the junction areas
a wider penumbra.
between the fields can be difficult to measure (Figure 7), which can
Source: Provided by G Fogarty for this article
result in under-dosing tumour or overdosing normal tissue, with

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the problems of either recurrence of the cancer or late normal In skin, imaging can include photography, dermoscopy and
tissue effects. Reflectance Confocal Microscopy (RCM). Targeted biopsy is another
aid to PE. Clinical Target Volume (CTV) is the volume that harbours
microscopic tumour. The CTV must be adequately treated to achieve
cure. The target in large fields of skin cancer that needs treatment
is the volume that is involved with a concretization process. In
skin, this volume is the product of the area on skin multiplied by
a depth including epidermis and the deepest skin appendages.
This distance is 5mm from the skin surface, or until an oncological
boundary is reached e.g. the skull.

Figure 7: A sagittal CT planning image showing treatment

of the scalp with electron fields junctioned together. Note
the inferior dosimetry at the field junctions. This plan is not
acceptable.
Source: Figure provided courtesy of Prof Peter Graham.

Overall, traditional RT modalities fall short in treating large

fields of skin cancer in two major ways.
Figure 8: Treatment volumes are determined by marking
a) The dose homogeneity is not uniform through the areas on skin at the planning phase and multiplying by
the depth. In this example of skin field concretization on a
thickness of the target. There is too much dose to the surface
leg. The CTV is the inner marking. The PTV in this case is
and too little to the depth of the appendages. This is the same
a one-centimetre radial expansion on the CTV. All the PTV
top down problem as traditional dermatological treatments will receive therapeutic dose.
have. Solutions to this have involved unacceptable increases in Source: Provided by G Fogarty for this article.
dose to deeper tissues.
Planning target volume (PTV) is a further expansion to account
b) The fields are small due to technical reasons, leading to for variation in daily treatment variables. PTV depends on the
the need for junctioning of radiation fields and the consequent effectiveness of patient immobilization protocols. The PTV size also
inaccuracies of dose at the junctions. depends on the modality of treatment used, which will determine
the size of the penumbra. PTV has been gradually reducing
Recent Advances in RT
over years with better and more reproducible immobilization
RT of skin cancer has benefitted from significant recent techniques, daily image guided radiotherapy and the ability to
advances in general RT. contour the targets on the planning Computed Tomography (CT).
These include: Organs at Risk (OARs) are normal tissues within the RT entrance or
exit beam that are sensitive to RT. Contouring these on a planning CT
a) Better understanding of the target to be treated, and allows measurement of the radiation received by that organ so that
normal tissues to be spared the dose can be well within that associated with side effects. These
b) Better modalities of radiotherapy planning, delivery and tolerance doses have been calculated over years of experience and
verification are well known in the radiotherapy world (Figure 8).

c) Improved techniques in using these modalities; and Better modalities of radiotherapy planning, delivery
and verification
d) Better understanding of the total dose needed and
adequate fractionation. Better modalities of radiotherapy delivery include the use of
megavoltage photon beams produced by a Linear Accelerator (or
Better Understanding of the RT Target to be Treated “linac”).
Traditionally RT treatments were defined in terms of radiation
These advances include:
fields. However, cancer, and normal tissues to be spared, occurs in
volumes. The definition of volumes for use in radiation oncology a) The use of megavoltage photon beams (MVT). MVT has a
is outlined in a consensus document, ICRU 50 [8]. These concepts longer SSD over SXRT, meaning that the incident radiation front
have been helpful in modern radiotherapy and are defined briefly is almost parallel to skin. (Figure 4C).
below: Gross Tumour Volume (GTV) is macroscopic cancer defined b) The use of computer tomography (CT) planning scans.
clinically. Physical Examination (PE) is aided by the use of imaging. MVT enables the use of computer tomography (CT) planning

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scans taken in the treatment position, and planning systems. and OARs. These standardized doses are known to predict cure
The volumes to be treated and avoided are contoured by the for tumour bearing volumes and are associated with acceptable
radiation oncologist on these scans. Doses are prescribed side effects in normal tissue volumes. Technology with the
for each volume. Dose Volume Histograms (DVHs) can be planning system is then used to optimize the plan to achieve
constructed and doses per volume on each individual patient these bench marks, ensuring tumour cure and normal tissue
plan can be compared to standardized doses for CTV and PTV tolerance at the end of treatment (Figure 9).

Figure 9: Photographs and CT plans of a patient preparing for VMAT.

A: Mark up of a scalp field at planning showing areas of gross tumour within the area of ESFC.
B: CTV is contoured on the planning scan. Red volume represents ESFC.
C: The resultant dosimetry avoiding brain. The dose homogeneity is uniform throughout the target. The dose profile across the
field is uniform with no need for junctioning radiation fields. Green volume represents gross tumour.

c) The use of Intensity modulated radiotherapy (IMRT). e) Vary the dose rate during beam on time. Modern linacs can
IMRT, using automated multileaf collimators in the head of also vary the rate at which the dose is delivered as the gantry
the linac, enables the intensity of the beam to be modified rotates around the patient, further enabling dose conformality;
during beam-on time, sculpting the dose to the contoured
f) Use of CT planning, MVT and VMAT enable dose
volumes. Prior to this advance radiotherapy was initially Two
homogeneity throughout the volume. The top down problem
Dimensional (2D) and based on fields. The application of CT
has been overcome using these modalities;
technology in planning accelerated the uptake of progression to
Three Dimensional Conformal Radiotherapy (3DCRT) with the g) Use of Image Guided RT (IGRT). MVT photon beams
concept of volume treatment. However, RT still came in “blocks”. can penetrate through the body to expose an X-ray detector
IMRT allowedtreatment around curves, especially sparing dose on the opposite side of the body. This allows for daily quality
to OARs in the concavity of a volume requiring treatment (e.g. assurance imaging during beam on time to verify that the
brain underneath a scalp) intended volume has been irradiated. This is called image
guided radiotherapy. The assurance that the correct volumes
are treated, only achievable by daily imaging, means that the
PTV can be significantly decreased, thereby sparing more
normal tissue from radiation. The traditional EBRT modalities
were not capable of this; and

h) Rapid delivery. VMAT can be delivered rapidly, meaning

that the patients are immobile on the treatment bed for a short
time. Time in the treatment room is the scarce resource in the
radiotherapy department. Time in the room for VMAT averages
approximately 10 minutes, while for IMRT treatments is 30
Figure 10: Cartoon showing that VMAT allows the point minutes. This means that VMAT treatments can be delivered
source of radiation to move around convex surface in an to more patients, rather than being rationed, as the initial
arc resulting in greater conformality. IMRT cases were. VMAT is therefore becoming the standard
Source: Provided by G Fogarty for this article. technique used in many modern departments.
d) The use of Volumetric modulated arc therapy (VMAT). Improved Techniques in Using These Modalities
VMAT, the latest evolution of IMRT, is essentially the application
The significance of these advantages for skin cancer is that
of CT technology to IMRT treatment. The point source is now
radiotherapy can now treat large curved convex surfaces, such as
in motion and not fixed as in traditional EBRT modalities. The
those found in ESFC. Large convex surfaces of ESFC can be found
patient can be continuously irradiated with the RT source in
covering anatomical sites such as the scalp, forehead, cheeks,
motion rather than only from fixed angles (Figure 10).
forearms, legs, chest, upper back, and shoulders, VMAT can now

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be used to treat these skin surfaces with definitive MVT photon months to years following treatment. Late radiation side effects
RT (Figure 9). These advances have overcome the problems of such as hypopigmentation, telangiectasia and fibrosis can develop
traditional RT. The dose can now be more uniform throughout the (Figure 11). These problems have prompted dermatologists to seek
target, with no need for junctioning radiation fields. other treatment solutions in the past. For patients unable to have
standard fractionation, compromise fractionation schedules have
Better understanding of the total dose needed and
been developed [12]. Skin cancer especially in the elderly may be
adequate fractionation
more radiosensitive and fewer doses may be needed [13]

Towards Trials of Modern Radiotherapy in ESFC

Theoretically modern RT may be of benefit in this clinical
scenario. To create meaningful studies the scope of the problem
needs definition and we would like to propose the following.

Is it ethical to treat patients with ESFC with RT?

RT has been used for ESFC in the past with good effect.
Dinehart, Graham, and Maners [14] treated 16 patients with three-
dimensional conformal megavoltage radiotherapy (3DCRT) with 40
to 60 Gray (Gy) with complete response in 13 after four weeks of
follow-up. Of 10 evaluable patients at one year, nine had continuing
complete response. Pipitone and Gloster [15] treated one patent
with extensive scalp recurrence with 3DCRT, 60 Gy in 30 fractions,
Figure 11: A: cSCC lip treated years ago with with enduring complete response at 18 months. Barta, Gräfe, and
hypofractionation leading to telangiectasia, cicatrisation, Wollina [16] treated a 66-year-old with a 10 x 8 cm field on the
atrophy and hypopigmentation. scalp full of AK with 28 Gy, given as 4 Gy fractions twice weekly,
B: Hypofractionation has had a deleterious cosmetic effect with a continuing complete response at 14months. There has been
on this person’s smile one report so far of using VMAT for skin field treatment [17]. RT
Source: Provided by G Fogarty for this article
traditionally has not been regarded as a first line treatment for
Table 1: Table of biologically equivalent dose (BED) doses for ESFC but as a salvage treatment.
microscopic disease for ESFC therapy.
Defining ESFC
No of
Total Dose EQD2*** EQD2****
fractions BED* BED**
dose per α/β α/β
/weeks of early late
(Gy) fraction =10(Gy) =3(Gy)
RT
60 30/6 2 72 100 60 60
55 25/5 2.25 68.91 98.44 56.15 57.75
50 20/4 2.5 62.5 91.67 52.08 55

45 15/3 3 58.5 90 48.75 54

Source: (Fowler JF1989, Fowler JF 2010)
Recent contributions to this aspect of RT include the importance Figure 12: Sizes of a 50cm2 field on a cheek of an adult
of understanding the total dose and fractionation to achieve better male with an 8cm diameter circle.
Source: Provided by G Fogarty for this article
oncological, functional, and cosmetic results. The total dose needed
to sterilise skin field concretization is intuited from head and neck There are various definitions of ESFC. Hofbauer et al. [18]
squamous cell carcinoma [9] which requires at least 60 Gy given in published The Swiss Registry of Actinic Keratosis Treatment
standard fractionation.The total dose is given in many smaller doses (REAKT) Working Group which suggests the presence of two or
or fractions to maximise normal tissue repair between the fractions. more AK lesions along with photodamage. Figueras Nart et al.[19]
Standard fractionation is 2 Gy per day. 60 Gy in 2 Gy fractions means propose a clinical definition, based on an anatomical region having
six weeks of treatment. To attend 6 weeks of five-days-a-week telangiectasia, atrophy, pigmentation and a sandpaper texture.
treatment may be inconvenient. Alternative fractionation patterns Surgery has been used for ESFC [19]. What is needed for trials is
can be devised using mathematical formulae [10,11](Table 1). a minimum ESFC size. ESFC can be defined when it is too large for
However, at fraction sizes greater than 2.5 Gy per day, late functional simpler surgical procedures e.g. primary closure, pedunculated flap
and cosmetic results may decline. This is because, at larger fraction or skin graft. Complex surgery may then be needed but may not
sizes, the radiation repair capacity of normal cells is swamped be possible due to patient factors e.g. comorbidities, expectations,
and normal cells die and is eventually replaced by fibrous tissue prior therapies and patient refusal. We propose for trial purposes

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that ESFC should be beyond the limits of reasonable surgery. 2. Askew DA, Mickan SM, Soyer HP, Wilkinson D (2009) Effectiveness of
Our experience is that a field of 50cm2 anywhere on the body is 5‐ fluorouracil treatment for actinic keratosis-a systematic review of
randomized controlled trials. International journal of dermatology
a reasonable definition of ESFC. Examples can be seen Figure 12 48(5): 453-463.
an 8cm diameter circle. Areas of treatment can also be defined as
3. Gupta AK, Paquet M, Villanueva E, Brintnell W (2012) Interventions for
anatomical regions. These should be treated as unit to ensure after actinic keratoses. Cochrane Database Syst Rev 12.
RT that functions and cosmesis is maximized. Irradiating less than
4. Krawtchenko N , Roewert Huber J, Ulrich M, Mann I, Sterry W, et al.
these areas can result in unnatural visible field treatment borders (2007) A randomised study of topical 5% imiquimod vs. topical 5‐
(Figure 13). fluorouracil vs. cryosurgery in immunocompetent patients with actinic
keratoses: a comparison of clinical and histological outcomes including
1‐year follow‐up. British Journal of Dermatology 157(s2): 34-40.
5. Philipp Dormston WG (2015) Field cancerization: from molecular basis
to selective field-directed management of actinic keratosis Actinic
Keratosis. Curr Probl Dermatol (46): 115-121.
6. Fogarty G, Hong A, Scolyer R, Lin E, Haydu L, et.al (2014) Radiotherapy
for lentigo maligna: a literature review and recommendations for
treatment. British Journal of Dermatology 170(1): 52-58.
7. Santos DE, Green JA, Bhandari N, Fogarty B, Hong A, et al. (2015)
Tangential Volumetric odulated Radiotherapy-A New Technique for
Large Scalp Lesions with a Case Study in Lentigo Maligna. International
Journal 19(2): 223-236.
Figure 13: Anatomical regions of the face and neck for RT
treatment for ESFC. 8. Rosenthal DI, Mohamed AS, Garden AS, Morrison WH, El Naggar AK,
et al. (2017) Final report of a prospective randomized trial to evaluate
A: Anterior projection showing forehead and nasal
the dose-response relationship for postoperative radiation therapy
regions. and pathologic risk groups in patients with head and neck cancer.
B: Lateral view showing forehead, nasal and cheek regions. International Journal of Radiation Oncology Biology Physics, 98(5):
Source: Provided by R Sinclair and L Spelman for this 1002-1011.
article
9. Fowler JF (1989) The linear-quadratic formula and progress in
fractionated radiotherapy. The British journal of radiology 62(740):
Conclusion 679-694.
RT has improved over the last few decades. These improvements 10. Fowler JF (2010) 21 years of biologically effective dose. The British
have been in better understanding of the target to be treated, and journal of radiology 83(991): 554-568.
normal tissues to be spared; better modalities of radiotherapy 11. Carney G, Fogarty G, Moutrie Z , Rose McLaren K (2017) Adaptive Split
planning, delivery and verification; improved techniques in using Course Radiotherapy for Skin Cancers Decreases Toxicity and Improves
these modalities in skin cancer; and better understanding of the Compliance 2(1): 00015
total dose needed and adequate fractionation. RT may now have a 12. Wambersie A, Landberg T (1999) ICRU Report 62: Prescribing, Recording
role in areas of dermatology that have defied durable treatments and Reporting Photon Beam Therapy (Supplement to ICRU Report 50)
International Commission on Radiation Units & Measurements 32(1).
including ESFC. Current dermatologic and traditional radiation
treatments have been disappointing. These therapies all suffer from 13. Dinehart SM, Graham M, Maners A (2011) Radiation therapy for
widespread actinic keratoses. The Journal of clinical and aesthetic
a top down problem. To give enough treatment to fully sterilize in
dermatology 4(7): 47.
situ disease in deep skin appendages, unacceptable side effects
14. Pipitone MA, Gloster HM (2006) Superficial squamous cell carcinomas
can be suffered in the more superficial layers, sometimes leading
and extensive actinic keratoses of the scalp treated with radiation
to a lack of compliance.Trials are now needed to place modern therapy. Dermatologic surgery 32(5): 756-759.
RT among the treatments usually given for this condition. We set
15. Bart U, Gräfe T, Wollina U (2000) Radiation therapy for extensive
the scene for doing trials by defining what constitutes ESFC as actinic keratosis. Journal of the European Academy of Dermatology and
areas of skin 50cm2 and over, in anatomical regions. If radiation Venereology 14(4): 293-295.
oncologists and dermatologists cooperate, trials testing RT for the 16. Veness M (2017) Hypofractionated radiotherapy in older patients with
treatment of ESFC should be possible and will lead to better and non-melanoma skin cancer: Less is better. Australas J Dermatol.
more durable oncological, functional, and cosmetic outcomes for 17. Hofbauer G, Anliker M, Boehncke WH, Brand C, Braun R, et al. (2014)
patients suffering from ESFC. Swiss clinical practice guidelines on field cancerization of the skin. Swiss
Med Wkly 144: w14026.
Acknowledgement 18. Figueras Nart I, Cerio R, Dirschka T, Dréno B, Lear J, et al. (2017) Defining
The authors wish to acknowledge the contirubiton of figures: the actinic keratosis field: a literature review and discussion. Journal of
the European Academy of Dermatology and Venereology 32(4): 544-
Figure 2 provided courtesy of Prof Richard Scolyer and Figures 7
563.
and Figure 9C: provided courtesy of Prof Peter Graham. Also to
19. Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B (2015) Scalp
Kristy Frappell for administrative support.
reconstruction: an algorithmic approach and systematic review. JAMA
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Biomedical Journal of
Scientific & Technical Research (BJSTR) 8/8

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