Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 7, Num. 2, 2011, pp. 157-161

Journal of Cancer Research and Therapeutics, Vol. 7, No. 2, April-June, 2011, pp. 157-161

Original Article

Treatment results of high dose rate interstitial brachytherapy in carcinoma of eye lid

Surendra Azad, Vivek Choudhary

Department of Radiotherapy, Regional Cancer Centre, Dr. B. R. A. M. Hospital, Raipur - 492 001, Chhattisgarh, India
Correspondence Address: Surendra Azad, Department of Radiotherapy, Regional Cancer Centre, Dr. B. R. A. M. Hospital, Raipur - 492 001, Chhattisgarh, India drskazad@gmail.com

Code Number: cr11037

PMID: 21768703
DOI: 10.4103/0973-1482.82922

Abstract

Keywords: Brachytherapy, eye lid, high dose rate, sebaceous cell carcinoma, squamous cell carcinoma

Introduction

Skin cancers of the eyelid account for 5%−10% percent of all skin cancers. Basal cell carcinoma is the most common eyelid tumor reported in western population and accounts for 90% of all eyelid malignancies. ^[1] It most frequently occurs in the lower eyelid (50%−66%) and medial canthus (25%−30%). Although basal cell carcinoma does not metastasize, it may be locally invasive. Surgical excision, Moh′s micrographic surgery, cryosurgery, and radiotherapy have all been reported to achieve 5 year cure rates of 90% or higher in basal cell carcinoma. ^[2],[3]

Squamous cell carcinoma (SCC) and sebaceous cell carcinoma are the common eyelid malignancy in India. Incidence of squamous cell carcinoma has been reported in the literature to account for 2.4%−30.2% of malignant eyelid tumors. ^[4] It has a predilection for developing at the mucocutaneous junction of the lower eyelid. Unlike basal cell carcinoma of eyelid, squamous cell carcinoma can be an aggressive tumor that has potential to invade the orbit, metastasize to lymph nodes and distant sites, and cause death. ^{[4],[5],[6],[7],[8]} Radiation therapy is used for patients who are unwilling or medically unable to undergo an extensive excision of the lesion. ^[9]

Sebaceous cell carcinoma tends to affect patients between the fifth and ninth decades of life. Women are affected at a rate of 2.5 times greater than men. It can originate from meibomian glands and sebaceous glands of the eyelid, eyebrow, and caruncle. Sebaceous cell carcinoma recurs in approximately 9%−36% of patients. It may recur with orbital involvement in 6%−17% of patients. Regional lymph nodes are the most common site of metastases. Distant metastatic site may include the lungs, liver, skull, and brain. The incidence of metastases is approximately 17%−28%. The 10-year tumor death rate is approximately 28%.

In eye lid cancers, there is a significant risk for tissue damage to nearby vital ocular structures and even of blindness. The skin around the eyelid is thin and contains little subcutaneous tissue and anatomic connections to the underlying bone in the region facilitate rapid local tumor spread into the nasal and orbital cavities. ^{[1],[10],[11]} Early detection is essential, but is often difficult to achieve due to the growth pattern of these tumors, which tend to infiltrate inwards along the deeper layers of the skin and orbital margin. Eyelid tumors often grow under the skin for years before presenting on the surface. ^{[1],[10],[11]} Management of any malignant eyelid lesion requires an early and accurate diagnosis followed by total removal of the tumor and reconstruction of the eyelid for restoration of both function and cosmesis.

Our hospital has facility of one HDR remote after loading brachytherapy unit (Microselectron HDR), and a computerized treatment planning system (Plato). This study aimed to evaluate the response of high dose rate interstitial brachytherapy in carcinoma eye lid.

Materials and Methods

A total of 20 new cases of carcinoma eye lid were reported to department of radiotherapy from January 2004 to December 2008. Histopathological confirmation was done for all patients. All patients were examined and staged clinically according to TNM staging system. All cases were investigated with routine hematological and biochemical examination, X-ray chest, before starting radiotherapy treatment. None of the patient had received prior treatment. Patient characteristics are shown in [Table - 1]. Plastic tube technique is used for interstitial implant. In O.T. treatment area was marked on patient. Under general anesthesia rigid hollow stainless steel needles were inserted in to the tumor area parallel to each other in single plane or double plain. The spacing between two needles was 1 cm. Plastic tubes were then threaded in to these hollow needles and left in place to cover the entire target area with subsequent removal of metal needles. The plastic tubes were then secured in close proximity to skin with metallic buttons. After this patient was shifted to brachytherapy treatment room and applicators were connected to Microselectron high dose rate brachytherapy machine through transfer tubes. Treatment planning was done on Plato computerized treatment planning system. Dose was prescribed at 0.5−1 mm depending on thickness of tumor. Fractionated high dose rate radiotherapy was delivered with single high activity 192 Iridium for predetermined time at various dwell position that are 2.5 mm apart. Isodose distribution in single plane is shown in [Figure - 1]. Total 39 Gy was delivered in six fractions in 6 days. The biological equivalent dose (BED) for tumor was 64.3 Gy and for late responding tissue dose was 123.5 Gy. After completion of brachytherapy applicators were removed under aseptic precaution in operation theatre. No procedural complication was seen.

All the patients were reviewed weekly for one month to observe acute radiation reaction and then monthly for 6 month for assessment of response and treatment related complications. After this they were reviewed every 2 months for 1 year and 3 monthly for next 3 years. On follow up patients were examined clinically and routine ophthalmic check up was done to see any vision deterioration, lid complication in each patient. The response rates were scored as per WHO guidelines. Complete response was defined as disappearance of all clinical diseases for 1 month after completion of therapy. Partial response and stable disease were defined as >50% and <50% reduction of tumor size for 1 month after treatment completion, respectively. An increase of tumor size of >25% has been considered as progressive disease. Ocular side effects were classified on the basis of the Common Toxicity Criteria manual (version 2.0) and Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) toxicity criteria.

Disease-free survival was calculated from the date of completion of treatment till the last follow up. The follow up period was 18−72 months. Patients who did not have either local residual/recurrent lesion or distant metastases till the last follow up were counted as disease free. Med Calc 11.1.0 is used for statistical analysis. For disease-free survival the duration was calculated from the date of completion of radiotherapy to the time of event. All losses to follow up were considered as an event for survival analysis.

Results

From January 2004 to May 2008, 20 patients were included in this study and all patients completed treatment and were eligible for evaluation. No patients were lost to follow up. Details of patient′s characteristics and treatment related parameters are given in [Table - 1], [Table - 2], [Table - 3], [Table - 4] and [Table - 5]. Median age of the patient was 53 years (range 34-72 years). Eighteen (90%) patients were in stage I and two (10%) were in stage II, respectively. Squamous cell carcinoma was seen in 10 (50%) patients and upper eye lid was involved in 60% patients and lower eye lid in 40% patients. M:F ratio was 1.5:1 and age range was 35-72 years for squamous cell carcinoma. Basal cell carcinoma was seen in 2 (10%) patients and age range was 55-65 years. Sebaceous carcinoma was seen in 8 (40%) patients and lower eye lid was involved in 62.5% patients. M: F ratio was 1:4 with female preponderance and age range was 40-65 years. Overall lower eye lid was involved in 11 (55%) patients and upper eye lid was involved in 9 (45%) patients. Complete response was seen in all patients (100%). Median follow up time was 39.5 months with 95% confidence interval of 30.1 to 62.6 month and range was 18−72 months. P value of t-test was <0.0001 and F-test was <0.001.

D′ Agostino−Pearson test for normal distribution was 0.346 with acceptance of normality. T-test was performed to compare results of this study with that of surgery. Test statistic t-value was 0.910 and P value of two tailed probability was 0.5299. Five year disease-free survival was 90% for squamous cell carcinoma, 50% for basal cell carcinoma and 57.14% for sebaceous carcinoma and P value was 0.39. On comparison of survival curves logrank test P value was 0.4707. There were no isolated lymph node failures in all 20 patients.

Erythema and mild lid edema was seen in 18 (90%) patients. Conjuctival congestion and chemosis seen in 11 (55%) patients and falling of eye lashes seen in 14 (70%) patients. Depigmentation of irradiated skin (Vitiligo) seen in 10 (50%) patients, and lid fibrosis seen in 3 (15%) cases. Epiphora was seen in 1 (5%) patient. Keratitis was seen in 1 (5%) patient. No vision impairment was seen. Cosmetic results are good and acceptable to patients [Table - 6].

Discussion

Eyelid cancer is a common problem in the West, representing about 10% of cancers in the head and neck region. About 5%9% of all skin cancers arise in the eyelid and cancers in this location account for at least 11% of all mortalities from skin malignancies.

The eyelid tumors are fairly common in Indian subcontinent. Sebaceous cell carcinomas of eye lid were more common in females similar to findings of Aurora and Blodi. Lower eyelid was more commonly involved in our study similar to previous studies. SCC was the most common lid cancer encountered in this study, comprising of 50% of all lid cancer followed by Sebaceous cell carcinoma (40%).

SCC and sebaceous cell carcinoma has a low incidence rate among white population. 1.5% of the lid cancer were sebaceous cell carcinoma and has been ranked second in Chinese population. In this study SCC occurred more commonly in males and involved upper lid predominantly, thus correlates with findings that SCC has definite predilection for upper lid.

BCC is the most common eyelid tumor reported in western population. The literature from Taiwan and Australia also has BCC leading the list. In our study BCC accounted for 10% of lid cancer.

The treatment of choice for eyelid carcinoma is Moh′s micrographic surgery or wide excision with standard frozen section control. Moh achieved the five year cure rates of 99% in 1773 cases of basal cell carcinoma and of 98.1% in 213 cases of squamous cell carcinoma of the eyelids and Malhotra reported 71% control rate in squamous cell carcinoma of eye lid with surgery. ^[2],[3] However, because of its location, eyelid carcinoma may produce severe dysfunction and can be associated with poor cosmesis after surgical treatment. Primary radiotherapy was used as an alternative treatment for these eyelid carcinoma by Fitzpatrick et al. and achieved local control rates of 93%97%. ^{[12],[13],[14],[15]} Conill et al. reported 91.6% local control rate in 24 eye lid tumor with good functional results from high dose rate brachytherapy. ^[16] Daly et al. reported 97.4% local control rate in 165 lid cancers with Iridium 192 high dose rate brachytherapy. ^[17] Fitzpatrick et al. reported a high local control rate (93%) and excellent cosmetic outcome for patients with SCC of the eyelid who are treated with radiotherapy. ^[12] In the present study, the local control rate at 5 years was 75.60% for all lid cancers [Figure - 2]. The Local control rate at 5 years was 90% for squamous cell carcinoma, 57.4% for sebaceous cell carcinoma and 50% for basal cell carcinoma of lid with good functional and cosmetic results in present study [Table - 7], [Figure - 3].

Previous studies have suggested that in patients with eyelid malignancies, primary radiotherapy might be an acceptable alternative to Moh′s micrographic surgery in patients who are not great surgical candidates to preserve function and avoid major disfiguring surgery.

The findings of the current study support the concept that radiotherapy is highly effective for treating early staged SCC of the eyelid with acceptable complications.

Conclusion

From the present study we came to conclusion that high dose rate interstitial brachytherapy with Iridium 192 is appropriate for the treatment of early staged squamous cell carcinoma of eye lid.

References

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