Panel consensus was not to include suggested revision.

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Holly Rogers
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1 DFSP-2 Footnote f should be revised to more accurately reflect current practice and the supporting literature and should read, 5,000-6,600 cgy for close-to-positive or positive margins (200 cgy fractions per day), consider higher doses for gross tumor. Fields to extend widely beyond surgical margin (e.g., 3-5 cm) when clinically feasible. SCC-3 Revise algorithm for negative margins to state, If extensive perineural or large nerve involvement, recommend RT; if deep structural or soft tissue involvement or multiple ( 3) high-risk features are present, consider RT. Add recommendation for adjuvant therapy for patients with negative margins after standard excision, as for those with negative margins after Mohs (see proposed statement). BCC-3 Revise algorithm for negative margins to state, If extensive perineural or large nerve involvement, deep structural or soft tissue involvement or multiple ( 3) high-risk features are present, consider RT. SCC-6 Revise footnote x to add the following: Consider palliative RT for symptomatic sites. SBRT may also be considered in select patients for re-irradiation of inoperable regional disease after prior RT. Panel consensus was to amend footnote f : Gy for close-to-positive indeterminate or positive margins, and up to 66 Gy for gross tumor (2 Gy fractions per day). Fields to extend widely beyond surgical margin (eg, 3 5 cm) when clinically feasible. Panel consensus was not to include the suggested revised language for adjuvant treatment after negative margins. However, for patients with negative margins after standard excision, the panel agreed to add a recommendation for adjuvant treatment: "If extensive perineural or large-nerve involvement, recommend adjuvant RT" revision. Panel consensus was to add the following to footnote x for "Multidisciplinary tumor board consultation": Consider palliative RT/surgery for symptomatic sites. SBRT may also be considered in select patients."

2 BCC-C & SCC-C Principles of Radiation Therapy External request: Submission request from Elektra to modify the statement There is insufficient long-term efficacy and safety data to support the routine use of electronic surface brachytherapy by either deleting completely or revising the sentence to read Electronic surface brachytherapy should be considered when appropriate. BCC-2, BCC-3 & SCC-2, SCC-3 Revise statement: non-surgical candidates and add for patients who decline surgery or prefer radiation therapy where appropriate in the guideline. BCC-2, BCC-3 & SCC-2, SCC-3 Revise statement to more accurately reflect the supporting literature and contemporary experience, and state, RT is often reserved for patients over 50 years of age or those who have higher risk features because of historical concerns about long-term sequelae, where appropriate in the guideline. Based on the data in the noted references and discussion, the panel consensus was to not delete or modify the statement. Panel consensus was to include a footnote for non-surgical candidates : See Principles of Treatment for Basal Cell Skin Cancer (BCC-B) and See Principles of Treatment for Squamous Cell Skin Cancer (SCC-B) where appropriate throughout the guideline. BCC-B and SCC-B include guidelines about treatment selection based on patient- and case-specific factors. Panel consensus was not to revise statement: RT is often reserved for patients older than 60 years because of concerns about long-term sequelae.

3 Revise existing table by adding two commonly used 3 Gy per fraction schedules under primary tumor: For <2 cm add, 48 Gy in 16 fractions over 3.2 weeks For 2 cm add, 54 Gy in 18 fractions over 3.6 weeks revisions. However, the Principles of Radiation Therapy for Squamous Cell Skin Cancer page was extensively revised. Revise existing table by adding additional text under Primary Tumor (specifically, below Postoperative adjuvant and above Regional Disease ) to include these well-described techniques that remain widely used in practice: Superficial therapy, orthovoltage therapy, or HDR Brachytherapy (surface or interstitial) For tumor diameter <2 cm, margins cm, examples of dose fractionation and treatment duration: Gy at 5 Gy/fraction over 4-5 weeks, 2/week Gy at 6 Gy/fraction over 3 weeks, 2/week Gy at 8 Gy/fraction over 3-4 weeks, 1-2/week For tumor diameter >2 cm, cm, examples of dose fractionation and treatment duration: Gy at 4 Gy/fraction over 5-6 weeks, 2/week Gy at 5 Gy/fraction over 4-5 weeks, 2/week revisions. However, the Principles of Radiation Therapy for Squamous Cell Skin Cancer page was extensively revised

4 Revise the third bullet point under the table to read, Low energy ionizing radiation may be produced by a variety of commercially available devices, some of which are labeled as teletherapy (superficial or orthovoltage) devices and others which have been labeled electronic brachytherapy devices. It remains unclear whether the latter devices involve distinct workflow processes that offer any clinical advantage, and their routine use is not supported due to a lack of long-term efficacy and safety data." revisions. However, panel consensus was to add a new bullet about brachytherapy: Radioisotope brachytherapy could be considered in highly selected cases.

5 Revise footnotes as follows: When using electron beam, wider field margins are necessary than with superficial or orthovoltage x-rays or HDR brachytherapy due to wider beam penumbra. Narrower field margins can be used with electron beam adjacent to critical structures (eg, the orbit) if lead skin collimation is used. Narrower field margins can similarly be used with superficial ( kv) or orthovoltage ( kv) therapy, and HDR brachytherapy: cm for welldemarcated lesions; cm for larger (>2cm) or poorlydemarcated lesions. These techniques are often advantageous in treating irregular shapes near critical organs and may be delivered using shorter fractionation schedules, selected based on tumor size and clinical judgment. Bolus is necessary when using electron beam to achieve adequate surface dose. An electron beam energy should be chosen that achieves adequate surface dose and encompasses the deep margin of the tumor by at least the distal 90% line. Electron beam doses are specified at 90% of the maximum depth dose (Dmax). Orthovoltage x-ray doses are specified at Dmax (skin surface) to account for the relative biologic difference between the two modalities of radiation. IMRT can facilitate treatment of regional target volumes or other complex target volumes where the avoidance of critical structures is necessary. If the primary site will be treated with IMRT, appropriate focus must be directed at assuring that there is adequate surface dose. The support of a qualified medical physicist is essential for all of these techniques. revisions. Instead, the panel agreed to remove these footnotes entirely.

6 Revise all instances to state: Radiation therapy is contraindicated in genetic conditions predisposing to skin cancer (e.g. basal cell nevus syndrome, xeroderma pigmentosum) and relatively contraindicated in connective tissue diseases (e.g. scleroderma). The panel agreed to make the suggested change. However, xeroderma pigmentosum was removed as a contraindication: Radiation therapy is contraindicated in genetic conditions predisposing to skin cancer (eg, basal cell nevus syndrome) and relatively contraindicated for patients with connective tissue diseases (eg, scleroderma).

HDR Brachytherapy for Skin Cancers. Joseph Lee, M.D., Ph.D. Radiation Oncology Associates Fairfax Hospital

HDR Brachytherapy for Skin Cancers Joseph Lee, M.D., Ph.D. Radiation Oncology Associates Fairfax Hospital No conflicts of interest Outline Case examples from Fairfax Hospital Understand radiation s mechanism