Radiotherapy treatment of non-melanoma skin cancer: A survey of current UK practice and commentary

Abstract

Objective:
In the ongoing absence of available trial data, a national survey was carried out to provide details on radiotherapy treatment strategy for non-melanoma skin cancer (NMSC).

Methods:
A survey of clinical oncologists treating NMSC was performed. The respondents were asked for basic information on workload as well as a proposed treatment strategy for various clinical scenarios for patients of varying fitness.

Results:
A total of 43 completed and 20 partially completed surveys were received. There was a wide variation in the workload and additional disease sites that respondents had responsibility for. Kilovoltage radiotherapy was available to 81% of responders. The respondents' approach was affected by the fitness of patients, with longer fractionation regimes proposed for younger, fitter patients and shorter or non-standard fractionations more likely for the infirm elderly. Four daily fractionation regimes (18-20 Gy in 1 fraction, 35 Gy in 5 fractions, 45 Gy in 10 fractions and 55 Gy in 20 fractions) were most commonly suggested. There was a large degree of variation in non-standard fractions proposed with significant potential differences in radiobiological effect. Concern over the use of kilovoltage photons on skin over cartilage was apparent, as was a reluctance to use radiotherapy in areas of increased risk of poor wound healing.

Conclusion:
The survey results largely showed practice to be in line with available published evidence. The variation seen in some areas, such as non-standard fractionation, would benefit from the publication of local outcomes to achieve a more consistent approach.

Advances in knowledge:
This study provides information on national practices and identifies variations, particularly within widespread use of non-standard fractionation.

Full text

BJR © 2014 The Authors. Published by the British Institute of Radiology
Received:
21 July 2014
Revised:
29 August 2014
Accepted:
3 September 2014
doi: 10.1259/bjr.20140501
Cite this article as:
McPartlin AJ, Slevin NJ, Sykes AJ, Rembielak A. Radiotherapy treatment of non-melanoma skin cancer: a survey of current UK practice and
commentary. Br J Radiol 2014;87:20140501.
FULL PAPER
Radiotherapy treatment of non-melanoma skin cancer:
a survey of current UK practice and commentary
A J MCPARTLIN, MB ChB, FRCR, N J SLEVIN, MB ChB, FRCR, A J SYKES, MB ChB, FRCR and A REMBIELAK, MD, PhD
The Christie NHS Foundation Trust, Manchester, UK
Address correspondence to: Dr Andrew James McPartlin
E-mail: andrew.mcpartlin@christie.nhs.uk
Objective: In the ongoing absence of available trial data,
a national survey was carried out to provide details on
radiotherapy treatment strategy for non-melanoma skin
cancer (NMSC).
Methods: A survey of clinical oncologists treating NMSC
was performed. The respondents were asked for basic
information on workload as well as a proposed treatment
strategy for various clinical scenarios for patients of varying
fitness.
Results: A total of 43 completed and 20 partially com-
pleted surveys were received. There was a wide variation in
the workload and additional disease sites that respondents
had responsibility for. Kilovoltage radiotherapy was avail-
able to 81% of responders. The respondents’approach was
affected by the fitness of patients, with longer fraction-
ation regimes proposed for younger, fitter patients and
shorter or non-standard fractionations more likely for the
infirm elderly. Four daily fractionation regimes (18–20 Gy
in 1 fraction, 35 Gy in 5 fractions, 45Gy in 10 fractions and
55 Gy in 20 fractions) were most commonly suggested.
There was a large degree of variation in non-standard
fractions proposed with significant potential differences
in radiobiological effect. Concern over the use of kilo-
voltage photons on skin over cartilage was apparent, as
was a reluctance to use radiotherapy in areas of increased
risk of poor wound healing.
Conclusion: The survey results largely showed practice to
be in line with available published evidence. The variation
seen in some areas, such as non-standard fractionation,
would benefit from the publication of local outcomes to
achieve a more consistent approach.
Advances in knowledge: This study provides information
on national practices and identifies variations, particularly
within widespread use of non-standard fractionation.
Non-melanoma skin cancer (NMSC) is the most common
malignancy in the UK. In 2010, around 100,000 people
were diagnosed with NMSC, and there were 585 related
deaths in 2011.
1
The vast majority of these lesions are basal
cell carcinomas (BCCs) or, less commonly, squamous cell
carcinomas (SCCs). Various treatment modalities can be
utilized to manage this condition, with a potential for ex-
cellent local control and cosmesis, including topical ther-
apies, surgical excision, electrocautery, cryotherapy and
radiotherapy. The choice of treatment approach is influ-
enced by the stage and location of disease, patient fitness
and preference. For patients who are not fit enough to be
considered for surgery or for disease in locations where
excision would be cosmetically undesirable, the use of radio-
therapyiscommonlyrecommended.
Various methods of radiotherapy delivery are available,
including electron, kilovoltage and megavoltage external
beam radiotherapy as well as brachytherapy, although there
is variable access to these methods between centres in the
UK. A lack of prospective trial data to guide treatment has
led to the development of local practice regarding dose
fractionation schedules, and it is unclear how much vari-
ation currently exists nationally. In the absence of likely
forthcoming trials, there is little impetus for variable practice
to change.
To potentially streamline clinical practice, details on the
most commonly used strategies employed in various clin-
ical scenarios would be of interest as a basis for harmo-
nizing dose/fractionation schedules.
METHODS AND MATERIALS
An invitation to complete an anonymous online survey was
sent to all 58 clinical heads of the Service and Clinical
Oncology Audit Leads throughout the UK to pass on to
consultants, with an interest in treating patients with NMSC.
The survey was hosted via the online website Qualtrics and
remained open for a period of 3 months. Basic information
regarding the experience of the responder and the number
of skin cases treated was requested as well as a proposed
treatment strategy for various clinical scenarios. In each of

these scenarios, a tissue diagnosis had been made, and the multi-
disciplinary meeting decision was for management with primary
radiotherapy. Owing to the wide diversity of both location and
types of tumour that occur, this was intended to give a flavour of
the current practice. For each scenario, a treatment strategy was
requested for a healthy 65 year old, a relatively well 80 year old
and an 85 year old nursing home resident with early dementia
and significant comorbidity. Details of each scenario can be found
in Figure 1. It was hoped that this would give some indication of
actual practice in a “real world”environment, although obviously
real clinical judgments would not be made on chronological age.
RESULTS
A total of 43 complete and 20 partially complete anonymous
surveys were received. 91% of responders worked in centres
with an identified clinical oncology team or individual to plan
“complex”skin radiotherapy. The volume of skin cases seen
varied nationally with 46.2% of respondents treating ,5 cases
per month; 21.1%, 5–10 cases; 25.0%, 11–20 cases; and 7.7%,
.20 cases. The age of the patient seen also differed between
centres with the proportion over the age of 80 years ,10% in
3.9%, 10–25% in 27.5%, 25–50% in 33.3% and .50% in 35.3%.
81% of responders had access to kilovoltage radiotherapy for the
treatment of skin cancers with varying energies available at
different centres.
Almost all responders were expected to have expertise in more
than one disease site. Only 2% treated skin cases exclusively,
24% treated two sites, 42% treated three sites, 20% treated four
sites, 8% treated five sites and 4% treated six sites.
Response to the clinical scenarios posed was varied with mul-
tiple, albeit similar, fractionation regimes employed. This study
mainly focused on the fractionation used and how this varied
dependent on the age and fitness of patient and disease location.
The results for each scenario are shown below (Figure 1). The
various regimes proposed were divided into obvious groups:
single fractions, 3–5 fractions, 8–10 fractions, $15 fractions,
non-standard fractionation, brachytherapy and palliative
treatments.
When treating disease at the inner canthus, a correction for
stand off was made by 74% of respondents. When treating an
area of recurrence within a previously grafted area, 40.6% would
treat the whole graft, 50% would treat the area of recurrence
with a margin and 9.4% would vary practice dependent on the
graft size. The use of kilovoltage photon or electron radiotherapy
varied according to the disease site and the status of the patient
(Figure 2).
An analysis of the fractionation regimes proposed in response
to each scenario shows a large number of different dose
fractionations employed, although several were, by far, the
most likely to be used: 18–20 Gy/1#, 35 Gy/5#, 45 Gy/10# and
55 Gy/20#. A large degree of heterogeneity amongst non-
standard (less than daily treatments) fractionation treatments
was also shown with 24 different dose fractionations proposed.
Figure 1. Fractionation regimes employed for a given scenario in different patient groups. BCC, basal cell carcinomas; SCC,
squamous cell carcinomas.
BJR AJ McPartlin et al
2of7 birpublications.org/bjr Br J Radiol;87:20140501

The total number of times that the more popular of these and
the other standard dose fractionations were suggested is shown
in Table 1.
DISCUSSION
The survey was answered by 63 respondents from 58 centres in
the UK. Of these respondents, 43 returned completed surveys,
taking a median of 28 min to do so. It is possible that the pro-
portion of respondents completing the survey may have been
improved by reducing the number of given clinical scenarios.
This would, however, have lost valuable clinical information. In
addition, less than 1 min was spent reviewing the survey by
almost all who failed to complete it, suggesting that the overall
number of scenarios that they would have been unlikely to know
was not the sole reason.
The survey has shown variation between clinicians regarding the
best treatment approach for a given clinical scenario. As many
responders identified, the decisions about the treatments are
strongly influenced by seeing the patient in the clinic. The gestalt
provided from this was not possible when answering this
survey, and decisions had to be made on the basis of limited
information from each scenario stem. This may have affected
interpretation and response. Each question was devised to high-
light differences in therapy approach for commonly encountered
clinical scenarios.
The survey has shown that the proportion of clinical practice
occupied by respondents to treat NMSC varies greatly with al-
most half treating less than one case per week. It is apparent that
management decisions on some skin cancers are complex such
that, where possible, a reasonable throughput of patients with a
limited number of other subspecialist interests is to be recom-
mended to engender expertise.
Standard daily fractionation
Owing to slight variation in practice between the centres, it
is not possible to present exact dose/fractionation regimes.
Responses did, however, divide naturally into various categories:
palliative treatments, single fractions, 3–5 fraction regimes giv-
ing 27.5–35.0 Gy, 8–10 fraction regimes giving 32–45 Gy, 15–33
fraction regimes giving 45–66 Gy and non-standard alternate
day, twice weekly or weekly regimes. These fractionation regimes
are in line with published international approaches.
2,3
The use of
hypofractionated daily regimes has been shown in retrospective
studies to be an effective treatment approach for NMSC with out-
comes equivalent to 2–3 Gy per fraction regimes and with ben-
efits in convenience for the patient and resource requirements;
4,5
these two studies used hypofractionated regimes of 44–45 Gy
given in ten daily fractions or 35 Gy in five daily fractions, both
of which were commonly chosen by respondents to this current
survey.
The survey responses also show wide variation in the use of
electron or kilovoltage photon therapy and the energies employed.
Many clinicians provided answers based both on actual and
preferred practice, with almost one in five not having access to
kilovoltage photon therapy. Again, the sheer heterogeneity of
these answers has been simplified with the focus being on
fractionation rather than the detail of technique. Electrons are
more likely to be used with larger lesions and younger patients.
This is supported by retrospective data that have shown elec-
trons to be at least equivalent to kilovoltage photons in small
series for local control and cosmesis.
6–8
In the very elderly with significant comorbidity, the challenge of
trying to offer radical therapy is evident in the variety of
responses seen. Palliative treatments, single fractions and non-
standard fractionation are more likely to be used and indeed, for
Figure 2. Radiation modality employed for given scenario in different patient groups. BCC, basal cell carcinomas; kv, kilovoltage;
SCC, squamous cell carcinomas.
Full paper: Current UK radiotherapy treatment of NMSC BJR
3of7 birpublications.org/bjr Br J Radiol;87:20140501

some scenarios, make up the most commonly employed ap-
proach. Retrospective data have shown that a single fraction is
an effective approach for the treatment of lesions ,3cm in
diameter.
9
Its appropriateness for lesions larger than this was not
demonstrated in that study owing to limited patient numbers,
but cosmesis was shown to be better with single fraction doses of
18 or 20 Gy compared w ith a higher dose of 22 Gy, which was
associated with a significantly increased rate of necrosis. In our
survey responses, reassuringly, the suggested dose was 18 or
20 Gy in 94% of radical single fraction treatments. We feel the
use of a 22-Gy single fraction should no longer be considered
acceptable practice unless correcting for stand-off. Single
fraction therapy should generally be avoided for large lesions,
even in the less fit when non-standard fractionation should be
considered.
Non-standard fractionation
The survey has shown widespread usage of non-standard frac-
tionations in patients who might otherwise struggle to complete
treatment. There is some limited published evidence supporting
this approach. A single centre review of 31 cases has previously
shown that 24 Gy in 3 fractions over 3 weeks, treating pre-
dominantly SCC of a median size of 5 cm, achieved local control
in 61.3% of tumours, with a further 25.8% unassessable, at
a median follow-up of 17 weeks and with no severe late toxicity
seen.
10
A retrospective review of 42 BCCs treated with 30 Gy in
5 fractions over 4 weeks demonstrated local control in 95.2%
with a median follow-up of 15 months and excellent or good
cosmesis in all cases.
11
There is, however, a wide variation in
overall treatment times, and total doses suggested in survey
responses, reflecting the paucity of trial data available to guide
treatment and the consequent development of local practices. It
would be of benefit to have more centres publish outcomes
following these treatments to establish which are most effica-
cious and allow development of a more uniform approach,
accepting that these schedules are often used for frail patients
who are not regularly reviewed post treatment.
A comparison of various non-standard regimes can be per-
formed by calculation of biological equivalent doses (BEDs),
derived from the linear quadratic equation for cell kill following
radiotherapy. Previous clinical studies have suggested an
a/b
tumour
for skin cancer of 8.5 Gy, a/b
late effects
of 3 Gy, the
onset time (T
k
) of 28 days, cell doubling time (T
p
) of approxi-
mately 4 days and avalue of 0.3:
12–15
BED 5Total dose 3½11ðdose per fraction=a=bÞ
2½ln2=ðap
Τ
pÞðTotal treatment time 2TkÞ
BEDtumour 5Total dose 3½11ðdose per fraction=8:5Þ
2ð0:693=1:2ÞðTreatment time 228Þp
pTime compensation is not applicable if total treatment time
is ,28 days
BEDlate effects5Total dose 3½11ðdose per fraction=3Þ
Applying this suggests that the three most commonly used non-
standard regimes (45 Gy/9# over 3 weeks, 27 Gy/3# over 2 weeks
and 38/6# over 3 weeks) have broadly similar radiobiological
characteristics. Further assuming an a/b53Gy for lateeffects
demonstrates that some of the proposed non-standard regimes
(28 Gy/2# 6 weeks apart, 32.4 Gy/3# weekly and 36 Gy/4#
weekly) may have too high a risk of late effects if the equations
are accurate and patients are living long enough to experi-
ence them. The adoption of another schedule in their place
should be considered. In addition, some other regimes are
clearly prescribed with a palliative intent (18 Gy/2# over 1 or
2weeks,25Gy/5#over4weeksand27Gy/6#over3weeks),
but, given the wide spread uses of non-standard regimes with
radical intent, they should be appropriate in only limited
circumstances.
Treatment of disease overlying cartilage
Historically, there has been concern about the use of kilovoltage
radiation for skin lesions overlying cartilage owing to a perceived
risk of dose build-up in cartilage and bone through the pho-
toelectric effect.
15
This theoretical concern has, however, been
contested.
16
The survey assessed how current practice when
treating small tumours at the ali-nasi and helical rim is affected
by this evolving debate and demonstrates a marked division in
practice.
Skin overlying the nose cartilage is a frequent location of skin
carcinoma, representing around 25% of disease occurring on the
head and neck.
17
It has been shown that treatment of the skin
overlying cartilage of the nose using kilovoltage radiotherapy
Table 1. Popularity of commonly suggested dose fractionations
Dose fractionation Number of times suggested
18 Gy/1# 41
20 Gy/1# 18
32 Gy/5# 27
35 Gy/5# 237
40.5 Gy/9# 22
40 Gy/10# 29
45 Gy/10# 170
45 Gy/9# 51
45 Gy/15# 15
50 Gy/15# 56
50 Gy/20# 57
55 Gy/20# 134
60 Gy/30# 26
66 Gy/33# 11
27 Gy/3# over 2 weeks 20
28 Gy/2# over 6 weeks 11
38 Gy/6# over 6 weeks 11
45 Gy/9# over 3 weeks 24
BJR AJ McPartlin et al
4of7 birpublications.org/bjr Br J Radiol;87:20140501

offers good or acceptable (mild skin atrophy or dyschromia)
cosmesis in 96.8% of lesions in remission.
18
When treating
a small 1.5-cm ali-nasi BCC, .80% of respondents to the survey
elect to use kilovoltage photons. The majority of these patients
are offered a treatment of 35 Gy delivered in five fractions, in line
with practice reported at other international centres.
18,19
By contrast, kilovoltage photons are used by only around 25%
of respondents for small (2 cm) SCCs of the helix of the ear,
although this proportion does increase with elderly infirm
patients. This is despite retrospective data showing kilovoltage
photons to have good local control in this site with low risk of
late complication for both SCC and BCC.
20–22
It may be that
kilovoltage photons would be more likely utilized for BCC in
this location, which is not a given scenario, but concerns about
increased late effects with kilovoltage photon treatments may
still persist nationally. This is presumably a consequence of local
experience of complications and may suggest that additional
factors contribute to the poor tolerance of the ear cartilage to
kilovoltage photons. Of note, it has been demonstrated that the
frostbite of the ear occurs almost three times more frequently
than those of the nose.
23
This may imply that there are vascular
causes contributing to late effects of radiotherapy to the ear.
Longer fractionations over 2 weeks or more are likely to be
employed for treatment of the ear, which may further reflect
concerns about toleration of treatment and the larger treatment
volume that the use of electrons necessitates.
The use of longer treatment regimens for disease overlying
cartilage is supported by outcomes from two retrospective series
of dose-fractionation schedules. These demonstrate that using
fraction sizes of ,4–6 Gy is associated with a significant re-
duction in necrosis following radiotherapy over the pinna.
20,22
Others have found a reduction in visible long-term cosmetic
defect using schedules of 4 weeks or more over the nasal skin.
19
Treatment of areas with impaired wound healing
Various areas of the body present significant clinical challenges
owing to concerns over impaired tolerance of radiotherapy and
an increased risk of late effects. This survey looked to identify
what general approaches are employed in this setting.
NMSC of the hand is a problematic area to treat with definitive
radiotherapy, and most would recommend surgical excision of
the lesion as the preferred treatment modality. In various clinical
scenarios, particularly with elderly infirm patients, this may not
be possible and radiotherapy can have a role to play. There are
few published data for outcomes of treatment to the hand. The
local control rate with radiotherapy has been quoted up to 96%,
in a case series of 50.
24
Historical data identified a 6% incidence
of radionecrosis following radiotherapy to the hand and con-
cerns about cosmesis persist.
25
A study of the use of brachy-
therapy for SCC of the hand using doses of 40–45 Gy have,
however, shown minimal treatment-related morbidity.
26
Most
respondents, around 70%, would favour a longer fractionation
regime ($15 fractions) when treating a 4-cm SCC of the dor-
sum of the hand. Concerns about the use of kilovoltage photons
owing to underlying bone, as in other areas, are reflected in
respondents using electrons in .80% of treatments in fitter
patients and around 70% of treatments of the infirm. The
perceived problems of radiotherapy treatment are demonstrated
by 7.7% of respondents, despite the scenario stating the patient
was not suitable for surgery, declining to suggest any fraction-
ation regime. Given the excellent published outcome data, the
survey demonstrates very limited and, perhaps, suboptimal use
of brachytherapy for this site.
This concern with effects of radiotherapy is even more pro-
nounced in the treatment of carcinoma of the shin, with around
20% of respondents refusing to offer treatment, even in the
infirm. Historical series have reported poor wound healing or
failure to heal in 9–33% of patients treated with external beam
radiotherapy to the lower leg, supporting clinician caution, with
local control up to 94%.
27–29
In younger patients, 60% of those
offering treatment for a 4-cm BCC of the shin would treat over 3
weeks or longer. In the elderly and infirm, faced with the
challenges of ensuring a patient completed treatment, 32% of
respondents would give 3–5 daily treatments and 30% would offer
non-standard fractionation.
Post-operative recurrent disease
There is a lack of published data on post-operative radiotherapy
to an area containing a skin graft. However, several published
articles on radiotherapy given to skin grafts either in a labora-
tory setting or single centre retrospective series have shown a
good tolerance with low likelihood of graft breakdown.
30–33
Responders to the survey are generally comfortable giving sal-
vage radiotherapy to recurrent disease within grafts, presumably
owing to local experience of good outcome. Only a small number
refuse to offer any treatment when dealing with the elderly and
infirm. The use of longer fractionations is preferred for younger
fitter patients, as at other sites. The lack of good data on which
to base treatment decisions is reflected in the almost equal split
between clinicians who would treat the entire graft or the area of
recurrence with a margin.
Treatment of anatomically challenging sites
Treatment of medial canthus NMSC, predominantly BCC, is
demanding both owing to its concave location and because of
underlying structures, which can be directly invaded by disease.
Following surgical resection, there is a risk of significant post-
operative defect. Primary kilovoltage radiotherapy can yield
good cosmetic results and local control rates of 94% have been
reported using 35–60 Gy in 5–30 daily fractions.
34,35
There is,
however, little detail reported on the radiotherapy technique
employed.
In this current survey, around 80% of respondents would use
kilovoltage photons to treat a 1.5–3.0-mm thick BCC at the
inner canthus. Owing to the anatomy of this region, it is usually
impossible to achieve apposition of an applicator to the tumour.
A decision, therefore, has to be made whether to compensate for
this stand-off distance in calculating the prescribed dose, termed
stand-off correction, which 74% (26) of responders would do.
Several comment that this correction is made if the gap is 5 mm
or more. The most common fractionation regime suggested is
35 Gy in five fractions, in line with published data.
Full paper: Current UK radiotherapy treatment of NMSC BJR
5of7 birpublications.org/bjr Br J Radiol;87:20140501

Cancer of the vermillion border is the most common cancer of
the head and neck after skin cancer. .90% of cases are SCCs and
the vast majority involve the lower lip. Radiotherapy generally
offers better cosmetic and functional results than does surgery,
particularly, with larger tumours. Retrospective review has
shown good local control, up to 99%, for early SCC treated with
electron or kilovoltage modalities.
36–40
Suggested dose fractio-
nations used in these series varied from 40 Gy in 8 fractions to
55 Gy in 22 fractions. The survey scenario requested treatment
strategy for a 1-cm thick SCC. A large majority of respondents
would use electron treatments in this setting and would use longer
fractionation regimes in fitter patients, similar to published data.
CONCLUSIONS
Overall, this survey has produced reassuring results. In most
scenarios, the majority of clinicians would offer treatment
that is in line with what published evidence is available. There
is a large degree of heterogeneity is some areas, particularly, in
non-standard fractionation treatments and the treatment of
recurrent disease within skin grafts. With the number of dose
fractionation schedules available, it should be possible to
harmonize UK practice. Any attempt to achieve a more
consistent approach would benefit from the publication of
local outcomes of differing techniques, and this should be
encouraged.
REFERENCES
1. Cancer Research UK. Skin Cancer statistics
report August 2013. [Cited March 2014.]
Avail abl e fr om: http://publications.
cancerresearchuk.org/downloads/Product/
CS_CS_SKIN.pdf
2. Halperin EC, Perez CA, Brady LW. Perez and
Brady’s principles and practice of radiation
oncology. London, UK: Lippincott Williams
& Wilkins; 2008. pp. 694.
3. Wong JR, Wang CC. Radiation therapy in the
management of cutaneous malignancies. Clin
Dermatol 2001; 19: 348–53.
4. Van Hezewijk M, Creutzberg CL, Putter H,
Chin A, Schneider I, Hoogeveen M, et al
Efficacy of hypofractionated schedule of
electron beam radiotherapy for epithelial
skin cancer: analysis of 434 cases. Radiother
Oncol 2010; 95: 245–9. doi: 10.1016/j.
radonc.2010.02.024
5. Kwan W, Wilson D, Moravan V. Radiotherapy
for locally advanced BCC and SCC of skin.
Int J Radiat Oncol Biol Phys 2004; 60:
406–11.
6. Lovett RD, Perez CA, Shapiro SJ, Garcia DM.
External irradiation of epithelial skin cancer.
Int J Radiat Oncol Biol Phys 1990; 19: 235–42.
7. Griep C, Davelaar J, Scholten AN, Chin A,
Leer JW. Electron beam therapy is not
inferior to superficial X-ray therapy in the
treatment of skin carcinoma. Int J Radiat
Oncol Biol Phys 1995; 32: 1347–50.
8. Locke J, Karimpour S, Young G, Lockett MA,
Perez CA. Radiotherapy for epithelial skin
cancer. Int J Radiat Oncol Biol Phys 2001; 51:
748–55.
9. Chan S, Dhadda AS, Swindell R. Single
fraction radiotherapy for small superficial
carcinoma of the skin. Clin Oncol (R Coll
Radiol) 2007; 19: 256–9.
10. Barnes E, Bren D, Culleton S, Zhang L,
Tsao M, Balogh J. Palliative radiotherapy
for non-melanoma skin cancer. Clin Oncol
2010; 22:844–9.
11 . Koul ou lias V, Kouv ar is J, Mosa E,
Georgakopoulos J, Platoni K, Papadopoulos O,
et al. Efficacy, cosmesis and skin toxicity in
a hypofractionated irradiation schedule for
cutaneous basal cell carcinoma of the head and
neck area. Head Neck Oncol 2012; 4:88.
12. Thames HD, Bentzen SM, Turesson I,
Overgaard M, Van den Bogaert W. Time
dose factors in radiotherapy: a review of the
human data. Radiother Oncol 1990; 19:219–35.
13. Maciejewski BA, Skates S, Zajusz A, Lange D.
Importance of tumour size and repopulation
for radiocurability of skin cancer. Neoplasma
1993; 40:51–4.
14. Bentzen SM, Thames HD. Clinical evidence
for tumour clonogen regeneration: interpre-
tations of the data. Radiother Oncol 1991; 22:
161–6.
15. Allan E, Stanton A, Pye D, Collins C, Perry L,
Filby M, et al. Fractionated high dose rate
brachytherapy moulds—a precise treatment
for carcinoma of the pinna. Radiother Oncol
1998; 48: 277–81.
16. Atherton P, Townley J, Glaholm J. Cartilage:
the “F”-factor fallacy. J Clin Oncol (R Coll
Radiol) 1993; 5: 391–2.
17. Koplin L, Zarem HA. Recurrent basal cell
carcinoma: a review concerning the inci-
dence, behaviour and management of re-
current basal cell carcinoma, with emphasis
in the incompletely excised lesions. Plast
Reconstr Surg 1980; 65: 656–63.
18. Caccialanza M, Piccinno R, Percivalle S,
Rozza M. Radiotherapy of carcinoma of the
skin overlying the cartilage of the nose: our
experience in 671 lesions. J Eur Acad
Dermatol Venereol 2009; 23: 1044–9. doi:
10.1111/j.1468-3083.2009.03247.x
19. Tsao MN, Tsang RW, Liu FF, Panzarella T,
Rotstein L. Radiotherapy management for
squamous cell carcinoma of the nasal skin:
the Princess Margaret Hospital experience.
Int J Radiat Oncol Biol Phys 2002; 52: 973–9.
20. Hayter CR, Lee KH, Brundage MD. Necrosis
following radiotherapy for carcinoma of the
pinna. Int J Radiat Oncol Biol Phys 1996; 36:
1033–7.
21. Lim JT. Irradiation of the pinna with
superficial kilovoltage radiotherapy. Clin
Oncol (R Coll Radiol) 1992; 4: 236–9.
22. Silva JJ, Tsang RW, Panzarella T, Levin W,
Wells W. Results of radiotherapy for epithe-
lial skin cancer of the pinna: the Princess
Margaret Hospital experience 1982–1993. Int
J Radiat Oncol Biol Phys 2000; 47: 451–9.
23. Lehmuskallio E, Lindholm H, Koskenvuo K,
Sarna K, Friberg O, Viljanen A. Frostbite of
the face and ears: epidemiological study of
risk factors in Finnish conscripts. BMJ 1995;
311: 1661–3.
24. Szabo P. Radiotherapy of carcinomas of the
dorsum manus. [In German.] Strahlenther-
apie 1981; 157: 242–4.
25. Raynor CR. The results of treatment of two
hundred and seventy three carcinomas of the
hand. Hand 1981; 13: 183–6.
26. Somanchi BV, Stanton A, Webb M,
Loncaster J, Allen E, Muir LT. Hand
function after high dose rate brachyther-
apy for squamous cell carcinoma of the
skin of the hand. Clinical Oncol (R Coll
Radiol) 2008; 20:691–7.
27. Cox NH, Dyson P. Wound healing on the
lower leg after radiotherapy or cryotherapy of
Bowen’s disease and other malignant lesions.
Br J Dermatol 1995; 133:60–5.
28. Dupree MT, Kiteley RA, Weismantle K,
Panos R, Johnstone PA. Radiation therapy for
Bowen’s disease: lessons for lesions of the
lower extremity. J Am Acad Dermatol 2001;
45: 401–4.
29. Podd TJ. Treatment of lower limb basal cell
and squamous cell carcinomas with radiother-
apy. ClinOncol(RCollRadiol)1992; 4:44–5.
30. Lawrence WT, Zabell A, McDonald HD. The
tolerance of skin grafts to postoperative
BJR AJ McPartlin et al
6of7 birpublications.org/bjr Br J Radiol;87:20140501

radiation in patients with soft-tissue sar-
coma. Ann Plast Surg 1986; 16: 204–10.
31. Sumi Y, Ueda M, Kaneda T, Eto K. Effects of
irradiation on grafted skin. J Oral Maxillofac
Surg 1983; 41: 586–91.
32. Bui DT, Chunilal A, Mehrara BJ, Disa JJ,
Alektiar KM, Cordeiro PG. Outcome of
split-thickness skin grafts after external
beam radiotherapy. Ann Plast Surg 2004;
52:551–6.
33. Kulahci Y, Duman H, Zor F, Bozkurt M,
Guden M, Gunhan O, et al. The effect of
external beam irradiation timing on skin
graft survival. Eur Surg Res 2010; 44: 142–51.
doi: 10.1159/00027698
34. Krema H, Herrmann E, Albert-Green A,
Payne D, Laperriere N, Chung C.
Orthovoltage radiotherapy in the manage-
ment of medial canthus basal cell carcinoma.
Br J Ophthalmol 2013; 97: 730–4. doi:
10.1136/bjophthalmol-2012-302991
35. Swanson EL, Amdur RJ, Mendenhall WM,
Morris CG, Kirwan JM, Flowers F.
Radiotherapy for basal cell carcinoma
of the medial canthus region. Laryngoscope
2009; 119: 2366–8. doi: 10.1002/lary.20658
36. de Visscher JG, Grond AJ, Botke G, van der
Waal I. Results of ra diotherapy for squa-
mous cell carcinoma of the vermilion
border of the lower lip: a retrospective
analysis of 108 patients. Radiother Oncol
1996; 39:9–14.
37. Cerezo L, Lui FF, Tsang R, Payne D.
Squamous cell carcinoma of the lip: analysis
of the Princess Margaret Hospital experience.
Radiother Oncol 1993; 28: 142–7.
38. Petrovich Z, Parker RG, Luxton G, Kuisk H,
Jepson J. Carcinoma of the lip and selected
sites of the head and neck skin. A clinical
study of 896 patients. Radiother Oncol 1987;
8:11–17.
39. Sykes J, Allen E, Irwin C. Squamous cell
carcinoma of the lip: the role of electron
treatment. Clin Oncol (R Coll Radiol) 1996; 8:
384–6.
40. Mccombe D, Macgill K, Ainslie J, Beresford
J, Matthews J. Squamous cell carcinoma of
the lip: a retrospective review of the Peter,
M McCallum Cancer Institute experience
1979–1988. Aust N Z J Surg 2000; 70:
358–61.
Full paper: Current UK radiotherapy treatment of NMSC BJR
7of7 birpublications.org/bjr Br J Radiol;87:20140501