Superficial Radiotherapy (SXT)

following ear lobe Keloid excision

CASE PRESENTATION

Authored by

Kikwai Richard , Ann Waita and Antony Mamati

Presented

By

Mamati Antony

• Introduction

• Case Presentation

• Case Description /Discussion

• SXT Process / Technique

• Safety Measures

• Conclusion

Keloid disease • A Keloid is a growth of dense fibrous tissue that extends beyond the boundaries of the original

wound. • Compromise aesthetic, itchy , painful and impair function Epidemiology : • Higher incidence in female than in men attributed to ear piercing as an aesthetic value

activity. Management : • Management to prevent recurrence has been a challenge and combined treatment is

advocated for best results. • Surgery followed by superficial radiotherapy documented to have successful rates to reduce

recurrence. Post excision radiotherapy: • Non- invasive treatment option that is applied within 24hrs to 48hrs post excision. • Safety ensured through application of the best practices in rdaiatiotherapy

Why present this case

• Safety concerns

• Share technological advancements

• Protocol reviews

• 22 year old female

• Developed Keloid 3 years on the left ear lobe (suspected to be as a resultant of ear piercing).

• No family history of Keloid disease.

• Reason for excision; itchiness and compromise aesthetic.

• Complained of numbness and intermittent pain around the infra auricular pinna region.

• A slight swelling was noted around the excised area.

• Most common presentation at NRC since 2000.

• The only SXT centre in East and Central Africa

• Keloid located close highly radiosensitive tissues to radiation : eyes, ear drum , brain, salivary glands.

Routine Questionnaire to ascertain :

• Patient comfort.

• Skin tolerability to ionising radiation

• Explanation of the procedure.

• Expected side effects appropriateness of the treatment regime and

• Consent for treatment.

• Superficial radiotherapy treatment is the use of low-energy X-rays to destroy unhealthy cells.

• Practitioners began using radiation therapy for treatment of keloids in 1906.

• This is very good for treating lesions on or just beneath the skin surface, as the X-rays don’t go deep into the body.

. Depths at Which the Dose is 100%, 80%, and 50% of the Maximum Dose for Common Photon Energies :

PHOTON BEAM ENERGY DEPTH (cm) VERSUS

PERCENTAGE OF MAXIMUM DOSE

100 % 80 % 50%

230 kV 0 3.0 6.8 60Co 0.5 4.7 11.6

4 MV 1.0 5.6 13.0

6 MV 1.2 6.8 15.6

10 MV 2.0 7.8 19.0

25 MV 3.0 10.2 21.8

SUPERFICIAL RADIOTHERAPY UNIT

STEP ONE: Definition of the target volume ( REGION OF INTEREST FOR TREATMENT)

• The gross tumour volume (GTV) includes the whole scar that is left after excision of the Keloid.

• The CTV including the scar and traumatised skin.

• Planning tumour volume should cover an area of at least 1cm-2cm around the scar.

• Done within 24-48hrs post excision

• Associated with the cell cycle

Sensitivity to radiation; G2(late G2 and M phase are the most sensitive S phase, (particularly late S phase)- more resistant G1 phase - average sensitivity

THE OXYGEN-FIXATION HYPOTHESIS

• Absorbed radiation –production of free radicals. highly reactive molecules that break chemical bonds,produce chemical changes and initiate the chain ofevents that result in biological damage.

• Most of the indirect effects occur by free radicals produced in water, since this makes up 70–80 per cent ofmammalian cells.It is the fate ofthe free radicals ultimately produced in the critical target,designated as R

• R=molecules are unstable and will react rapidly with oxygen,if present,to produce RO2,which then undergoes further reaction ultimately to yield ROOH in the target molecule.Thus we have a stable change in the chemical composition of the target.

• Patient lied prone

• Arms along the head on a firm pillow case

• The head is immobilised using immobilising tapes and straps.

• Post excision dressing is removed carefully to exposé the excision scar.

Cone Identification:

Accessories used to conform radiation to treatment area.

• In this case a 4x6 cm

• 30SSD cone was used.

• 0.2mmcu filter used as a beam hardener.

: • TREATMENT TIME AND

DOSE CALCULATION: determines the amount

of radiation to be delivered and the duration of delivery

Prescribed dose is 12Gy

using 100Kev 20mAS in single fraction

SHIELDING AND RADIATION PROTECTION MEASURES

• Provide shielding to sensitive organs and adjacent tissues that do not fall within the target volume.

• Irregular nature of the target area.

• Minimise exposure to adjacent structures not in the path treatment

1If the technology is safe, then we will be safe.

2. If the human is safe, then we will be safe

3. If the organization is safe, then we will be safe’.

STEP FIVE

• PATIENT REASSURANCE OF THE PROCEDURE:

• No pain during treatment

• No scarring sounds or manoeuvres

• Expected to remain still during the treatment

• Estimated time of the procedure is revealed to the patient.

STEP SIX

• Verification of treatment set-up

• Treatment time calculations

• Radiation safety measures .

STEP SEVEN • Treatment delivery

• Monitoring of the patient. This was done using a

CCTV camera that is installed in the treatment room with a screen in a separate controll room.

Completion of treatment

• Removal of lead shielding material around the treated area

• Dressing the treated area.

• Skin care post superficial radiotherapy • No harsh antiseptic to be applied on the treated

area. • No rubbing, scratching or scrubbing the treated

area in the event of itchy. • Minimise contact with water on the excised area,

for at least 14 days. • Given referral note indicating the amount of dose

delivered and the fractionating regime. • and booked for review after two months

• Use of SXRT is well tolerated for ear lobe Keloid treatment post excision.

• Safe & Effective • Short treatment sessions • No pain • No scarring • No anesthesia required • No post reconstructive surgery required • High cure rates

AREAS OF CONCERN

1. Open sites post excision.

2. Absorbable and non-absorbable suture materials.

3. Post radiotherapy injection.

Don’t give up the fight to

overcome keloid recurrence

NRC

Says

THANK YOU