Clinical and Translational Oncology

, Volume 20, Issue 4, pp 431–442 | Cite as

Recommendations of the Spanish brachytherapy group (GEB) of Spanish Society of Radiation Oncology (SEOR) and the Spanish Society of Medical Physics (SEFM) for high-dose rate (HDR) non melanoma skin cancer brachytherapy

  • S. Rodríguez
  • M. Arenas
  • C. Gutierrez
  • J. Richart
  • J. Perez-Calatayud
  • F. Celada
  • M. Santos
  • A. Rovirosa
Clinical Guides in Oncology


Clinical indications of brachytherapy in non-melanoma skin cancers, description of applicators and dosimetry recommendations are described based on the literature review, clinical practice and experience of Spanish Group of Brachytherapy and Spanish Society of Medical Physics reported in the XIV Annual Consensus Meeting on Non Melanoma Skin Cancer Brachytherapy held in Benidorm, Alicante (Spain) on October 21st, 2016. All the recommendations for which consensus was achieved are highlighted in blue. Regular and small surfaces may be treated with Leipzig, Valencia, flap applicators or electronic brachytherapy (EBT). For irregular surfaces, customized molds or interstitial implants should be employed. The dose is prescribed at a maximum depth of 3–4 mm of the clinical target volume/planning target volume (CTV/PTV) in all cases except in flaps or molds in which 5 mm is appropriate. Interstitial brachytherapy should be used for CTV/PTV >5 mm. Different total doses and fraction sizes are used with very similar clinical and toxicity results. Hypofractionation is very useful twice or 3 times a week, being comfortable for patients and practical for Radiotherapy Departments. In interstitial brachytherapy 2 fractions twice a day are applied.


Skin brachytherapy Technical Dosimetric aspects Consensus 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Alam M, Nanda S, Mittal BB, Kim NA, Yoo S. The use of brachytherapy in the treatment of nonmelanoma skin cancer: a review. J Am Acad Dermatol. 2011;65:377–88.CrossRefPubMedGoogle Scholar
  2. 2.
    Kowalik L, Lyczek J, Sawicki M, Kazalsky D. Individual applicator for brachytherapy for various sites of superficial malignant lesions. J Contemp Brachytherapy. 2013;5:45–9.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Skowronek J. Brachytherapy in the treatment of skin cancer: an overview. Postepy Dermatol Alergol. 2015;5:362–7.CrossRefGoogle Scholar
  4. 4.
    Arenas M, Arguis M, Diez-Presa L, Henriquez I, Murcia-Mejía M, Gascón M, et al. Hypofractionated high-dose-rate plesiotherapy in nonmelanoma skin cancer treatment. Brachytherapy. 2015;14:859–65.CrossRefPubMedGoogle Scholar
  5. 5.
    Kwan W, Wilson D, Moravan V. Radiotherapy for locally advanced basal cell and squamous cell carcinomas of the skin. Int J Radiat Oncol Biol Phys. 2004;60:406–11.CrossRefPubMedGoogle Scholar
  6. 6.
    Köhler-Brock A, Prager W, Pohlmann S, Kunzw S. The indications for and results of HDR after loading therapy in diseases of the skin and mucosa with standardized surface applicators (the Leipzig applicator). Strahlenther Onkol. 1999;175(4):170–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Rose JN, McLaughlin PY, Hanna TP, D’Souza D, Sur R, Falkson CB. Surface mold brachytherapy for nonmelanoma skin cancer: Canadian patterns of practice. Pract Radiat Oncol. 2014;4:398–403.CrossRefPubMedGoogle Scholar
  8. 8.
    Arenas M, Sabater S, Sintas A, Arguis M, Hernandez V, Arquez M, et al. Individualised 3D scanning and printing for non-melanoma skin cancer brachytherapy: a financial study for its integration into clinical workflow. J Contemp Brachytherapy. 2017;9(3):270–6.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Bhatnagar A, Loper A. The initial experience of electronic brachytherapy for the treatment of non-melanoma skin cancer. Radiat Oncol. 2010;5:87.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Ballester-Sánchez R, Pons-Llanas O, Candela-Juan C, Celada-Alvárez FJ, de Unamuno-Bustos B, LLavador-Ros M, et al. Efficacy and safety of electronic brachytherapy for superficial and nodular basal cell carcinoma. J Contemp Brachytherapy. 2015;7(3):331–8.Google Scholar
  11. 11.
    NCCN Clinical Practice Guidelines in Oncology. Squamous Cell Skin Cancer Version 1.2017 Scholar
  12. 12.
    NCCN Clinical Practice Guidelines in Oncology. Basal Cell Skin Cancer Version 1.2017 Scholar
  13. 13.
    TNM staging American Joint Committee on Cancer. 7th ed. In: Sobin LH, Gospodarowicz MK, Wittekind Ch, editors. TNM Classification of Malignant Tumors, 7th ed. Oxford: Wiley-Blackwell, 2009. 310 p. ISBN 978-1-4443-3241-4.Google Scholar
  14. 14.
    Pons-Llanas O, Ballester-Sánchez R, Celada-Álvarez FJ, Candela Juan C, García-Martinez T, Llavador-Ros M, et al. Clinical implementation of a new electronic brachytherapy system for skin brachytherapy. J Contemp Brachytherapy. 2014;6:417–23.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ouhib Z, Kasper M, Calatayud JP, Rodríguez S, et al. Aspects of dosimetry and clinical practice of skin brachytherapy: the American Brachytherapy Society working group report. Brachytherapy. 2015;14(6):840–58.CrossRefPubMedGoogle Scholar
  16. 16.
    Fulkerson RK, Micka JA, DeWerd LA. Dosimetric characterization and output verification for conical brachytherapy surface applicators. Part I. Electronic brachytherapy source. Med Phys. 2014;41(2):022103.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Fulkerson RK, Micka JA, DeWerd LA. Dosimetric characterization and output verification for conical brachytherapy surface applicators. Part II. High dose rate 192Ir sources. Dosimetric characterization and output verification for conical brachytherapy surface applicators. Part II. Med Phys. 2014;41(2):022104.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Perez-Calatayud J, Granero D, Ballester F, Puchades V, et al. A dosimetric study of Leipzig applicators. Int J Radiat Oncol Biol Phys. 2005;62(2):579–84.CrossRefPubMedGoogle Scholar
  19. 19.
    Granero D, Pérez-Calatayud J, Gimeno J, Ballester F, et al. Design and evaluation of a HDR skin applicator with flattening filter. Med Phys. 2008;35(2):495–503.CrossRefPubMedGoogle Scholar
  20. 20.
    Granero D, Pérez-Calatayud J, Ballester F, Ouib Z. Radiation leakage study for the Valencia applicators. Med Phys. 2013;29:60–4.CrossRefGoogle Scholar
  21. 21.
    Granero D, Candela-Juan C, Ballester F, Ouib Z, et al. Commissioning and quality assurance procedures for the HDR Valencia skin applicators. J Contemp Brachytherapy. 2016;8(5):441–7.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ibañez-Rosello B, Bautista-Ballesteros JA, Candela-Juan C, Villaescusa JI, et al. Evaluation of the shielding in a treatment room with an electronic brachytherapy unit. J Radiol Prot. 2017;37(2):N5–12 (epub ahead of print).CrossRefPubMedGoogle Scholar
  23. 23.
    Brenner DJ, Leu CS, Beatty JF, Shefer RE. Clinical relative biological effectiveness of low-energy X-rays emitted by miniature X-ray devices. Phys Med Biol. 1999;44(2):323–33.CrossRefPubMedGoogle Scholar
  24. 24.
    García-Martinez T, Chan J-P, Perez-Calatayud J, Ballester F. Dosimetric characteristics of a new unit for electronic skin brachytherapy. J Contemp Brachytherapy. 2014;6:45–53.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Rivard MJ, Davis SD, De Werd LA, Rusch TW, Axelrod S. Calculated and measured brachytherapy dosimetry parameters in water for the Xoft Axxent X-ray source: an electronic brachytherapy source. Med Phys. 2006;33:4020–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Lam SCP, Xu Y, Ingram G, et al. Dosimetric characteristics of INTRABEAM® flat and surface applicators. Transl Cancer Res. 2014;3:106–11.Google Scholar
  27. 27.
    Schneider F, Clausen S, Thölking T, Wenz F, Abo-Madyan Y. A novel approach for superficial intraoperative radiotherapy (IORT) using a 50 kV X-ray source: a technical and case report. J Appl Clin Med Phys. 2014;5:4502.Google Scholar
  28. 28.
    Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy. 2013;12:134–40.CrossRefPubMedGoogle Scholar
  29. 29.
    Bhatnagar A, Patel R, Werschler WP, Ceilley RI, Strimling R. High-dose rate electronic brachytherapy: a nonsurgical treatment alternative for nonmelanoma skin cancer. J Clin Aesthet Dermatol. 2016;9(11):16–2.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Jankarashvili N, Topeshashvili M. Treatment of skin cancer with intrabeam. 9th ZEISS INTRABEAM User Meeting. 2015.Google Scholar
  31. 31.
    Granero D, Vijande J, Ballester F, Rodríguez S, et al. Prescription depth in surface skin brachytherapy. Brachytherapy. 2017;16(3):S1.CrossRefGoogle Scholar
  32. 32.
    Granero D, Candela-Juan C, Vijande J, Ballester F, et al. Technical note: dosimetry of Leipzig and Valencia applicators without the plastic cap. Med Phys. 2016;43(5):2087.CrossRefPubMedGoogle Scholar
  33. 33.
    Candela-Juan C, Niatsetski Y, Ouhib Z, Ballester F, et al. Commissioning and periodic tests of the Esteya® electronic brachytherapy system. J Contemp Brachytherapy. 2015;7(2):189–95.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rodriguez-Villalba S, Perez-calatayud MJ, Bautista JA, Carmona V, et al. Novel simple templates for reproducible positioning of skin applicators in brachytherapy. J Contemp Brachytherapy. 2016;8(4):1–5.Google Scholar
  35. 35.
    Lliso F, Granero D, Perez-Calatayud J, Carmona V, Pujades MC, Ballester F. Dosimetric evaluation of internal shielding in a high dose rate skin applicator. J Contemp Brachytherapy. 2011;3(1):32–5.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Granero D, Pérez-Calatayud J, Vijande J, Ballester F, Rivard MJ. Limitations of the TG-43 formalism for skin high-dose-rate brachytherapy dose calculations. Med Phys. 2014;41(2):021703.CrossRefPubMedGoogle Scholar
  37. 37.
    Candela-Juan C, Granero D, Vijande J, Ballester F, Rivard MJ, et al. Dosimetric perturbations of a lead shield for surface and interstitial high-dose-rate brachytherapy. J Radiol Prot. 2014;34(2):297–311.CrossRefPubMedGoogle Scholar
  38. 38.
    Safigholi H, Song WY, Meigooni AS. Optimum radiation source for radiation therapy of skin cancer. J Appl Clin Med Phys. 2015;16(5):5407.CrossRefGoogle Scholar
  39. 39.
    Delishaj D, Rembielak A, Manfredi B, Ursino S, Pasqualetti F, Laliscia C, et al. Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature. J Contemp Brachytherapy. 2016;8(6):533–40.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Federación de Sociedades Españolas de Oncología (FESEO) 2017

Authors and Affiliations

  1. 1.Radiation Oncology DepartmentHospital Clínica BenidormBenidormSpain
  2. 2.Radiation Oncology DepartmentHospital Universitari Sant Joan de ReusTarragonaSpain
  3. 3.Radiation Oncology DepartmentInstitut Català d’Oncologia, Hospitalet de LlobregatCataloniaSpain
  4. 4.Radiation Oncology DepartmentHospital La Fe-IRIMEDValenciaSpain
  5. 5.Radiation Oncology DepartmentICMHO, Hospital Clínic I UniversitariBarcelonaSpain

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