8.5 Radiotherapy for actinic keratosis and cutaneous squamous cell carcinoma in situ
Unless stated otherwise, tumour stage is according to the American Joint Committee on Cancer (AJCC) cancer staging manual 8th edition and Union for International Cancer Control (UICC) TNM classification of malignant tumours 8th edition.
Actinic keratoses (AKs) can be symptomatic and may be a precursor to invasive disease. A minority (less than 5%) become invasive, although genital lesions such as squamous cell carcinoma in situ of the penis (erythroplasia of Queyrat, Bowen’s disease) may have higher rates of invasion (10–30%).
Actinic keratoses can involve large areas (skin field cancerisation).
Actinic keratoses are routinely cleared with cryotherapy, 5-fluorouracil cream or surgery. Surgery has been considered the gold standard, but its superiority has not been definitively demonstrated in a properly conducted randomised controlled trial.
Adequate surgical margins are important to achieve control, but this involves more tissue loss.
All these modalities can cause significant side effects and may not achieve long-term control.
Occasionally, longstanding cutaneous squamous cell carcinoma (cSCC) in situ can grow to a large diameter and become extended skin field cancerisation, which can be difficult to treat with the usual modalities. Field cancerisation can also occur in cosmetically sensitive areas such as the nose, where current treatments may not be possible or effective. Radiotherapy (RT) can be used to treat widespread and resistant AK.
Overview of evidence (non-systematic literature review)[edit source]
Historically, the role of RT in the treatment of AK has been considered to be limited to salvage treatment for smaller areas after a number of failed previous therapies in a minority of patients.
Squamous cell carcinoma in situ of the scalp has traditionally been treated with brachytherapy moulds. Newer, improved external beam RT (EBRT) techniques provide better treatment options, especially for convex areas of extensive skin field cancerisation, which comprise most ultraviolet (UV)-induced AK fields.
Techniques for RT in the treatment of AK have not been well defined. A review found that doses from 25–70 Gy were effective. Fractions sizes over 4 Gy were associated with long-term poor cosmetic outcome.
RT has been used in AK in the salvage setting and therefore most evidence is anecdotal and consists of small series and case studies. All have shown prolonged duration of control in heavily pre-treated patients. One case study using modern techniques (VMAT) shows enduring control.
An Australian review reported that a dose fractionation schedule of 40–50 Gy in 10–20 fractions using superficial (110–150 kVp) energy photons will achieve a local control rate of 95–100%.
Large convex surfaces of extensive skin field cancerisation are common and include the scalp, forehead, cheeks, forearms, legs, chest, upper back, and shoulders. Volumetric modulated arc therapy (VMAT) can now be used to treat these skin surfaces with definitive VMAT photon RT (see: Recent advances in the radiotherapy of skin cancer).
For patients with persistent or recurrent actinic keratosis, consider referral to a radiation oncologist for assessment.
- Radiotherapy – Introduction
- Radiotherapy with or without surgical treatment for keratinocyte cancer
- Radiotherapy for basal cell carcinoma
- Radiotherapy for cutaneous squamous cell carcinoma
- Radiotherapy for regional (nodal) metastatic disease (non-distant)
- Radiotherapy for keratoacanthoma
- Recent advances in the radiotherapy of skin cancer
- Management of side effects of radiotherapy
- Radiotherapy – health system implications and discussion
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