What is the role of hypofractionation in port wine stain skin cancer treatment?

From the Guidelines

Hypofractionation is recommended for skin cancer radiation therapy as it offers effective treatment with fewer hospital visits, as supported by the most recent evidence from 2019 1. When considering radiation therapy for skin cancer, it is essential to prioritize morbidity, mortality, and quality of life as the primary outcomes.

• The goal of radiation therapy is to achieve high cure rates while minimizing side effects and maintaining cosmesis.
• Hypofractionation regimens, such as 20 Gy in 5 fractions, have been shown to be equally effective as standard regimens, with complete response rates reported in the range of 68%–92% 1.
• The use of hypofractionation allows for fewer hospital visits, improving patient convenience and resource utilization.
• This approach is particularly valuable for treating superficial basal cell carcinomas, squamous cell carcinomas, and for elderly patients who may have difficulty with prolonged treatment courses.
• Side effects are generally limited to the treatment field and include erythema, dry or moist desquamation, and potential hyperpigmentation after healing.
• The alpha/beta ratio of skin cancers, approximately 10, allows for the delivery of larger doses per fraction, exploiting the relatively low alpha/beta ratio compared to late-responding normal tissues 1.
• In the context of skin cancer radiation therapy, hypofractionation is a recommended approach, as it provides effective treatment with minimal side effects, improving patient outcomes and quality of life.

From the Research

Hypofractionation in Skin Cancer

• Hypofractionation is a radiation therapy regimen that delivers higher doses of radiation in fewer fractions, resulting in a shorter overall treatment time 2, 3, 4, 5, 6.
• Studies have shown that hypofractionated radiation therapy can be effective in treating skin cancer, including basal and squamous cell carcinomas, with favorable cosmetic outcomes 2, 3, 4, 5.
• Hypofractionation has been found to produce similar cosmesis to conventionally fractionated schedules, at the same biologically equivalent dose (BED) 2.

Efficacy and Tolerance

• A meta-analysis of 21 studies found that hypofractionated radiation therapy resulted in a trend to decreased "good" cosmesis with higher total dose, but still achieved "good" cosmesis in 79% of patients at a BED of 100Gy 2.
• A study of very elderly patients with locally advanced epithelial skin cancer found that hypofractionated radiotherapy achieved an overall response rate of 96.1%, with 92.4% complete responses, and low toxicity 3.
• Another study found that hypofractionated radiotherapy for invasive squamous cell carcinoma of the scalp in elderly patients resulted in complete or partial response for more than 70% of patients, with no major side effects 4.

Safety and Effectiveness

• A case series of frail and elderly patients with facial non-melanoma skin cancer found that strongly hypofractionated electron beam radiotherapy was safe and effective, with complete response achieved in 22/23 lesions, and widely tolerated toxicities 5.
• A review of the evidence supports the use of hypofractionation in older patients with non-melanoma skin cancer, citing excellent in-field control and improved quality of life 6.
• Hypofractionation can be delivered over a shorter time, improving patient quality of life and avoiding the need for surgery, especially in elderly or unwell patients 3, 6.