Epithelian skin cancer Efficacy of a hypofractionated schedule in electron beam radiotherapy for epithelial skin cancer: Analysis of 434 cases Marjan van Hezewijk a, * , Carien L. Creutzberg a , Hein Putter b , Alim Chin a , Irmhild Schneider a , Mascha Hoogeveen a , Rein Willemze c , Corrie A.M. Marijnen a a Department of Radiation Oncology; b Department of Medical Statistics; and c Department of Dermatology, Leiden University Medical Center, Leiden, The Netherlands article info Article history: Received 29 June 2009 Received in revised form 19 February 2010 Accepted 23 February 2010 Available online 23 March 2010 Keywords: Epithelial skin cancer Radiotherapy Electron beam irradiation Local control Prognostic factors abstract Background and purpose: Efficacy of radiotherapy for epithelial skin cancer was evaluated and treatment outcomes of two electron beam fractionation schedules were compared. Materials and methods: Outcome data of 434 epithelial skin cancers in 333 patients were analysed; 332 were basal cell carcinomas (BCCs) and 102 squamous cell carcinomas (SCCs). Patients were treated with electron beam, and received either 54 Gy in 18 fractions (n = 159) or 44 Gy in 10 fractions (n = 275). Local recurrence free (LRF) rates were analysed as well as metastases free rates, cancer specific survival (CSS) and cosmetic result. Results: Median follow-up was 42.8 months. For BCC, actuarial 3-year LRF rates were 97.6% for tumours treated with 54 Gy and 96.9% for 44 Gy. In SCC 3-year LRF rates were 97.0% for 54 Gy and 93.6% for 44 Gy (n.s.). T stage was found to be the only significant factor for recurrence (p = 0.036). Three-year CSS was 98% for SCC and 100% for BCC. Conclusions: Electron beam irradiation is a safe and effective treatment modality for epithelial skin can- cer. In view of a similar efficacy and patient convenience of the hypofractionated schedule, 44 Gy in 10 fractions can be regarded the radiation schedule of choice. Ó 2010 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 95 (2010) 245–249 Epithelial skin cancer is a common neoplasm. The majority are basal cell carcinomas (BCCs), the remainder squamous cell carcino- mas (SCCs) [1]. The annual incidence in the Netherlands is 100 per 100,000 for BCC and 20 per 100,000 for SCC. Incidence is increas- ing, probably as a result of increasing age and sun exposure of the population. Median age at diagnosis is 74 years for SCC and 66 years for BCC [2,3]. Treatment options and preferences are diverse, including sur- gical excision, radiotherapy, cryotherapy, photodynamic therapy and topical treatment using 5-fluorouracil or imiquimod cream. Surgery and radiotherapy have been reported to be the most effective treatments methods [4]. Reported local control rates after primary treatment with radiotherapy are 87–97% for BCC and 56–91% for SCC [5–10]. Studies on the efficacy of radiother- apy have used a wide range of radiotherapy modalities, includ- ing brachytherapy, superficial X-ray treatment and electron beam radiotherapy with different dose levels, which makes com- parison of the results difficult [5–10]. Previous studies have shown that recurrence rates and cosmetic results after electron beam irradiation were similar to superficial X-rays and even bet- ter for larger tumours [11]. Fractionation schedules previously used in our institution were 60 Gy in 2 Gy fractions for tumours in a cosmetically critical area such as the face, and 54 Gy in 3 Gy fractions for other locations. A hypofractionated schedule using 44 Gy in 10 fractions of 4.4 Gy each was designed in view of the trend towards improved local control reported for fraction doses exceeding 3 Gy [1] and to make treatment more tolerable for the often very elderly patients, who might benefit from the reduction of the number of hospital visits. The 44 Gy schedule was calculated to be equivalent to 54 Gy in 3 Gy fractions for late effects, using an a/b of 3. The aims of this study were to retrospectively analyse and com- pare the efficacy of these treatment schedules, and especially to evaluate whether the hypofractionated schedule (44 Gy in 4.4 Gy fractions) was as safe and effective as the conventional fraction- ation schedule (54 Gy in 3 Gy fractions). Because epithelial skin cancers rarely metastasise, our primary outcome measure was lo- cal recurrence free rate. Secondary outcome measures were metas- tases free rate, overall and cancer specific survival and the cosmetic result. 0167-8140/$ - see front matter Ó 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2010.02.024 * Corresponding author. Department of Radiation Oncology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands. E-mail address: m.van_hezewijk@lumc.nl (M. van Hezewijk). Radiotherapy and Oncology 95 (2010) 245–249 Contents lists available at ScienceDirect Radiotherapy and Oncology journal homepage: www.thegreenjournal.com