cancer of the eyelid accounts for 5 - 10% of all skin cancers with 90% being basal cell carcinoma ( bcc ) .
post - operative radiotherapy is usually indicated depending upon the presence of high - risk features for recurrence .
positive surgical margins in primary bcc excisions in the head and neck region were reported to be 3 - 20% in the literature and recurrence rates in incompletely excised patients were reported at 26 - 67% as well . among the indian population , squamous and adenocarcinoma involving tarsal glands are more common , incidence ranging between 2.4% to 30.2% of all malignant eyelid tumours in various literatures .
they are more aggressive and invasive than basal cell carcinoma , and have a definite metastatic potential .
if treatment is delayed , they can invade the orbital and intracranial structures , and hence have a considerable potential for mortality and morbidity .
sebaceous carcinoma tends to affect patients at older age , mostly around fifth decade , with a female preponderance .
they arise from the meibomian glands of the eyelid and have a local recurrence rate around 30% including invasion of orbital contents and distant metastasis in 20% cases .
traditionally , surgical excision has been the mainstay of treatment in this group of patients .
moh 's micrographic surgery , cryosurgery , laser excision have been used with 5 year control rates in the range of 90% .
radiotherapy , mostly as external beam radiation is added in cases having high chances of local recurrence such as lymph nodal involvement , positive or close margin , perineural invasion , and poorly differentiated tumours [ 6 , 7 ] .
the major hindrance in application of post - operative external beam radiotherapy ( ebrt ) is the close association of vital structures of the globe and the thin skin around the eyelid .
radiation - induced ocular morbidity encompasses a spectrum from transient eyelid erythema to complete loss of vision , with or without loss of the globe [ 810 ] .
post - operative adjuvant interstitial brachytherapy ( ibrt ) has been infrequently used for the treatment of eyelid malignancies . in the presence of high risk factors warranting adjuvant radiotherapy ,
most of the patients receive ebrt , which has its own shortcomings . post - operative adjuvant high - dose - rate ( hdr ) brachytherapy can be considered as an effective option in this group of patients for maintaining local control , while preserving cosmesis and function .
we present a series of 8 patients who received post - operative hdr brachytherapy ( hdr ibrt ) in our hospital .
this study aims at proposing an effective alternative for preserving function and cosmesis among eyelid cancer patients , warranting adjuvant radiotherapy after primary excision while maintaining disease control .
between august 2007 and july 2012 , 8 patients of eyelid cancer receiving post - operative hdr ibrt were analysed .
there were 5 male and 3 female patients with age between 23 - 82 years .
all of them underwent primary surgery in the form of wide excision followed by appropriate reconstruction .
the disease was staged by american joint committee on cancer ( ajcc ) 6 edition of tnm staging .
the implant procedure was carried out under general anaesthesia . the tumour volume ( post - operative target volume for brachytherapy )
the irradiated volume included the primary disease extent with a margin of 3 - 5 mm with modifications if required .
plastic tubes were then threaded through these needles and left in place after removal of the stainless steel needles .
plastic tubes were then secured , opposing the skin by means of plastic buttons and plastic beads ( fig .
1 ) . during treatment , a custom made conformer was fashioned out of dental prosthesis material to prevent additional dose spillage to normal eyes .
images were acquired using the ge system light speed ct simulator ( ge health care , milwaukee , wi , usa ) with patients in supine position with slice thickness of 1 - 1.5 mm .
the brachytherapy planning was done using nucletron plato sunrise v 14.3.1 computerized treatment planning system ( nucletron , an elekta company , elekta ab , stockholm , sweden ) .
optimization was done along dose points specified at a distance of 2 - 3 mm from the catheters depending on thickness of tumour bed . in the case of single wire implant , dose prescription point of 2 mm was selected as per the american association of physicist in medicine ( aapm ) task group ( tg ) report no .
the 85 or 100% isodose lines were used as reference isodose based on the adequacy of tumour bed coverage and the dose to normal structures like skin and cornea ( fig .
postoperative ibrt in eyelid cancer - planning and dosimetry demographics of ibrt patients fractionated high - dose - rate brachytherapy was administered using single high activity ir-192 , as radio - active source with predetermined time at various dwell positions which were 2.5 mm apart .
total dose was between 21 gy in 7 fractions to 35 gy in 10 fractions , respectively .
( twice daily fractionation with gap of 6 - 8 hours between them ) , local anaesthetic was sprayed over the treatment region , antibiotic ointment dressing was carried out , and patients were kept on oral analgesics and if required intravenous tramadol as well .
all the 8 patients were reviewed weekly for one month to document acute radiation reactions , 3 monthly for 2 years , and then 6 monthly up to 5 years , then annually once .
one patient was lost to follow up after completion of treatment . on follow - up , patients were examined clinically as well as with ophthalmologic evaluation as warranted .
the status of these patients pertaining to disease control was done by clinical examination of both the primary site and neck . at certain intervals
it was supplemented by detailed ophthalmologic examination , which also took care of toxicity assessment . any visual deterioration and complications pertaining to skin over eyelid , conjunctiva , and overall cosmesis
acute toxicities were graded by rtog acute toxicity scale and ctcae version 3 criteria were used for late complications pertaining to skin , eyelid , and vision , respectively .
the indigenous caib scale was designed keeping in mind the different ocular structures and their late effects viz .
depigmentation of skin , eyelid dysfunction like ectropion or entropion , dry eye , keratitis , cataract , and glaucoma .
if present , they were scored as 1 and 0 if they were absent . on a total score between 0 - 6 ,
4 groups were made with score 0 being excellent cosmesis , scores 1 - 2 as very good , 3 - 4 as fair , and scores 5 - 6 as poor cosmesis .
this scale was specifically devised with responses yes / no to actually document effectiveness of hdr ibrt in terms of cosmetic outcome ( table 2 ) . 
 
four patients had sebaceous carcinoma , while 3 had squamous cell carcinoma and 1 patient had a nodular basal cell carcinoma .
the acute toxicities were graded by rtog acute toxicity criteria . all the 8 patients had grade 1 acute reactions , either faint erythema ( 6 patients ) or mild epiphora ( 2 patients ) .
the late toxicities that we looked at were the skin of the eyelid in terms of pigmentary changes , eyelid in terms of dysfunction like ectropion or trichiasis , and visual complaints such as cataract , glaucoma and keratitis .
only 2 patients had late toxicity in terms of pigmentory changes persisting over skin of right upper eyelid and mild ectropion .
one of the patients was lost to follow up and no comment could be made upon late toxicity or cosmesis .
there was no incidence of corneal ulcer , conjunctival foreign body sensation , corneal perforation and cataract , which are of significant concern with ebrt .
the dosimetric analysis of the organs at risk in vicinity to eyelid cancer like remaining uninvolved eyelid , cornea , lens , and lacrimal gland were carried out .
the dmax for uninvolved eyelid was 17.2 gy , for cornea 6.7 gy , lens received 1.9 gy and lacrimal gland on the ipsilateral side 3.4 gy , respectively .
dosimetric parameters of eyelid brachytherapy cosmesis was documented as per the objective caib scoring criteria indicated excellent ( 5 patients ) to very good ( 2 patients ) cosmesis .
two patients failed at the node but were salvage effectively and remain controlled at subsequent follow - up .
the three distinct types of eyelid cancers with their variable local and distant invasion rates coupled with surrounding critical visual apparatus have always posed a challenge towards the effective management . while basal cell cancers are locally recurrent , squamous cell carcinomas are more aggressive and invasive , and sebaceous carcinomas also have high distant failure rates [ 1416 ] .
the therapeutic challenge is to be able to preserve cosmetic and functional results and therefore the goal of therapy would be both tumour control and function preservation [ 17 , 18 ] .
a variety of approaches are available for the management of skin cancer , including curettage and electrodessication , mohs micrographic surgery , cryotherapy , surgical resection , and external beam radiotherapy .
radiotherapy is used as adjuvant treatment in high - risk lesions , which include positive margins , perineural invasion , and lymph node disease after surgical resection / debulking [ 6 , 7 ] .
the indications for postoperative radiation include positive surgical margins , perineural spread , invasion of bone and cartilage , extensive skeletal muscle infiltration and poor differentiation [ 15 , 20 ] .
recent literature also suggests pathological stage more than pt2 alone warrants postoperative radiotherapy for better survival in eyelid sebaceous carcinomas .
traditional radiotherapy was feared because of acute and late sequelae to the ocular structures . for dry eye to develop , incidence of injury increases from 0% with doses of 30 gy to 100% after doses
the eyelid also develops transient erythema at doses of 30 gy , with telangiectasia and loss of eye lashes beginning to occur at 40 gy . late squeal like ectropion and entropion
chances of corneal perforation increase when the cornea receives ebrt dose in excess of 60 gy .
cataract is a well - known radiation complication presenting as posterior sub capsular opacification . in general ,
latency and frequency of cataract is a function of radiation dose and conventionally fractionated ebrt dosage exceeding 12 gy is held responsible .
the complications in inner eye structures like retina and optic nerve is primarily determined by the total radiation dose .
none of the patients receiving a dose of < 50 gy developed optic neuropathy or chiasm injury .
in contrast , the 10-year actuarial incidence of optic nerve - chiasm injury was 5% for patients receiving 50 - 60
the current literature with postoperative ibrt showed promise with organs at risk ( oar ) receiving dosage much lower than that can cause complications . 
 
early and late effects of radiation on ocular structures when ebrt is used in postoperative setting effects such as atrophy , telangiectasia , pigment changes , and other potential complications like tissue necrosis and wound breakdown , have been observed in about 2% of the patients treated .
late effects include dry eye , hypopigmentation , skin atrophy , cataracts , radiation keratopathy , optic neuropathy , and retinopathy .
the incidence of these complications depends on the location and size of the tumour , radiation doses delivered fractionation , and volume of treated areas .
being extremely conformal and targeting only the tumour bed , it can spare considerable amount of normal tissue .
the total radiation dose delivered ranges from 26 to 63 gy in various literatures ( median : 60 gy ) . in our study , 21 gy in 7 fractions to 30 gy in 10 fractions was used depending upon the indication .
the low dose rate ( ldr ) equivalent dose was calculated by standard linear - quadratic ( lq ) model delivered at 0.5 gy / hr . this translates to a ldr dose range of 27 gy to 39 gy . for tumour and acute reacting tissues , the biological equivalent dose ( bed )
was kept around 40 gy ( with / ratio kept at 10 ) and that for late reacting tissues around 60 gy ( with / of 3 ) .
one of the larger series with basal cell carcinomas that were more than 2 cm in dimension has reported eqd2 around 54 gy for adequate local control .
there have been no comparisons between postoperative brachytherapy and postoperative external beam radiation for eyelid cancer in literature , and there is unlikely to be such a study due to the rarity of such cases .
the study indicated slightly better loco - regional control by surgery , but also highlighted the cosmetic deformity by surgery specially in cases of flap reconstructions .
most of the series had mixed populations in terms of both histology ( squamous and basal cell ) and type of brachytherapy ( radical and postoperative ) .
one large series of peri - orificial skin cancer by emmanuel et al . has reported 7 cases of postoperative eyelid cancer treated by brachytherapy amongst a total of 97 cases .
the cosmesis and functional outcomes were graded on a 4 point scale namely anatomic deformity , telangiectasia , pigmentation disorders , and changes in skin texture ( atrophy , folds ) .
another recent series reporting interstitial brachytherapy for eyelid cancers with basal and squamous cell carcinomas reported very high local control rates ( > 95% ) after almost 8 years median follow up and also acceptable cosmetic outcomes .
kowalik et al . have tried to use individual applicator for different disease sites in the head and neck region , and one of their cases had a recurrence of squamous cell cancer at root of nose close to eyes .
they have also showed excellent results in treating these recurrences . to re - emphasise ,
brachytherapy techniques seem to be the most effective and easy treatment to protect organs located deeper than 2 cm below the surface , and from the perspective of protecting critical healthy organs as well . however , it demands technical expertise in these cases .
our study in comparison to available literature also showed an excellent local control with a median follow up of 4 years .
the indigenous yet to be validated caib scale , taking into considerations the important late toxicities in the ocular structures was found to be quite useful both in terms of applicability and accuracy .
the small sample size and heterogeneous population of eyelid cancer patients actually highlight the rarity of such cases and treatment approach like postoperative hdr ibrt .
the caib scale used in our study showed excellent to very good cosmesis in all cases .
adjuvant hdr brachytherapy in patients of eyelid cancer undergoing primary surgical excision is safe and efficacious .
the small numbers in the series reflect the low incidence of this cancer in our part of the world , but the results prove that effective adjuvant therapy can be provided when necessary with very good disease control and functional outcomes .
the indigenous caib scale with future prospective validation studies would definitely streamline management of this rare disease with acceptable cosmetic outcomes .
 purposeto analyse feasibility and safety of postoperative interstitial brachytherapy ( ibrt ) in patients of eyelid cancer treated primarily by surgical excision.material and methodsin this series , 8 patients with eyelid cancer were treated using postoperative interstitial brachytherapy . 
 patients were followed up for local control , cosmetic outcome , and acute and late toxicities . 
 cosmetic outcome was measured using a 6 point indigenous cosmesis after interstitial brachytherapy ( caib ) scale.resultsthe patients were between 23 - 82 years ( median : 71 years ) . 
 there were 3 females and 5 males , and 3 patients had lesions in upper eyelid . 
 postoperative high - dose - rate brachytherapy was used in all with 2 catheters implanted in most of them ( 6 out of 8) . 
 local control was calculated from end of treatment to last follow - up . 
 at last follow - up , all patients remained locally controlled . 
 two patients had nodal recurrence 6 months after interstitial brachytherapy and were salvaged effectively by external beam radiotherapy . at last follow - up , 7 patients were loco - regionally controlled and one was lost to follow up . 
 all patients had radiation therapy oncology group ( rtog ) grade 1 acute toxicity and 2 had grade 1 common terminology criteria for adverse events ( ctcae ) version.3 late toxicities . 
 the cosmesis score for the whole group ranged between 0 - 1 indicating excellent to very good cosmesis.conclusionspostoperative high - dose - rate brachytherapy resulted in excellent disease control and cosmesis without significant acute or late toxicities . 
 it is an effective modality for treatment of eyelid cancers in selected patients . 
 future prospective studies with the validation of caib scale would give us more insight to this effective yet often ignored modality of ibrt . 
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Material and methods
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