Radiation Therapy for Skin Cancer - Dermatology Office Appropriate or Too Hot to Handle?

[music] Welcome to Derms on Drugs. A video podcast brought to you by Scholars and Medicine, the best educational platform of dermatology, which also happens to be provided to healthcare providers at no cost. All you need is an NPI number. Derms on Drugs is where cutting-edge derm meets in a hit or miss comedy. I'm Mad Zyres and each week I'm joined by my residency buddies, Dr. Laura Ferris and Dr. Tim Patton, to use our 60 years of combined derm experience to discuss, debate, and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of derm and it will be the most fun you've ever had while actually learning something useful. New episodes drop every Friday on Scholars and Medicine, Apple podcasts, Spotify, and anywhere else you might happen to get your podcasts. Now I do want you to know that we do have a video component to the podcast. So if you want to watch, we actually do show the slides and visuals that are most crucial from each of the articles and we've got additional bonus content over on Scholars and Medicine. So you're going to have to head over there if you want the absolute full episode where we're going to talk about one of the coolest things I've seen in the long time for treating skin cancer and it should be coming to the US in the next year or so. But for today's episode, we've got a great topic lined up for you. So you've probably heard some about this image-guided superficial radiation therapy, which is an in-office procedure that some dermatologist are starting to add. It's showing up more and more in our literature. Well, we're going to go over two of the best recent articles about it. But then for our deep dive, we've got on two radiation oncologists, a lot of experience dealing with cutaneous oncology. And we're really going to get into the nitty-gritty of if this is something that's really appropriate for us to be doing in dermatology offices. So we are going to start it off with me kicking it over to Dr. Ferris. Dr. Ferris, what do you got? Thanks, Matt. So I have a paper recently published in BMC Cancer, Maloney at all. Title updated results of a 3,050 non-millinum skin cancer lesions in 1725 patients treated with high-resolution dermal ultrasound guided superficial radiation therapy, a multi-institutional study. Nice snappy title. Yes, it is. Exactly. Rolls right off the tongue. So this is -- so just to sort of give you some background. So this is a retrospective chart review from -- that is sort of a follow-up of a 2016 to 2020 retrospective chart review looking at patients treated with IGSRT, which will be a faster way to say this, and looking at their outcomes. So first of all, what is IGSRT or what does image guided mean when dermatologists are giving radiation therapy? So I think our guests will be able to tell us what they mean when they say image guided. So the image that's used here is 22 megahertz dermal ultrasound and color doppler to visualize superficial depths of the skin. And so this lets the physician visualize the lesion prior to during and after treatment to sort of adjust treatments as necessary. So basically in June of 2021, there was a published study that retrospectively looked at, you know, about 2,900 lesions from 1,600 patients, and they looked for rates of local control. And they said, you know, local control rates were extremely high, 99.3% with a mean follow-up of 16 months. And so what this study does is it adds another 93 patients with another, with an additional 133 lesions adding in basically results from another derm practice and also updates the results with longer follow-up. So we have over 3,000 lesions treated from 2016 to 2020. So what were these lesions? These were all stages. These are basal cells and squamous cells from inside 2 tumors, T1 to T2, actually, were the thickest studies. So this was not a prospective study. This was retrospective. And interestingly, if you look at how they followed up patients, in some cases they actually, you know, looked at data from charts. But they also, for some patients, did not actually have that. They did not manually extract the data, but they used this algorithmic analysis from a healthcare company called Sympto Health. So this was an IRB exempt study. Why does that matter? It does mean that when you have an IRB exempt study, you're sort of stuck with using the data that's there. You can't go back and say, let me call that patient and see, you know, do they, were they treated anywhere else? You know, was there a recurrent starting thing like that? Okay. So that's just sort of a little background. So in this study, we can see that. Really, Paris, I got, I got to ask, does that, this algorithmic follow-up thing sounds to me like baloney. I know nothing about it, but as you just described it, it sounded very suspect to me. Do you, do you think of it as suspect, or do you think it's legit? I think it's not the typical way that we do oncology studies. So, you know, I think it means that, you know, it's a large sample size, but I think it means that you're not necessarily going to have, you know, I think about it when we talk about studies done in trinetics, right? We say, this is a big database, you know, the, the, the advantage is the large size, but we don't necessarily get the same granular level of detail that we would, for example, if we did a chart by chart review. Okay. Just think about it that way. Okay. So, once, so basically what they said is once treatment ended, patients were evaluated for two to six weeks after completion, and then every one to six months after. So, in this study, patients, the median follow-up was 25 months. The, the mean, so looking at, you know, the mean number of fractions, or meaning the number of treatments, that a patient had the mean was 20, so they came in and had 20 different fractions of radiation. The total dose received, the median was 5,184 centigrays. Dehration of treatment was an average seven weeks, and the median size of the lesion was one centimeter. Most of these were basal cells. Most of these were on the head and neck. And so, you know, looking at their results, they had local, they're very high level of local control. They had 23 recurrences out of three thousand 50 lesions. So, that's an absolute local control rate of 99.2 percent of the lesions that concern that, that return 15 ribazels, seven were squamous cell carcinomas, and there's one squamous cell carcinoma inside too. They did look at toxicity. And so, you know, they, they looked at, if you look at RTOG acute toxicity, so that's radiation treatment on college group. And so they look at it by grades. And so, most of these were grade one. So, there are 18, 18, 18, RTOG grade one, toxicities. And so, you know, those were low number of grade four toxicities. However, they did note that, you know, they didn't have a procedure to record RTOG grade grading and toxicity. So, you know, there's going to be some missing values. And there's going to be some missing data in this. We also really didn't get any report of what those adverse events or toxicities were. So, you know, the author said, you know, when we compare it, now this was a retrospective study, we don't have a control group. We don't have a group, for example, that was controlled with maybe most surgery or topical therapy or, you know, anything else. So, they did compare their results to some older guided SRT studies where they had the radiation therapy, but not image guidance. They reported one by cognitive, Armin Cognitis group with at a two year recurrence rate of about 2%. And so, they said, well, our local control was a little bit better than that. Although it's hard to do, you know, those are two very different studies and different modalities. And of course, not, you know, randomized. They also compared their results to another study, Hernandez, Mocchine, et al. And said that their five year absolute local control rates were 94.4% per basal cells 92.7% for squamous cells. So, you know, so basically the authors make the point that the image guidance seems to be better. And they suggest that we should consider superficial radiation therapy of some sort as a, as a first line treatment. So, you know, I guess one of the questions that I had looking at this was, you know, we could say, all right, this is a pretty decent local control rate. But, you know, what were these lesions? These were things that were about a centimeter. They recommend not doing this for anything that has a depth greater than six millimeters because of the low penetrance of their 50 to 100 kilobalt energy. Limitations in the covered surface, they suggest you shouldn't do this. If you've got concavity of greater than a centimeter, in that case a flap or might be a better option for this patient, you might want to do that. So I guess my question is, is this a huge unmet need that we have to treat lesions that are thin, small, non-melanoma skin cancers? Maybe something we could have eaten, treated from the insi. So what I'll be interested in, because at initial glance, like, shift, I mean it's almost 100 percent and it seems like this would be great for the tiny little BCC on your nasal a la or your margin of your eyelid or somewhere that's a real pain in the butt to do treatment maybe. But I'll be honest, I just don't know enough about how safe this is. Like that's what I'm excited to have our guests on and I assume this is pretty safe if they're doing in derb offices, but I'd like to know a lot more about it. I think we'll be interested in that in the discussion of what do I mean? So I know what 5,100 Centigrays really correlates to not really, you know, like you make the point of eyelids, they're tough, but you know, that's also really thin skin. I mean, and you know, there's an eyeball under there that maybe it'll be interesting to see what they think about that. Yeah, no, because it really is a fascinating, you know, to get out of the costs, to effectively get us up and all that, but just if I had a tiny little baseless cell on the main A-lar rim, I don't know if it wasn't too hard to drive for 20 visits, I probably wouldn't probably consider this instead of getting a pair of median forehead flap or something. Well, let's from from that point, let's go into where Dr. Padden is going to our next article here. Do you have any fat and do you have any thoughts on this paper? Is this so were these cases all done by the same group? Was this multi center? Was it one? It was multi group. I think it was about seven practices. Okay. Right. Because I'm wondering, like the lead author is, it says they did, right? It's not like here's a consecutive series of every baseless cell that we saw or every squamous cell. Yeah, right. So we're done. Do these guys really know, you know, the lead author is a radiation oncology, a radiation oncologist, he works for skin cure. And that's who makes the gentle cure system that's marketed to the Durham offices. Is he really good at picking out the lesions that he knows are going to respond to this? And is it, you know, is he way better at selection than giving us to just any marine dermatologist and saying, Hey, you know, you can treat skin cancers too. Is there something like that involved it? I just had a lot of questions. Like what didn't he treat? You know what I mean? I mean, presumably, so that's one author, but I mean, presumably in a multi center study is not picking all three thousand. Yeah. That was the question. Yeah. Yeah. Right. I think it's, there's the availability and who picked the lesions and did the treatment. Yeah. It's like, all right. So my article was the, from January, 2025 issue of skin, the Journal of Coutainist Medicine, that's titled the role of image guided superficial radiation therapy and the treatment of non-millanoma skin cancer by Zachary at all. For this paper, the author's performed a literature search that produced 87 articles about IGS RT and skin cancer of these 87 papers. 12 papers made the final cut and were reviewed and used to develop consensus statements about the use of IGS RT for skin cancer. I know it is early in the year, but I'm ready to award this paper, the most bonkers article of the year. D. M. Day. It's a Derm, turns on drugs exclusive. I don't know if you guys know this or not, but there are physicians that undergo years of training working with the type of radiation that's described in the article. They're called Radiation. On colleges. There's a lot of colleges that's right there in their name. You know how many radiation oncologists were involved in the development of these consensus statements. 0.0. I'll get this published. I'm not saying they all need to be rad on, but at least get one for crying out loud. If it's sensitive paper was published about most surgery for an MSC and it didn't have one single most surgeon on it, would you even read it? Sorry, it was wrong. I know. I never thought about that when you put it that way. Yeah, I couldn't believe it. Like, let's go. All right. So, you know, I think that that influences a lot of these consensus statements and how they were voted. The authors created 10 statements eight received a unanimous six out of six votes for adoption and to receive five out of six votes for adoption strength of the statements was either a or b. I'm not going to go through all the statements. Maybe when we bring our radiation oncologists on, they can address specific ones. Most of them are pretty like, banal, like SRT's well established modality for the treatment of NMSC dependent on individual patient characteristics. I mean, sure. Yeah, that's going to get a six out of six vote. Nothing too crazy. And most of them were like that. Some of them I was like, well, I don't know about that. So SRT, including IGS RT can be considered a first line treatment for NMSC for appropriately selected patients. That didn't seem too crazy. But if you read the text under that particular statement, the authors, this is quote, quote, the authors concluded that IGS RT outperforms most micrographic surgery for NMSC based on statistically significantly. Significant superior two year recurrence probability that that I mean, banal they said that this is better than most with with non-randit. It's not like they were randomizing. Hey, mose Roger, like 97 99 point, whatever sounds great. But those were not. Yeah, they they tried to walk it back and they're like, oh, however, but no, that sentence is in this paper. So like if not that patients are going to be scouring the literature. But if any of them came to you and said, I got this thing that says IGS RT is better than mose. Why would you recommend mose? Like do we just say, you know what those, those people were crazy that did that paper. I mean, I don't know where that puts us, but let's move on. There was another one. I don't want to get. Oh, oh, patients with NMSC need to be offered all appropriate treatment options and should be part of the decision making process. I mean, in a perfect world, but if you have a spot on the nose and it's a basil, I'm like mose is the best treatment for you. I'm sending you to mose. I've never ever ever offered IGS RT. I've never acknowledged that that's even an option for a patient. Like am I going to start doing that now? I, uh, but whatever, the one that made my head explode, figuratively speaking, of course, because that would be otherwise. Or the most appropriate clinician to direct and administer. I mean, take that back. Dermatologists are the most appropriate clinician to administer srt, including IGS RT. That got a six out of six vote. Have they all gone insane? Radiation oncologists are the most appropriate clinician to administer srt period end of statement, no debate. If I wasn't doing this paper for the podcast, I would have stopped reading it right there, concluding that the Delphi panel was all high on the same themes that the original Delphi article is where exposed to. So that's where I'm stopping it. What did you guys, I mean, I thought this paper was absolutely insane. Am I, am I being unfair? My take is that, and I can't wait to have the have a relational college you colleagues on, is that IGS RT works, you know, appropriately selected lesions. But it really makes a lot more sense. I agree that this doesn't make sense as something to me that's in every dermatologist office and that every patient we're going to. Talk about this as an option. Man, it just, yeah, it might take us that it's a good treatment when it's used appropriately and that they're trying to make it. What is appropriate use become an extremely broad category. Which is why we had to have the appropriate use criteria for mose, you know, come out 10 years ago because you can't just use mose on everything. I think that's what we needed here and that's what I was kind of hoping this article was going to be was give very specific. Hey, these are what you should, these are the, you know, the five types of basal cell that you should really think about this in. But now and then look like that's what they did. Yeah, I have a hard time with, you know, this is, you know, superior to most surgery without any data. This is a very, you know, it's obviously a selected set of lesions from the first paper that we reviewed. I mean, you know, most of them are basically, you know, a centimeter. I also would not argue that I am the most important. appropriate clinician, the director, administer any kind of radiation. So I agree with you that that's a tough, that's a tough one to get behind. I mean, look, I think I like the idea that there's multiple different modalities to treat patients with non-melanoma skin cancer. I get that there are patients for hem surgeries, not a good option. But man, 20 trips to the office for radiation is also not nothing. Maybe not the easiest thing on some of our patients for whom we might think are not, you know, surgeries, not a great option. So, you know, I think we just, as with all of these modalities, we need to think about what, who was the right patient, what is the right use, and make sure that it's not just like, well, it's the tool that I have here. So I'll offer it. Yep. Well, let's, with that said, let's introduce our radiation oncology colleagues. We've got Dr. Maureen, Dr. Patel, who I believe are both faculty at the University of Pittsburgh Medical Center, which is where doctors Pat and Ferris got to know them through virtual tumor boards. So Dr. Maureen, Dr. Patel, thank you for joining us today. Excited to have you on the show. Thanks for having us. So, so before we get really too far, just explain kind of the basics of, like, as a dermatology resident, I was literally, I was taught once there used to be this old thing called Grendzre's, which like we don't use anymore in dermatology. That's pretty much the extent of the training I had on radiation therapy. Superficial radiation therapy is it? Like, what, give me the basics of it compared to like, shooting a beam inside somebody's head. I assume it's, it's a very different thing from like, real radiation therapy, but I don't know. So, give us the low down here. Traditional radiation, we use high energy. So radiation is typically light. It's when they're superficial or what we do clinically for deeper tissues. It's a higher energy. So, it's in the MB range, like mega voltage. So, the more magnitude, you know, higher, or 1000 times more than our KV ranges that these superficial beams are. And the superficial radiation or KV voltage radiation is, it's not a new thing. We used to call it ortho voltage back in the old days, and they used to develop ortho voltage machines to treat skin cancers. It didn't have much, the advantages, it doesn't penetrate very deep, so you don't go through a lot of tissue. So, in some ways, it's an advantageous, other ways it's disadvantageous. Both Dr. Maureen and myself, we use this in preclinical studying KV radiations, radiate cells, or preclinical studies. And so, it's not a new technology, but what radiation is doing is it's causing DNA damage and cells undergo mytonic catastrophe or felt that through radiation treatments. So, as a general rule, are these, like, could an office hurt the staff or the physicians with one of these things? Or is the radiation kind of from you guys' perspective so pathetic and weak radiation that even if you're like, happened to be walking by the room and they pointed at, you know, and idiot pointed at, and was like, "Zoo, oh, I gotcha." Like, you wouldn't care. Like, it was, because it's so such weak radiation, or is it like, is radiation dangerous, no matter what? I mean, you adapted the x-rays that we get, like, x-ray machines and dentist's office. They're KV radiation, right? We don't just shoot that at people who are nearly, when there's regulations around that. So, but relatively speaking, it doesn't penetrate very far and I'm sure I have not used one of these machines personally, but I'm hopeful that they are developed so that it's not that radiation is being pointed outside of where you're targeted at. I think in fairness, these actually, like, a radiation technician comes to your office and administers it. So, it's not like the dermatologist is, you know, the one, you know, administering. Probably like you guys have radiation technologies who help you, like, you're not in there doing it all yourself, too. So, I think that there is actually a radiation, I know that there is actually a radiation technologist who comes in. And do we use their long term? So, it also is someone reassuring to me that you said people have been doing this for a long time, because right, 100 or not 170 years ago, they were using radiation to treat acne. And then it wasn't till, you know, decades later that, oh my god, that was a bad idea. These people are getting cancer all over their face. Like, do we know that this type of radiation is, it's not going to be 20 years from now. Oh my god, we got rid of that basal cell 20 years ago. But now you've got this horrible squame or Merkel cell or whatever. Do we have reasonable long term safety data on this? We do. I think the main thing to highlight though with any radiation, whether it's killable, touch or mega voltage, is there is a risk of radiation induced cancer in malignancy. So, with every patient that we consent for radiation, we talk about that risk of radiation induced malignancy. So, I've seen patients treated for one skin cancer who get another skin cancer 20 years later in that spot where it was cured, and it was probably a radiation induced malignancy. So, that same phenomenon can happen whether we're talking mega voltage or ortho voltage. And still, you know, there was, you mentioned earlier, what if we were treating someone's eye? Well, when Robbie and I treat someone's eyelid, we put a lead shield, like contact lens and their eye to shield their eye, because you still are going to have potential for cataracts or, you know, damage to the retina from the radiation. So, there's certain precautions that have to be, that we can take for certain things like that, but there's nothing we can really do to reduce the risk of radiation induced malignancy. It's a small but real risk, regardless of the energy of the radiation being used. So, so Robbie and Robbie and Avant, do you guys are our skin cancer patients referred to you? Like, is primary treatment? Like, a patient says, "I don't want surgery. I'm going to talk to the radiation oncologist." Then you guys use SRT for those patients? We don't use SRT, but we can use electrons, which is similar, and they don't have much penetration. We put on a ballast to make sure that the skin gets proper dose. Dr. Maury mentioned, if it's in a tricky location in the eye, we protect the eye with eye shields. Sometimes like, for the nasal mucosa, we can put things into protect the other nostril. So, one of the consensus, one of the consensus statements was that SIGSRT is way better compared to electron beam. Do you agree with that or any issues with that? I mean, it's never been compared. I mean, we just have retrospective data, right? So, they used to have orbital voltage, like radoncs used to have orbital voltage, but I mean, stopped using it because electrons work just as well. And so, as I was saying, this is not a new technology. It's an old technology package in a new device. The technology, you know, like an SRT machine from 20 years ago, and an SRT machine now, like you would not say, oh yeah, the technology in 20 years has been so much better. These machines are just, they blow these old ones out of the water. I am, I'll be honest, I've never used the old one or the new one, but I use KBs. And the X-rays are the same, right? Okay, that KB X-ray at 50 KB or 100 KBs is going to change over time. The thing that they have packaged into this one is that ultrasound. Yeah, what do you think about the image guided part of this? You know, I'm not, I think, I think it's probably for billing because you can build a SRT, which we end right off, general, that's, that's, there's a billing code for that. Typically, we treat to a depth for these lesions anyways. And there's also a margin with radiation, with modes, you get right to the margin, you don't go extra and watch, right? With radiation, we put an extra margin on. That's one of the things that we do because we are trying to get those cells. Oftentimes, we're radiating post-op aftermodes, we're trying to get those nerves with PNI and get that margin around the surrounding area. With this kind of sort of ortho voltage and superficial radiation therapy, how much does it matter the schedule? Meaning, hey, this week I can get in twice. Oh, next week, I'm going to be out of town and I'm going to have to skip a week. Then the week after that, I can come in through. Does it, like, does that affect treatment efficacy or is it like, ah, As long as you get in at least once every two weeks, till we get in your 20, you'll be fine. Like, does it matter? - It's a great question. It matters a lot. And so that is one of my concerns is that that really would need to be emphasized to patients like not having treatment breaks because treatment breaks are gonna allow more time for repopulation and for radiation resistance to develop. So when we treat these patients, we are giving them daily Monday through Friday treatments. Sometimes we will, particularly in elderly patients, will really hypofractionate, where we'll give a larger dose of radiation and we'll give it just twice a week. But it doesn't seem like that's being done with this. It seems like these are usually kind of smaller, two and a half grade per fraction times 20 treatments, but it's gonna be really important for efficacy not to have treatment breaks. And I think to the image guidance portion, I think that the ultrasound is essential and it comes particularly planning and selecting what energy you're gonna choose because higher energy is gonna be able to go to greater depth and you're gonna also wanna make sure, as Robby mentioned, we add margin. Well, when we treat with electrons, there's a little bit more penumbra or a little bit of the radiation goes out a little bit further with or the voltage, it's a rapid drop off. There's no forgiveness. So if they aren't treating laterally or giving enough margin around the lesion, they're gonna miss. And then I really wanna make the biggest concerns is about perinural invasion because that's where you're gonna have some microscopic disease further out from the lesion you can see. And if you've got that sharp dose fall off from the or the voltage, you very well might miss. But I think getting the ultrasound to know the depth and to choose the energy to make sure that your beam is going deep enough is going to be important. But what Robby and I do for our planning is we typically do CT-based planning so we get real three-dimensional and we map out, if it's post-op, where the tumor used to be, if it's, you know, period of intense without prior surgery we'll map out the disease, we'll add margin, we'll often treat to two different dose levels, higher dose to the gross disease and a lower dose to a larger area where we're more concerned about microscopic disease. And then our image guidance is usually a cone beam CT scan and again three-dimensional lining things up every day. Sometimes, you know, we're doing like matched KB 90 degree images but usually we're doing CT scans. So our image guidance is very different from the image guidance that's being done with ultrasound. - How often do you image like to sort of refine your plan? Like I think in with this, it's done every single session. Is that? - We do, we image every before each treatment. Typically, but we don't always refine the plan. When we see a change or we need to, like we review and we do refine plan as our plan is needed. - Where that post-opin happens is post-operatively where there was a lot of swelling and there's kind of anatomic changes that we need to replan for, but you're typically not gonna see a major change in the tumor size during treatment to require replanning during treatment. But this is probably a somewhat location, that's obviously a very location specific question. So how far in few between our radiation on ecology places? So the one of the benefits, like I could imagine this thing being, hey, there's two most surgeons in a city the size, I live in Columbus, Ohio, you know, we're a million people city. Hey, there are two most surgeons that have one of these. They, you know, really went through some training, really know what they're doing. If you have a patient, they think it's good for, send it to them. And it would be nice because, right, the most surgeon's office is usually easy parking, easy in and out, like the blah, blah. With radiation on ecology, is it like something that you're gonna have to, all departments are like in the basement, 100 yards below the surface, so you're not radiating. Like is it, is it super hard for people to get in and out of radiation on ecology places and do community, are there many community hospitals that have them or is it, you gotta go downtown to the mothership to get stuff radiated? So we have 26 satellite centers at UPMC. We cover like Eure B. Eure Gron-Douas, like we, so we, we, radiate patients who have breast cancer, prostate cancer, they have to come in for daily radiation, sometimes Dr. Marri Tritonnec, 35 treatment sometimes. So they have to be in the community. And we, yeah, most, there is radiation on ecology at most communities sites. - I think rural areas, just like any, but you know, rural areas, some rural areas are undercovered, but you know, generally speaking, there's a good distribution of community radiation on ecology sites that are comfortable treating skin cancer. But you know, very rural areas where you probably don't have those surgeons, you probably also don't have radiation on colleges, unfortunately. - And we'll just about, will the vast majority of radiation on colleges and radiation on ecology sites be able to do ortho voltage like this, or is it like, oh, the vast majority couldn't, you know, there's, well, UPMC's got 35 satellite locations. Only two of them could treat, you know, superficial radiation therapy. - Any radiation on ecology center will have electrons, or I'm almost universally, but very few are gonna have ortho voltage, but as Robbie was saying earlier, electrons work just as well. I don't believe what this paper says. I think that's a selection bias from a retrospective study that the patients who get selected for the superficial ortho voltage radiation have smaller, you know, less complex tumors. And that's probably why there's a difference in recurrence rates. But any radiation center should have electrons and should be able to treat skin. I mean, in residency, I mean, Robbie and I specialize in this, but in residency everyone, every radiation oncologist learns how to treat skin cancer. And I just wanna put in like one other plug is that it's not just, you know, Robbie and me, we mentioned the radiation therapists are the machine, but we also work with physicists and dosimetry. It's a whole team that I'm a little bit perplexed as to how much that whole team is involved in the planning, you know, radiation physicists look at every plan and due quality assurance. When I treat a skin cancer, I usually do a dose check on the first day. We've got physicists who come in with diodes and we measure, I suspect those sorts of things and the daily quality assurance that we do on our machines daily, weekly, monthly, annual. I'm not sure that that same kind of QA that's really radiation physics driven is being done in sites that just have these ortho voltage machines. So that gives me a little bit of another pause about just what the QA is on this. - Yeah, I'd like to just follow up on that point. Like from a physician standpoint, I think obviously like knowing the margins and everything, dermatologists know that, probably better than I do. But all the support staff in the QA, like these machines go down, they can deliver the wrong dose, you can have a misinterestation. We've seen how much radiation machines like things go down like time to time and you can have a bad mistake. And even the ones that we have in lab, they go down with these KVs. So you do need to make sure that you're doing things properly. - You know, it's interesting, this is reminding, we have some conversations I've had with most surgeons over the years, some of whom who have been like, "Well, my text's not that good." And I'm not sure that I'm that good at reading this. These are usually people who are not like, they kind of do mose, but are not a mose surgeon. And I haven't had a conversation like this in 15 years, but 15 years ago, well, you know, it's just, it's moses and that. You just get in there and the inflammation is gonna get rid of it anyways, whether you could. And it's like, it makes you say, "Well, they're okay, so moses and that." And then you talk to like a, what I would call a real mose surgeon, and they're like, "Oh my God, no, are you out of your mind?" Like if you're just like Willie Nilly, "Ah, I probably got it, I can't really tell." Like, so this sounds like it sort of falls into the category of like, in Durham, there's a common sort of debate among so people who went and did a weekend course on how to do mose surgery versus people who did a one-year fellowship. And that like, "Yeah, for some reason, you probably can be fine if you did the weekend course." But it's overall, it's not really the same. - You guys are probably seeing people who mistake a markle as something else, and they do a non-oncolytic surgery on that. And then we have, you guys have to clean up afterwards and we have to radiate afterwards. I know in the Pittsburgh area, it's a plastic surgeon that has that SRT. So it's not gonna just be dermatology clinic. It's gonna, I think a lot of the motivation behind this is like, you know, it's marketing and financial. - Yeah, that do. - Right, 20 visits where you don't, even if you're only getting reimbursed, 120 bucks a visit, if you as the physician don't have to do anything, you're basically getting 120 bucks for doing nothing. You can still, it's just extra money. So yeah, I certainly does seem like there's some financial incentive there. Now one other question for you guys, in either of these articles, did they really talk much about the healing phase? Like, so with electrons or superficial radiation, like the lesions ulcerate, does it like this horrible thing or is it like, oh, it gets a little red and it gets your might scab and crust a little bit, but it's no big deal. Like what do you, what do you expect? When you get somebody for skin cancer, you know, for whatever reason they just are, they've had nine surgeries, or sick of surgery that don't want to know. What do you tell them about the kind of the healing process? So radiation dermatitis is an expected toxicity. They have very few great twos, which is surprising because when you're target, does it matter whether you have ortho voltage or electron or megaboltage? It's the total dose accumulated by the tissue. One of those is independent of what type of beam you use. That's more on penetration. And so they say they have a lot of grade one, they don't have much grade two. That suggests that they're either waiting a lot of time between their fractions. And so, or they're not documenting it correctly. It's hard for me to know which one on a retrospective surgery. But you do expect radiation dermatitis. So you buy a few months, like I see them for a two, three month follow-up that's healed. Sometimes you can get more significant radiation side effects. I have some patients who had cellulitis that we've had to start antibiotics. There are some studies looking at the microbiome on the skin and effects on radiation dermatitis as well. It's typically just kind of a red itchy, dry, healing type thing. The kind of size of tumors that are going to be treated with this, they're going to be so small, you're not really going to get ulceration. I mean, I've treated things that are five centimeters, eight centimeters, big masses. When you treat those, then you're going to get ulceration. And it's going to put the tumors gradually into a conmush and you're going to get a reaction around it. But for these things, it's going to just be like a little bit of scabbing, peeling, and then the scab folds off like very minimal toxicity. Okay. Patent fairs, you guys got anything else? I think I've gotten my questions answered. Patent fairs, you guys got anything else before we kind of switch to our next topic. I was curious, if a patient does come to you and they say, "I don't want to get cut, I can't eat anesthesia, I'm nervous, I like this radiation idea." Do you try and talk them out of it? I mean, do you kind of say, like, you know, we got to be honest, like, most works really, really well. It's one treatment. How do you approach that patient? Oh, so there's definitely patients that I try and push more into surgery. They're immunosuppressed, for example. Like, I think radiation alone doesn't work as well in that patient population. You know, if it's a small thing like this and they have had a lot of those and they don't want it, I think that like for a one centimeter BCC, radiation also has a quite high, it's pretty effective. But you know, there are definitely patients where I try and push them or convince them that they should get surgery. But even in your hands, you would say, "This is, you're going to be coming in for 20 fractions." For the most part, there are some elderly hypo-fractionation trials that we can do. There was, I say, very interesting. But most of the time, I like to do 20, especially if it's something like the eyelid or nose, I don't hypo-fractionate those areas because there's at risk structures. And again, we have methods to protect the eyeball and other nostrils like that. For elderly patients, I'm finding myself more often in doing two fractions a week, usually for six treatments, just because it's too hard for them to come in every day. But then those treatments, each dose of radiation is much bigger than we give if we give daily for 20 fractions. But when I see a patient, like the most common patients that I see are those that have had multiple mows, and they just say they do not want to go through that procedure again, I usually still do try to convince them and say, "I think global control is going to be slightly better, but usually it's when patients get to us because they have refused, outright refuse surgery." What is the downside of hypo-fractionating? There could be some increased risk of toxicity and transmesis. Definitely when we're looking at the island, I definitely worry about because it's not been tested in that location at a hypo-fractionate too much. I worry about potentially more, sorry, just worry about more fibrosis. And then in areas of cartilage, like the nose and the ear, there may be a high risk of cartilage necrosis with a higher dose per fraction. So those are the kind of things to worry about. Where I trained, actually, we treated a lot of small basal cells on the nose with four grade times ten every day for two weeks. And I was shocked because the traditional people think, "Oh, porcosmesis with that hypo-fractionation and cosmetic outcome, I probably treated 20 patients that way, it was always good." And I never saw any necrosis. So I think we maybe are overly cautious with the hypo-fractionation. And now I treated a lot of people, a lot of elderly people with the two fractions a week and haven't seen issues with porcosmesis or necrosis. And so that actually brings up one of the other questions I always got for superficial radiation therapy is, if a patient, again, with a small basal cell on their nose or even their forehead, whatever, says, "What is the absolute best cosmetic outcome? What am I likely to get it with?" My take is that SRT might be a reasonably good answer that, you know, compared to anything surgical, you're probably going, like, is it usually you can't even tell there was ever anything there or does it, you know, leave a fibiotic white spot or something? It's a little bit unpredictable, I think, as the problem. Because a lot of times you can't tell anything. But sometimes it's a little hypo-pigmented. Sometimes it's a little hyper-pigmented. And then sometimes you can get to learn justages. And it's just hard to predict if people are going to get those. So most of the time you can barely tell anything, but I think, in the good hand of hands of good moseurgeon, mose probably is going to give you better cosmetic outcome or a liability because with the radiation you just can't predict as much how exactly the skin texture and color is going to be after radiation. Well, everybody, we are going to kind of end this part of our conversation. And we are next going to jump into talking about a really interesting therapy that's starting to show up in the literature called "Renium Cream." And so this is basically a radioactive cream that you apply topically. And it also has some very good data on skin cancer treatment. But we're going to take this part of the conversation over to the scholars in medicine platform. So if you're interested in hearing more about this "Renium" that is on its way, jump over to scholars in medicine for the full episode. And then here on the main podcast, we're going to jump next to our trivia section. So Dr. Patten, what do you got for us this week? It's radiation and the silver screen. Oh, I have a really stupid question. But as radiation oncologist, do you guys ever daydream that there would be like some accident and then you would gain some sort of super power like the Hulk or Spiner Pan? I would think about that all the time. Does it ever cross your mind? Or no, you've seen too many accidents and nothing cool ever happens. I have any other questions about that tonight, but I've never had such thought. I think the best you do right now is me. Good. I think the last you go for would be that you'd be able to have sex without having to worry about getting anyone pregnant. That would probably be the best. That would be the super power. Again, it's a problem that are addressed surgically. That's a risk. Let's answer. Obviously, you know, that's part of the reason why we give two great perfection. They used to do like in our bio course, you know, the ramps testicles. So like we learned they used to give radiation all at once to castrate ramps for like sheep farmers. But then if they gave it a two great perfection, they didn't cause necrosis and dermatitis of the scurvel fact of the ramps. So that's actually what a lot of the basis of how we fractionate radiation comes from that. Ram testicles. That sounds that would be a normal patent trivia question. I was just thinking the same thing. All right. I'll leave it in there. All right. Let's go. First one, a 2019 HBO series dramatized the nuclear disaster that occurred at this Soviet Union power plant. Chernobyl Chernobyl. Chernobyl. I got a Vaughan on that one. Yeah. By the way, if anybody hasn't watched that, that is amazing. That is a great show. Yeah. Yeah, it was great. And I was working with this PA and I'm like this series on on HBO is fantastic. It's called Chernobyl. And she said, what's it about? That's scary. It's a good show. I saw some real the other day that was like asking a teenager about a 15 year old, about 9/11. And they were like, oh, it happened on September 11. That's why it's called 9/11. Yeah. They were like, well, how many hijackers were it's they were like, there were hijackers. They honestly thought that the buildings just fall down for no reason. All right. I think that is any intelligent person knows Bruce Banner gained his superhuman power. speaking of radiation accidents as the result of an accident involving gamma radiation, which actors besides Mark Ruffalo have played Bruce Banner in Hulk live action films? Lufor Ignore. That was the TV series. I was going to include it. I may give that to you. He didn't play Bruce Banner. He played the Hulk. He played the Hulk. Right. So you're not really right. I have no idea. I don't know. It was Eric Banner was in this 2003 angley Hulk movie. And then Edward Norton was the first MCU guy. He just couldn't make it to all the other ones. Mark Ruffalo took over. All right. I'm giving you a point two five. Oh, wait a minute. I had a Ferris. This could be my first win ever. We'll see. You know what? I'm not hopeful about this last one. It's a two-parter and it contains a movie spoiler. So everyone before warranted. It's a really old movie. So you should know this by now. All right. In the second film of the original Star Trek movie series, a major character dies from radiation poisoning near the end of the movie. Part A. Which character dies? Spock. It is Spock. The good of the many outweighed the good of the few. Yeah, that's very good. I know the name of the movie too. I'm hoping that's not going to say that was my that was my part beat. What is the subtitle of Star Trek 2? The revenge of Khan. No. Oh, shoot. I was never enough of a nerd to know anything Star Trek. I'll just take the last one. I know all this stuff. Bruce Banner, cartoon, Star Trek. And that's why like Ferris is a chair. And I'm not. Lawyers of Out. You know, where this stands. It was the wrath of Khan. That's what I said. You said revenge. Oh. That was also the way they put the worms and people's ears to control their mind. I had nightmares about that as a kid for a long time. That's actually the secret to being a chair too. So, they don't know they did that. Mind control with worms. Yeah. We're going to we're going to base all of your compensation on non-work RV use. Okay. That would be fine. All right. Well, I want to thank Dr. Mowery and Dr. Patel for joining us today. This was a really fun discussion. And I honestly feel like I understand radiation therapy for skin cancer much, much better now. And I understand much better about what you guys actually do is radiation on colleges. So I really want to thank you guys for coming on. Dr. Paten, Ferris, any last comments for our guests? I feel like you have a sling in common with dermatologists. I think radiation is given Monday through Friday because we all like the same schedule. Thank you for having us. It was a pleasure. Thank you. You're welcome. And I want to thank everybody for joining us today. You know, it really is a fun thing to think about our multidisciplinary care for these patients. And if you've got questions, comments, or ideas for topics we should cover on the show, shoot us an email at [email protected]. We hope you learned a few things. We hope to laugh once or twice. Mostly we are hoping you're planning to join us next week. And until then, I'm Matt Zyrus. I'm Tim Paten. I'm Laura Ferris and we are GERMSON Drugs.