Proposed guidelines for appropriate utilization of superficial radiation therapy in management of skin cancers. Zemtsov‐Cognetta criteria

Abstract Objective To develop appropriate use criteria (AUC) for the treatment of basal cell and squamous cell carcinoma by superficial radiation therapy (SRT) technique. Material and Methods Delphi‐type discussion of the experts. Results Presented in Figure 1. Conclusion These AUCs are in compliance both with the position statement of the American Academy of Dermatology (AAD) and the ASTRO Clinical Practice Guideline on this subject. It is further recommended that SRT will be only performed by either a dermatologist who is board certified in Mohs surgery (MDS) and who had adequate SRT training or by radiation oncologists. Hopefully, this publication will stimulate further discussion on this topic.


INTRODUCTION
The incidence of three major forms of skin cancers, namely basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma, and associated overall mortality and morbidity continues to increase both in the USA and worldwide. [1][2][3] These proposed guidelines will primarily focus on our recommendations for appropriate treatment of BCC and SCC by SRT technique. The authors completely agree with the American Academy of Dermatology (AAD) position statement 4

F I G U R E 1
Radiation therapy for non-melanoma skin cancers appropriate use criteria.
tumors in suitable patients" 7 needs to be reconciled with the AAD position statement mentioned above.
3. Furthermore, their publication did cover too many topics namely, patient safety, radiation dermatitis, dose fractionation, keloid therapy, and even discussion of all forms of radiation available for the treatment of NMSC. 7 We also reviewed ASTRO guidelines for definite and postoperative radiation therapy of cutaneous SCC and BCC. 8 These guidelines are excellent in describing indications for postoperative and regional lymph node therapy, dose fractionation schedules, and the use of chemotherapy. However, AUC similar to Mohs AUC was not part of the discussion. This report will laser focus on SRT AUC.
Hopefully, this publication will stimulate further dialogue on this topic.

MATERIAL AND METHODS
Delphi-type discussion of the experts. Alexander Zemtsov is a boardcertified Mohs surgeon who has been using SRT since 1990 (including in the past also using of ultrasoft Grenz X-rays); he is also one of the first physicians in the US to develop expertise in high-frequency skin ultrasonography (HFUS). 9 Armand Cognetta is a fellowship-trained Mohs surgeon who is considered the expert in the field of SRT and the main author of the most authoritative book on this subject. 10 John Marvel and Ann Logan are board-certified radiation oncologists who in the past few years have specialized and primarily focused on treating NMSC with SRT. We appreciate ASTRO members reviewing this report and their comments were incorporated into our final recommendations.

DISCUSSION
When evaluating patients for SRT we use the criteria shown in Figure 1.
Obviously, if a patient categorically refuses surgery SRT is offered as an alternative; on the other hand, as a rule, we do not offer SRT to patients younger than 60 years old, with recurrent tumors, Marjolin ulcers, previously irradiated tumors, and other rare instances that are beyond the scope of this paper discussion (such as basal cell nevus syndrome, etc.). Furthermore, we believe SRT is an excellent option for frail, medically unstable patients (including uncooperative patients with some dementia). SRT is also a good treatment option for patients with previously untreated and very large or multiple untreated skin cancers in the same anatomically important location (eyelid, ear, nose, or lip; on the nose SRT produces remarkably excellent cosmetic results). Finally, as a part of the informed consent discussion, SRT should be presented as a reasonable alternative to surgery when there is a substantial risk of surgical complications (medial canthus or external nasal valve areas and areas where there is a high-risk injury to tendons/nerves). For each patient referred for SRT, we fill out a form shown in Figure 1 justifying ZEMTSOV ET AL.

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the need for SRT. This form is scanned into the chart and functions as our SRT AUC.
Our final recommendations (not related to SRT AUC criteria).  In summary, the authors provided their suggested guidelines for the appropriate use of SRT in the management of skin cancers. Hopefully, this manuscript will stimulate further research and discussion on this subject.