Variations in whole brain radiation therapy fractionation for brain metastases in Victoria.

INTRODUCTION: We aim to evaluate the use of different whole brain radiation therapy (WBRT) fractionation schedules for brain metastases (BM) in Victoria, and the factors associated with it. METHODS: This is a population-based cohort of patients who received radiation therapy for BM between 2012 and 2017, as captured in the Victorian Radiotherapy Minimum Dataset. We excluded patients with primary brain tumour and those who had 'prophylactic' intent treatment. The Cochran-Armitage test was used to evaluate changing trend in WBRT fractionation. Multivariate multinomial logistic regressions were used to evaluate factors associated with WBRT fractionation. RESULTS: Of the 3111 patients who had WBRT, 1048 (45%), 1291 (42%) and 312 (13%) had ≤5, 6-10 and >10 fractions WBRT respectively. There was progressive increase in ≤5 fractions WBRT use over time, from 37% in 2012 to 50% in 2017 (P-trend < 0.001). In multivariate analyses, increasing age, patients with gastrointestinal cancer, patients living in remote/regional areas and more recent treatment were associated with the use of shorter WBRT fractionation (≤5 fractions), while patients who had WBRT plus stereotactic radiosurgery, and those treated in private institutions were associated with the use of prolonged WBRT fractionation (≥6 fractions). Three hundred eighty-nine (13%) patients died within 30 days of WBRT, of which 241 (64%), 119 (32%) and 17 (5%) had ≤5, 6-10 and > 10 fractions WBRT respectively. CONCLUSION: We observed large variations in WBRT fractionation that are associated with patient, tumour, treatment and institutional factors. It is important to continuously monitor and benchmark our practice in order to reduce potentially unwarranted variations.

Curative Radiotherapy for Locally Advanced Scalp Squamous Cell Carcinoma.

A 73-year-old man presented to his primary physician with an ulcerative growth on his scalp vertex. Biopsy of the lesion confirmed the growth to be a moderately differentiated squamous cell carcinoma, but the patient declined medical intervention. The lesion increased in size over six months, measuring 12 cm in diameter and 3 cm thickness with erosion of the skull of the vertex. CT and MRI scans showed a large fungating mass with erosion of the skull of vertex without intra-cranial extension, meningeal enhancement, or distant metastatic disease. The patient declined surgical intervention. The patient received radiotherapy using volumetric-modulated arc therapy (VMAT) to a total dose of 60 Gy over six weeks. No evidence of clinical invasive disease apart from a 15 cm * 12 cm skin defect detected three months after completion of radiotherapy. At three years of follow-up, the patient is clinically disease-free. This case report provides evidence that high-dose radiotherapy is a potential effective definitive treatment for locally advanced (T4) squamous cell carcinoma for patients who are unwilling to undergo surgery.