| Coverage Policy Manual | |
| Policy #: | 2015018 |
| Category: | Radiology |
| Initiated: | June 2015 |
| Last Review: | January 2024 |
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| Electronic Brachytherapy for Nonmelanoma Skin Cancer | |
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| Description: |
Electronic brachytherapy is a form of radiotherapy designed to deliver high-dose rate (HDR) radiation to treat nonmelanoma skin cancer. This technique focuses a uniform dose of x-ray source radiation to the lesion with the aid of a shielded surface application.
Nonmelanoma Skin Cancer
Squamous cell carcinoma and basal cell carcinoma are the most common types of nonmelanoma skin cancer in the United States, affecting between 1 and 3 million people per year respectively, and increasing at a rate of 3% to 8% per year (Bhatnagar, 2013; Madan, 2010). Other types (e.g., T-cell lymphoma, Merkel cell tumor, basosquamous carcinoma, Kaposi sarcoma) are much less common. Skin cancer can affect anyone, regardless of skin color; however, the incidence of skin cancer among non-Hispanic White individuals is approximately 30 times higher than that among non-Hispanic Black or Asian/Pacific Islander individuals (AAD Association, 2022). In individuals with darker skin tones, skin cancer is often diagnosed at a later stage when it is more difficult to treat. Additionally, these individuals are prone to skin cancer in areas not commonly exposed to the sun such as the palms of the hands, soles of the feet, the groin, and inside of the mouth.
The primary risk factor for nonmelanoma skin cancer is sun exposure, with additional risk factors such as toxic exposures, other ionizing radiation exposure, and immunosuppression playing smaller roles (Madan, 2010). Although these cancers are rarely fatal, they can impact quality of life, functional status, and physical appearance.
In general, the most effective treatment for nonmelanoma skin cancer is surgical. If surgery is not feasible or preferred, cryosurgery, topical therapy, or radiotherapy can be considered, though the cure rate may be lower (Kim, 2018). When considering the most appropriate treatment strategy, recurrence rate, preservation of function, patient expectations, and potential adverse events should be considered.
The choice of surgical procedure depends on the histologic type, and size and location of the lesion. Patient preferences can also play a factor in surgical decisions due to cosmetic reasons, as well as the consideration of comorbidities and patient risk factors such as anticoagulation. Local excisional procedures, such as electrodessication and curettage or cryotherapy, can be used for low-risk lesions, while surgical excision is indicated for lesions that are not low risk. Mohs surgery is a type of excisional procedure that uses microscopic guidance to achieve greater precision and sparing of normal tissue. In patients who meet criteria for Mohs surgery, 5- year cure rates for basal cell cancer are in the range of 98% to 99%, making Mohs surgery the preferred procedure for those who qualify (Alam, 2011).
Radiotherapy is indicated for certain nonmelanoma skin cancers that are not amenable to surgery. In some cases, this is due to the location of the lesion on the eyelid, nose, or other structures that make surgery more difficult and which may be expected to have a less desirable cosmetic outcome. In other cases, surgery may be relatively contraindicated due to clinical factors such as bleeding risk or advanced age. In elderly patients with a relatively large tumor that would require extensive excision, the benefit/risk ratio for radiotherapy may be considered favorable. The 5-year control rates for radiotherapy are in the range of 80% to 92%, which is lower than for surgical excision (Alam, 2011). A randomized controlled trial published in 1997 reported that radiotherapy for basal cell carcinoma resulted in greater numbers of persistent and recurrent lesions compared with surgical excision (Avril, 1997).
When radiotherapy is used for nonmelanoma skin cancer, the primary modality is external beam radiation. A number of different brachytherapy techniques have also been developed, including low-dose rate systems, Iridium-based systems, and HDR systems (Alam, 2011).
Electronic Brachytherapy
Electronic brachytherapy is a form of radiotherapy delivered locally, using a miniaturized electronic x-ray source rather than a radionuclide-based source. A pliable mold, constructed of silicone or polymethyl-methacrylate, is fitted to the tumor surface. This mold allows treatment to be delivered to nonflat surfaces such as the nose or ear. A radioactive source is then inserted into the mold to deliver a uniform radiation dosage directly to the lesion (Alam, 2011). Multiple treatment sessions within a short time period (typically within a month) are required.
This technique is feasible for well-circumscribed, superficial tumors because it focuses a uniform dose of x-ray source radiation on the lesion with the aid of a shielded surface application. Advantages of this treatment modality compared with standard radiotherapy include a shorter treatment schedule, avoidance of a surgical procedure and hospital stay, less severe side effects because the focused radiation spares healthy tissue and organs, and the avoidance of radioisotopes (Alam, 2011).
Regulatory Status
Electronic brachytherapy systems for the treatment of nonmelanoma skin cancers are designed to deliver high-dose rate brachytherapy to treat skin surface lesions. This technique focuses a uniform dose of x-ray source radiation to the lesion with the aid of a shielded surface application. The Superficial X-Ray Radiation Therapy SRT-100 Vision™ System (Sensus Healthcare), Esteya® Electronic Brachytherapy System (Nucletron BV), and the Xoft® Axxent® Electronic Brachytherapy System (iCAD) are systems that have been cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process.
U.S. Food and Drug Administration product code: JAD.
Coding
The current CPT code for electronic brachytherapy is:
0182T High dose rate electronic brachytherapy, per fraction.
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Policy/ Coverage: |
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Electronic brachytherapy for nonmelanoma skin cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, electronic brachytherapy for nonmelanoma skin cancer is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
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| Rationale: |
This policy was created with review of the literature through April 30, 2015.
Assessment of efficacy for a therapeutic intervention involves a determination of whether the intervention improves health outcomes compared with available alternatives. The optimal study design for this purpose is a randomized controlled trial that compares the therapeutic intervention with existing alternative treatments and includes clinically relevant measures of health outcomes. Intermediate outcome measures, also known as surrogate outcome measures, may also be adequate if there is an established link between the intermediate outcome and true health outcomes. Nonrandomized comparative studies and uncontrolled studies can sometimes provide useful information on health outcomes but are prone to biases such as noncomparability of treatment groups, placebo effect, and variable natural history of the condition.
For the purposes of this evidence review, relevant outcomes will include measures of efficacy (e.g., response rates, recurrence rates) and measures of safety (e.g., skin toxicity). Cosmetic outcomes will not be considered in the analysis of benefits and risks unless it is demonstrated that a poor cosmetic outcome is associated with deficits in functional status.
Review of Evidence
The available evidence on electronic brachytherapy for nonmelanoma skin cancer consists of case series. No controlled trials were identified in the published literature that compared outcomes of electronic brachytherapy with alternative treatments. The focus of review will be on those case series that use a commercially available device for treatment, or that use a technology similar to the commercially available devices.
The largest series was published in 2013 by Gauden et al. (Gauden, 2013) and included 200 patients with 236 lesions (121 basal cell, 115 squamous cell). Brachytherapy was the primary treatment modality in 69% of the lesions, while in the remaining 31% (74/236) brachytherapy was used as follow-up treatment to surgery when there were positive margins. Outcomes included treatment efficacy, as measured by local recurrence rate, skin toxicity measured according to the Radiation Therapy Oncologic Group (RTOG) criteria, and cosmetic outcome according to the RTOG Cosmesis scale. After a median follow-up of 66 months, there were recurrences in 2% of the treated lesions (4/236). Cosmetic outcome was judged to be excellent or good in 88% of treated lesions (208/236). Grade 1 skin toxicity was common at 71% of treated lesions; grade 2 toxicity was less common in 34%; and there were no grade 3 or higher toxicities noted. Late hypopigmentation of treated skin was reported in 5.5% of treated lesions (13/236).
Bhatnager published a case series using a commercially available device (Axxent eBx System; Xoft Inc., Sunnyvale, CA) (Bhatnager, 2013). There were 122 patients with 171 nonmelanoma skin lesions included. Most patients had either basal cell carcinoma (53%) or squamous cell carcinoma (41%), but there were 10 patients (5.8%) with other types of cancer. Outcome measures included recurrence rates, adverse events using common terminology, and cosmetic results using a standardized cosmesis scale. After a mean duration of follow-up of 10 months, there were no local recurrences. Dermatitis and pruritus were common early adverse events, occurring in 83% and 18% of the treated lesions respectively. Skin hypopigmentation was the most common late adverse event, occurring in 10.9% of lesions at 1 year. Other late complications included rash (6.5%), alopecia (2.2%), and dry desquamation (2.2%). All patients had their cosmetic outcomes rated as good or excellent.
Other case series report similar rates of recurrence, in the 2% to 3% range (Guix, 2000; Tomo, 2014). Additional case series identified in the literature are less relevant because they treat a more specialized population (Kasper, 2013), or because they are older studies that used a different treatment delivery system (Guix, 2000; Ducassou, 2011; Guibert, 2011; Sedda, 2008; Rio, 2005).
Ongoing and Unpublished Clinical Trials
The following are some currently unpublished trials that might influence this policy.
Summary of Evidence
There is a small body of evidence that evaluates electronic brachytherapy as a treatment for nonmelanoma skin cancer. This evidence consists entirely of case series, usually with a mixed patient population of basal and squamous cell carcinomas. No controlled trials were identified that compared electronic brachytherapy with alternative treatment options. The case series report low rates of recurrence, ranging from 0% to 3.1%, at follow-up periods ranging from 10 to 66 months. Skin toxicity is relatively common, but usually mild, and the adverse events reported in the literature are confined to Radiation Therapy Oncologic Group grade 1 and 2 toxicity. It is not possible to determine from this evidence whether outcomes of electronic brachytherapy are as good as with alternative treatment options. Controlled trials are needed that compare electronic brachytherapy with alternatives, either other forms of radiotherapy or surgical approaches. As a result of the lack of high-quality evidence on efficacy, electronic brachytherapy is considered investigational for the treatment on nonmelanoma skin cancer.
Practice Guidelines and Position Statements
National Comprehensive Cancer Network (NCCN)
NCCN guidelines for nonmelanoma skin cancers (2015) did not discuss electronic brachytherapy in review of chapters on basal, squamous or merkel cell carcinomas and additionally in the chapter on dermatofibrosarcoma (NCCN, 2015).
As of March 2015, the American Academy of Dermatology was developing guidelines for nonmelanoma skin cancers (AAD, 2015).
2017 Update
A literature search conducted through January 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Paravati, and colleagues published a retrospective analysis of clinical and cosmetic outcomes in patients treated for nonmelanoma skin cancer (NMSC) with high-dose-rate (HDR) electronic brachytherapy (EBT) using surface applicators (Paravati, 2015). 127 patients who had 154 NMSC lesions, 149 of which were basal cell carcinoma, treated with HDR EBT between July 2012 and March 2014. Lesions were treated to 40 Gy in 8 fractions. Local control, acute toxicity, late toxicity, and cosmetic outcomes were analyzed retrospectively. Acute and late toxicities were graded using the Common Terminology Criteria for Adverse Events, version 4.0. Cosmetic outcomes were graded using a standard scale based on the Radiation Therapy Oncology Group and European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema. Median (range) follow-up from completion of treatment was 16.1 (3.4-34.8 months). The overall crude recurrence rate was 1.3% (n = 2). Grade 0 to 1 acute radiation dermatitis was observed in 52.6% of treated lesions (n = 81), grade 2 in 34.4% (n = 53), and grade 3 in 13.0% (n = 20). No acute toxicity greater than grade 3 was observed and all acute toxic events resolved after treatment. Grade 0 to 1 late toxicity was observed in 94.2% of cases (n = 145), and grade 2 in 5.8% (n = 9). No late toxicity greater than grade 2 was observed. Across the 152 controlled lesions, cosmetic results were excellent in 94.2% of treated lesions (n = 145), good in 3.3% (n = 5), fair in 0.7% (n = 1), and poor in 0.7% (n = 1).
Delishaj and colleagues published a retrospective case study with the aim to estimate tumour control, toxicity and aesthetic events in elderly patients treated with high-dose-rate (HDR) brachytherapy (BT) using Valencia applicator (Delishaj, 2015). From January 2012 to May 2015, 57 lesions in 39 elderly eligible patients were enrolled. All the lesions had a diameter ≤ 25 mm (median: 12.5 mm) and a depth ≤ 4 mm. The appropriate Valencia applicator, 2 or 3 cm in diameter was used. The prescribed dose was 40 Gy in 8 fractions (5 Gy/fraction) in 48 lesions (group A), and 50 Gy in 10 fractions (5 Gy/fraction) in 9 lesions (group B), delivered 2/3 times a week. The biological effective dose (BED) was 60 Gy and 75 Gy, respectively. After median follow-up of 12 months, 96.25% lesions showed a complete response and only two cases presented partial remission. Radiation Therapy Oncology Group - European Organization for Research and Treatment of Cancer (RTOG/EORTC) G 1-2 acute toxicities were observed in 63.2% of the lesions: 56.3% in group A and 77.7% in group B. Late G1-G2 toxicities was observed in 19.3% of the lesions: 18.8% in group A and 22.2% in group B, respectively. No G3 or higher acute or late toxicities occurred. In 86% of the lesions, an excellent cosmetic result was observed (87.5% in group A and 77.8% in group B). Six lesions had a good cosmetic outcome and only 2.3% presented a fair cosmetic impact.
In May 2016, Delishaj and colleagues published results of a systematic search of bibliographic database of PubMed, Web of Science, Scopus, and Cochrane Library with a combination of key words of "skin cancer", "high dose rate brachytherapy", "squamous cell carcinoma", "basal cell carcinoma", and "non melanoma skin cancer" was performed (Delishaj, 2016). In this systematic review, we included randomized trials, non-randomized trials, prospective and retrospective studies in patients affected by NMSC treated with HDR-BT. Searches generated a total of 85 results, and through a process of screening, 10 publications were selected for the review. Brachytherapy was well tolerated with acceptable toxicity and high local control rates (median: 97%). Cosmetic outcome was reported in seven studies and consisted in an excellent and good cosmetic result in 94.8% of cases. Based on the review data, we can conclude that the treatment of NMSC with HDR-BT is effective with excellent and good cosmetics results, even in elderly patients. The hypo-fractionated course appears effective with very good local disease control. More data with large-scale randomized controlled trials are needed to assess the efficacy and safety of brachytherapy.
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2018. No new literature was identified that would prompt a change in the coverage statement.
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2018. No new literature was identified that would prompt a change in the coverage statement.
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2019. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Patel et al published preliminary results from a multi-center prospective matched pair cohort study comparing clinical outcomes of nonmelanoma skin cancer treated with electronic brachytherapy (EBT) or Mohs micrographic surgery (MMS) (Patel, 2017). Patients from four treatment centers who had already received treatment for NMSC with EBT and met eligibility criteria were invited to participate. A retrospective chart review was used to individually match patients with patients who had received MMS for NMSC based on patient age (±15 years), lesion size, type and location, and treatment dates. All MMS treated subjects treated in the same time-frame were considered for matching and the final pair was selected based on the closest match of demographics and lesion characteristics. A total of 369 patients were included for study representing 208 matched lesion pairs.
Additional eligibility criteria included:
Exclusion criteria included:
Patients were evaluated for follow-up at 2.3 to 5.0 years post-treatment. Treatment with EBT was performed with a miniature, HDR electronic X-ray source using standard surface applicators. A dose of 40.0 Gy in 8 fractions (5 Gy twice weekly) was used to deliver to a depth of 2-3 mm but in some cases a customized dose, depth, or schedule. MMS was performed by clinicians according to guidelines of the American College of Mohs Surgery. Matching of patients based on lesion characteristics was based on histopathology of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), cancer staging (Stage 0, Stage 1, Stage 2), size (≤ 1 cm, >1 cm and ≤ 2 cm, > 2 cm and ≤ 3 cm), and location (head, ear, eyelid, face/neck, lip, scalp, nose, torso, lower extremity, upper extremity). The mean follow-up length was 3.3 years for the EBT group and 3.5 years for the MMS group. The primary outcome was absence of NMSC recurrence at follow-up. Secondary outcomes included late toxicities, cosmetic outcomes, and patient satisfaction with treatment. All patients completed all evaluations.
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2020. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2021. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Lee et al published a meta-analysis of 58 studies including 21,371 patients treated with conventional surgical excision (24 studies), Mohs micrographic surgery (MMS; 13 studies), EBRT (19 studies), or high-dose-rate brachytherapy (7 studies) for indolent BCC and SCC of the skin (Lee, 2019). "Good" cosmesis was reported in 81% (95% confidence interval [CI], 70.6% to 89.6%), 74.6% (95% CI, 63% to 84.6%), and 97.6% (95% CI, 91.3% to 100%) of patients treated with conventional excision, EBRT, and brachytherapy, respectively. This was comparable to the 96% "good" cosmesis grade outcome reported in 1 MMS study. The 5-year local recurrence rate for brachytherapy was 2.5% (95% CI, 0.8% to 5.1%), which was comparable to both MMS (1.8%; 95% CI, 1.1% to 2.7%) and conventional excision (2.1%; 95% CI, 1.0% to 3.5%). The authors concluded that interpretation of results may be limited by selection bias and subjective and heterogeneous cosmesis grading systems, warranting further prospective, comparative studies.
A case study by Pellizzon et al evaluated the use of Leipzig applicator in 71 patients with basal or squamous cell carcinoma (Pellizzon, 2020). After 42.8 months, a recurrence of 6.9% was reported.
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2022. No new literature was identified that would prompt a change in the coverage statement.
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
The American Brachytherapy Society issued a consensus statement on electronic brachytherapy following a literature review focused on trials, prospective studies, multi-institutional series, and single institution reports addressing clinical outcomes and toxicities (Tom, 2019). Due to a lack of comparative data to traditional treatments and limited long-term follow-up, prospective studies with a larger number of patients undergoing electronic brachytherapy for nonmelanoma skin cancer are recommended. At this time, the statement recommends that treatment with electronic brachytherapy in this patient population should be performed in the context of a clinical registry or trial. This recommendation was reaffirmed in a 2020 American Brachytherapy Society consensus statement on skin brachytherapy (Shah, 2020).
The American Society for Radiation Oncology (ASTRO) issued clinical practice guidelines regarding definitive and postoperative radiation therapy for basal and squamous cell cancers of the skin (Likhacheva, 2020). Key questions were addressed by a systematic literature review and recommendations were developed via consensus with a modified Delphi approach. Consensus recommendations for specific dose-fractionation schemes are detailed for the definitive and post-operative settings. The guideline also states that appropriate use of any of the 4 major radiation modalities, including electronically-generated low energy sources such as electronic brachytherapy, result in similar local control and cosmetic outcomes. Therefore, "the decision of which modality and fractionation scheme to use should be based on both tumor characteristics (eg, shape, contour, depth, and location) and normal tissue considerations."
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| References: |
Alam M, Nanda S, Mittal BB, et al.(2011) The use of brachytherapy in the treatment of nonmelanoma skin cancer: a
review. J Am Acad Dermatol. Aug 2011;65(2):377-388. PMID 21496952 American Academy of Dermatology (AAD) Association.(2022) Skin cancer. Updated April 22, 2022. https://www.aad.org/media/stats-skin-cancer. Accessed May 24, 2022. American Academy of Dermatology.(2015) Guidelines for Non-Melanoma Skin Cancers, currently in development. https://www.aad.org/education/clinical-guidelines. Accessed March, 2015. Avril MF, Auperin A, Margulis A, et al.(1997) Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. Br J Cancer. 1997;76(1):100-106. PMID 9218740 Bhatnagar A, Loper A.(2010) The initial experience of electronic brachytherapy for the treatment of non-melanoma skin cancer. Radiat Oncol. 2010;5:87. PMID 20875139 Bhatnagar A.(2013) Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy. Mar-Apr 2013;12(2):134-140. PMID 23312675 Delishaj D, Laliscia C, Manfredi B, et al.(2015) Non-melanoma skin cancer treated with high-dose-rate brachytherapy and Valencia applicator in elderly patients: a retrospective case series. J Contemp Brachytherapy. Dec 2015;7(6):437-444. PMID 26816500 Delishaj D1, Rembielak A2, Manfredi B1, et al.(2016) Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature. J Contemp Brachytherapy. 2016 Dec;8(6):533-540. Ducassou A, David I, Filleron T, et al.(2011) Retrospective analysis of local control and cosmetic outcome of 147 periorificial carcinomas of the face treated with low-dose rate interstitial brachytherapy. Int J Radiat Oncol Biol Phys. Nov 1 2011;81(3):726-731. PMID 21435798 Gauden R, Pracy M, Avery AM, et al.(2013) HDR brachytherapy for superficial non-melanoma skin cancers. J Med Imaging Radiat Oncol. Apr 2013;57(2):212-217. PMID 23551783 Guibert M, David I, Vergez S, et al.(2011) Brachytherapy in lip carcinoma: long-term results. Int J Radiat Oncol Biol Phys. Dec 1 2011;81(5):e839-843. PMID 21163589 Guix B, Finestres F, Tello J, et al(2000) Treatment of skin carcinomas of the face by high-dose-rate brachytherapy and custom-made surface molds. Int J Radiat Oncol Biol Phys. Apr 1 2000;47(1):95-102. PMID 10758310 Kasper ME, Richter S, Warren N, et al.(2013) Complete response of endemic Kaposi sarcoma lesions with high-doserate brachytherapy: treatment method, results, and toxicity using skin surface applicators. Brachytherapy. Sep- Oct 2013;12(5):495-499. PMID 23466358 Kim JYS, Kozlow JH, Mittal B, et al.(2018) Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. Mar 2018; 78(3): 540-559. PMID 29331385 Lee CT, Lehrer EJ, Aphale A, et al.(2019) Surgical excision, Mohs micrographic surgery, external-beam radiotherapy, or brachytherapy for indolent skin cancer: An international meta-analysis of 58 studies with 21,000 patients. Cancer. Oct 15 2019; 125(20): 3582-3594. PMID 31355928 Likhacheva A, Awan M, Barker CA, et al.(2020) Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol. 2020; 10(1): 8-20. PMID 31831330 Madan V, Lear JT, Szeimies RM.(2010) Non-melanoma skin cancer. . Lancet. Feb 20 2010;375(9715):673-685. PMID 20171403 National Comprehensiv Cancer Network (NCCN).(2015) Guidelines Non-Melanoma Skin Cancers. 2015; http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site. Accessed March, 2015. National Comprehensive Cancer Network (NCCN).(2018) NCCN Clinical Practice Guidelines in Oncology: Basal Cell Skin Cancer. Version 1.2018. https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf. Accessed May 29, 2018. National Comprehensive Cancer Network (NCCN).(2018) NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version 2.2018. https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf. Accessed May 29, 2018. Paravati AJ, Hawkins PG, Martin AN, et al.(2015) Clinical and cosmetic outcomes in patients treated with high-dose-rate electronic brachytherapy for nonmelanoma skin cancer. Pract Radiat Oncol. Nov-Dec 2015;5(6):e659-664. PMID 26432680 Patel RR, Strimling RR, Doggett SS, Willoughby MM, et al.(2017) Comparison of electronic brachytherapy and Mohs micrographic surgery for the treatment of early-stage non-melanoma skin cancer: a matched pair cohort study. J Contemp Brachytherapy, 2017 Sep 28;9(4). PMID 28951753. Pellizzon ACA, Fogaroli R, Chen MJ, et al.(2020) High-dose-rate brachytherapy using Leipzig applicators for non-melanoma localized skin cancer. J Contemp Brachytherapy. Oct 2020; 12(5): 435-440. PMID 33299432 Pons-Llanas O, Ballester-Sanchez R, Celada-Alvarez FJ, et al.(2015) Clinical implementation of a new electronic brachytherapy system for skin brachytherapy. J Contemp Brachytherapy. Jan 2015;6(4):417-423. PMID 25834587 Rio E, Bardet E, Ferron C, et al.(2005) Interstitial brachytherapy of periorificial skin carcinomas of the face: a retrospective study of 97 cases. Int J Radiat Oncol Biol Phys. Nov 1 2005;63(3):753-757. PMID 15927410 Sedda AF, Rossi G, Cipriani C, et al.(2008) Dermatological high-dose-rate brachytherapy for the treatment of basal and squamous cell carcinoma. Clin Exp Dermatol. Nov 2008;33(6):745-749. PMID 18681873 Shah C, Ouhib Z, Kamrava M, et al.(2020) The American Brachytherapy society consensus statement for skin brachytherapy. Brachytherapy. 2020; 19(4): 415-426. PMID 32409128 Tom MC, Hepel JT, Patel R, et al.(2019) The American Brachytherapy Society consensus statement for electronic brachytherapy. Brachytherapy. 2019; 18(3): 292-298. PMID 30497939 Tormo A, Celada F, Rodriguez S, et al.(2014) Non-melanoma skin cancer treated with HDR Valencia applicator: clinical outcomes. J Contemp Brachytherapy. Jun 2014;6(2):167-172. PMID 25097557 |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association. |
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