Enhanced surface dose via fine brass mesh for a complex skin cancer of the head and neck: Report of a technique

The use of fine brass mesh in conjunction with rotational intensity modulated radiation to enhance surface dose for a complex skin cancer of the head and neck has not previously been described. Methods and materials: We present a case of locally advanced basal cell carcinoma with temporal bone erosion treated with rotational intensity modulated radiation via helical tomotherapy with brass mesh. In vivo surface dose was assessed at multiple locations to verify delivered surface dose. Phantom measurements identified the enhancement ratio with the addition of brass mesh, and evaluated impact on the underlying dose distribution. Results: The brass mesh use was feasible and conformed well to the underlying surface. In vivo dosimetry identified excellent skin surface dose with a mean of 103% of the prescription dose at the surface (range, 97%-120%). Phantom measurements identified a surface dose enhancement ratio of 1.36, and 1.38, respectively, with placement of brass mesh. Clinically, the patient is without evidence of disease or major treatment sequelae at 12 months follow-up. Conclusions: For complex cutaneous malignancies with irregular surfaces unsuitable for tissue equivalent bolus, brass mesh provides an alternate method of increasing surface dose if inadequate surface dosimetry is identified with phantom or in vivo measurements.