Dear Editor,
I read with great interest the pictorial essay by Jose Luis Guinot and colleagues entitled, “High-dose-rate brachytherapy for eyelid carcinoma: Implant technique and review”, published in the Journal of Contemporary Brachytherapy [1]. The authors are to be commended for providing a clear and practical description of interstitial high-dose-rate (HDR) brachytherapy for eyelid carcinoma, a relatively uncommon, yet clinically delicate malignancy. The step-by-step illustration of catheter placement, planning considerations, and shielding strategies is particularly valuable. Given the anatomical complexity of periocular region and the priority to preserve both function and cosmesis, the emphasis on multidisciplinary collaboration is timely and appropriate.
The reported local control rates exceeding 90% with limited high-grade toxicity are consistent with previously published evidence, reinforcing HDR brachytherapy as an effective and organ-preserving treatment modality for eyelid malignancies. In particular, systematic reviews and long-term institutional experiences have highlighted its favorable balance between tumor control and cosmetic outcomes, even in challenging anatomical sites [2-4]. Alternative approaches, such as mould-based surface HDR brachytherapy, further expand the therapeutic armamentarium, offering individualized solutions depending on tumor depth and location [5].
Nevertheless, several issues merit further discussion. First, while the authors appropriately highlight variations in fractionation schedules and prescription depths (3-5 mm), the absence of standardized regimens underscores the need for multicenter prospective data. Although biological equivalent dose (BED) ranges are provided, comparative outcome analyses between commonly used schedules would greatly enhance clinical decision-making. Prior reports have similarly emphasized heterogeneity in dose fractionation strategies, reflecting the lack of consensus in this field [6].
Second, long-term ocular toxicity, particularly cataract formation, chronic dry eye, and lacrimal duct stenosis, requires extended follow-up beyond the median durations reported in most series. Although survival outcomes are generally favorable in early-stage eyelid carcinoma, late functional sequelae may substantially affect patients’ quality of life. Long-term studies have demonstrated the importance of structured cosmetic and functional assessment, including validated scales, such as the cosmesis after interstitial brachytherapy scale [3, 4].
Third, technical refinements and quality assurance remain critical. Recent work has emphasized the importance of meticulous implantation techniques, individualized applicator design, and rigorous quality control protocols in head and neck brachytherapy [7]. Moreover, dosimetric studies evaluating internal shielding strategies have provided valuable insights into minimizing dose to critical ocular structures [8], which is particularly relevant in the periocular setting.
Fourth, owing to the rarity of this tumor, treatment recommendations are based largely on isolated case reports. A systematic review reported on 46 patients with head and neck apocrine carcinoma, 30.4% of which were eyelid tumors [9]. The relative rarity of this neoplasm will always represent a limitation that cannot be overcome in any other way. Multicenter studies, collaborative registries, and standardized reporting, may help partially address this issue by increasing sample sizes and improving comparability across studies.
Finally, incorporation of patient-reported outcome measures and standardized cosmetic assessment tools in future studies would provide a more comprehensive evaluation of therapeutic success. Emerging evidence suggests that aesthetic outcomes and patient satisfaction are key determinants of the overall treatment value, especially in visible anatomical regions.
In conclusion, this well-structured review and technical guide reinforces the role of HDR brachytherapy as a minimally invasive, organ-preserving modality for eyelid carcinoma. Further collaborative research integrating standardized protocols, long-term follow-up, and patient-centered outcomes, may help optimize both oncologic and functional results in this highly sensitive region.
