Definitive And Postoperative Radiation Therapy For Basal And Squamous Cell Cancers Of The Skin

Publication Date: December 1, 2019
Last Updated: March 14, 2022

Recommendations

Definitive RT

In patients with BCC and cSCC who cannot undergo or decline surgical resection, definitive RT is recommended as a curative treatment modality. (Strong, Moderate)
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In patients with BCC and cSCC in anatomic locations where surgery can compromise function or cosmesis, definitive RT is conditionally recommended as a curative treatment modality. (Conditional, Moderate)
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Definitive RT for BCC and cSCC is conditionally not recommended in patients with genetic diseases predisposing to heightened radiosensitivity. (Conditional, Expert Opinion)
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PORT


Both BCC and cSCC

PORT is recommended for gross perineural spread that is clinically or radiologically apparent. (Strong, Moderate)
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cSCC

PORT is recommended for patients with cSCC having close or positive margins that cannot be corrected with further surgery (secondary to morbidity or adverse cosmetic outcome). (Strong, Low)
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PORT is recommended for patients with cSCC in the setting of recurrence after a prior margin-negative resection. (Strong, Moderate)
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In patients with cSCC, PORT is recommended for T3 and T4 tumors. (Strong, Moderate)
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In patients with cSCC, PORT is recommended for desmoplastic or infiltrative tumors in the setting of chronic immunosuppression. (Strong, Moderate)
†The presence of desmoplasia on light microscopy is defined as fine branches of tumor cells at the periphery and a surrounding stromal reaction. All cSCC in which at least one-third of the representative tumor specimen meet these criteria is classified as desmoplastic cSCC. One study reported findings that perineural or perivascular invasion were always associated with desmoplasia.
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BCC

PORT is conditionally recommended in patients with BCC with close or positive margins that cannot be corrected with further surgery (secondary to morbidity or adverse cosmetic outcome). (Conditional, Low)
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PORT is conditionally recommended in patients with BCC in the setting of recurrence after a prior margin-negative resection. (Conditional, Low)
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PORT is conditionally recommended in patients with BCC with locally advanced or neglected tumors involving bone or infiltrating into muscle. (Conditional, Low)
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RT for treating regional nodes and regional disease management

For patients with cSCC or BCC that metastasized to clinically apparent regional lymph nodes, therapeutic lymphadenectomy followed by adjuvant RT is recommended, with the exception of patients who have a single, small (<3 cm) cervical lymph node harboring carcinoma, without extracapsular extension. (Strong, Moderate)
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For patients with cSCC or BCC that metastasized to clinically apparent regional lymph nodes, definitive RT is only recommended for patients who are medically inoperable or surgically unresectable. (Strong, Moderate)
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For patients with cSCC at high risk of regional nodal metastasis, imaging and sentinel lymph node biopsy are conditionally recommended to guide the need for and target of lymph node basin RT. (Conditional, Expert Opinion)
Implementation remark:
  • Close clinical follow-up of the lymph node basin is important for patients in whom sentinel lymph node biopsy is unlikely to be accurate due to (1) an extensive initial primary resection and/or reconstruction or (2) tumor location in the head and neck area.
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For patients with cSCC at high risk of regional nodal metastasis (thickness >6 mm), elective lymph node basin RT is conditionally recommended only for those undergoing RT to the primary site with overlap of the adjacent nodal basin. (Conditional, Low)
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For patients with BCC or cSCC undergoing adjuvant RT after therapeutic lymphadenectomy, a dose of 6000-6600 cGy (conventional fractionation [180-200 cGy/fx]) is recommended. (Strong, Moderate)
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For patients with cSCC undergoing elective RT in the absence of a lymphadenectomy, a dose of 5000-5400 cGy (conventional fractionation [180-200 cGy/fx]) is recommended. (Strong, Moderate)
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Radiation techniques and dose-fractionation schedules for primary site management

In patients with BCC and cSCC receiving RT in the definitive setting, the following dose-fractionation schemes are recommended:
  • Conventional (180-200 cGy/fx): BED10 70-93.
  • Hypofractionation (210-500 cGy/fx): BED10 56-88
(Strong, Low)
Implementation remark:
  • Conventional fractionation is delivered 5 days per week; hypofractionation is delivered daily or 2-4 times per week.
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In patients with BCC and cSCC receiving RT in the postoperative setting, the following dose-fractionation schemes are recommended:
  • Conventional (180-200 cGy/fx): BED10 59.5-79.2
  • Hypofractionation (210-500 cGy/fx): BED10 56-70.2
(Strong, Low)
Implementation remark:
  • Conventional fractionation is delivered 5 days per week; hypofractionation is delivered daily or 2-4 times per week.
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BED10 = biologically effective dose assuming an α/β = 10

Use of chemotherapy, biologic, and immunotherapy agents before, during, or after RT

In patients with resected locally advanced cSCC, the addition of concurrent carboplatin to adjuvant RT is not recommended. (Strong, Moderate)
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In patients with unresected locally advanced cSCC, the addition of concurrent drug therapies to definitive RT is conditionally recommended. (Conditional, Low)
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Recommendation Grading

Overview

Title

Definitive And Postoperative Radiation Therapy For Basal And Squamous Cell Cancers Of The Skin

Authoring Organization

Publication Month/Year

December 1, 2019

Last Updated Month/Year

December 5, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline reviews the evidence for the use of definitive and postoperative radiation therapy (RT) in patients with basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC).

Target Patient Population

Patients with BCC/cSCC

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D002294 - Carcinoma, Squamous Cell, D018787 - Radiation Oncology, D011827 - Radiation, D012878 - Skin Neoplasms, D002280 - Carcinoma, Basal Cell, D018295 - Neoplasms, Basal Cell, D018307 - Neoplasms, Squamous Cell

Keywords

radiation therapy, skin cancer, Adjuvant Radiation Therapy

Methodology

Number of Source Documents
100
Literature Search Start Date
May 1, 1988
Literature Search End Date
June 1, 2018