Radiation Therapy for Basal and Squamous Cell Cancers of the Skin Clinical Practice Guidelines (2020)

American Society for Radiation Oncology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guideline by clicking the link in the reference.

March 02, 2020

Definitive and postoperative radiation therapy clinical practice guidelines for basal and squamous cell cancers of the skin were released in February 2020 by the American Society for Radiation Oncology.[1]

Recommendations regarding definitive radiation therapy are as follows:

  • Recommended as curative treatment in patients with basal cell carcinoma (BCC) or cutaneous squamous cell carcinoma (SCC) who cannot undergo or who decline surgical resection

  • Conditionally recommended as curative treatment in patients with BCC or cutaneous SCC in anatomic locations where surgery can endanger function or cosmesis

  • Conditionally not recommended for patients with BCC or cutaneous SCC who have genetic diseases that predispose to increased radiosensitivity

Postoperative radiation therapy is recommended in the following clinical scenarios:

  • Gross perineural spread that is apparent clinically or radiologically

  • Cutaneous SCC with narrow or positive margins that is refractory to further surgical correction owing to morbidity or adverse cosmetic outcome

  • Cutaneous SCC associated with recurrence after a previous margin-negative resection

  • Cutaneous SCC with T3 and T4 tumors

  • Cutaneous SCC with desmoplastic or infiltrative tumors in the setting of chronic immunosuppression

Postoperative radiation therapy is conditionally recommended in the following clinical scenarios:

  • BCC with narrow or positive margins that is refractory to further surgical correction owing to morbidity or adverse cosmetic outcome

  • BCC associated with recurrence after a previous margin-negative resection

  • BCC associated with locally advanced or neglected tumors that involve bone or those infiltrating muscle

Recommendations for cutaneous SCC or BCC that has metastasized to clinically apparent regional lymph nodes are as follows:

  • Therapeutic lymphadenectomy followed by adjuvant radiation therapy (Exception: Patients with a single, small (<3 cm) cancerous cervical lymph node, without extracapsular extension)

  • Definitive radiation therapy only recommended if patient is medically inoperable or surgically unresectable

Conditional recommendations for cutaneous SCC or BCC in patients who are at high risk of regional nodal metastasis are as follows:

  • Imaging and sentinel lymph node biopsy, in order to guide the need for and target of lymph node basin radiation therapy

  • If tumor thickness is greater than 6 mm, elective lymph node basin radiation therapy only in patients undergoing radiation therapy on the primary site, with overlap of the adjacent nodal basin

The recommended radiation dose for patients with cutaneous SCC or BCC who are undergoing adjuvant radiation therapy after therapeutic lymphadenectomy is 6000-6600 cGy (conventional fractionation [180-200 cGy/fx]).

The recommended radiation dose for patients with cutaneous SCC who are undergoing elective radiation therapy in the absence of a lymphadenectomy is 5000-5400 cGy (conventional fractionation [180-200 cGy/fx]).

Recommended radiation techniques/dose-fractionation schedules for patients with BCC or cutaneous SCC who are receiving radiation therapy in a definitive setting are as follows:

  • Conventional (180-200 cGy/fx): BED10 (biologically effective dose assuming an α/β = 10) 70-93.5 (delivered 5 days/wk)

  • Hypofractionation (210-500 cGy/fx): BED10 56-88 (delivered daily or 2-4 times/wk)

Recommended dose-fractionation schedules for patients with BCC or cutaneous SCC who are receiving radiation therapy in a postoperative setting are as follows:

  • Conventional (180-200 cGy/fx): BED10 59.5-79.2 (delivered 5 days/wk)

  • Hypofractionation (210-500 cGy/fx): BED10 56-70.2 (delivered daily or 2-4 times/wk)

Recommendations regarding biologic agents, chemotherapy, and immunotherapy before, during, or after radiation therapy are as follows:

  • Not recommended: Adding concurrent carboplatin therapy to adjuvant radiation therapy in patients with resected locally advanced cutaneous SCC

  • Conditionally recommended: Adding concurrent drug therapies to definitive radiation therapy in patients with unresected locally advanced cutaneous SCC

For more information go to Cutaneous Squamous Cell Carcinoma and Basal Cell Carcinoma.

For more Clinical Practice Guidelines, go to Guidelines.

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