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Slide1
Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: An ASTRO Clinical Practice Guideline
Developed in Collaboration with the American Society of Clinical Oncology and Society of Surgical Oncology
Endorsed by the American Association of Physicists in Medicine, American Brachytherapy Society, American College of Radiology, American Head and Neck Society, and the Society of Surgical Oncology
Slide2Citation
This slide set is adapted from the
Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin Guideline
,
published in the January/February
2020 issue of Practical Radiation Oncology (PRO).
The guideline was e-published (
https://doi.org/10.1016/j.prro.2019.10.014
) on
December 9, 2019, and is also available on the
ASTRO website:
www.astro.org
Slide3Guideline Task Force
Chairs:Phillip M. Devlin, MDAnna Likhacheva, MD, MPH
Members:
Musaddiq Awan, MD
Christopher A. Barker, MD
Ajay Bhatnagar, MD
Lisa Bradfield
Mary Sue Brady, MD
Ivan Buzurovic, PhD
Jessica L. Geiger, MD
Upendra Parvathaneni, MBBS
Sandra Zaky, MD
Slide4Task Force Composition
Radiation oncology
Drawn from academic practice, private or community practice, and the Veterans Health Administration system
Include a RO resident and a member of the Guidelines Subcommittee
Related specialties/disciplines*
radiation, medical, and surgical oncologists
Medical physicist
*Non-RO physicians are nominated by their respective societies
Patient representative
Slide5Guideline Scope
To review the evidence and provide recommendations for the use of definitive and postoperative radiation therapy (RT) in patients with basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (
cSCC
) as well as dose-fractionation schemes, target volumes, basic aspects of treatment planning, choice of radiation modality and the role of systemic therapy in combination with radiation.
Slide6Systematic Review
MEDLINE® PubMed - 5/01/1988 – 6/31/2018
Both
MeSH
terms and text words used and then supplemented with hand searches
Outcomes
:
local and regional recurrence risk,
d
isease-free survival, overall survival,
toxicity, quality of life (QoL)
Inclusion
: Age ≥18 years, diagnosis of nonmetastatic invasive BCC and
cSCC
, RT delivered with curative intent.
KQ1 included studies with ≥100 patients, KQs 2-4 used ≥50 patients and KQ5 reduced the patient number to ≥15 since minimal evidence exists on chemotherapy, biologic, and immunotherapy agents
Exclusion
:
metastatic BCC and
cSCC
;
dermatopathologic
aspects of diagnosis, surgical nuances, technical details of RT,
mucosal head and neck SCC, vulvar, penile, and perianal skin carcinoma;
preclinical and
dosimetric
studies, publications addressing re-irradiation or palliation, non-English, case reports, not relevant to KQs
1515 citations identified
193 articles assessed
143 articles included and abstracted into evidence tables
Slide7Rating Strength of Recommendation
Strength of Recommendation
Definition
Overall QoE
Grade
Recommendation Wording
Strong
Benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits.
All or almost all informed people would make the recommended choice.
Any
(usually high, moderate, or expert opinion)
“Recommend/ Should”
Conditional
Benefits are finely balanced with risks and burden or appreciable uncertainty exists about the magnitude of benefits and risks.
Most informed people would choose the recommended course of action, but a substantial number would not.
A shared decision-making approach regarding patient values and preferences is particularly important.
Any
(usually moderate, low, or expert opinion)
“Conditionally Recommend”
Slide8Rating Quality of Evidence
Overall QoE Grade
Type/Quality of Study
Evidence Interpretation
High
2 or more
well-conducted and highly-generalizable RCTs or meta-analyses of such trials.
The true effect is very likely to lie close to the estimate of the effect based on the body of evidence.
Moderate
1
well-conducted and highly-generalizable RCT or a meta-analysis of such trials
OR
2 or more
RCTs with some weaknesses of procedure or generalizability
OR
2 or more
strong observational studies with consistent findings
.
The true effect is likely to be close to the estimate of the effect based on the body of evidence, but it is possible that it is substantially different.
Low
1 RCT with some weaknesses of procedure or generalizability
OR
1 or more RCTs with serious deficiencies of procedure or generalizability or extremely small sample sizes
OR
2 or more observational studies with inconsistent findings, small sample sizes, or other problems that potentially confound interpretation of data.
The true effect may be substantially different from the estimate of the effect. There is a risk that future research may significantly alter the estimate of the effect size or the interpretation of the results.
Expert Opinion
*
Consensus of the panel based on clinical judgement and experience, due to absence of evidence or limitations in evidence.
Strong consensus (≥90%) of the panel guides the recommendation despite insufficient evidence to discern the true magnitude and direction of the net effect. Further research may better inform the topic.
Slide9Consensus Methodology
Modified Delphi approach
Task force members rated their agreement with each recommendation using an online consensus survey
5-point Likert scale from “strongly disagree” to “strongly agree”
Consensus defined using pre-specified threshold of ≥75% (≥90% for expert opinion recommendations) agreement
Recommendations for which consensus is not achieved are removed or are revised and re-surveyed.
Recommendations achieving consensus edited with substantive changes after the first round are also re-surveyed.
Slide10KQ 1: What are the appropriate indications for definitive RT for BCC and cSCC?
KQ1 Recommendations
Strength of Recommendation
Quality of Evidence
In patients with BCC and cSCC who cannot undergo or decline surgical resection, definitive RT is recommended as a curative treatment modality.
Strong
Moderate
Slide11Randomized evidence to support the use of definitive RT
A randomized study comparing surgery and RT for treatment of early stage BCC of the face.347 patients (174 patients in the surgery group and 173 patients in the RT group) started in 1982.The 4-year actuarial failure rate was 0.7% in the surgery group compared with 7.5% in the RT group (p=0.003).87% of the surgery-treated patients and 69% of the radiation-treated patients considered the cosmetic result as good (p<0.01).
Avril MF, Auperin A, Margulis A, et al. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study.
British journal of cancer.
1997;76(1):100-106.
Slide12Evidence to support the use of definitive RT for cSCC and BCC
Retrospective and single-arm prospective evidence characterizing outcomes for skin carcinomas after treatment with modern RT:A meta-analysis of 9729 patients (21 studies) with BCC and cSCC confirmed excellent control with RT.1 Median 1-year LR rate was 2% and the 5-year LR rate was 14% when combining all fractionation regimens. A meta-analysis of 40 randomized and 5 nonrandomized studies of various available interventions for primary cutaneous BCC.2 LR rates were similar for excision (3.8%), Mohs surgery (3.8%), and EBRT(3.5%).LR rates for cryotherapy (22.3%) curettage and cryotherapy (19.9%), 5-fluorouracil (18.8%), imiquimod (14.1%), and photodynamic therapy using methyl-aminolevulinic acid (18.8) or aminolevulinic acid (16.6).
1. Zaorsky NG, Lee CT, Zhang E, Keith SW, Galloway TJ. Hypofractionated radiation therapy for basal and squamous cell skin cancer: A meta-analysis. Radiotherapy & Oncology. 2017;125:13-20.
2. Drucker AM, Adam GP, Rofeberg V, et al. Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Network Meta-analysis.
Ann Intern Med.
2018;169(7):456-466.
Slide13KQ 1: What are the appropriate indications for definitive RT for BCC and cSCC?
KQ1 Recommendations
Strength of Recommendation
Quality of Evidence
2. In patients with BCC and cSCC in anatomical locations where surgery can compromise function or cosmesis, definitive RT is conditionally recommended as a curative treatment modality.
Conditional
Moderate
Slide14Cosmetic and functional aspect of definitive RT for BCC and cSCC
Good functional outcomes are especially relevant for commonly sun exposed area of the face where surgical deformity can cause decreased QoL.
Nose
Lips
Eyelids
Ears
Slide15Cosmetic and functional aspect of definitive RT for BCC and cSCC
Zaorsky meta-analysis found “good” or “better” cosmesis in the 21 studies to be 80% at 5 years.Single arm studies reporting excellent functional preservation inPeri-orbital targetsLipNose
Zaorsky NG, Lee CT, Zhang E, Keith SW, Galloway TJ. Hypofractionated radiation therapy for basal and squamous cell skin cancer: A meta-analysis. Radiotherapy & Oncology. 2017;125:13-20.
de Visscher JG, Botke G, Schakenraad JA, van der Waal I. A comparison of results after radiotherapy and surgery for stage I squamous cell carcinoma of the lower lip.
Head & neck.
1999;21(6):526-530.
Mazeron JJ, Chassagne D, Crook J, et al. Radiation therapy of carcinomas of the skin of nose and nasal vestibule: a report of 1676 cases by the Groupe Europeen de Curietherapie.
Radiotherapy & Oncology.
1988;13(3):165-173.
Krengli M, Masini L, Comoli AM, et al. Interstitial brachytherapy for eyelid carcinoma. Outcome analysis in 60 patients.
Strahlentherapie und Onkologie.
2014;190:245-249.
Slide16KQ 1: What are the appropriate indications for definitive RT for BCC and cSCC?
KQ1 Recommendations
Strength of Recommendation
Quality of Evidence
3. Definitive RT for BCC and cSCC is conditionally
not
recommended in patients with genetic diseases predisposing to heightened radiosensitivity.
Conditional
Expert Opinion
Slide17Contraindications to definitive RT
The use of definitive RT is discouraged for the treatment of cSCC or BCC in patients with genetic conditions predisposing to heightened radiosensitivity, such as ataxia telangiectasia, nevoid basal cell carcinoma syndrome (Gorlin Syndrome) and Li Fraumeni syndrome.Poorly controlled connective tissue disorders are a relative contraindication to treatment.Overall life expectancy should be considered and discussed with younger patients, for whom a larger lifetime risk of developing secondary malignancy in the treatment field is expected.
Baker S, Joseph K, Tai P. Radiotherapy in Gorlin Syndrome: Can It Be Safe and Effective in Adult Patients?
Journal of cutaneous medicine and surgery.
2016;20(2):159-162.
Martin F. Lavin. Ataxia-telangiectasia: from a rare disorder to a paradigm for cell signalling and cancer. Nature Reviews Molecular Cell Biology volume 9, pages 759–769 (2008)
Heymann, et al. Radio-induced malignancies after breast cancer postoperative radiotherapy in patients with Li-Fraumeni syndrome. Radiat Oncol. 2010 Nov 8;5:104. doi: 10.1186/1748-717X-5-104.
Slide18KQ 2: Indications for postoperative radiation therapy (PORT)
KQ2 Recommendations
Strength of Recommendation
Strength of Recommendation
Quality of Evidence
Both BCC and cSCC
PORT is recommended for gross perineural spread that is clinically or radiologically apparent.
Strong
Moderate
Slide19Indications for PORT in cSCC
Cutaneous SCC is a much more aggressive entity than BCC with a far greater risk for regional and nodal spread. Thus, the task force recommends more wide-ranging utilization of PORT in the SCC population.
Lin C, Tripcony L, Keller J, Poulsen M, Dickie G. Cutaneous carcinoma of the head and neck with clinical features of perineural infiltration treated with radiotherapy.
Clinical oncology (Royal College of Radiologists (Great Britain)).
2013;25(6):362-367.
Jackson JE, Dickie GJ, Wiltshire KL, et al. Radiotherapy for perineural invasion in cutaneous head and neck carcinomas: toward a risk-adapted treatment approach.
Head & neck.
2009;31(5):604-610.
Slide20KQ 2: Indications for PORT (Con’t)
KQ2 Recommendations
Strength of Recommendation
Quality of Evidence
cSCC
1. PORT is recommended for patients with cSCC having close/positive margins that cannot be corrected with further surgery (secondary to morbidity and/or adverse cosmetic outcome).
Strong
Low
2. PORT is recommended for patients with cSCC in the setting of recurrence following a prior margin negative resection.
Strong
Moderate
3. In patients with cSCC, PORT is recommended for T3 and T4 tumors.
*
Strong
Moderate
4. In patients with cSCC, PORT is recommended for desmoplastic
†
/infiltrative tumors in the setting of chronic immunosuppression.
Strong
Moderate
Slide21Perineural invasion
Retrospective review of patients with HN cSCC with perineural involvement: gross cranial nerve involvement (GCNI), microscopic focal perineural invasion (MFPNI), and microscopic extensive perineural invasion (MEPNI), managed with or without RT.102 patients were observed or treated with RT from 2000 through 2013. The pattern of relapse was predominantly local, with a low rate of successful salvage.
Sapir E, Tolpadi A, McHugh J, et al. Skin cancer of the head and neck with gross or microscopic perineural involvement: Patterns of failure. Radiotherapy and oncology. 2016;120(1):81-86.
Type of PNI
Definition
2 year RFS
2 year DFS
Gross cranial nerve involvement, 100% definitive RT
64%
56%
Microscopic
extensive
perineural invasion, 63% adjuvant RT
Involvement of >2 nerves with diameter >0.1 mm
94% (RT) vs 25% (no RT)
73% (RT) vs 40% (no RT)
Microscopic
focal
PNI, 27% adjuvant RT
Involvement of 1–2 nerves with diameter >0.1 mm
86% (RT) vs 83% (no RT)
61% (RT) vs 74% (no RT)
Slide22Other high-risk features for recurrence
Retrospective analysis of stage I through IV head and neck cSCC who underwent surgery and also received PORT for primary or recurrent disease. 205 patients treated between 1995 and 2015On MVA, immunosuppressed status (hazard ratio [HR]: 3.79), recurrent disease (HR: 2.67), poor differentiation (HR: 2.08), and PNI (HR: 2.05) were significantly associated with locoregional recurrence
Manyam BV, Garsa AA, Chin RI, et al. A multi-institutional comparison of outcomes of immunosuppressed and immunocompetent patients treated with surgery and radiation therapy for cutaneous squamous cell carcinoma of the head and neck.
Cancer.
2017;123(11):2054-2060.
Slide23KQ 2: Indications for PORT (Con’t)
KQ2 Recommendations
Strength of Recommendation
Quality of Evidence
BCC
6. PORT is conditionally recommended in patients with BCC with close/positive margins that cannot be corrected with further surgery (secondary to morbidity and/or adverse cosmetic outcome).
Conditional
Low
7. PORT is conditionally recommended in patients with BCC in the setting of recurrence following a prior margin negative resection.
Conditional
Low
8. PORT is conditionally recommended in patients with BCC with locally advanced or neglected tumors involving bone or infiltrating into muscle.
Conditional
Low
Slide24KQ 3: What are the appropriate indications for RT for treating regional nodes? What dose and fractionation should be used for management of regional disease?
KQ3 Recommendations
Strength of Recommendation
Quality of Evidence
1. 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 that have a single, small (<3 cm) cervical lymph node harboring carcinoma, without extracapsular extension.
Strong
Moderate
2. 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
Slide25Best outcomes associated with therapeutic lymphadenectomy and adjuvant radiation
Median 2-year regional relapse free survival rates from literature review:
RT alone: 63%
Therapeutic lymphadenectomy alone: 72%
Therapeutic lymphadenectomy and adjuvant RT: 87%
Median 2-year overall survival rates from literature review:
RT alone: 50%
Therapeutic lymphadenectomy alone: 62%
Therapeutic lymphadenectomy and adjuvant RT: 77%
Slide26Best outcomes associated with therapeutic lymphadenectomy and adjuvant radiation
However, in medically inoperable or surgically unresectable nodal metastases, radiation therapy is recommended
In addition, patients with a single, small (<3 cm) cervical lymph node were found to be at low risk for regional recurrence after therapeutic lymphadenectomy alone, and may not need RT
Slide27KQ 3: What are the appropriate indications for RT for treating regional nodes? What dose and fractionation should be used for management of regional disease?
KQ3 Recommendations
Strength of Recommendation
Quality of Evidence
3. 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.
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.
Conditional
Expert Opinion
4. 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
Slide28Regional recurrence most strongly associated with tumor thickness (>6 mm)
VariableCrude risk of recurrenceMultivariable model HR (p=)Tumor thickness≤2 mm: 0%2.1-6.0 mm: 4%>6.0 mm: 16%4.92 (<0.001)Tumor siteEar: 10%Lip: 5%Non-ear: 3%Non-lip: 4%3.37 (<0.01)Immune statusImmunocompetent: 4%Immunosuppressed: 16%3.36 (<0.05)Tumor horizontal size≤20 mm: 2%21-50 mm: 8%>50 mm: 20%2.10 (<0.05)Desmoplastic Not desmoplastic: 4%Desmoplastic: 12%1.80 (0.26)Number of tumors1: 3%>1: 8%1.21 (0.66)DifferentiationGood/moderate: 3%Poor: 7%1.06 (0.88)
Prospective, multivariable analysis of risk factors for regional recurrence after margin-negative excision of cSCC in 615 patients
Brantsch KD et al, Lancet Oncology 2008
Slide29KQ 3: What are the appropriate indications for RT for treating regional nodes? What dose and fractionation should be used for management of regional disease?
KQ3 Recommendations
Strength of Recommendation
Quality of Evidence
5. 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
6. 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
Slide30KQ 4: What is the preferred dose-fractionation schedules & radiation techniques for management of the primary site in BCC and cSCC?
KQ4 Recommendations
Strength of Recommendation
Quality of Evidence
1. In patients with BCC and
cSCC
receiving RT in the definitive setting, the following dose-fractionation schemes* are recommended:
Conventional (180–200 cGy/fx): BED
10
70–93.5
Hypofractionation (210–500 cGy/fx): BED
10
56–88
Implementation Remark
: Conventional fractionation is delivered 5 days per week; hypofractionation is delivered daily or 2
–4
times/wk.
Strong
Low
2. In patients with BCC and
cSCC
receiving RT in the postoperative setting, the following dose-fractionation schemes* are recommended:
Conventional (180–200 cGy/fx): BED
10
59.5–79.2
Hypofractionation (210-500 cGy/fx): BED
10
56–70.2
Implementation Remark:
Conventional fractionation is delivered 5 days per week; hypofractionation is delivered daily or 2
–4
times/wk.
Strong
Low
Slide31Why Biological Effective Dose (BED10) instead of Total Dose?
To address the wide variation in dosing schemes within the literature. BED calculations involve the use of an established radiobiological equation to compare different fractionation regimens by converting them to comparable values for a given tissue of interest.
Slide32Radiation modalities
ELS (electronically generated low-energy source) utilize x-ray sources with peak voltage up to 120 kVp:OrthovoltageContact x-raysSoft x-raysIntermediate x-raysElectronic brachytherapySuperficial x-rays
HDR and LDR brachytherapy
Megavoltage Electrons
Megavoltage Photons
Slide33Local control with varying radiation modalities
5-year local control for ELS, brachytherapy and electrons: 75%-100%
5-year local control for photon therapy: 54%-80%
No long-term studies (>10 years) for electronic brachytherapy in regards to local control and toxicity
Slide34Tumor characteristics with varying radiation modalities
Stage
Depth
Bolus
Margin
Treatment Planning
ELS
T1/T2
0.5 cm
Yes/No
1 cm
Mostly 2-D; 3-D may be needed to evaluate critical structures
HDR/LDR brachytherapy
T1/T2
0.3-0.5 cm
No
0.5 cm
Nomograms or 3-D planning
Electrons
T1-T3
N/A
Yes
1-2 cm
Clinical set-up with MU calculations or
3-D planning
Photons
T3-T4
N/A
Yes
2 cm
3-D planning
Slide35Conventional fractionation dose schemes
Total dose (cGy)
# fx
Fx size (cGy)
Weekly
fx
BED
10
Definitive
Postop
ELS
5040
28
180
5
59.5
---
X
6000
30
200
5
72
---
X
6600
33
200
5
79.2
X
X
7000
35
200
5
84
X
---
7400
37
200
5
88.8
X
---
Slide36Conventional fractionation dose schemes
Total dose (cGy)
# fx
Fx size (cGy)
Weekly fx
BED
10
Definitive
Postop
HDR Brachytherapy
5940
33
180
5
70.1
X
---
6480
36
180
5
76.5
X
---
7920
44
180
5
93.5
X
---
Electrons
6000
30
200
5
72
---
X
Photons
6000
30
200
5
72
---
X
6600
33
200
5
79.2
X
X
7000
35
200
5
84
X
---
Slide37Hypofractionation dose schemes - ELS
Total dose (cGy)
# fx
Fx size (cGy)
Weekly fx
BED
10
Definitive
Postop
ELS
4500
15
300
5
58.5
X
X
4500
10
450
4
65.3
X
X
5000
20
250
5
62.5
X
X
5100
17
300
5
66.3
X
---
5400
18
300
4–5
70.2
X
X
5500
20
275
5
70.1
X
X
6120
18
340
5
82
X
X
Slide38Hypofractionation dose schemes - HDR
Total dose (cGy)
# fx
Fx size (cGy)
Weekly fx
BED
10
Definitive
Postop
HDR Brachytherapy
4000
8
500
2
60
X
---
4050
9
450
BID for 9 fx/wk
58.7
X
X
4400
14
300 (1
st
dose); 400 (last dose)
BID for 10 fx/wk
58.0
X
---
4500
9
500
BID for 9 fx/wk
67.5
X
X
4800
16
300
5
62.4
X
---
6120
18
340
5
82
X
X
Slide39Hypofractionation dose schemes - electrons and photons
Total dose (cGy)
# fx
Fx size (cGy)
Weekly fx
BED
10
Definitive
Postop
Electrons
4400
10
440
4
63.4
X
X
4500
15
300
5
58.5
X
X
5000
20
250
5
62.5
X
X
5400
18
300
4–5
70.2
X
X
Photons
4500
15
300
5
58.5
X
X
5000
20
250
5
62.5
X
X
5500
20
275
5
70.1
X
X
6120
18
340
5
82
X
X
Slide40KQ 5: When is it appropriate to use chemotherapy, biologic, and immunotherapy agents before, during or after RT in the treatment of BCC or cSCC?
KQ5 Recommendations
Strength of Recommendation
Quality of Evidence
1. In patients with resected locally advanced cSCC, the addition of concurrent carboplatin to adjuvant RT is
not
recommended.
Strong
Moderate
2. In patients with unresected locally advanced cSCC, the addition of concurrent drug therapies to definitive RT is conditionally recommended.
Conditional
Low
Slide41Postoperative concurrent chemoradiation with carboplatin in cSCC
Phase III randomized study comparing PORT alone versus chemoradiation with weekly carboplatin in patients with high-risk cSCC of the head and neck310 patientsMedian RT dose 60 GyCarboplatin AUC 2
Porceddu et al.
J Clin Oncol
36:1275-1283
Slide42Postoperative concurrent chemoradiation with carboplatin in cSCC
FFLRR
DFS
OS
Porceddu et al.
J Clin Oncol
36:1275-1283
Slide43Postoperative concurrent chemoradiation with carboplatin in cSCC
No significant differences in DFS or OS with the addition of carboplatin to PORT compared with PORT alone2- and 5-year freedom from locoregional relapse rates were 88% and 83% for RT vs 89% and 87% for chemoradiationNo observed enhancement of RT toxicity with carboplatin
Porceddu et al.
J Clin Oncol
36:1275-1283
Slide44Key take away messages
Definitive RT for BCC and cSCC is associated with high rates of disease control
High-risk features for recurrence after surgery may warrant PORT to the primary bed or regional nodal basins
Several dose and fractionation schemes for treatment of BCC and cSCC are preferred
Concurrent carboplatin with adjuvant RT is not recommended