Radiotherapy regimens in patients with nonmelanoma head
and neck skin cancers
, Richard B. Cannon
, Jason P. Hunt
, Gita Suneja
, and Ying J. Hitchcock
Otolaryngology – Head & Neck Surgery,
Rize Government Hospital, Rize, Turkey,
Division of Otolaryngology, Department of
Surgery, University of Utah, Salt Lake City,
UT, USA, and
Department of Radiation
Oncology, Huntsman Cancer Hospital,
University of Utah, Salt Lake City, UT, USA
Ying J. Hitchcock,
Department of Radiation Oncology
University of Utah Huntsman Cancer
1950 Circle of Hope, Room 1570
Salt Lake City, UT 84112
Conﬂicts of interest: None.
Background To assess the effectiveness and outcomes of adjuvant radiotherapy regimens
for nonmelanoma skin cancers (NMSC) of the head and neck, particularly for elderly
Methods A retrospective review of patients with head and neck NMSC was conducted.
Radiotherapy dose per fraction regimens included ≤200, 240–250, 300–400, and 500–
600 cGy. Demographics, tumor characteristics, local control (LC), regional control (RC),
and survival outcomes were analyzed.
Results Of the 90 patients with 140 disease sites, 76.6% were squamous cell carcinoma,
15.5% were basal cell carcinoma, and 7.7% were other histologies. The mean age at
diagnosis was 72.1 years old. The most common location was preauricular (20.0%),
followed by temple, scalp, cheek, and forehead. The overall LC and RC rates were 88.8%
and 88.8%, respectively by patients, and 92.8% and 86.4%, respectively by treatment
sites. Age, primary tumor location, T classiﬁcation, N classiﬁcation, overall stage,
perineural invasion, comorbid disease, skull base invasion, and radiotherapy subgroup
were signiﬁcantly associated with disease-free and overall survival (P < 0.05). LC and RC
were not signiﬁcantly different among the radiotherapy dose subgroups. The mean survival
was longer in patients treated with 240–250 cGy/fraction (50.3 months). There was no
signiﬁcant difference in radiotherapy toxicity between the subgroups.
Conclusion Short-term radiotherapy regimens for patients with locally or regionally
advanced head and neck NMSC appear feasible and effective, particularly in elderly
patients or those that cannot tolerate the length of standard regimens.
Nonmelanoma skin cancer (NMSC) is the most common can-
cer worldwide. Approximately 3 million individuals are diag-
nosed with NMSC in the United States each year. Of these,
75–80% are basal cell carcinoma (BCC), and 20–25% are
squamous cell carcinoma (SCC).
The head and neck
region is the most commonly affected site (80%), largely due
to signiﬁcant sun exposure to this area.
The incidence of
skin cancers continues to rise and is highest in Australia, with
an age-standardized incidence rate of 387 cases per 100,000
individuals for SCC and 884 cases per 100,000 individuals
The vast majority of patients with NMSC are at low risk for
invasion and recurrence and are typically treated with simple
excision or Mohs surgery. External beam radiotherapy (EBRT)
can be offered when surgery is not preferred.
5% of patients with NMSC have high-risk clinicopathologic fea-
tures for loco-regional recurrences, distant metastasis, and
death, and these patients need more aggressive treatment.
High-risk features for NMSC are regional nodal involvement,
perineural invasion (PNI), recurrent disease, poor histologic dif-
ferentiation, and immunosuppression.
The published literature
addressing high-risk features and indications for adjuvant radio-
therapy are largely comprised of SCC datasets, which are more
likely to develop severe disease with a poor prognosis. Patients
who have NMSC with these characteristics or have locally
advanced disease (American Joint Committee on Cancer
[AJCC] classiﬁcation T3–T4) likely beneﬁt from review by a mul-
tidisciplinary tumor board and may need more comprehensive
treatment. The standard of care for these patients is complete
surgical resection and adjuvant radiotherapy as indicated,
depending on the risk factors. Deﬁnitive radiotherapy (RT), with
or without chemotherapy, is also another treatment option for
NMSC with high-risk features or for locally advanced diseases
that cannot be treated with surgery and elderly nonsurgical can-
didates. Nonsurgical therapy is increasing in utilization in sev-
eral head and neck subsites for SCC.
ª 2018 The International Society of Dermatology International Journal of Dermatology 2018, 57, 441–448