How do you manage the elective lymphatics in high risk squamous cell carcinoma of the skin?

For the high risk features mentioned in the question, elective RT to draining nodes and neural pathways should be considered. The acceptable dose/fx for elective RT in SCC is generally 50 Gy in 25 fx (ranges from 45-54 Gy). <1.8-2 Gy/fx is acceptable in dose painted plans. For the nodal fields a good resource is the 2013 updated international multi group consensus atlas that is available on the RTOG web site. This has addressed parotid, facial and posterior scalp/neck lymphatic pathways, in addition to the previously published standard nodal levels. Obviously, the location of the primary determines what to chase. For elective neural coverage, it is mainly the trigeminal & facial nerve pathways that get chased based on the location of the pr...

I agree with above. 50 Gy in 25 fractions is the common fractionation scheme. See UF data. https://www.ncbi.nlm.nih.gov/pubmed/26391010

"Essentially for tumor diameter > 2 cm, tumor thickness > 5 mm, poor differentiation, tumor location within ear, age > 70 years, perineural invasion (PNI), history of recurrence, and immunosuppression"

The first echelon nodes were treated most commonly the parotid/facial nodes. However, there are many sentinel node studies showing that skin cancer of the face can be unpredictable. Being generous has been my practice.