How would you approach adjuvant radiation therapy in a patient with recurrent skin SCC of the gluteus s/p multiple resections with positive margins and adjacent osteomyelitis to the ischium and pubic ramus?

In this scenario, wherein a patient with recurrent cutaneous SCC has active osteomyelitis (assuming this is being treated), it would be prudent to avoid the involved bone as an OAR. I would not include the infected bone (I'd review the best imaging with radiology to ensure there's no involvement by tumor), and if there was a question or concern, I would consider holding the RT course and referring the patient to medical oncology for consideration of cemiplimab. In terms of dose and fractionation, I'd treat to 66 Gy in 2 Gy fractions. If the tumor extent is deeper than what can be covered with electrons, hypofractionation to a curable dose can result in moderate fibrosis, which can impact on range of motion.