What dose-fractionation would you recommend for a small basal cell carcinoma of the nasal ala in a patient with poor performance status or transportation difficulties?

I would suggest several caveats to the above answers.

Electron distributions are unpredictable, particularly on curved surfaces and in small fields. The larger margins required would likely be problematic on a nasal ala, and orthovoltage or HDR brachy would be preferred for fields 3 cm or less to avoid a marginal miss or underdosing.

I would hope that we would strive for better than 80% "good" cosmesis and <15% local recurrence. While these numbers may be ok for larger tumors in patients with comorbidities, we can usually do much better, even with significantly hypofractionated regimens (42 Gy/6). Keeping the field as small as possible (6 mm margins, if possible, on margins viewed under magnification), greatly improves cosmesis. Care with t...

This is a perfect case for high dose limited fractions. I would use 6mV electrons. The smaller the field, the faster you can go. 3 FX per week M-W-F.

350 cGy to 5250

400 cGy to 4800

500 cGy to 4000

600 cGy to 3600

The final stop point determined by response and reaction.

The NCCN guidelines for indolent skin cancers (basal cell carcinoma and squamous cell carcinoma) list four examples of fractionation schedules for definitive treatment of early stage tumors < 2 cm: 64 Gy in 32 fractions over 6 weeks, 55 Gy in 20 fractions over 4 weeks, 50 Gy in 15 fractions over 3 weeks, and 35 Gy in 5 fractions over 5 days. However, there are currently limited prospective data comparing outcomes and toxicities of hypofractionated regimens. Current dogma asserts that the trade-off of more convenient treatment is worse cosmesis; however, the data supporting this are not strong. Further, prolonged treatment times are inconvenient to elderly patients and are not cost-effective.

Our team performed a meta-analysis of the publishe...

This patient appears to be an excellent candidate for HDR brachytherapy. An appropriately selected surface applicator (Leipzig or Valencia) may be advantageous compared to electrons by allowing for

• homogeneous dose distribution to a small area
• conformality to an irregular/curved surface
• shallow dose deposition.

HDR brachy is most commonly prescribed in a hypofractionated regimen. A prescription of 40-42 Gy in 6-8 fractions can be employed and would deliver a similar BED as suggested above.

I agree completely. I have had good success (tumor control and good cosmesis) with 600 cGy x 6 fractions given 2 fractions per week.