What is the most appropriate dose-fractionation for an early stage, progressive cutaneous squamous cell carcinoma of the nose in an elderly/frail patient in the setting of the COVID-19 pandemic?

30 Gy/5 fractions or 40 Gy/10 fractions. I prefer 250 kvp. Increase dose by 10% with electrons and increase margins from 1 to 2 cm. Collimate on skin with a lead mask.

Prior to COVID we routinely prescribed 40-45/10 with orthovoltage, using 2-3cm circle. We would hyperfractionate when increasing the field size. With electrons, the Dutch trial comparing 44/10 and 54/18 found no difference in outcomes for T1-2 lesions (van Hezewijk et al., Radiother Onc 2010). The London Cancer Skin guidelines are also a useful resource in general. UK COVID skin radiotherapy guidelines have been published, and recommend deferring treatment of BCC, and hypofractionated regimes fo...

There are a variety of radiotherapy dose-fractionation regimens that could be considered in this situation. The recently published ASTRO guidelines present some examples (but not an exhaustive list of options).

However, before making this decision, one should probably consider how critical it is for this patient to be treated now (or ever). Elderly/frail patients often have competing causes for morbidity and mortality which may obviate the need for treatment of their keratinocyte carcinoma. In th...

I agree with several of the recommendations. However, I would be cautious, as a lesion in the nose, in addition to tumor control, requires some thought regarding cosmesis (even in elderly patients!). Hypofractionation is the best approach, but we must remember that cosmetic results are closely intertwined with dose per fraction and total dose. Since this is a squamous cell cancer, I would favor 45 Gy in 15 fractions (300 cGy per fraction). By the way, what is the tumor size?

For the fractionation schedules I suggested, I would employ them regardless of the pandemic, including 20 Gy in 1 fraction, depending on field size.
Mendenhall et al., Laryngoscope 2009. 119:1994-1999,