Radiotherapy for locally advanced basal cell and squamous cell carcinomas of the skin Winkle Kwan. IJROBP 2004;60:406 A retrospective review of the outcomes of patients with basal cell and squamous cell carcinomas treated with radical radiotherapy was conducted. Patients with T2 or more advanced disease or nodal disease were included. The clinical course after radiotherapy and factors that can affect locoregional control were analyzed. Results: Four-year locoregional controls for basal cell and squamous cell carcinomas are 86% and 58%, respectively. The median time to recurrence of basal cell and squamous cell carcinomas are 40.5 months and 5.0 months, respectively. No deaths resulted from basal cell carcinomas, but 65% (30/46) of all patients with locoregional recurrent squamous cell cancers died from the disease. Uncontrolled locoregional disease was the cause of death in 81% (30/37) of all patients who died of squamous cell cancers. Discussion    Basal cell carcinomas recur late (median, 40 months in this report), do not spread to regional nodes even upon recurrence, and are rarely fatal even if treatment fails. Squamous cell carcinomas recur early (median 5 months in our series), have a higher locoregional failure rate, and are the cause of death in two-thirds of patients when radiotherapy fails.  Although there were no deaths attributable to basal cell carcinomas, the 4-year disease-specific survival for locally advanced squamous cell carcinomas was only 60%. The current report illustrates the importance of achieving locoregional control. Eighty-one percent (30/37) of all deaths from squamous cell cancers had locoregional recurrences first. In younger and medically fit patients, a combined surgical and radiotherapeutical approach can be adopted to improve on locoregional control. However, with the advanced age of patients typical in this population, more intensive treatment to maximize locoregional control is often poorly tolerated. Improving on the radiotherapy volume may help in the locoregional control of patients with squamous cell carcinomas. Due to the retrospective nature of this report, we are not able to distinguish between local failure and regional failure. However, patients with locally advanced squamous cell carcinomas (particularly T3 and T4 patients) are found to have a significant locoregional failure rate (29% and 50%, respectively)  when prophylactic nodal radiation is not given. From our series, it seems reasonable to include the first echelon nodes in the radiation volume for T3/T4 disease when it is practically feasible. Another strategy for improving on the locoregional control is by giving a higher dose of radiation.  For example, in British Columbia, 6000 cGy in 25 fractions is often given to this group of patients. Consideration can be given to deliver an additional 1000 cGy in 200-cGy fractions to the gross bulky disease. The higher dose is often well tolerated because the volume is relatively small. Conclusions: Basal cell carcinomas can be well controlled with radiotherapy even when locally advanced. Squamous cell carcinomas have a much poorer outcome and can recur quickly after radiotherapy. Locoregional failure remains the predominant cause of death in recurrent squamous cell carcinomas. Radical radiotherapy for T4 carcinoma of the skin of the head and neck: a multivariate analysis. Lee WR, Mendenhall WM, Parsons JT, Million RR  Head Neck 1993; 15:320-4. Sixty-seven patients with 68 stage T4 carcinomas of the skin of the head and neck were treated with radical radiotherapy at the University of Florida between October 1964 and November 1989. Thirty-three lesions were previously untreated and 35 were recurrent. Twenty-nine lesions were squamous cell carcinomas, 37 were basal cell carcinomas, and 2 were basosquamous carcinomas. Minimum follow-up was 2 years. The 5-year local control, local control including surgical salvage, and cause-specific survival probabilities were 53%, 74%, and 75%, respectively. Local control rates with radiotherapy alone were poorer in patients with recurrent lesions (41% vs. 67%, p = .07) or bone involvement (40% vs. 62%, p = .08). Results were analyzed by multivariate methods using local control, local control with surgical salvage, and cause-specific survival as endpoints. The parameters analyzed were histology; size of primary lesion; previous treatment (previously untreated vs. recurrent); involvement of bone, nerve, or cartilage; and skeletal muscle invasion. Three important prognostic factors were identified, each predictive of poorer ultimate local control and cause-specific survival rates: (a) bone involvement (p < .01); (b) recurrent lesions (p < .01); and (c) nerve involvement (p < .02). Radiotherapy alone can control advanced carcinomas of the skin of the head and neck, although lesions that have recurred after prior treatment and those with involvement of bone or nerve are associated with a lower likelihood of cure.