{"doi":"10.1016/j.adro.2021.100684","title":"Unconventional Wisdom?","abstract":"I read the report by Cook and colleagues1Cook M.M. Schaub S.K. Goff P.H. et al.Postoperative, single-fraction radiation therapy in Merkle cell carcinoma of the head and neck.Adv Radiat Oncol. 2020; 5: 1248-1254Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar describing the outcome of adjuvant single-fraction radiation therapy (RT) for Merkel cell carcinoma (MCC) of the head and neck with interest. As the authors point out, patients with MCC are often elderly and frail, which makes “conventional” RT a challenging proposition. More convenient, safe, and effective strategies are desirable for this reason. However, I am concerned about the data that were selected for presentation in the current manuscript, and the validity of this “unconventional” approach. The authors previously presented results of a similar study at the 2019 Society of Investigative Dermatology and the 2020 American Radium Society meetings.2Cook M. Schaub S. Park S. et al.Efficacy and toxicity of hypofractionated adjuvant radiotherapy in Merkel cell carcinoma.JID. 2019; 139: S95Abstract Full Text Full Text PDF Google Scholar,3Goff P. Cook M. Schaub S. et al.Efficacy and toxicity of hypofractionated adjuvant radiotherapy in Merkle cell carcinoma.Int J Radiat Oncol Biol Phys. 2020; 108: E46Abstract Full Text Full Text PDF PubMed Google Scholar Table 1 compares the findings of the prior abstract and the present manuscript. In the published abstract, 3 of 23 irradiated volumes (13%) subsequently developed “in-field” recurrences.Table 1Comparison of previously published abstract and current manuscriptCharacteristics2019 Abstract2020 ManuscriptPatients (n =)1712Disease sites(not given)Head and neckRadiation therapy doses8-24 Gy in 1-3 fractions of 8 Gy8 Gy in 1 fractionPrimary tumor sites irradiated (n =)1712Regional lymph node beds irradiated (n =)61Follow up (median [range])483 days (range not given)19 months (8-34 months)Median age (years [range])75 (range not given)81 (58-96)In-field recurrences3/23 irradiated sites (calculated 95% CI of 2.7-33.6%)0/13 irradiated sites (calculated 95% CI of 0-24.7%)Abbreviation: CI = confidence interval. Open table in a new tab Abbreviation: CI = confidence interval. One of the patients not described in the present manuscript was a 46-year-old man with pT2N1bM0R0 MCC of upper extremity who underwent wide excision of the primary tumor and lymphadenectomy at my center. He subsequently received a single fraction of 8 Gy at the author’s institution to his primary tumor site and 2 regional lymph node basins. Two months later he developed an unresectable recurrence in 1 of the treated lymph node basins, which was initially treated with an ineffective course of immunotherapy and subsequent reirradiation, complicated by autoimmune complications and lymphedema, respectively. This narrative provides additional context to the possible sequelae of a treatment regimen that causes “minimal toxicity.” Finally, it should be noted that the estimated risk of in-field recurrence in this study is 0%, but given the small sample size, the 95% confidence interval of this event is estimated to be 0% to 25% using binomial “exact” methods. Given the short follow-up of the current series, this is unlikely to be statistically different than the cited 26.3% to 31.9% rates of local recurrence noted 3 to 5 years after surgery alone. Moreover, several centers have reported low rates of excised primary tumor recurrence after wide excision alone (without adjuvant RT).4Frohm M.L. Griffith K.A. Harms K.L. et al.Recurrence and survival in patients with Merkel cell carcinoma undergoing surgery without adjuvant radiation therapy to the primary site.JAMA Dermatol. 2016; 152: 1001-1007Crossref PubMed Scopus (40) Google Scholar,5Fields R.C. Busam K.J. Chou J.F. et al.Recurrence after complete resection and selective use of adjuvant therapy for stage I through III Merkel cell carcinoma.Cancer. 2012; 118: 3311-3320Crossref PubMed Scopus (59) Google Scholar","journal":"Advances in Radiation Oncology","year":2021,"id":210452,"datarank":0.10397207708399181,"base_score":0.6931471805599453,"endowment":0.6931471805599453,"self_citation_contribution":0.10397207708399181,"citation_network_contribution":0.0,"self_endowment_contribution":0.10397207708399181,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":1,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9516,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2021-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":343934,"name":"Christopher A. Barker","orcid":"0000-0003-1882-1088","position":0,"is_corresponding":true}],"reference_count":6,"raw_metadata":{"citation_network_status":"fetched"},"created_at":"2026-07-18T23:52:12.491146Z","pmid":"34195496","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}