{"doi":"10.1016/j.ijrobp.2023.11.052","title":"Gray Matters: Managing Locally Advanced Skin Cancer Near the Brain","abstract":"This patient1Megahed RJ Patel MA Put your thinking cap on: A fungating scalp mass..Int J Radiat Oncol Biol Phys. 2024; 119: 6-7Google Scholar presented with a cT4aN0M0 cutaneous squamous cell carcinoma (CSCC) of the bilateral parietal scalp, which is possibly recurrent after prior treatment. His symptoms and imaging suggest invasion of the calvarium (and possibly the superior sagittal sinus and brain) by the tumor.1.Although upfront surgery is the standard approach to locally advanced CSCC, most would consider tumors involving the superior sagittal sinus to be “unresectable.” His smoking history potentially increases perioperative complication risk (including reconstruction failure) but is not an absolute contraindication to surgery.2.The standard of care for unresectable CSCC is definitive radiation therapy. A phase 2 trial of 21 patients with unresectable CSCC investigated concurrent platinum chemotherapy with radiation therapy and observed a 53% complete response rate and a 2-year disease-free survival rate of 30% to 40%.2Nottage MK Lin C Hughes BG et al.Prospective study of definitive chemoradiation in locally or regionally advanced squamous cell carcinoma of the skin.Head Neck. 2017; 39: 679-683Crossref PubMed Scopus (39) Google Scholar Retrospective analyses describe similar rates of response and disease-free survival after radiation therapy alone, so the role of chemotherapy is unclear.3Al-Othman MO Mendenhall WM Amdur RJ Radiotherapy alone for clinical T4 skin carcinoma of the head and neck with surgery reserved for salvage.Am J Otolaryngol. 2001; 22: 387-390Crossref PubMed Scopus (42) Google Scholar Given the efficacy of immunotherapy for CSCC, I would recommend enrollment in a clinical trial of immunotherapy and definitive radiation therapy for unresectable CSCC at my center (NCT05574101) or another center (NCT03737721, ACTRN12618001573246).3.My recommended dose for gross tumor would be 70 Gy in 35 fractions, with 50 Gy in 25 fractions given to areas of subclinical spread (adjacent skin, soft tissues, bone, dura). I would use either intensity modulated photon or proton therapy, with possible acceleration or twice-daily fractionation, and/or an integrated boost based on patient preferences, dosimetric assessment, and tumor response. I would attempt to limit the brain dose to 70 Gy.","journal":"International Journal of Radiation Oncology*Biology*Physics","year":2024,"id":496662,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.96,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2024-01-01","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":3,"raw_metadata":null,"created_at":"2026-07-19T02:09:27.134858Z","pmid":"38631750","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":[]}