Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(2):e2023110 1 “RT STRIKES BACK”: Radiotherapy in Ultra Elderly with Cutaneous Basal Cell Carcinoma Valerio Nardone1, Federico Gagliardi1, Gabriella Brancaccio2, Stefania Napolitano1, Giulia Briatico2, Alfonso Reginelli1 1 Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy 2 Dermatology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy Key words: skin cancer, basal cell carcinoma, elderly patients, radiotherapy Citation: Nardone V, Gagliardi F, Brancaccio G, Napolitano S, Briatico G, Reginelli A. “RT STRIKES BACK”: Radiotherapy in Ultra Elderly with Cutaneous Basal Cell Carcinoma. Dermatol Pract Concept. 2023;13(2):e2023110. DOI: https://doi.org/10.5826/ dpc.1302a110 Accepted: October 17, 2023; Published: April 2023 Copyright: ©2023 Nardone et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Valerio Nardone, Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Via De Crecchio 7, 80138 Naples, Italy; Email: Valerio.nardone@unicampania.it Introduction Basal cell carcinoma (BCC) is the most common human can- cer and, recently, its clinical management among elderly pa- tients represents an important issue [1]. We present the case of a 99-year-old patient affected by an advanced and heavily pre-treated BCC that was success- fully treated with radiotherapy. Case Presentation The reported patient presented an ulcerated skin lesion in the left subnasal region for several years. The patient underwent in June 2019 a skin punch biopsy that showed solid nested basal cell carcinoma with morphoeic aspects. Noted the clinical condition, a surgical approach was excluded and was referred to upfront curettage plus elec- trode-dissecation. Due to disease progression, the patients in the subsequent months also underwent cryotherapy and ad- ministration of topical imiquimod, with little efficacy. In October 2021 (Figure 1A), the patient was discussed in the multidisciplinary tumor board (MTB) of skin cancers, evaluating the possibility of a radiotherapy approach. The patient came to our hospital in November 2021 (Figure 1B) with a locally advanced morphoeic lesion (>5 cm). We proposed hypofractionated radiotherapy (twice weekly, for a total duration of 5 weeks of therapy, total dose of 60Gy) [2], using a 6MeV electron beam with a treatment field included the lesion with a free margin of 2 cm. After each session the skin lesion was medicated with sa- line solution, betadine and hyaluronic acid medication. The patient finished radiation treatment in December, reporting no acute toxicities except grade 1 mucositis (CTCAE v.5) (Figure 1C). The follow-up was postponed due to increase of COVID-19 pandemic, following the patient choice. 2 Research Letter | Dermatol Pract Concept. 2023;13(2):e2023110 We saw the patient only in April 2022 (Figure 1D), and the patient presented a clinical and dermoscopical complete response of the skin lesion, with the presence of only residual area of alopecia in the irradiation area. All procedures performed were in accordance with the ethical standards of the institutional and national research committees and with the Helsinki Declaration. Conclusions Radiotherapy can be safely used if imaging procedures can define the tumor area and the depth of invasion [3], in pa- tients with a high risk of uncomplete surgical resection or if surgery is contraindicated. RT has been reported as a valid alternative to surgery, with a negligible risk of developing secondary skin cancer [3-5]. A recent systematic review investigating the efficacy of different strategies for BCC reported an estimated recurrence rate of 3.8% for surgery, 3.8% for Mohs surgery and 3.5% for radiotherapy [6]. Higher doses per fraction lead to higher rates of late toxicity, therefore accelerated fractionation schedules should be reserved for a limited subset of patients. In fact, elderly patients may not be able to attend hos- pital daily, especially in the pandemic era that we are expe- riencing, therefore they can benefit from hypofractionation schemes that can still reach an high control rate (92.4% of complete response rate) [2]. Our patient responded excellently to hypofractionated RT treatment after the failure of several local treatments. Although blind techniques and topical therapies can be easier to perform, “difficult to treat” BCC should be always discussed in MTB, in order to choose and to tailor the most efficacious therapy, especially for elderly patients. References 1. Linos E, Schroeder SA, Chren MM. Potential overdiagnosis of basal cell carcinoma in older patients with limited life expectancy. JAMA. 2014;312(10):997-998. DOI: 10.1001/jama.2014.9655. PMID: 25203077. 2. Valeriani M, Nicosia L, Agolli L, et al. Mono- and Bi-weekly Hypofractionated Radiation Therapy for the Treatment of Ep- ithelial Skin Cancer in Very Elderly Patients. Anticancer Res. 2017;37(2):825-830. DOI: 10.21873/anticanres.11384. PMID: 28179337. 3. Peris K, Fargnoli MC, Garbe C, et al. Diagnosis and treatment of basal cell carcinoma: European consensus-based interdisciplin- ary guidelines. Eur J Cancer. 2019;118:10-34. DOI: 10.1016/j. ejca.2019.06.003. PMID: 31288208. 4. Work Group; Invited Reviewers; Kim JYS, Kozlow JH, Mittal B, Moyer J, Olencki T, Rodgers P. Guidelines of care for the management of basal cell carcinoma. J Am Acad Dermatol. 2018;78(3):540-559. DOI: 10.1016/j.jaad.2017.10.006. PMID: 29331385. 5. Nasr I, McGrath EJ, Harwood CA, et al. British Association of Dermatologists guidelines for the management of adults with basal cell carcinoma 2021. Br J Dermatol. 2021;185(5):899-920. DOI: 10.1111/bjd.20524. PMID: 34050920. 6. Drucker AM, Adam GP, Rofeberg V, et al. Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Net- work Meta-analysis. Ann Intern Med. 2018;169(7):456-466. DOI: 10.7326/M18-0678. PMID: 30242379. Figure 1. Evolution of the reported case. (A) Discussion of the patient in the multidisciplinary tumor board. (B) Locally advanced morphoeic lesion (>5 cm), that was contiguous to nasal vestibule and upper lip, photo taken at the beginning of RT. (C) Photo taken at the end of ra- diotherapy, the lesion showed an initial response. Panel D: (D) At 4-month follow-up visit, complete resolution of the basal cell carcinoma.