P213 Management challenges in scalp osteoradionecrosis after radiotherapy for cutaneous squamous cell carcinoma

Abstract

Adjuvant radiotherapy reduces local recurrence in excised high-risk cutaneous squamous cell carcinoma (cSCC) of the scalp. Osteoradionecrosis is a rare complication of this treatment. Risk factors may include radiotherapy-related variables and skin grafting. Management is challenging, and there is an absence of ­evidence-based guidelines. This study aims to highlight the challenges in managing scalp osteoradionecrosis in our patient cohort. Single-centre analysis from a district general hospital over a 5-year period identified seven male patients (aged 79–88 years) who underwent excision of scalp cSCC with skin grafting, received adjuvant fractionated radiotherapy (total dose 45–55 Gy) and subsequently developed scalp osteoradionecrosis. The latency period from radiotherapy to clinical osteoradionecrosis ranged from 4 months to 6 years. Ulcer size varied from 2 cm to > 10 cm, with some lesions exposing the dura. Two patients developed intracranial complications, including brain abscess and venous sinus thrombosis. Investigations included bacterial swabs, punch biopsies to exclude cutaneous squamous cell carcinoma recurrence, and computed tomography (CT) and magnetic resonance imaging (MRI) scans. Management was individualized. All patients received wound care, six received antibiotics, and one underwent craniectomy with debridement and flap reconstruction. Advanced frailty and significant comorbidities often precluded major surgical procedures. Outcomes included three patients with stable chronic defects, one with severe morbidity and complications, and three deaths: two from progressive disease and one from an unrelated disease. As demonstrated by our case series, scalp osteoradionecrosis is a severe, challenging complication, particularly in frail patients. Noncontrast CT and ­contrast-enhanced MRI may be helpful in assessing for osteoradionecrosis and osteomyelitis, but diagnosis on imaging alone is difficult due to crossover of many characteristics. Cases would benefit from discussion in multidisciplinary team meetings to achieve clinical, pathological and radiological concordance. Despite ongoing trials such as SCC-AFTER evaluating the benefit of adjuvant radiotherapy in high-risk cSCC, there remains an urgent need for evidence-based guidelines for management of scalp osteoradionecrosis.