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Page 12 of 15 Tropiano et al. Mini-invasive Surg 2024;8:17 https://dx.doi.org/10.20517/2574-1225.2024.41

In terms of oncological effectiveness, our results suggest a high rate of local control with IRT. However, it is
important to note that IRT is only a local treatment and nodal involvement at diagnosis is a crucial factor
for survival in NV-SCC [47-55] , as well as in most head and neck mucosal malignancies. In our study, 20% of
cases had positive nodes at diagnosis and were managed with surgery (bilateral comprehensive neck
dissection), and a 20% nodal relapse rate was observed. In this regard, the role of sentinel lymph node
biopsy surely warrants further investigation. All neck metastases at diagnosis and recurrences in previously
observed cN0 were at level I; the recurrence in the already operated cN+ case occurred at level IX. Notably,
the ultrasound-guided FNAB, obtained by a head and neck surgeon, allowed the detection of two-thirds of
cN+ cases, which had been classified as cN0 at morphological imaging. This highlights the importance of
comprehensive neck evaluation in the management of NV-SCC. In fact, small nodes in level I are most
often present and are usually interpreted as reactive/aspecific; the ultrasound screening of a well-trained
head and neck surgeon and the FNAB performed in the lump clinic with rapid on-site evaluation [43,44] seem
to be powerful tools for the early detection and treatment of neck metastasis in this disease, with a probable
impact on prognosis. On the other hand, the inclusion of neck evaluation in a lump clinic in the work-up of
NV-SCC clearly increases the reliability of the cN0 staging and therefore the safety of neck observation.

Our experience [16,20] , supported also by the findings of this study, suggests that local recurrence typically
occurs within the first months after IRT. Therefore, a series with an average follow-up period of seven
months provides useful information regarding local control.

Furthermore, even if evidence on the subject is still lacking, the salvageability of local recurrences is, in
theory, very good, as it would involve anyway a rhinectomy and diagnosis of recurrence can be relatively
easy and early.

Regarding dosimetric parameters, it is important to note that IRT is characterized by a highly favorable dose
distribution. It delivers high doses to the target area with a very rapid fall-off in surrounding tissues .
[56]
Specifically, assessing doses to critical OARs, such as the eyes and lens, is crucial but largely depends on the
distance of the CTV from the ocular region . For this reason, we consistently monitor the dose to the eyes
[57]
and lens, which typically remains below established constraints; however, in certain situations, additional
[58]
measures may be implemented to further reduce the dose .

However, the following limitations should be kept in mind when reading these results.

Limitations of the study
• Most of the data about the comparison of different treatment modalities are not direct, but extrapolated
from different series. However, if the current results are confirmed, it could not be ethically acceptable to
keep proposing total rhinectomy when a nose preservation option with the same oncological results is
available .
[41]
• This is a relatively small series with a short follow-up, making it difficult to detect small differences or to
generalize the findings broadly; yet, the described disease is considered rare, and our focus is mainly on
acute and subacute toxicity, therefore providing valuable information.

• While immediate and short-term benefits are clear, a deeper exploration of long-term outcomes,
particularly concerning regional recurrence rates and long-term cosmetic results (which, for example, may
be impacted by the development of radiation-induced telangiectasia), is needed.