Background: Scalp-associated cutaneous squamous cell carcinoma (cSCC) presents formidable treatment challenges, especially when it leads to full-thickness defects involving bone. Aggressive or recurring cases often demand a multidisciplinary approach. Leveraging our surgical experience and a literature review, we introduce a therapeutic algorithm to guide the selection of reconstruction methods, particularly for locally advanced lesions, furthermore showing the synergy between surgery and other therapies for comprehensive, multidisciplinary disease management. Methods: Our algorithm stems from a retrospective analysis of 202 patients undergoing scalp cSCC resection and reconstruction over a 7-year period, encompassing 243 malignancies. After rigorous risk assessment and documentation of surgical procedures, reconstruction methods were therefore related to malignancy extent, depth, and individual clinical status. Results: The documented reconstructions included 76 primary closures, 115 skin grafts, 7 dermal substitute reconstructions, 33 local flaps, 1 locoregional flap, and 1 microsurgical free flap. Patients unsuitable for surgery received radiotherapy or immunotherapy after histological confirmation. Precise analysis of tumor characteristics in terms of infiltration extent and depth guided the selection of appropriate reconstruction and treatment strategies Combining these insights with an extensive literature review enabled us to formulate our algorithm for managing scalp cSCCs. Conclusions: Effectively addressing scalp cSCC, especially in locally advanced or recurrent cases, demands a systematic approach integrating surgery, radiotherapy, and immunotherapy. Our multidisciplinary team’s decision-making algorithm improved patient outcomes by offering a broader spectrum of therapeutic options that can synergistically achieve optimal results.

Whole breast radiotherapy in adjuvant breast cancer (BC) treatment has been commonly delivered in supine positioning for more than 50 years. Its widespread use is related to the broad availability of simple and common breast board immobilization devices, which exploit the natural recumbent position of the body with arms above the head, the good match with linac tables and well-established set up procedures. However, in scenarios like painful arm discomfort in patients with post-surgery arm or arthritic limitation, unfavorable chest geometry like pectus excavatum (PE), large and pendulous breasts in obese women and cardiac morbidity in left sided BC, supine position seems very uncomfortable for patients and troublesome for radiation oncologists. The question is how to proceed when supine IMRT or DIBH are ineffective strategies? Alternative positions have been analyzed over the past twenty years, starting with a lot of trials testing prone positioning variants with and without DIBH, lateral decubitus or upright standing radiotherapy. A better recognition of new treatment position options in BC adjuvant therapy may provide more opportunities for personalized radiotherapy in this population, to ensure they receive an appropriate, safe and comfortable treatment.

Radiation oncology departments are increasingly required to deliver complex, technology-dependent care while facing medical workforce constraints. In the Italian context, reduced attractiveness of radiation oncology training and increasing workflow complexity highlight the need for transparent skill-mix models. This technical note proposes a practical framework for advanced practice radiation therapists (APRTs) to support selected technical, organisational and protocol-driven components of the radiotherapy pathway while preserving radiation oncologist (RO) accountability for clinical decision-making. A structured narrative and implementation-oriented approach was used. Literature on radiotherapy utilisation, workforce constraints, APRT roles, time-driven activity-based costing and governance was integrated with the Italian professional context. Activities were classified according to medical decision intensity, technical standardisation, patient-specific variability, safety risk and suitability for protocol-based execution. Potential APRT roles include simulation preparation, image-guided radiotherapy matching within defined thresholds, organ-at-risk contouring support, auto-contouring review, dosimetric data extraction, toxicity screening, quality assurance, incident reporting and pathway coordination. Non-delegable medical responsibilities include treatment indication, informed consent, prescription, target definition, final plan approval, adaptive decisions affecting prescription or target coverage, toxicity management and oncological follow-up. Safe implementation requires formal education, clinical mentorship, competency assessment, written standard operating procedures, escalation rules, audit and multidisciplinary governance. APRTs should not be viewed as substitutes for ROs, but as a structured workforce strategy to preserve medical decision-making capacity and improve workflow resilience in Italian radiotherapy services. Prospective time-motion, safety and health-economic evaluations are needed to quantify the operational impact and transferability of APRT implementation.