Mortality risk from squamous cell skin cancer

Concurrent primary and metastatic cutaneous head and neck squamous cell carcinoma: Analysis of prognostic factors

BACKGROUND

There is a small subgroup of patients with head and neck cutaneous squamous cell carcinoma (cSCC) in which nodal metastases present concurrently with the primary lesion. There is evidence that these tumors may represent a more aggressive subset of cSCC. The aim of this study was to determine whether alternative clinicopathologic prognostic factors should be applied to this patient cohort.

METHODS

A retrospective analysis of data from prospective databases of 2 large head and neck cancer units in Sydney, Australia, was performed. Ninety-five patients with concurrent primary and nodal metastatic head and neck cSCC were suitable for inclusion in the study.

RESULTS

Univariable analysis was performed for overall survival (OS) and disease-specific survival (DSS). OS was adversely affected by immunosuppression (p = .011) and nodal extracapsular spread (ECS) (p = .006). Similarly, immunosuppression (p = .005) and ECS (p = .005) indicated a worse outcome for DSS. ECS and immunosuppression remained significant in the multivariable analysis.

CONCLUSIONS

This study found that adverse prognostic factors were similar to the current evidence for nonconcurrent metastatic cSCC. In particular, the primary lesion had no significant influence on survival.

Three apoptotic genes are upregulated in a patient with Alzheimer's disease and well-differentiated squamous cell carcinoma

We report the case of a 74-year-old man with Alzheimer's disease (AD) and an extensive ulcerative lesion on the right ear. AD is a neurodegenerative disease with progressive loss of memory and cognitive deterioration. It has been suggested that apoptotic cell injury and eventually cell death is a major contributor to the AD neurodegenerative process. The ulcerative lesion was surgically excised and the histological analysis reported a well-differentiated squamous cell carcinoma. Caspase-3 (CASP3) plays an important role in neuronal death during nervous system development and under certain pathological conditions. Furthermore, in vitro and in vivo studies reported elevated expression and activation of CASP3 in models of AD. Molecular epidemiological studies suggest that CASP3 may contribute to head and neck squamous cell carcinoma susceptibility and disease progression and that increased CASP3 expression is associated with tumors of the head. Also poly (ADP-ribose) polymerase 1 (PARP1) and the leucine zipper downregulated in cancer 1 (LDOC1) genes play a proapoptotic role. We therefore evaluated the differential expression of LDOC1, PARP1, and CASP3 mRNA in peripheral blood leukocytes of our patient. We found increased expression of all these genes compared with the expression in control subjects.

Skin carcinoma of the head and neck with perineural invasion

PURPOSE

The aim of the study was to update the experience treating cutaneous squamous cell and basal cell carcinomas of the head and neck with incidental or clinical perineural invasion (PNI) with radiotherapy (RT).

MATERIALS AND METHODS

From 1965 to 2007, 216 patients received RT alone or with surgery and/or chemotherapy.

RESULTS

The 5-year overall, cause-specific, and disease-free survivals for incidental and clinical PNIs were 55% vs 54%, 73% vs 64%, and 67% vs 51%. The 5-year local control, local-regional control, and freedom from distant metastases for incidental and clinical PNIs were 80% vs 54%, 70% vs 51%, and 90% vs 94%. On univariate and multivariate (P = .0038 and .0047) analyses, clinical PNI was a poor prognostic factor for local control. The rates of grade 3 or higher complication in the incidental and clinical PNI groups were 16% and 36%, respectively.

CONCLUSIONS

Radiotherapy plays a critical role in the treatment of this disease. Clinical PNI should be adequately irradiated to include the involved nerves to the skull base.

Mohs frozen tissue sections in comparison to similar paraffin-embedded tissue sections in identifying perineural tumor invasion in cutaneous squamous cell carcinoma

BACKGROUND

Perineural invasion (PNInv) in cutaneous squamous cell carcinoma (cSCC) increases the risk of recurrence, possibly because of suboptimal identification on frozen or paraffin-embedded tissue sections. Perineural inflammation (PNInf) may portend PNInv.

OBJECTIVE

We sought to correlate identification of PNInv and PNInf in hematoxylin-eosin-stained Mohs frozen sections with PNInv and PNInf identified in similarly oriented paraffin-embedded sections obtained in cases of cSCC.

METHODS

We reviewed same patient Mohs frozen and paraffin-embedded tissue sections for all patients presenting within a 2-year period to our Mohs micrographic surgical unit for removal of cSCC with PNInv or PNInf identified on either type of tissue section.

RESULTS

Of 537 patients undergoing surgical resection of cSCC, 21 (3.9%) had either PNInv (n = 11) or PNInf (n = 10) on frozen sections. PNInv on Mohs frozen sections was identified in 11 cases and confirmed on paraffin-embedded sections in 9 cases (82%). Paraffin-embedded sections failed to identify PNInv present in Mohs frozen sections in two (2/11), or 18% of cases. PNInf on Mohs frozen sections was confirmed on paraffin-embedded sections in 3 cases (30%), but PNInv was identified in 5 cases (50%).

LIMITATIONS

Our results are a retrospective case review from a specific time period by one institution. Furthermore, it is impossible to compare identical tissue specimens using two sequential tissue processing techniques.

CONCLUSION

PNInv can be accurately identified with Mohs frozen sections. PNInf on Mohs frozen sections suggests the presence of PNInv and requires further histologic investigation.

The 7th edition AJCC staging system for cutaneous squamous cell carcinoma accurately predicts risk of recurrence for heart and lung transplant recipients

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is the most common malignancy after solid organ transplantation, with an increased risk of recurrence and metastasis over the general population. The newly updated 7th edition American Joint Committee on Cancer (AJCC) staging system for cSCC is based on consensus expert opinion and requires validation in large cohort studies and in specific patient subpopulations.

OBJECTIVE

Our objective was to evaluate the risk of cSCC recurrence in a high-risk population of heart and lung transplant recipients, based on the 7th edition AJCC staging system.

METHODS

We performed a 10-year retrospective cohort study of all primary cSCC diagnosed in heart and lung transplant recipients at a tertiary care academic dermatology center.

RESULTS

The cumulative incidence of local recurrence was 4% for cSCC in situ and 19% for stage I cSCC at 5 years, and 54% for stage II cSCC at 3 years. Stage II tumors had a 10-fold greater risk of recurrence than stage I, and a 43-fold greater risk of recurrence than in situ tumors.

LIMITATIONS

This study is limited to a specific patient subgroup at a tertiary care center, and may not be generalizable to all populations.

CONCLUSIONS

Heart and lung transplant recipients are at high risk for local recurrence of cSCC. These data substantiate the prognostic accuracy of the newly updated 7th edition AJCC staging system for stage 0, I, and II cSCC in this population and demonstrate the aggressive behavior of this cancer in immunosuppressed patients.

A phase II study of gefitinib for aggressive cutaneous squamous cell carcinoma of the head and neck

PURPOSE

To determine the disease control rate and toxicity of treating patients with aggressive cutaneous squamous cell carcinoma (CSCC) with neoadjuvant gefitinib.

EXPERIMENTAL DESIGN

A prospective phase II clinical trial evaluating neoadjuvant gefitinib given prior to standard treatment with surgery and/or radiotherapy. Patients with stable disease after one cycle received escalated doses. Patients who responded were given gefitinib during radiation therapy, as well as maintenance therapy after definitive treatment. We analyzed the correlation between epidermal growth factor receptor (EGFR) expression, mutation status, and gene copy number on available tissue samples and clinical response.

RESULTS

Twenty-three patients were accrued and 22 patients were evaluable for response prior to definitive local treatment; complete responses were attained by 18.2% of patients and partial responses by 27.3%. Grades 2 to 3 toxicities were observed in 59.1% of patients experiencing class-specific effects during induction therapy. After induction, 11.8% underwent surgery alone, 17.6% had definitive radiation, 11.8% were treated with radiation and concurrent gefitinib, and 47% had surgery with postoperative radiation and concurrent gefitinib. Median follow-up for the censored observations was 32 months. Two-year overall, disease-specific, and progression-free survival rates were 72.1%, 72.1%, and 63.6%, respectively. No EGFR-activating mutations were identified in tumor samples available from 10 patients. No associations between EGFR correlative studies and patient outcomes were identified.

CONCLUSIONS

Gefitinib, in the neoadjuvant setting, was active and well tolerated in patients with aggressive CSCC and did not interfere with definitive treatment. In view of the 18% complete response rate we observed, EGFR tyrosine kinase inhibitors should be further explored in the treatment of aggressive CSCC.

The role of the E2F transcription factor family in UV-induced apoptosis

The E2F transcription factor family is traditionally associated with cell cycle control. However, recent data has shown that activating E2Fs (E2F1-3a) are potent activators of apoptosis. In contrast, the recently cloned inhibitory E2Fs (E2F7 and 8) appear to antagonize E2F-induced cell death. In this review we will discuss (i) the potential role of E2Fs in UV-induced cell death and (ii) the implications of this to the development of UV-induced cutaneous malignancies.

Update on the management of high-risk squamous cell carcinoma

Cutaneous squamous cell carcinoma (CSCC) is the second most common malignancy occurring in white patients in the United States and incidence rates are increasing. While the majority of the 87,000-760,000 cases that occur yearly in the U.S. are curable, 4% develop lymph node metastases and 1.5% die from the disease. Given the frequency of occurrence of CSCC, it is estimated to cause as many deaths yearly as melanoma, with the majority occurring in patients with high risk tumors or in those at high risk for metastasis due to a variety of host factors, most commonly systemic immunosuppression. There are currently no standardized prognostic or treatment models to assist clinicians in most effectively identifying and managing these patients. Identification of patients at risk for poor outcomes as well as standardization regarding classification, staging, and treatment of high-risk tumors is critical for optimizing patient care. In this article, available literature on the classification and management of high risk CSCC is briefly summarized, emphasizing new information.

Management of high-risk squamous cell carcinoma of the skin

Cutaneous squamous cell cancer (SCC) is the second most common skin cancer, accounting for one-fifth of all cutaneous malignancies. The majority arise on the head and neck skin, and cumulative UV exposure is thought to be the most likely etiological factor. The majority of deaths from SCC occur in a high-risk subgroup of patients. This high-risk subgroup of patients can be identified as those with tumors greater than 2 cm in diameter; tumor thickness over 4 mm; moderately/poorly differentiated or desmoplastic histological SCC subtype; ear, lip, hand, feet or genital tumor site; presence of perineural or lymphovascular invasion; nodal metastasis at presentation; recurrent SCC; SCC arising from scars or chronic skin disease, for example, chronic ulcers; and SCC arising in immunosuppressed patients. It is important to identify and aggressively treat these patients, as high-risk SCC are associated with a greater mortality and morbidity. This article reviews the diagnosis and management of such high-risk SCC.

Auricular squamous cell carcinoma

Squamous cell carcinoma is a common cancer to the head and neck region that is typically diagnosed when it is 2 cm in size. This case report illustrates a patient who had neglected an auricular carcinoma for over a year. At the time of presentation the entire ear was infected with pseudomonas and yeast and chronic friability and bleeding caused an anemia which required blood transfusion.

Outcomes of recurrent head and neck cutaneous squamous cell carcinoma

Recurrent, advanced stage cutaneous squamous cell carcinoma (cSCC) is uncommon with limited publications on patient outcomes. A retrospective study including patients who underwent surgical resection for recurrent, advanced stage cSCC of the head and neck was performed (n = 72). Data regarding tumor site, stage, treatment, parotid involvement, perineural invasion, positive margins, metastasis, and disease-free survival was analyzed. The majority of patients were male (85%) and presented with recurrent stage III (89%) cSCC. Two-year disease-free survival was 62% and decreased to 47% at 5 years. Parotid involvement, positive margins, nodal metastasis, or the presence of perineural invasion did not correlate with decreased survival (P > .05). Distant metastasis was a strong indicator of poor overall survival (P < .001). Adjuvant postoperative radiotherapy did not improve overall survival (P = .42). Overall survival was poor for patients with advanced recurrent cSCC despite the combined treatment with surgery and radiotherapy.

A new American Joint Committee on Cancer staging system for cutaneous squamous cell carcinoma: creation and rationale for inclusion of tumor (T) characteristics

BACKGROUND

The incidence of cutaneous squamous cell carcinoma (cSCC) is increasing. Although most patients achieve complete remission with surgical treatment, those with advanced disease have a poor prognosis. The American Joint Committee on Cancer (AJCC) is responsible for the staging criteria for all cancers. For the past 20 years, the AJCC cancer staging manual has grouped all nonmelanoma skin cancers, including cSCC, together for the purposes of staging. However, based on new evidence, the AJCC has determined that cSCC should have a separate staging system in the 7th edition AJCC staging manual.

OBJECTIVE

We sought to present the rationale for and characteristics of the new AJCC staging system specific to cSCC tumor characteristics (T).

METHODS

The Nonmelanoma Skin Cancer Task Force of AJCC reviewed relevant data and reached expert consensus in creating the 7th edition AJCC staging system for cSCC. Emphasis was placed on prospectively accumulated data and multivariate analyses. Concordance with head and neck cancer staging system was also achieved.

RESULTS

A new AJCC cSCC T classification is presented. The T classification is determined by tumor diameter, invasion into cranial bone, and high-risk features, including anatomic location, tumor thickness and level, differentiation, and perineural invasion.

LIMITATIONS

The data available for analysis are still suboptimal, with limited prospective outcomes trials and few multivariate analyses.

CONCLUSIONS

The new AJCC staging system for cSCC incorporates tumor-specific (T) staging features and will encourage coordinated, consistent collection of data that will be the basis of improved prognostic systems in the future.

Cutaneous squamous cell carcinoma of the head and neck

Cutaneous squamous cell carcinoma of the head and neck is an epidemic that reaches all parts of the world. Making the diagnosis relies on the acumen of the clinician and pathologist. Various pathologic subtypes exist and differ in histology and prognosis. High-risk tumors need aggressive treatment and vigilant surveillance to monitor for recurrence. Large tumors, deep tissue invasion, perineural involvement, recurrence, location in high-risk areas, and immunosuppression are implicated in worsening prognosis. Surgery is the mainstay of treatment with adjuvant radiation therapy as needed for aggressive tumors; however, other modalities are potentially useful for low-risk lesions. The use of Mohs surgery has become increasingly useful and has shown high success rates. Involvement of parotid and neck lymph nodes significantly affects outcomes and the physician should be comfortable with management of this complex disease. This paper examines the diagnosis, pathology, clinical course, and treatment options for cutaneous squamous cell carcinoma of the head and neck.

Predicting the pattern of regional metastases from cutaneous squamous cell carcinoma of the head and neck based on location of the primary

BACKGROUND

We aimed to analyze the distribution of regional nodal metastases according to primary tumor location in patients with cutaneous squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Analysis of 295 neck dissections performed for patients with clinically evident regional metastases from cutaneous SCCHN between 1987 and 2009.

RESULTS

Level I involvement in the absence of level II or III only occurred in patients with facial primaries. In patients with clear nodes in level II-III, the risk of level IV-V involvement was 0.0% for external ear primaries, 2.7% for face and anterior scalp, and 15.8% for posterior scalp and neck.

CONCLUSION

In patients undergoing parotidectomy for metastatic cutaneous SCCHN with a clinically negative neck, the results of this study support selective neck dissection including level I-III for facial primaries, level II-III for anterior scalp and external ear primaries, and levels II-V for posterior scalp and neck primaries.

Dual inhibition of epidermal growth factor receptor and insulin-like growth factor receptor I: reduction of angiogenesis and tumor growth in cutaneous squamous cell carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma (CSCC) is the second most common nonmelanoma skin cancer. Most of the approximately 250,000 cases occurring annually in the United States are small, nonaggressive, and cured by excision alone. However, a subset of these tumors which are defined by poorly differentiated histology, large tumor size, invasion of adjacent structures, and/or regional metastases can prove resistant to treatment despite adjuvant radiotherapy and can have an increased risk of recurrence and nodal metastasis. Novel therapeutic approaches are necessary to improve the outcomes for patients with aggressive CSCC.

METHODS

We analyzed the effect of targeted therapy on the growth and survival of CSCC cell lines using an anti-insulin-like growth factor-I receptor (IGF-IR) antibody, A12, alone or in combination with an anti-epidermal growth factor receptor (EGFR) antibody, cetuximab, both in vitro and in vivo in an athymic nude mouse model of CSCC.

RESULTS

Treatment with A12 and cetuximab inhibited the signaling pathways of IGF-IR and EGFR and inhibited proliferation and induced apoptosis of squamous cell carcinoma (SCC) cell lines in vitro. Immunohistochemical staining revealed decreased proliferating cell nuclear antigen (PCNA), microvessel density, and increased apoptosis within the treated tumor xenografts. In addition, the administration of A12, alone or in combination with cetuximab inhibited the growth of tumors by 51% and 92%, respectively, and significantly enhanced survival in the nude mouse model of CSCC (p = .044 and p < .001, respectively).

CONCLUSION

These data suggest that dual treatment with monoclonal antibodies to the EGFR and IGF-IR may be therapeutically useful in the treatment of CSCC.

Treatment of unresectable and metastatic cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (SCC) is an already common disorder with a rapidly increasing incidence. Treatment of early disease depends primarily on surgery or destructive techniques. In contrast to the frequency of early SCC, unresectable or metastatic SCC is relatively rare, but potentially life-threatening without clearly proven treatment options. Few rigorous studies of the treatment of advanced SCC have been undertaken. In the past, various agents have been explored in a limited fashion, including chemotherapy (cisplatin, fluoropyrimidines, bleomycin, doxorubicin), 13-cis-retinoic acid, and interferon-α2a. Clinical activity has been suggested by these trials, but their small sizes, heterogeneous patient populations, and lack of randomization have hindered the use of their results in defining treatment paradigms. Only one rigorous randomized trial has focused on cutaneous SCC. Enrolling 66 patients, that trial randomized patients at high recurrence risk to either observation or postoperative interferon-α2a and 13-cis-retinoic acid. This treatment did not improve time to recurrence or prevent secondary cutaneous SCC from developing. Though not in the metastatic setting, this study casts doubt on the ability of this regimen to control metastatic disease. Recently, agents targeting the human epidermal growth factor receptor (erlotinib, gefitinib, cetuximab) have displayed preliminary evidence of activity in phase II clinical trials and case series reports. Expression of this receptor is frequent in cutaneous SCC and appears to be prognostically adverse. Only the conduct of rigorous trials, with well-defined endpoints, adequate patient numbers, and preferably randomization, can prove the clinical efficacy of this promising treatment approach and define better therapy for this vexing clinical problem.

Perineural invasion detected by high-field 3.0-T magnetic resonance imaging

The presence of perineural invasion (PNI) with cutaneous squamous cell carcinoma portends a poor prognosis. PNI may be detected radiographically or clinically, with motor or sensory deficits, and is confirmed by histologic evaluation. Recent interest has grown regarding the role of imaging in determining the presence of PNI and its preoperative implications. We report on a patient with cutaneous squamous cell carcinoma invading the parotid gland with clinical evidence of facial nerve weakness. On standard 1.5 Tesla (T) magnetic resonance imaging (MRI), bilateral parotid glands were symmetric; however, a second high-field 3-T MRI revealed asymmetric enhancement of the left facial nerve at the stylomastoid foramen and extending throughout the left parotid gland. PNI was later confirmed on histopathology. The presurgical determination of PNI was essential in our mapping the exact tumor location and in our surgical planning.

Cutaneous squamous cell carcinoma (SCC) of the head and neck: risk factors of overall and recurrence-free survival

BACKGROUND

Head and neck cutaneous squamous cell carcinoma (HNCSCC) although rarely fatal has significant adverse public health effects due to high medical costs, compromised quality of life, functional impairment and other serious consequences. The present longitudinal cohort study of HNCSCC was designed to determine whether certain clinical-pathologic features of HNCSCC are associated with reduced overall and recurrence-free survival, as suggested by previous data.

PATIENTS

The cohort sample consisted of 315 consecutive patients presenting with primary HNCSCC of the head and neck. Life-table analysis and Kaplan-Meier survival analysis were performed. Multivariate Cox's proportional hazards regression models were used to assess the effects of covariates on the length of the interval.

RESULTS

There were 145 male and 170 female Caucasian patients. At the time of analysis, 222 patients were alive. The mean follow-up time of a patient after enrolment has been 46.7 months (range, 12-124 months). Broder's differentiation grade, perineural involvement, the presence of inflammation and T-stage were independent adjusted predictors for overall survival. pT and N-stage, inflammation and perineural involvement were significant predictors for recurrence-free survival while adjuvant irradiation was associated with a 92% reduced risk for recurrence. Life-table analysis showed that 87% and 69% study patients were free from recurrence at years 3 and 5, respectively.

CONCLUSIONS

Certain clinico-pathological predictors can be used to discriminate subsets of high-risk patients that could benefit from long-term follow-up. After excision in negative margins, patients with HNCSCC should be referred to specialised multidisciplinary oncology clinics for counselling on adjuvant radiotherapy and follow-up.

UV-induced squamous cell carcinoma--a role for antiapoptotic signalling pathways

The incidence of nonmelanoma skin cancer including squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) has dramatically increased in the last decades, and chronic sun exposure was identified as a main etiologic agent. UV radiation may produce DNA damage either directly or through reactive oxygen species (ROS). As mutations caused by UV may lead to skin cancer due to oncogene activation and tumor suppressor gene inactivation, efficient safeguard mechanisms have been developed during evolution. These enclose induction of apoptosis and formation sunburn cells aiming at the removal of premalignant cells. The keratinocyte apoptotic machinery in response to UV consists of both intrinsic/mitochondrial and extrinsic/death receptor-mediated cell-death pathways, which are particularly regulated by mitogen-activated protein kinases (MAPKs, JNK and p38) and the tumor-suppressor protein p53. For development of skin cancer, it appears that critical steps in apoptosis control are dysregulated leading to resistance both to death ligand-mediated and intrinsic proapoptotic pathways. These particularly include inactivation of p53, as well as activation of EGFR, COX-2 and MAPKs, which result in specific regulation of Bcl-2 proteins, death ligands and death receptors. The final unravelling of apoptosis regulation in epithelial skin cancer may allow the development of new targeted therapeutic strategies.

Development and validation of a prediction model for the risk of developing febrile neutropenia in the first cycle of chemotherapy among elderly patients with breast, lung, colorectal, and prostate cancer

Purpose

Current guidelines recommend prophylactic use of granulocyte-colony stimulating factors (G-CSF) when febrile neutropenia (FN) risk is greater than 20%. Advanced age is a risk factor for FN; however, little is known about the impact of other factors on the incidence of FN in an older population.

Patients and methods

We analyzed SEER-Medicare data (1994–2005) to develop and validate a prediction model for hospitalization with fever, infection, or neutropenia occurring after chemotherapy initiation for patients with breast, colorectal, prostate, and lung cancer.

Results

In multivariate analysis (N = 58,053) independent predictors of FN included advanced stage at diagnosis [stage 2 (OR 1.29; 95% CI: 1.09–1.53), stage 3 (1.38; 95% CI: 1.19–1.60), and stage 4 (1.57; 95% CI: 1.35–1.83)], number of associated comorbid conditions [one condition (1.13; 95% CI: 1.02–1.28), two conditions (1.39; 95% CI: 1.22–1.57), and three or more conditions (1.81; 95% CI: 1.61–2.04)], receipt of myelosuppressive chemotherapy (1.11; 95% CI: 0.94–1.32), and receipt of chemotherapy within 1 month of diagnosis [1 to 3 months (0.70; 95% CI: 0.62–0.80) and greater than 3 months (0.63; 95% CI: 0.55–0.73)].

Conclusion

We created a prediction model for febrile neutropenia with first cycle of chemotherapy in a large population of elderly patients with common malignancies.

Nonmelanoma skin cancer

This article provides readers with a comprehensive review of the evaluation and management of nonmelanoma skin cancers. Treatment recommendations are heavily based on the most recent guidelines from the National Comprehensive Cancer Network. Merkel cell carcinoma and dermatofibrosarcoma protuberans are also discussed. After reviewing this article, readers should be equipped with a better understanding of these entities and the current recommendations for their management.

Long-term outcome of squamous cell carcinoma of the upper and lower limbs

Cutaneous squamous cell carcinoma (SCC) is the second most common malignant skin tumour in the European population, with an annual estimated age-standardised incidence of 1-6 per 1000. After the head and neck, the upper and lower limbs are the most common sites affected with 14% of SCCs occurring in these areas. SCC has the potential to be a highly aggressive tumour but there are no recent studies looking at the long-term outcome of patients with extremity SCC. A retrospective study was performed of 243 patients with a total of 517 upper and lower extremity SCCs who had been followed up for at least 4yrs. All patients' lesions were studied at one institution and data was collected from the Medical and Histopathology records. We found that there is only a low rate of recurrence or metastasis for extremity SCCs and that patients had a good prognosis overall.

Incidência do carcinoma de células escamosas da pele na cidade de Tubarão (SC) - Brasil nos anos de 2000, 2003 e 2006

FUNDAMENTOS: Observa-se tendência mundial de aumento na incidência do carcinoma de células escamosas da pele, porém na região sul do estado de Santa Catarina (SC) não há dados sobre a incidência desse tipo de câncer. OBJETIVOS: Estabelecer dados epidemiológicos do carcinoma de células escamosas da pele em Tubarão (Santa Catarina). MÉTODOS: Laudos anatomopatológicos positivos para o carcinoma de células escamosas da pele dos laboratórios de Tubarão foram revisados quanto às variáveis: ano, idade, gênero, localização, subtipo histológico, maior diâmetro da lesão e comprometimento das margens. A incidência anual foi calculada utilizando o número de neoplasias encontradas e a população anual estimada para os anos de 2000, 2003 e 2006. RESULTADOS: Foi encontrada uma incidência de carcinoma de células escamosas da pele por 100.000 habitantes de 50,86 para o ano de 2000, de 71,16 para 2003 e de 94,39 para 2006. Não houve predomínio de gênero, a face foi o local de acometimento mais frequente em ambos os gêneros e o subtipo histológico mais comum foi o bem diferenciado. CONCLUSÃO: A incidência do carcinoma de células escamosas da pele encontrada superou a estimativa da literatura consultada. Houve aumento na sua incidência; as variáveis idade, localização e tipo histológico foram concordantes com a literatura, porém a distribuição quanto ao gênero se mostrou diferente.

Prognostic criteria for squamous cell cancer of the skin

BACKGROUND

Non-well-differentiated cutaneous squamous cell carcinomas may display a more aggressive behavior. It is important to better define prognostic criteria for these tumors.

METHODS

This was a retrospective case-control analysis of a squamous cell carcinoma database. Patients with non-well-differentiated and well-differentiated tumors were matched based on site of tumor, age, and immunocompromised status. Comparisons included demographics, histology, immunohistochemical protein expressions (Ki-67, p53, E-cadherin, cyclin D1), and clinical outcomes.

RESULTS

Demographic features were similar between cases (n=30) and controls (n=30). Non-well-differentiated tumors were larger (1.8 cm versus 1.3 cm, P=0.08), deeper (0.81 cm versus 0.32 cm, P<0.0001), and had greater recurrence (P=0.003). Non-well-differentiated tumors showed increased proliferation rate, Ki-67 index (77% versus 61%, P=0.001); no significant difference in activity of p53, E-cadherin, and cyclin D1 between the two groups.

CONCLUSIONS

Tumor differentiation and depth are important pathologic and prognostic criteria for cutaneous squamous cell carcinoma. Immunohistochemistry helps describe patterns of biomarker protein expression and may exemplify aggressive subtypes.

Regional spread of cutaneous squamous cell carcinoma of the face via facial vein tumor thrombus: a case report

Cutaneous squamous cell carcinoma of the head and neck most often spreads via direct extension or through lymphatics to regional lymph nodes. This is a unique case of a cutaneous squamous cell carcinoma of the nasal dorsum with direct vascular invasion of the facial vein. This was initially incorrectly identified as a regional level Ib lymph node metastases, and the intervening venous structures were neither extirpated during an initial surgery nor recognized during subsequent radiation therapy. The patient then presented with a sizable recurrence in the right suborbital subcutaneous tissue region extending into the neck and internal jugular vein. During further resection, direct tumor invasion into the facial vein was pathologically confirmed. This unusual involvement is presented as the first documented report of regional spread via tumor thrombosis within the facial vein as demonstrated in the facial vein with a tumor thrombus, as demonstrated by computed tomography and microscopic findings.

Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study

BACKGROUND

Cutaneous squamous-cell carcinomas (SCC) are among the most common cancers capable of metastasis. Current Tumour Node Metastasis (TNM) staging includes horizontal tumour size, involvement of extradermal structures, and degree of differentiation. The aim of this study was to prospectively analyse the key factors predicting metastasis and local recurrence in cutaneous SCC.

METHODS

We assessed prospectively investigated potential risk factors for metastasis or local recurrence of SCC, previously suggested by retrospective studies and small case series, in 615 white patients. Between Jan 1, 1990, and Dec 31, 2001, all patients underwent surgery for cutaneous SCC with complete histological examination of the three-dimensional excision margins (3D-histology) in one centre. Univariate and multivariate analysis included tumour thickness, horizontal size, body site, histological differentiation, desmoplastic growth, history of multiple SCC, and immunosuppression. Primary endpoints were time to metastasis and time to local recurrence, defined as the time from date of diagnosis of the primary tumour to the date of diagnosis of metastasis or local recurrence, respectively.

FINDINGS

653 patients were enrolled in the study. 38 patients were lost to follow-up leaving 615 assessable patients (median age 73 years [range 27-98]). During a median follow-up period of 43 months (range 1-165), 26 (4%) of 615 patients developed metastases and 20 patients developed local recurrence (3%). Tumours 2.0 mm or less in thickness did not metastasise. Metastases occurred in 12 (4%) of 318 tumours between 2.1 mm and 6.0 mm in thickness, and in 14 (16%) of 90 tumours with a thickness greater than 6.0 mm. On multivariate analysis, key prognostic factors for metastasis were increased tumour thickness (hazard ratio 4.79 [95% CI 2.22-10.36]; p<0.0001), immunosuppression (4.32 [1.62-11.52]; p=0.0035), localisation at the ear (3.61 [1.51-8.67]; p=0.0040), and increased horizontal size (2.22 [1.18-4.15]; p=0.0128). The risk of local recurrence depended on increased tumour thickness (6.03 [2.71-13.43]; p<0.0001) and desmoplasia (16.11 [6.57-39.49]; p<0.0001).

INTERPRETATION

Only SCC greater than 2.0 mm in thickness are associated with a significant risk of metastasis. Tumours greater than 6.0 mm are associated with a high risk of metastasis and local recurrence. Desmoplastic growth is an independent risk factor for local recurrence. Studies should assess the role of follow-up visits and sentinel-lymph-node biopsy in high-risk patients.