Nodal staging of high-risk cutaneous squamous cell carcinoma

Metastatic patterns and treatment options for head and neck cutaneous squamous cell carcinoma (Review)

According to current predictions, one-fifth of all Americans will develop skin cancer during their lifetime. Cutaneous squamous cell carcinoma (cSCC) most commonly occurs in the head and neck region, which is the area of the body with the highest level of sun exposure. High-risk head and neck cSCC (HNcSCC) is a broad category with numerous high-risk factors that are associated with unfavorable results. In cSCC staging systems, clinical and tumor traits that are likely to result in poor outcomes are identified. Metastasis occurs in ~2.5% of patients with cSCC, most often in the local lymph nodes, and there is some indication that lymph node metastasis has a distinct pattern based on the tumor site. Current findings on tumor molecular targets have suggested the use of systemic treatments, particularly immunotherapy (such as cemiplimab, pembrolizumab and nivolumab), over radiotherapy or chemotherapy for this type of metastasis. However, when used simultaneously with immunotherapy, radiotherapy may be beneficial in the treatment of metastatic HNcSCC by improving the efficacy of immunotherapy. The present review aims to assess the existing literature on metastatic HNcSCC pathways and treatment options, in order to define current and future directions. Notably, there is an urgent need to identify patients who may benefit from local or systemic cancer treatments. The treatment of lymph node metastasis presents a therapeutic challenge and requires comprehensive management.

Use of Imaging in Cutaneous Squamous Cell Carcinoma to Detect High-Risk Tumor Features, Nodal Metastasis, and Distant Metastasis: A Systematic Review

BACKGROUND

Imaging has been shown to impact management and disease outcomes in cutaneous squamous cell carcinoma, but the literature on optimal modalities is lacking.

OBJECTIVE

To perform a systematic review evaluating the performance of various imaging studies for the detection of perineural spread, bony invasion, nodal metastasis (NM), and distant metastasis in cutaneous squamous cell carcinoma.

MATERIALS AND METHODS

Four databases were searched for relevant terms. Articles were included if they presented primary data on 5 or more subjects with cutaneous squamous cell carcinoma who underwent imaging to detect perineural spread, bony involvement, NM, or distant metastasis.

RESULTS

Thirty studies and 1,027 subjects were included in the pooled analysis. Magnetic resonance imaging had a 94.9% sensitivity in detecting perineural spread. Computed tomography (CT) demonstrated a sensitivity of 75.7% and specificity of 98.6% in detecting bony invasion. While ultrasound, positron emission tomography-computed tomography, and CT all performed reasonably well in detecting NM, CT demonstrated the highest sensitivity (96.4%) and specificity (100%). Imaging changed management in up to 33% of cases.

CONCLUSION

Imaging is useful in high-risk cutaneous squamous cell carcinoma. Magnetic resonance imaging performs best in the detection of perineural spread, and CT is the most accurate modality to detect bony invasion and NM.

Lymphovascular Invasion in Cutaneous Squamous Cell Carcinoma

BACKGROUND

Although there is a large body of literature regarding risk stratification and outcomes for perineural invasion (PNI) in cutaneous squamous cell carcinoma (cSCC), there is a relative paucity of studies exploring the role of lymphovascular invasion (LVI) in cSCC and a lack of clear evidence-based guidelines for how to manage patients with these tumors.

OBJECTIVE

This article is intended to review the available literature regarding LVI in cSCC and formulate evidence-based recommendations for clinical management.

METHODS AND MATERIALS

A literature review was conducted using PubMed to find relevant articles relating to outcomes and management of primary cSCC with LVI.

RESULTS

The available literature suggests that LVI is a major risk factor for poor outcomes and increased morbidity and mortality in cSCC.

CONCLUSION

Lymphovascular invasion is a very high-risk feature that should place these tumors in the highest-risk category, and management of these tumors should be similar to that of squamous cell carcinoma with PNI.

Management of Cutaneous Squamous Cell Carcinoma of the Scalp: The Role of Imaging and Therapeutic Approaches

Cutaneous squamous cell carcinoma (cSCC) is the second most common subtype of skin cancer. The scalp is one of the most frequently affected locations and is associated with a higher rate of complications, compared to other locations. In addition, it has a characteristic thickness and anatomical structure that may influence both growth pattern and treatment of primary cSCC; while clinical peripheral margins may be easily achieved during the surgery, vertical excision of the tumor is limited by the skull. Despite having a unique anatomy, current guidelines do not contemplate specific recommendations for scalp cSCC, which leads to inconsistent decision-making in multidisciplinary committees when discussing tumors with high risk factors or with close margins. This article provides specific recommendations for the management of patients with scalp cSCC, based on current evidence, as well as those aspects in which evidence is lacking, pointing out possible future lines of research. Topics addressed include epidemiology, clinical presentation and diagnosis, imaging techniques, surgical and radiation treatments, systemic therapy for advanced cases, and follow-up. The primary focus of this review is on management of primary cSCC of the scalp with localized disease, although where relevant, some points about recurrent cSCCs or advanced disease cases are also discussed.

Extensive Perineural Invasion vs Nerve Caliber to Assess Cutaneous Squamous Cell Carcinoma Prognosis

Importance

Perineural invasion (PNI) is an adverse risk feature in cutaneous squamous cell carcinoma (CSCC) that affects patient prognosis and disease management. However, research comparing different PNI patterns on patient outcomes is limited.

Objective

To compare 4 assessments of PNI in CSCC, their associations with poor outcomes, and implications for their inclusion in the Brigham and Women's Hospital (BWH) staging system.

Design, Setting, and Participants

This retrospective cohort study was performed at a single tertiary care institution and compared 4 PNI assessments: nerve caliber, number of involved nerves per section, PNI maximal depth, and PNI location with respect to tumor. Patients with primary, localized, invasive CSCC with PNI diagnosed between January 1, 2000, and December 31, 2017, were identified via an electronic in-house database. Available pathology slides were secondarily reviewed by study authors. Relevant patient and tumor characteristics and outcomes were abstracted from the medical record. Data analysis was performed between September 6 and October 20, 2022.

Main Outcomes and Measures

Risks of recurrence, disease-specific death, and a composite end point (any poor outcome) were calculated via multivariable stepwise Fine and Gray competing-risks regression. Considered revisions to the BWH staging system were assessed via receiver operating characteristic curves and test characteristics.

Results

This study included 140 patients with CSCC, with a mean (SD) age of 75.1 (11.2) years. More than half of the patients were men (93 [66.4%]), and most identified as White (132 [94.3%]). Of the 4 PNI assessments studied, only involvement of multiple nerves was associated with poor outcomes. Perineural invasion of 5 or more distinct nerves (extensive PNI [ePNI]) was independently associated with local recurrence (subhazard ratio [SHR], 13.83 [95% CI, 3.50-54.62]; P < .001), disease-specific death (SHR, 6.20 [95% CI, 1.59-24.21]; P = .009), and any poor outcome (SHR, 10.21 [95% CI, 2.88-36.15]; P < .001). A revised BWH staging system with substitution of ePNI for large-caliber PNI resulted in improved area under the curve and test characteristics compared with current BWH staging criteria that use nerve caliber as the measure of PNI.

Conclusions and Relevance

The findings of this cohort study suggest that ePNI is the best prognostic measure of PNI. Because ePNI obviated the need for a micrometer and had superior prognostic capacity to nerve caliber in this cohort, ePNI should be considered for inclusion in CSCC tumor staging. Inclusion of ePNI as a high-risk factor in CSCC staging systems may optimize patient selection for primary treatment and adjuvant interventions.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma. Part 1: Diagnostics and prevention-Update 2023

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in white populations, accounting for 20% of all cutaneous malignancies. Overall, cSCC mostly has very good prognosis after treatment, with 5-year cure rates greater than 90%. Despite the overall favourable prognosis and the proportionally rare deaths, cSCC is associated with a high total number of deaths due to its high incidence. A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV) and the European Organization of Research and Treatment of Cancer (EORTC), was formed to update recommendations on cSCC, based on current literature and expert consensus. Part 1 of the guidelines addresses the updates on classification, epidemiology, diagnosis, risk stratification, staging and prevention in immunocompetent as well as immunosuppressed patients.

40-Gene Expression Profile Representative of Metastatic Risk of Squamous Cell Carcinoma in a Mohs Surgical Patient

This case study examines using a 40-gene expression profile (40-GEP) as an independent predictor of metastatic risk in a 74-year-old male with cutaneous squamous cell carcinoma on the scalp. The patient's previous medical history included melanoma and non-melanoma skin cancers. While conventional staging methods, such as the American Joint Committee on Cancer 8th edition (AJCC8) and Brigham and Women's Hospital (BWH) staging, indicated a higher metastatic risk, the 40-GEP testing classified the patient as low risk (Class 1 result) for metastasis within three years. The patient underwent successful Mohs surgery with no evidence of perineural invasion. This case highlights the discrepancy between current staging techniques and gene expression profile testing, demonstrating the potential of the 40-GEP as a more accurate predictor of metastatic risk. The study contributes to the growing body of literature on the use of gene expression profile testing in cutaneous cancers, emphasizing the need for further research in this area to improve patient care outcomes using 40-GEP testing.

A Novel Method Using Fine Needle Aspiration from Tumor-Draining Lymph Nodes Could Enable the Discovery of New Prognostic Markers in Patients with Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell cancer (cSCC) is the second most common form of skin cancer, characterized by abnormal, accelerated growth of squamous cells. When caught early, most cSCCs are curable. About 5 percent of the cSCC cases have advanced to such an extent, generally metastatic, that they are far more dangerous, with very poor prognosis and challenging to treat. All efforts to find biomarkers, in blood or in the tumor itself, for early identification of patients with a risk for metastasis have so far failed. The present study describes a novel method that enables the identification of lymphocyte markers in tumor-draining lymph nodes. Six patients with advanced cSCC were analyzed using a combination of a sentinel lymph node biopsy (SLNB) protocol, fine needle aspiration (FNA), and flow cytometry. Immunological results from the sentinel nodes were combined with corresponding data from peripheral blood and unfixed tumor tissues. The result demonstrates a striking difference between the subsets of T-cells from the three compartments. Our interpretation of this first pilot study is that the ability to follow specific immunological markers on lymphocytes in tumor-draining lymph nodes will enable the identification of novel prognostic biomarkers not detectable in material from blood and tumor tissues.

Comparative Performance of Four Staging Classifications to Select «High-Risk» Head and Neck Cutaneous Squamous Cell Carcinomas

BACKGROUND

Many classifications exist to select patients with "high-risk" head and neck cutaneous squamous cell carcinoma (HNCSCC).

OBJECTIVE

To compare the performance of the Brigham and Women's Hospital (BWH) classification with the performance of the American Joint Committee on Cancer 8th Edition (AJCC8), the Union for International Cancer Control 8th Edition (UICC8), and the National Comprehensive Cancer Network (NCCN) classifications.

METHODS

In this single-center retrospective study, HNCSCC resected in a tertiary care center were classified as "low-risk" or "high-risk" tumors according to the four classifications. Rates of local recurrence (LR), lymph node recurrence (NR), and disease-specific death (DSD) were collected. The performance of each classification was then calculated in terms of homogeneity, monotonicity, and discrimination and compared.

RESULTS

Two hundred and seventeen HNCSCC from 160 patients, with a mean age of 80 years, were included. For predicting the risk of any poor outcome and risk of NR, the BWH classification had the best specificity and positive predictive value. However, its concordance index was not significantly higher than that of the AJCC8 and UICC8 classifications. The NCCN classification was the least discriminant.

CONCLUSIONS AND RELEVANCE

This study suggests that the BWH classification is the most appropriate for predicting the risk of poor outcomes in patients with HNCSCC when compared with the NCCN, UICC8, and AJCC8 classifications.

[Cutaneous squamous cell carcinoma of the head and neck]

OBJECTIVE

Cutaneous squamous cell carcinoma (cSCC), predominantly located on the scalp and face, is the second most prevalent skin cancer globally. Due to the increasing elderly population and rising incidence of cSCC, it has been gaining relevance in otorhinolaryngology.

MATERIAL AND METHODS

This review article is based on a selective PubMed literature search, German and European guidelines and the clinic's own experience.

RESULTS

In addition to chronic UV exposure, a disruption of the body's own immune system is becoming increasingly important. Vertical tumor thickness is associated with the highest risk of metastatic spread and local recurrence. Other significant risk factors are: horizontal tumor diameter, dedifferentiation, desmoplasia, perineural growth and localization on the face. Most cases are manageable by local excision with histological control of the excision margins. If regional metastases are clinically suspected, the draining cervical lymph node levels should be dissected depending on primary tumor location. cSCC of the upper face and the auricle primarily metastasize to the parotid gland. With the approval of the PD-1-blocking antibody cemiplimab in Europe, an active ingredient has been made available for the treatment of advanced cSCC where surgery or radiotherapy are no longer an option.

CONCLUSIONS

The otherwise very low mortality rate of cSCC increases considerably with metastases. Therefore, imaging, surgical therapy and follow-up intervals should be based on risk factors. This allows early detection of metastases or local recurrences and improves the prognosis.

Using Gene Expression Profiling to Personalize Skin Cancer Management

Risk-stratification of cancer, traditionally performed through staging, directs optimal disease management decisions with the result of improved patient outcomes. Many forms of cutaneous cancer have overall excellent survival rates, but conventional staging methods are imperfect in identifying high-risk patients. Gene expression profiling (GEP) is a clinically available, objective metric that can be used in conjunction with traditional clinicopathological staging to help clinicians stratify risk in patients with skin cancer, even in those who lack traditional risk markers. For patients with melanoma, the 31-GEP test provides personalized prognostic information that can guide risk-appropriate clinical management and surveillance decisions. The i31-GEP integrates 31-GEP results with clinicopathological features to provide a risk of recurrence (i31-GEP for ROR) and likelihood of having a positive sentinel lymph node biopsy (SLNB) (i31-GEP for SLNB) for patients with melanoma. For patients with cutaneous squamous cell carcinoma who have at least one risk factor, the 40-GEP test allows for better risk stratification by identifying the high-risk patients who are most likely to develop metastasis. These tests can be easily integrated into clinical practice to help guide treatment choices.

Advances in Cutaneous Squamous Cell Carcinoma Management

Simple Summary

Cutaneous squamous cell carcinoma (cSCC) is an increasingly prevalent and morbid cancer worldwide. Management of this cancer has changed significantly in the last decade through improved risk stratification and new therapies offering patients with locally advanced and metastatic disease more effective, less toxic, and more durable treatment options. Ongoing clinical trials are assessing new therapeutic options as well as optimizing existing regimens in efforts to better manage this cancer. The recent developments highlight the need for multidisciplinary care, especially for those with locally advanced and metastatic disease.

Abstract

cSCC is increasing in prevalence due to increased lifespans and improvements in survival for conditions that increase the risk of cSCC. The absolute mortality of cSCC exceeds melanoma in the United States and approaches that of melanoma worldwide. This review presents significant changes in the management of cSCC, focusing on improvements in risk stratification, new treatment options, optimization of existing treatments, and prevention strategies. One major breakthrough in cSCC treatment is the advent of immune checkpoint inhibitors (ICIs) targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1), which have ushered in a renaissance in the treatment of patients with locally advanced and metastatic disease. These agents have offered patients with advanced disease decreased therapeutic toxicity compared to traditional chemotherapy agents, a more durable response after discontinuation, and improved survival. cSCC is an active field of research, and this review will highlight some of the novel and more developed clinical trials that are likely to impact cSCC management in the near future.

Management of the parotid for high-risk cutaneous squamous cell carcinoma: A review from the salivary section of the American Head and Neck Society

BACKGROUND

Metastases to the parotid nodal basin in patients with high-risk cutaneous squamous cell carcinoma (HRcSCC) impact disease specific survival (DSS) and overall survival (OS).

METHODS

A writing group convened by the Salivary Section of the American Head and Neck Society (AHNS) developed contemporary, evidence-based recommendations regarding management of the parotid nodal basin in HRcSCC based on available literature, expert consultation, and collective experience. The statements and recommendations were then submitted and approved by the AHNS Salivary Committee.

RESULTS

These recommendations were developed given the wide variation of practitioners who treat HRcSCC in order to streamline management of the parotid nodal basin including indications for imaging, surgery, radiation, and systemic treatment options as well.

CONCLUSIONS

This clinical update represents contemporary optimal management of the parotid nodal basin in HRcSCC and is endorsed by the Salivary Section of the AHNS.

Evidence-Based Consensus Recommendations for the Evolving Treatment of Patients with High-Risk and Advanced Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma is the second most common skin cancer in the United States. Currently, there is no standardized management approach for patients with cutaneous squamous cell carcinoma who develop metastatic or locally advanced disease and are not candidates for curative surgery or curative radiation. To address this issue, the Expert Cutaneous Squamous Cell Carcinoma Leadership program convened an expert steering committee to develop evidence-based consensus recommendations on the basis of a large, structured literature review. Consensus was achieved through modified Delphi methodology. The steering committee included five dermatologists, three medical oncologists, two head and neck surgeons, one radiation oncologist, and a patient advocacy group representative. The steering committee aligned on the following clinical topics: diagnosis and identification of patients considered not candidates for surgery; staging systems and risk stratification in cutaneous squamous cell carcinoma; the role of radiation therapy, surgery, and systemic therapy in the management of advanced disease, with a focus on immunotherapy; referral patterns; survivorship care; and inclusion of the patient’s perspective. Consensus was achieved on 34 recommendations addressing 12 key clinical questions. The Expert Cutaneous Squamous Cell Carcinoma Leadership steering committee’s evidence-based consensus recommendations may provide healthcare professionals with practically oriented guidance to help optimize outcomes for patients with advanced cutaneous squamous cell carcinoma.

Update of advanced cutaneous squamous cell carcinoma

The incidence of cutaneous squamous cell carcinoma (cSCC) is rapidly increasing. A growing part of this patient group is formed by immunocompromised patients, for example organ-transplant recipients (OTR). Although over 90% of the cSCC show a relatively harmless clinical behaviour, there is also a chance of developing advanced cSCC and metastases. Locally advanced cSCC are defined as cSCC that have locally advanced progression and are no longer amenable to surgery or radiation therapy. Better understanding of the clinical behaviour of cSCC is essential to discriminate between low- and high-risk cSCC. Staging systems are important and have recently been improved. Genetic characterisation of SCC will likely become an important tool to help distinguish low and high-risk cSCC with an increased potential to metastasise in the near future. Available treatments for high-risk and advanced cSCC include surgery, radiotherapy, chemotherapy and targeted therapy with epidermal growth factor receptors inhibitors. Anti-PD-1 antibodies show promising results with response rates of up to 50% in both locally advanced and metastatic cSCC but, in its present form, is not suitable for OTR.

Cutaneous squamous cell carcinoma staging may influence management in users: A survey study

Purpose

This study aims to determine whether there is consensus regarding staging and management of cutaneous squamous cell carcinoma (CSCC) across the various specialties that manage this disease.

Materials and Methods

A survey regarding CSCC high‐risk features, staging, and management was created and emailed to cutaneous oncology experts including dermatology, head and neck surgery/surgical oncology, radiation oncology, and medical oncology.

Results

One hundred fifty‐six (46%) of 357 invited physicians completed the survey. Depth of invasion (92%), perineural invasion (99%), histologic differentiation (85%), and patient immunosuppression (90%) achieved consensus (>80%) as high‐risk features of CSCC. Dermatologists were more likely to also choose clinical tumor diameter (79% vs. 54%) and histology (99% vs. 66%) as a high‐risk feature. Dermatologists were also more likely to utilize the Brigham and Women's Hospital (BWH) staging system alone or in conjunction with American Joint Committee on Cancer (AJCC) (71%), whereas other cancer specialists (OCS) tend to use only AJCC (71%). Respondents considered AJCC T3 and higher (90%) and BWH T2b and higher (100%) to be high risk and when they consider radiologic imaging, sentinel lymph node biopsy, post‐operative radiation therapy, and increased follow‐up. Notably, a large number of respondents do not use staging systems or tumor stage to determine treatment options beyond surgery in high‐risk CSCC.

Conclusion

This survey study highlights areas of consensus and differences regarding the definition of high‐risk features of CSCC, staging approaches, and management patterns between dermatologists and OCS. High‐risk CSCC is defined as, but not limited to, BWH T2b and higher and AJCC T3 and higher, and these thresholds can be used to identify cases for which treatment beyond surgery may be considered. Dermatologists are more likely to utilize BWH staging, likely because BWH validation studies showing advantages over AJCC were published in dermatology journals and discussed at dermatology meetings. Additional data are necessary to develop a comprehensive risk‐based management approach for CSCC.

Lack of documentation of lymph node examination in patients with squamous cell carcinoma of the lower lip

Cutaneous squamous cell carcinoma is the second most common cutaneous malignancy with a 5-year disease-specific survival rate of approximately 90%, which decreases dramatically to 50% in the presence of regional lymph node metastases. We sought to examine clinicians' documentation of pertinent neurological symptoms/signs and lymph node palpation at the time of initial biopsy and treatment using lower lip SCC patients as a cohort. Subsequently, we investigated the correlation between clinical and pathologic SCC features and the aforementioned documentation. A single center, retrospective study of all squamous cell carcinomas of the lower lip biopsied over 10 years was conducted, and univariate models were implemented to correlate the variables. A total of 66 squamous cell carcinomas of the lip in 63 patients were identified. Neurological signs and symptoms were not documented and only three of the tumors were palpated, therefore statistical analysis was not performed. A lymph node exam was documented in 14 of the 63 patients (22%), and statistical analysis showed that among all variables (age, gender, tumor size, tumor stages, tobacco or alcohol use, or history of skin cancer), only the size of the tumor correlated positively with a lymph node examination (RRE 1.15 [95% CI 1.06-1.25], p < 0.001). Our study illustrates a possible practice gap and quality improvement potential in tumor, neurologic, and lymph node examination and documentation in patients with cutaneous squamous cell carcinoma.

New Developments in the Management of Cutaneous Squamous Cell Carcinoma

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. List important prognostic features that affect cutaneous squamous cell carcinoma risk. 2. Summarize the changes to the AJCC Cancer Staging Manual, Eighth Edition, staging system for cutaneous squamous cell carcinoma. 3. Evaluate the draining nodal basin with appropriate imaging modalities. 4. Recommend adjuvant radiation therapy in the correct clinical setting for high-risk tumors. 5. Recognize the currently available treatments for advanced cutaneous squamous cell carcinoma.

SUMMARY

This continuing medical education article reviews the features, management, and prognosis of cutaneous squamous cell carcinoma with an emphasis on high-risk squamous cell carcinoma and data from the past 3 years. This review will discuss the primary tumor management, high-risk features of a squamous cell carcinoma, changes to the American Joint Committee on Cancer staging system, and the utility of sentinel lymph node biopsy, and critically review the evidence regarding adjuvant therapy.

Sentinel Lymph Node Biopsy in High-Risk Cutaneous Squamous Cell Carcinoma: Analysis of a Large Size Retrospective Series

BACKGROUND

One of the most important prognostic factors for mortality in cutaneous squamous cell carcinoma (cSCC) is the development of nodal metastasis. There is no consensus regarding which patient with cSCC should be offered sentinel lymph node biopsy (SLNB).

OBJECTIVE

This study aimed to establish the rate of positive SLNBs among patients with high-risk cSCCs and to identify which high-risk features are associated with a positive SLNB.

METHODS

Five-year retrospective case series in an academic tertiary care center reviewing 93 SLNBs.

RESULTS

Of the 93 SLNBs performed, 5 (5.4%) were positive. Three patients (3/5) had neck dissection and one (1/5) had radiation therapy, with no recurrence at the time of last follow-up. A tumor diameter ≥2 cm, a tumor depth >6 mm or below subcutaneous fat, perineural invasion of nerves with a diameter ≥0.1 mm, moderate or poor histological differentiation, lymphovascular invasion, and immunosuppression were associated with a positive SLNB. All tumors with a positive SLNB were classified as T2b according to the Brigham and Women's Hospital (BWH) tumor staging.

LIMITATIONS

Retrospective study and absence of a control group.

CONCLUSION

Sentinel lymph node biopsy can be considered for BWH T2b and T3 tumors. However, more randomized controlled studies are needed.

Diagnostic Value of Real-Time Elastography in Diagnosing Lymph Node Metastasis of Skin Cancer

Objective

The purpose of this study was to examine the diagnostic performance of real-time tissue elastography in detecting lymph node involvement in skin cancers.

Methodology

We retrospectively analyzed B-mode sonography and real-time elastography (RTE) images of 70 lymph nodes from 34 patients diagnosed with squamous cell carcinoma (SCC) or malignant melanoma (MM). In the B-mode examination, the appearance or loss of the hilar architecture in the lymph node, contour lobulation, and the presence of focal cortical thickening were evaluated. Elastography scores were classified according to the ratio of soft and hard areas across the lymph node on a 4-point scale system. Largely soft lymph nodes were scored as “1” and largely hard lymph nodes were scored as “4”.

Results

When patients with SCC and MM were evaluated together, the sensitivity of elastography was 94%, specificity was 70%, and the accuracy rate was 86% in detecting lymph node involvement. When both tumor groups were evaluated separately, for SCC, the sensitivity of elastography was 90%, specificity was 61%, and the accuracy rate was 80% in detecting lymph node involvement. When the receiver operating characteristic (ROC) curve was taken, the area under the curve (AUC) was 0.78 for SCC. Elastography showed full compliance with pathology in lymph node metastases of MM and the AUC was 1.00.

Conclusions

Based on our findings, RTE provides important contributions to B-mode ultrasonography (USG) in evaluating lymph node metastases of skin cancers.

Sex-based differences in the anatomic distribution of cutaneous squamous cell carcinoma

Background

Cutaneous squamous cell carcinoma (cSCC) is the second most common malignancy in the United States, and its incidence is increasing. Ultraviolet radiation is the main environmental risk factor for cSCCs; thus, they tend to arise on sun-exposed skin. Most publications cite the head and neck as the predominant location for cSCCs, but these papers do not account for the differential anatomic predication of cSCCs by sex. No prior studies have examined the differential distribution of cSCCs by sex, particularly invasive cSCCs that have the potential for recurrence and metastasis.

Objective

We examined the association between cSCC tumor features, including anatomic site and invasiveness, by key patient features, including age and sex.

Methods

Using an institutional cSCC registry, we identified 618 non-Hispanic white patients diagnosed with 2,111 histologically-confirmed cSCCs between 2000–2016.

Results

We found differential anatomic distributions of cSCC by patient sex. Men were more likely to have cSCCs arise on the head and neck (51.7%), whereas women were more likely to have cSCCs develop on the lower extremity (41.2%). Stratification by dichotomized age (younger [<65 years] vs. older [≥65 years]) revealed that nearly half of invasive cSCCs (47.7%) among older women arose on the lower extremities, whereas approximately half of the invasive cSCCs (52.4%) arose on the head and neck among older men.

Conclusion

Lower extremities can be easily overlooked, particularly when practitioners perform waist-up-only skin examinations in time-limited settings. Understanding the anatomic predilection for invasive cSCCs by patient characteristics, including our findings, which suggest that the lower extremities are an important anatomic site for invasive cSCCs among women, can help further inform skin cancer screening and prevention efforts.

Performance of the American Joint Committee on Cancer Staging Manual, 8th Edition vs the Brigham and Women's Hospital Tumor Classification System for Cutaneous Squamous Cell Carcinoma

Importance

Brigham and Women's tumor classification (BWH) better predicts poor outcomes than American Joint Committee on Cancer (AJCC) 7th edition (AJCC 7). AJCC 8th edition (AJCC 8) has not been evaluated.

Objectives

To compare BWH and AJCC 8 tumor classifications for head and neck cutaneous squamous cell carcinoma (HNCSCC).

Design, Setting, and Participants

A total of 459 patients with 680 HNCSCCs in this cohort study were staged via BWH and AJCC 8 classifications and poor outcomes (ie, local recurrence [LR], nodal metastasis [NM], disease specific death [DSD], and overall survival [OS]) were compared. The study was carried out at a single academic tertiary care center in Boston, Massachusetts.

Main Outcomes and Measures

Distinctiveness (outcome differences between tumor class), homogeneity (outcome similarity within tumor class), monotonicity (outcome worsening with increasing tumor class), and C statistic.

Results

A total of 680 HNCSCCs in 459 patients were included in this study, of which 313 (68%) were men with the mean (SD) age of 70.2 (12.7) years. The AJCC 8 (T3/T4) and BWH (T2b/T3) high tumor classes accounted for 121 (18%) vs 63 (9%), 17 (71%) vs 16 (70%), and 11 (85%) vs 12 (92%) of total cases, metastases, and deaths, respectively. The AJCC 8 T2 and T3 comprised 23% of cases and had statistically indistinguishable outcomes. The BWH had higher specificity (93%) and positive predictive value (30%) for identifying cases at risk for metastasis or death. C statistics showed BWH to be superior in predicting NM and DSD (P = .01 and P = .005, respectively), but there was no difference for LR and OS.

Conclusions and Relevance

Lack of distinction between AJCC T2 and T3 resulted in a 23% subset of HNCSCCs with significant risk of metastasis and death-too large of a group for routine nodal staging or consideration of adjuvant therapy. The BWH identifies the same number of poor outcomes in a 9% subset of HNCSCCs, thus minimizing inappropriate upstaging of low-risk disease.

Sentinel lymph node biopsy for high-thickness cutaneous squamous cell carcinoma

Squamous cell carcinomas are among the most common skin tumors and show a risk of metastasis depending on various factors such as tumor thickness, localization, histological subtype and immune status of the patient. Sentinel lymph node biopsy (SLNB) SLNB represents a possibility for assessing the locoregional lymph node status. In this study, the role of the SLNB in lymph node status and survival was analyzed. Retrospectively, 720 patients with high-risk squamous cell carcinoma (tumor thickness > 5 mm) were examined. 150 patients agreed to SLNB, 570 patients did not undergo histologic confirmation of lymph node status and were included directly in follow-up. In 101 patients, a sentinel lymph node was successfully marked and extirpated, followed by regular follow-up examinations.A total of 11.11% of the patients showed lymph node metastasis in the course of their treatment, with no difference in the proportion of patients in the SLNB group (11.9%) and the observation group (11.4%) (p = 0.873). The proportion of distant metastasis also did not differ between the groups (p = 0.898). In 3.96% of the patients in the SLNB group, a metastasis was found in the sentinel lymph node. Tumor-specific death was observed in 7.14% of the patients in the SLNB group and 4.74% in the observation group (p = 0.269). Although SLNB is a principally suitable method for determining lymph node status, the available data do not provide any benefit regarding further metastasis or tumor-specific survival.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 1. epidemiology, diagnostics and prevention

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in the white populations, accounting for 20% of all cutaneous malignancies. Factors implicated in cSCC etiopathogenesis include ultraviolet radiation exposure and chronic photoaging, age, male sex, immunosuppression, smoking and genetic factors. A collaboration of multidisciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organisation of Research and Treatment of Cancer (EORTC) was formed to update recommendations on cSCC classification, diagnosis, risk stratification, staging and prevention, based on current literature, staging systems and expert consensus. Common cSCCs are typically indolent tumors, and most have a good prognosis with 5-year cure rates of greater than 90%, and a low rate of metastases (<4%). Further risk stratification into low-risk or high-risk common primary cSCC is recommended based on proposed high-risk factors. Advanced cSCC is classified as locally advanced (lacSCC), and metastatic (mcSCC) including locoregional metastatic or distant metastatic cSCC. Current systems used for staging include the American Joint Committee on Cancer (AJCC) 8th edition, the Union for International Cancer Control (UICC) 8th edition, and Brigham and Women's Hospital (BWH) system. Physical examination for all cSCCs should include total body skin examination and clinical palpation of lymph nodes, especially of the draining basins. Radiologic imaging such as ultrasound of the regional lymph nodes, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography-computed tomography (PET-CT) scans are recommended for staging of high-risk cSCC. Sentinel lymph node biopsy is currently not recommended. Nicotinamide, oral retinoids, and topical 5-FU have been used for the chemoprevention of subsequent cSCCs in high-risk patients but are not routinely recommended. Education about sun protection measures including reducing sun exposure, use of protective clothing, regular use of sunscreens and avoidance of artificial tanning, is recommended.

Evaluation of the utility of localized adjuvant radiation for node-negative primary cutaneous squamous cell carcinoma with clear histologic margins

BACKGROUND

Though the National Comprehensive Cancer Network recommends consideration of localized adjuvant radiation after clear-margin surgery for cutaneous squamous cell carcinoma (cSCC) with large-caliber (≥0.1-mm) nerve invasion (LCNI) and other high-risk features, only a single small study has compared surgery plus adjuvant radiation therapy (S+ART) to surgical monotherapy (SM) for cSCC.

OBJECTIVE

Compare S+ART to SM for primary cSCCs with LCNI and other risk factors.

METHODS

Matched retrospective cohort study of primary cSCCs (matched on sex, age, immune status, type of surgery, diameter, differentiation, depth, and LCNI) treated with S+ART versus SM. A subgroup analysis of cSCCs with LCNI was performed.

RESULTS

In total, 62 cSCCs were included in matched analysis (31 S+ART and 31 SM) and 33 cSCCs in the LCNI analysis (16 S+ART and 17 SM). There were no significant differences in local recurrence, metastasis, or death from disease in either analysis. Risk of local recurrence was low (8%, 7/89), with 3 of the local recurrences being effectively treated upon recurrence.

LIMITATIONS

Single academic center and nonrandomized design.

CONCLUSION

Adjuvant radiation did not improve outcomes compared with SM due to a low baseline risk of recurrence, although adjuvant radiation for named nerve invasion and LCNI of ≥3 nerves has been shown to improve outcomes in a prior study. Randomized studies are needed to define the subset of cSCC for whom adjuvant radiation has utility.