7.7 Protocol to manage rapidly growing tumours
Rapidly growing tumours are more likely to quickly enlarge to a size of more than 2cm diameter.
Basal cell carcinoma (BCC) is generally regarded as a slow-growing tumour. Features of BCCs reported to be associated with rapid growth include those at the periocular site (particularly when recurrent, large, or in men).
Cutaneous squamous cell carcinomas (cSCCs) in younger patients, particularly cSCCs of the face (especially lips), can have a short and aggressive course, and are more at risk of developing subsequent cancers.
Systematic review evidence[edit source]
What should be the protocol to manage rapidly growing tumours?
A systematic review was undertaken to answer this clinical question.The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.
A total of nine studies reported relevant outcomes for cSCCs or BCCs with perineural invasion (PNI), or for poorly differentiated cSCCs, after different treatments.
One case series had a moderate risk of bias. All other studies had a high risk of bias.
Treatment modalities included radiotherapy, chemotherapy, excision and Mohs micrographic surgery (MMS).
Reported outcomes included recurrence, local control, local treatment failure, distant metastasis, recurrence-free survival and disease-free survival.
No study specifically investigated the management of rapidly growing tumours. The studies provided only indirect evidence to answer this clinical question.
A small Australian retrospective case series reported higher recurrence-free survival numbers for high-risk tumours treated with MMS plus radiotherapy or MMS, compared with excision alone or excision plus radiotherapy.
Another Australian case series and a US retrospective cohort study reported a possible survival benefit with extensive subcranial and cranial resection including nerve for patients with symptomatic PNI.
An Australian retrospective case series found that most failures occurred in patients with gross PNI. Those with microscopic extensive PNI also received a benefit with radiotherapy, but those with microscopic focal PNI did well with or without irradiation.
A US cohort study found a possible benefit with MMS and radiotherapy in head and neck cSCC, compared with surgery and RT.
A US retrospective case series in 131 patients with 155 cSCCs found a benefit with RT in both incidental and symptomatic PNI. A Dutch retrospective case series found that metastasis-free survival at 5 years was significantly higher in well-differentiated cSCCs (70%) compared with moderately differentiated (51%) and poorly differentiated cSCCs (26%; p=0.012).
Evidence summary and recommendations[edit source]
BCCs and cSCCs with PNI had higher recurrence rates with excision or excision with RT than MMS or MMS plus RT.
For tumours with PNI, recurrence-free survival rates were 58.6% after surgical excision in one study, and 62- 71% after surgery plus adjuvant RT in two studies.
For tumours with microscopic focal PNI, recurrence-free survival was significantly higher after RT (94%) than observation (25%).
However, there was no significant difference between radiotherapy and observation for tumours with microscopic extensive PNI.
|III-3, IV||, , , , |
Among various observational studies, reported disease-free survival was highest after postoperative RT plus chemotherapy, followed by surgery plus RT (87%), MMS plus RT (84%) postoperative RT (76%), RT (58–74%), not MMS plus RT (68%), observation (40–62%), skull base/subcranial surgery (50–53.6%) and RT and palliative therapies (0%), and was only found to be significantly higher for MMS plus RT, RT and subcranial and skull base therapies than not MMS and RT, observation and palliative therapies.
Cancer-specific mortality ranged from 10% to 53% after surgical excision.
|III-3, IV||, , , , , , , |
Locoregional control was highest after postoperative RT plus chemotherapy (100%), then treatment other than MMS plus RT (92%), RT alone (84%), postoperative RT (77%), RT plus chemotherapy (62%) and postoperative RT (50%) for poorly differentiated cSCCs and cSCCs with PNI.
|III-3, IV||, , |
Most metastasis for mostly cSCCs with PNI or poor differentiation occurred after surgical excision (26%) or excision plus RT (12.5%), whereas distant metastasis-free survival at 2–5 years of follow-up was 100% for tumours treated with observation or RT.
|III-3, IV||, , |
|EBR 7.7.2. For tumours with perineural invasion, the combination of surgery and radiotherapy is recommended when a nerve with diameter >0.1mm is involved.||C|
|EBR 7.7.3. Cutaneous squamous cell carcinomas with high-risk features should be managed with wider surgical margins, adjuvant radiotherapy, and regular follow-up for locoregional or distant recurrence.||C|
PP 7.7.2. Patients with rapidly growing squamous cell carcinomas should be referred timely for assessment for specialised therapies or combination therapies.
Notes on the recommendations[edit source]
Follow-up of patients after treatment is individually tailored according to patient factors, tumour factors, anatomic site and the perceived adequacy of treatment.
The available evidence supports an individualised approach in the management of incompletely resected cSCCs at low-risk sites with low-risk histopathology. High-risk tumours in high risk sites warrant further surgery, possibly including a wider excision or excision with a margin control technique.
- Surgical treatment – Introduction
- Considerations before selecting a surgical treatment modality
- Optimal primary excision techniques:
- Post-surgical care and interpretation of the pathology report
- Protocol to manage incompletely resected basal cell carcinoma
- Criteria for choosing Mohs micrographic surgery in preference to other surgical techniques
- Surgical management of advanced cutaneous squamous cell carcinoma
- Surgical treatment – Health system implications and discussion
|PICO question SX4||Evidence statement form SX5||Systematic review report SX5|
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