7.9 Surgical management of advanced cutaneous squamous cell carcinoma
Recurrence in a nodal basin after standard lymphadenectomy radical node dissection almost invariably leads to the development of distant disease. The risk of regional recurrence after radical lymphadenectomy depends on the number of nodes containing metastases on histopathology, and the presence of extranodal spread manifested clinically by gross fixation of nodes.
See also: Prognosis
Overview of evidence (non-systematic literature review)[edit source]
Nodal involvement[edit source]
Lymphadenectomy for disease in the axilla or groin is straightforward. Occasionally lymph node metastases of cSCC occur at unusual sites including the epitrochlear region and popliteal fossa.
For cervical lymph nodes, most authors recommend a selective neck dissection. The extent of the lymphadenectomy is determined by the site of the primary lesion and the involved node(s), and the extent of the disease. Generally the accessory nerve and sternomastoid muscle can be preserved, which reduces the morbidity of the procedure.
Adjuvant postoperative radiotherapy should be considered in patients with a significant risk of recurrence (see: Radiotherapy). Risk factors for recurrence including involvement of multiple nodes, large size, extracapsular extension or tumour spill at the time of operation (including an open biopsy).
Recurrent nodal disease[edit source]
Salvage surgery is sometimes possible if complete or durable control is not achieved with radiotherapy alone.
Dermal lymphatic spread (in-transit metastasis)[edit source]
Dermal lymphatic spread (in-transit metastasis) is a very uncommon condition and may be seen in association with regional spread and/or locally recurrent disease. Wide surgical excision is indicated followed by adjuvant radiotherapy.
Further recurrence is not uncommon.
Practice Points[edit source]
PP 7.9.1. Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy.
For patients with lymph node involvement who have a significant risk of recurrence, adjuvant postoperative radiotherapy should be considered after lymphadenectomy.
- Surgical treatment – Introduction
- Considerations before selecting a surgical treatment modality
- Optimal primary excision techniques
- Optimal surgical technique for the treatment of basal cell carcinoma
- Considerations when planning surgical treatment for cutaneous squamous cell carcinoma
- Post-surgical care, interpretation of the pathology report and follow-up
- Protocol to manage incompletely resected basal cell carcinoma
- Management protocol for rapidly growing tumours
- Criteria for choosing Mohs micrographic surgery in preference to other surgical techniques
- Surgical treatment – Health system implications and discussion
- Epstein E, Epstein NN, Bragg K, Linden G. Metastases from squamous cell carcinomas of the skin. Arch Dermatol 1968 Mar;97(3):245-51 Available from: http://www.ncbi.nlm.nih.gov/pubmed/5641327.
- Joseph MG, Zulueta WP, Kennedy PJ. Squamous cell carcinoma of the skin of the trunk and limbs: the incidence of metastases and their outcome. Aust N Z J Surg 1992 Sep;62(9):697-701 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1520151.
- Dinehart SM, Pollack SV. Metastases from squamous cell carcinoma of the skin and lip. An analysis of twenty-seven cases. J Am Acad Dermatol 1989 Aug;21(2 Pt 1):241-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2768574.
- Wang JT, Palme CE, Wang AY, Morgan GJ, Gebski V, Veness MJ. In patients with metastatic cutaneous head and neck squamous cell carcinoma to cervical lymph nodes, the extent of neck dissection does not influence outcome. J Laryngol Otol 2013 Jan;127 Suppl 1:S2-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23046820.
- Shiu MH, Chu F, Fortner JG. Treatment of regionally advanced epidermoid carcinoma of the extremity and trunk. Surg Gynecol Obstet 1980 Apr;150(4):558-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7361247.