7.9 Surgical management of advanced cutaneous squamous cell carcinoma

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Clinical practice guidelines for keratinocyte cancer > 7.9 Surgical management of advanced cutaneous squamous cell carcinoma


Background

The presence of nodal metastasis of cutaneous squamous cell carcinoma (cSCC) in associated with an overall 5-year survival rate of 40%.[1][2]

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.[1][3][2]

See also: Prognosis

Overview of evidence (non-systematic literature review)

Nodal involvement

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.[4] 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

Salvage surgery is sometimes possible if complete or durable control is not achieved with radiotherapy alone.

Dermal lymphatic spread (in-transit metastasis)

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.[5]

Practice Points

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PP 7.9.1. Dermal lymphatic spread (in-transit metastasis) should be managed by wide surgical excision followed by adjuvant radiotherapy.

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PP 7.9.2. For patients with cutaneous squamous cell carcinoma, consider referral to a specialistMedical practitioners who through training, experience and peer opinion specialise in the management of keratinocyte cancers or multidisciplinary team if there are any risk factors for poor prognosis, such as:

  • size >2 cm in diameter
  • tumour depth > 4 mm
  • recurrent lesion
  • high-risk anatomic location
  • perineural invasion or lymphovascular invasion
  • poorly differentiated subtype
  • immunosuppression.
Key point(s)

For patients with lymph node involvement who have a significant risk of recurrence, adjuvant postoperative radiotherapy should be considered after lymphadenectomy.

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References

  1. 1.01.1 Epstein E, Epstein NN, Bragg K, Linden G. Metastases from squamous cell carcinomas of the skin. Arch Dermatol 1968 Mar;97(3):245-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/5641327.
  2. 2.02.1 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 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1520151.
  3. 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 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/2768574.
  4. 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 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23046820.
  5. 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 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7361247.

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