High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck

Abstract

Nonmelanoma skin cancers (squamous cell and basal cell carcinomas) occur at an epidemic rate in many countries with the worldwide incidence increasing. The sun-exposed head and neck are the most frequent sites for these cancers to arise and in most patients diagnosed with a cutaneous squamous cell carcinoma, local treatment is usually curative. However, a subset is diagnosed with a high-risk cutaneous squamous cell carcinoma. High-risk factors include size (>2 cm), thickness/depth of invasion (>4 mm), recurrent lesions, the presence of perineural invasion, location near the parotid gland, and immunosuppression. These patients have a higher risk (>10–20%) of developing metastases to regional lymph nodes (often parotid nodes), and in some cases also of experiencing local morbidity (perineural invasion), based on unfavourable primary lesion and patient factors. Despite treatment, many patients developing metastatic cutaneous squamous cell carcinoma experience mortality and morbidity usually as a consequence of uncontrolled metastatic nodal disease. It is therefore important that clinicians treating nonmelanoma skin cancers have an understanding and awareness of these high-risk patients. The aim of this article is to discuss the factors that define a high-risk patient and to present some of the issues pertinent to their management.

Significance of clinical stage, extent of surgery and outcome in cutaneous squamous cell carcinoma of the head and neck

“…6,21 A large study conducted by Brantsch et al with 615 patients designated tumor depth and histological differentiation as risk factors for metastatic disease, with 75% of lesions being <2 cm, confirming the opinion held by Veness et al, that even small lesions have a significant metastatic potential. 8,22 Lymphatic metastases were identified in 23.3% of the patients, which is slightly higher than previously reported rate, ranging from 0.3% to 20.7%. The incidence reflects the practice environment of the authors, since the patients referred to our comprehensive cancer center are more likely to suffer from aggressive or advanced disease.…”

“…The median 10-year survival rate for patients with regional metastatic disease was 12.1±9.8%, and for the entire patient cohort 45.5±10.2%, which is consistent with published results. 8 Analysis of the entire population with head and neck CSCC, including patients with regional disease (n=103) showed that women are affected significantly later (p<0.0012), probably due to a lesser degree of sun exposure and longer life expectancy. 19,20 Detailed histopathological analysis has identified perineural invasion as a risk factor for nodal metastasis.…”

“…1,8,13 Bearing that in mind, local and regional disease control is essential in improving survival. O'Brien et al have shown the importance of the parotid gland in the management and prognosis of CSCC, using a modification to current staging systems that includes parotid involvement.…”

“…5,6,7 Only limited data exist on the relationship between clinical staging of advanced regional disease and patient survival rate. 8,9,10,11,12 The parotid gland is the first site for metastatic spread of head and neck CSCC, and parotid involvement poses a significant diagnostic and therapeutic challenge. 1,13,14 Therefore it is important to examine the relationship between patterns of metastatic spread in the parotid and the neck when planning surgical treatment.…”

High-risk Cutaneous Squamous Cell Carcinoma

“…Veness et al 69 have reported 266 cases of metastatic cSCC, with 162 (61%) involving the parotid gland. On this basis, authors have suggested parotidectomy in cases of T3 or T4 lesions with high-risk features.…”