Review
Nodal staging of high-risk cutaneous squamous cell carcinoma

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Background

While progress has been made in defining the clinical and histopathologic features of high-risk cutaneous squamous cell carcinoma (HRcSCC), optimal staging guidelines remain elusive.

Objective

We seek to guide clinical practice regarding nodal staging options for patients with HRcSCC via review of evolving definitions of HRcSCC, nodal staging options, and how nodal staging may impact treatment and affect outcomes.

Methods

This was a retrospective review of the published peer-reviewed literature regarding risk stratification, nodal staging, and treatment and outcomes for patients with HRcSCC via PubMed.

Results

For patients without clinical lymphadenopathy, based on literature from head and neck SCC, preoperative nodal staging with ultrasonography may be more useful than computed tomography or magnetic resonance imaging. Early nodal disease is usually curable, and therefore obtaining a sentinel lymph node biopsy specimen may be considered in those with negative imaging while we await studies of nodal staging outcomes.

Limitations

More data are needed to validate the relationships between primary tumor stage and sentinel lymph node biopsy status and to determine if early detection of nodal disease impacts survival for patients with HRcSCC.

Conclusion

It is reasonable to consider nodal staging for patients with HRcSCC (Brigham and Women's Hospital stage T2b and T3) in the absence of clinically palpable lymphadenopathy via radiographic imaging and, if negative, sentinel lymph node biopsy.

Section snippets

Clinical examination

Patients with HRcSCC should receive a comprehensive history and physical examination including a full-body skin examination, evaluation of peritumoral nerve function, and regional lymph node examination via manual palpation, generally every 6 to 12 months or more often depending on the risk profile of the tumor(s).17 The predictive value and limitations of clinical lymph node examination are outlined in Table III.18, 19, 20, 21, 22, 23 While clinical lymph node examination is clearly a

Discussion

The importance of risk stratification among patients with cSCC is clear, and the process of defining meaningful prognostic markers among the subset of patients with HRcSCC continues to evolve.

Among patients with cSCC who were diagnosed in the BWH cohort study from 2000 to 2009, the risk of nodal metastasis using the BWH T staging system is 0.1% (95% CI 0-0.4%) for BWH T1 tumors and 3% (1-5%) for BWH T2a tumors.11 The risk increases to 21% (13-27%) for BWH T2b tumors and 67% (30-90%) for BWH T3

References (52)

  • C. Navarrete-Dechent et al.

    High-risk cutaneous squamous cell carcinoma and the emerging role of sentinel lymph node biopsy: a literature review

    J Am Acad Dermatol

    (2015)
  • J.A. Moody et al.

    Complications of sentinel lymph node biopsy for melanoma - A systematic review of the literature

    Eur J Surg Oncol

    (2017)
  • J.M. Tomaszewski et al.

    Utility of positron emission tomography/computed tomography for nodal staging of cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia

    Am J Otolaryngol

    (2014)
  • C.D. Schmults et al.

    Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study

    JAMA Dermatol

    (2013)
  • D. Czarnecki et al.

    Metastases from squamous cell carcinoma of the skin in southern Australia

    Dermatology

    (1994)
  • M.G. Joseph et al.

    Squamous cell carcinoma of the skin of the trunk and limbs: the incidence of metastases and their outcome

    Aust N Z J Surg

    (1992)
  • A. Jambusaria-Pahlajani et al.

    Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system

    JAMA Dermatol

    (2013)
  • G.L. Clayman et al.

    Mortality risk from squamous cell skin cancer

    J Clin Oncol

    (2005)
  • J.T. Mullen et al.

    Invasive squamous cell carcinoma of the skin: defining a high-risk group

    Ann Surg Oncol

    (2006)
  • P.S. Karia et al.

    Evaluation of American Joint Committee on Cancer, International Union Against Cancer, and Brigham and Women’s Hospital tumor staging for cutaneous squamous cell carcinoma

    J Clin Oncol

    (2014)
  • A.R. Schmitt et al.

    Staging for cutaneous squamous cell carcinoma as a predictor of sentinel lymph node biopsy results: meta-analysis of American Joint Committee on Cancer criteria and a proposed alternative system

    JAMA Dermatol

    (2014)
  • M. Brunner et al.

    Distant metastases from cutaneous squamous cell carcinoma--analysis of AJCC stage IV

    Head Neck

    (2013)
  • J.R. Clark et al.

    Analysis and comparison of the 7th edition American Joint Committee on Cancer (AJCC) nodal staging system for metastatic cutaneous squamous cell carcinoma of the head and neck

    Ann Surg Oncol

    (2012)
  • A. Ebrahimi et al.

    Metastatic head and neck cutaneous squamous cell carcinoma: defining a low-risk patient

    Head Neck

    (2012)
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    Funding sources: None.

    Conflicts of interest: Dr Schmults developed the Brigham and Women's Hospital staging system for high-risk squamous cell carcinoma referenced herein. Drs Nehal and Schmults are members of the American Joint Committee on Cancer cutaneous squamous cell carcinoma subcommittee for the American Joint Committee on Cancer 8th edition. The other authors have no conflicts of interest to disclose.

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