Cutaneous Squamous Cell Carcinoma Guidelines

Updated: Jul 08, 2020
  • Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Guidelines Summary

American College of Radiology

Appropriateness Criteria® for the treatment of aggressive nonmelanomatous skin cancer of the head and neck, issued by the American College of Radiology (ACR) in 2014, include the following recommendations [68] :

  • Cutaneous squamous cell cancer (cSCC) that is resected with negative margins and does not display high-risk features can be safely observed postoperatively
  • Consider adjuvant radiotherapy for resected SCC that demonstrates perineural invasion, especially multifocal; in cases of extensive perineural invasion or invasion of named nerves, the nerve should be targeted with radiotherapy back to the skull base
  • Patients with periparotid nodal disease should be managed by surgical resection with neck dissection, followed by adjuvant radiotherapy
  • Concurrent cisplatin-based chemotherapy can be considered in patients with high-risk pathologic features (eg, margin positivity or extracapsular extension) or in patients with unresectable, locally advanced disease
  • Intensified adjuvant therapies, such as radiotherapy for intermediate-risk patients and incorporating systemic therapies concurrently with radiotherapy, may benefit certain classes of patients

Scottish Intercollegiate Guidelines Network

Recommendations from the Scottish Intercollegiate Guidelines Network's (SIGN's) updated guidelines for the management of primary cutaneous squamous cell carcinoma (cSCC), published in 2014, are summarized below. [69]  

The following are considered high-risk clinical features [69] :

  • Immunosuppression
  • Ear as the tumor site
  • Horizontal tumor diameter of >20 mm 
  • Tumor depth >4 mm; >6 mm indicates a very–high-risk tumor
  • Tumor extension beyond the dermis into or through subcutaneous fat 
  • Perineural invasion
  • Desmoplastic subtype 
  • Poorly differentiated tumor status 

The presence of any of the above high-risk features in a patient with primary SCC warrants discussion of the patient in a multidisciplinary team (MDT) meeting.

SCC treatment options include the following [69] :

  • Surgical excision for high-risk tumors - A clinical peripheral margin of 6 mm or greater is indicated when surgically achievable and clinically appropriate
  • Surgical excision for low-risk tumors - A clinical peripheral margin of 4 mm or greater is indicated when surgically achievable and clinically appropriate
  • Mohs micrographic surgery should be considered for selected patients with high-risk tumors when tissue preservation or margin control is challenging, as well as for patients with any tumor at a critical anatomic site
  • Consider curettage and cautery for patients with low-risk tumors if healthcare professionals have had appropriate training with a blunt curette
  • Photodynamic therapy should not be used for treatment of primary SSC
  • Consider primary radiotherapy for patients if surgical excision would be extremely challenging or difficult to perform or would be likely to result in an unacceptable functional or aesthetic outcome
  • Consider adjuvant radiotherapy for patients with a high risk of local recurrence or with close or involved margins when further surgery carries an increased risk of complications, including functional or aesthetic morbidity

For patients with SCC with any high-risk features, posttreatment follow-up appointments every 3-6 months for 24 months should be offered. Depending on the clinical risk, it may be appropriate to also schedule one 3-year follow-up appointment. [69]

Dermatological Cooperative Oncology Group

Guidelines on cutaneous squamous cell carcinoma (cSCC) from the Dermatological Cooperative Oncology Group of the German Cancer Society and the German Society of Dermatology were published in April 2020. They include the following. [70]

Because data are insufficient regarding the value of regional lymphadenectomy following positive sentinel lymph node biopsy (SLNB), do not perform prophylactic lymphadenectomy.

When lymph node metastasis is clinically manifested, the patient should undergo regional (therapeutic) lymphadenectomy.

When local disease is inoperable or not completely resectable, radiation therapy should be performed.

The following cases should prompt use of postoperative radiation therapy:

  • R1 or R2 resection (if reexcision is not feasible)
  • Extensive lymph node involvement (>1 affected lymph node, lymph node metastasis >3 cm, capsular penetration)
  • Intraparotid lymph node involvement

Existence of the following risk factors should prompt treatment with adjuvant radiation therapy:

  • Surgical margins < 2 mm and reexcision is not feasible
  • Extensive perineural infiltration

Employ micrographically controlled surgery (MCS) for the treatment of local or locoregional recurrence.

If, over the course of the resection, residual, unresectable tumor tissue (R1 or R2 resection) is in evidence, the affected area should undergo radiation therapy.

If an interdisciplinary tumor board determines inoperability, radiation therapy should be performed.