A 90-year-old man from an extended care facility presents for evaluation of a growth emanating from his right zygomatic region. The man is aphasic secondary to a stroke, and relatives accompanying him cannot provide information on the duration of the lesion. Examination reveals a golf-ball-sized tumor. Cervical lymph nodes are nonpalpable.
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Histopathology revealed a well-differentiated squamous cell carcinoma (SCC) with perineural invasion. Cutaneous SCC is the second most commonly occurring skin malignancy in white patients in the United States, with an annual incidence of approximately 700,000 cases.1 Although most SCC are curable, lymph node metastases develop in 4% of cases and 1.5% of those affected die from the disease.2
A number of variables have been proposed by the National Comprehensive Cancer Network to identify high-risk SCC.3 High-risk SCC is diagnosed by the following: large diameter (≥2 cm or >1 cm on cheeks, forehead, scalp, or neck, or >6 mm on other areas of the face, genitalia, hands, or feet), depth of 4 mm or beyond the papillary dermis, ill-defined margins, recurrence after definitive treatment, immunosuppression, prior radiation, chronic inflammation, rapid growth, neurologic symptoms, perineural or vascular invasion, moderately or poorly differentiated histology, infiltrative or acantholytic pattern, or mucin production.
In those diagnosed with high-risk SCC, evaluation of palpable lymph nodes should be carried out using fine needle aspiration or excisional biopsy.1 Mohs surgery to remove the primary tumor and achieve clear margins is recommended as primary management of high-risk SCC.1,4 Inoperable tumors may respond to radiation therapy, which can also be used as adjuvant treatment following tumor removal.
Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He practices dermatology in Hazleton, Pennsylvania.
- LeBoeuf NR, Schmults CD. Update on the management of high-risk squamous cell carcinoma. Semin Cutan Med Surg. 2011;30(1):26-34.
- Mourouzis C, Boynton A, Grant J, et al. Cutaneous head and neck SCCs and risk of nodal metastasis—UK experience. J Craniomaxillofac Surg. 2009;37(8):443-447.
- Miller SJ, Alam M, Andersen J, et al. Basal cell and squamous cell skin cancers. J Natl Compr Cancer Netw. 2010;8(8):836-864.
- Longo I. Managing high-risk squamous cell carcinoma. Melanoma Res. 2010;20:e26-e27.