Surgery for Cutaneous Squamous Cell Carcinoma and its Limits in Advanced Disease

Abstract

Surgery remains the first-line therapeutic option for most patients with cutaneous squamous cell carcinoma (cSCC). However, in the current therapeutic landscape, surgery must attempt to the complete tumor resection (R0 resection) with the lowest risk of surgical complications. This double aim is usually accomplished through standard excision with clinical margins in patients with low-risk tumors or by some of the micrographically controlled surgery procedures for patients with tumors at high-risk of local recurrence and metastasis. Surgery is also a first-line treatment for nodal metastases of cSCC as well as an option to consider in patients who develop recurrences while receiving immunotherapy, or as a palliation procedure in patients with advanced tumors. Neoadjuvant immunotherapy, that is the use of a medical treatment before surgery, is under investigation in patients with cSCC. The decision-making process and guidelines recommendations regarding cSCC surgery are reviewed in this manuscript.

Keywords: Mohs surgery; cutaneous squamous cell carcinoma; nodal metastases; nodal surgery; oncologic surgery; surgery.

Figure 1

Decision algorithm for the surgical management of patients with primary cutaneous squamous cell carcinoma. (A) ECOG-PS 0-2, acceptable overall condition, lack of non-controlled major cardiovascular or hematologic morbidities. (B) Assessment of accepted high-risk criterion (Table 1). (C) Micrographically controlled surgery always preferred as first option in high-risk tumors. Intraoperative frozen-section assessment or paraffin-embedded sections with delayed closure techniques based on tumor-, patient-related features, and availability of the procedures. (D) For definition of incomplete resection see the text.

Figure 2

Lymph node metastasis of cutaneous squamous cell carcinoma on the right arm. (A) Regional ultrasound shows a 17 mm hypoecoic structure also identified in the PET-CT scan. (B) The patient undewent right axillary lymph node dissection.

Figure 3

Lymph node metastasis of cutaneous squamous cell carcinoma from a primary tumor on the right sole. (A) CT-scan shows a well defined 20 mm nodule on the right superficial groin (white asterisk). (B) Regional ultrasound showed an anecoic rounded structure. The patient underwent a groin lymph node dissection.

Figure 4

Advanced cutaneous squamous cell carcinoma (cSCC). A 70-year old man with unresectable lymph node metastasis on the groin from a previously resected high-risk cSCC arising on a previously radiated area on the left heel.

Figure 5

Advanced cutaneous squamous cell carcinoma (cSCC). (A) A 32-year old man with dystrophic epidermolysis bullosa who developed an unresectable cSCC over a chronic wound on the left hand stump. The patient underwent amputation. (B) A 50-year old man with polyomelitys who developed an unresectable cSCC over a chronic ulcer on the right sole. The patient refused radiation therapy and systemic immunotherapy and a lower leg transtibilial amputation was carried out. (C) A 70 year-old woman who developed a neglected 10-year history ulcer on the right leg tha was considered unresectable. Radiation therapy achieved partial response and knee disarticulation had to be performed. (D) A 70-year old man immunosuppresed due to kidney grafting who developed fast-growing ulcer on the right hand. Systemic immunotherapy and radiation therapy did not achieved clinical response and consequently the patient underwent major amputation.