Predicting the pattern of regional metastases from cutaneous squamous cell carcinoma of the head and neck based on location of the primary

Tumor-to-Tumor Metastasis: Dissemination of Cutaneous Squamous Cell Carcinoma Involving Parotid Warthin Tumor-Case Report

Warthin tumors (WTs) are the second most common salivary gland tumors, most commonly found in the tail of the parotid gland. The lymphoid components of a WT may also serve as a site for tumor-to-tumor metastasis. This report describes the metastasis of cutaneous squamous cell carcinoma (cSCC) from the preauricular region to a parotid WT. A 68-year-old male patient was admitted to the Department of Cranio-Maxillofacial Surgery of the Jagiellonian University in Cracow, Poland, with a two-year history of a growing, painless skin tumor of the right preauricular region. The patient was eligible for surgical treatment with elective neck dissection at the Va, III, II, I levels with parotidectomy and the excision of the cSCC. In the histopathological examination of the components of the surgical specimen beside the primary cutaneous squamous cell carcinoma (cSCC), a parotid WT was found; in the majority, it was occupied and destroyed by the metastatic cSCC and radically removed. After a tumor board consultation, due to the advanced stage (pT3N2b LVI2 PNI0 R0), with three intraparotid lymph node metastases and LVI2, the patient was authorized for postoperative radiotherapy. In conclusion, tumor-to-tumor metastasis is an extremely rare entity. Surgery is the standard of care for both WTs and head and neck cSCC. In most cases, metastasis into the parotid gland can be successfully treated with superficial parotidectomy with facial nerve preservation. Dissemination into the parotid gland requires elective neck dissection, as well as adjuvant treatment.

Surgical Management of Patients with Parotid Involvement from Non-Melanoma Skin Cancer of the Head and Neck

We conducted a retrospective, longitudinal study on a single-center series of patients who underwent parotidectomy in the management of advanced head and neck non-melanoma skin cancer (hnNMSC). The aim of this study was to identify prognostic factors associated with worse outcomes. Forty-one men and nine women were included. The mean age at the time of surgery was 78.9 years. The 5-year overall survival, disease-specific survival, locoregional recurrence-free survival, and distant metastasis-free survival calculated with Kaplan-Meier curves were 39.9%, 56.3%, 58.6%, and 82.1%, respectively. A univariate analysis showed that the status of the margins, facial nerve direct involvement, lymph vascular invasion, and histological grading were associated with worse outcomes (p < 0.05). Positive margins were associated with worse disease-specific survival also in a multivariate analysis (p = 0.001, HR = 32.02, and CIs 4.338 to 351.3). Because the resection in free margins is the most important prognostic factor, early diagnosis or, in the case of advanced disease, extensive surgical resection with concomitant reconstruction is needed. Adjuvant therapy is indicated in selected cases.

Parotid Gland Metastases of Cutaneous Squamous Cell Carcinoma of the Head: Occult Metastases Occurrence and Their Late Manifestation

Cutaneous squamous cell carcinomas (cSCC) are malignant tumours with excellent prognosis unless nodal metastases develop. The aim of our study is to determine the prognostic significance of the clinical stage of parotid gland metastases and the incidence of occult cervical lymph node involvement in cSCC of the head. Our retrospective analysis includes 39 patients with cSCC parotid gland metastases, 15 of whom had concurrent cervical node involvement. In 32 patients, the lymph nodes manifested at stage N3b. A total of 26 patients were treated with parotidectomy, 9 patients received radiotherapy alone, and 4 received symptomatic therapy. The surgical treatment included either total conservative (21 cases) or superficial parotidectomy (5 cases) and neck dissection (therapeutic neck dissections in 11 cases and elective in 14 cases). In all cases, surgery was performed with sufficient tumour-free resection margins. Adjuvant radiotherapy was administered postoperatively in 16 patients. Occult metastases were present in 21% of cases after an elective neck dissection, but not in any case in the deep lobe of the parotid gland. The five-year overall survival and recurrence-free interval were 52% and 55%, respectively. Patients with the cN3b stage and G3 histological grade tend to have a worse prognosis, but not at a statistically significant level. The prognosis was not worse in patients with concurrent parotid and cervical metastases compared to those with metastases limited to the parotid gland only. The addition of adjuvant irradiation, in comparison to a single modality surgical treatment, was the only statistically significant prognostic factor that reduced the risk of death from this diagnosis (p=0.013). The extent of parotidectomy (partial vs. total) had no impact on either the risk of recurrence or patient prognosis. The combination of surgery with irradiation provides the best results and should be applied to all patients who tolerate the treatment. A partial superficial parotidectomy should be sufficient, with a minimum risk of occult metastasis in the deep lobe. Conversely, the relatively high incidence of occult neck metastases indicates that patients could likely benefit from elective neck dissection.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

[Cutaneous squamous cell carcinoma of the head and neck]

OBJECTIVE

Cutaneous squamous cell carcinoma (cSCC), predominantly located on the scalp and face, is the second most prevalent skin cancer globally. Due to the increasing elderly population and rising incidence of cSCC, it has been gaining relevance in otorhinolaryngology.

MATERIAL AND METHODS

This review article is based on a selective PubMed literature search, German and European guidelines and the clinic's own experience.

RESULTS

In addition to chronic UV exposure, a disruption of the body's own immune system is becoming increasingly important. Vertical tumor thickness is associated with the highest risk of metastatic spread and local recurrence. Other significant risk factors are: horizontal tumor diameter, dedifferentiation, desmoplasia, perineural growth and localization on the face. Most cases are manageable by local excision with histological control of the excision margins. If regional metastases are clinically suspected, the draining cervical lymph node levels should be dissected depending on primary tumor location. cSCC of the upper face and the auricle primarily metastasize to the parotid gland. With the approval of the PD-1-blocking antibody cemiplimab in Europe, an active ingredient has been made available for the treatment of advanced cSCC where surgery or radiotherapy are no longer an option.

CONCLUSIONS

The otherwise very low mortality rate of cSCC increases considerably with metastases. Therefore, imaging, surgical therapy and follow-up intervals should be based on risk factors. This allows early detection of metastases or local recurrences and improves the prognosis.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone

Objective

The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone.

Methods

We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible.

Results

Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years.

Conclusions

Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin.

Level of Evidence

3.

The Effect of Tumor Characteristics and Location on the Extent of Lymph Node Metastases of Head and Neck Cutaneous Squamous Cell Carcinoma

Background

The extent of a neck dissection for patients with metastasis of cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is still subject to debate and clear guidelines are lacking. Tumor characteristics like size, differentiation and tumor location are known risk factors for lymph node metastasis (LNM). There is some evidence that, depending on tumor location, LNM follows a specific pattern. This study aims to identify which tumor characteristics can predict the pattern and extent of LNM.

Method

In this cohort study 80 patients were included, who underwent a primary neck dissection for LNM of HNcSCC between 2003 and 2018 at the University Medical Center Groningen, the Netherlands. Retrospective data was collected for primary tumor characteristics and LNM and included surgical and follow-up data. Influence of tumor characteristics on the extent of LNM was analyzed using non-parametric tests. Logistic regression analysis were used to identify a metastasis pattern based on the primary tumor location.

Results

Only primary tumor location was associated with the pattern of LNM. HNcSCC of the ear metastasized to level II (OR = 2.6) and the parotid gland (OR = 3.6). Cutaneous lip carcinoma metastasized to ipsilateral and contralateral level I (OR = 5.3). Posterior scalp tumors showed a metastasis pattern to level II (OR = 5.6); level III (OR = 11.2), level IV (OR = 4.7) and the parotid gland (OR = 10.8). Ear canal tumors showed a low risk of LNM for all levels. The extent of LNM was not related to age or any tumor characteristics i.e. tumor diameter, infiltration depth, differentiation grade, perineural growth and vascular invasion.

Conclusion

Primary tumor location determines the LNM pattern. Whereas known unfavorable tumor characteristics did not relate to the extent of LNM. Location guided limited neck dissection combined with parotidectomy will treat most patients adequately.

[Diagnostics and treatment of secondary malignancies of the parotid gland-An overview]

BACKGROUND

Secondary malignancies of the parotid gland frequently have a cutaneous origin and the incidence in central Europe is increasing.

OBJECTIVE

The aim of this review article was to present the epidemiology, (differential) diagnostics and treatment of secondary malignancies of the parotid gland.

MATERIAL AND METHODS

A literature search of the current guidelines and evidence was carried out in the web-based databank PubMed.

RESULTS

The incidence of secondary malignancies of the parotid gland seems to be increasing in Europe, mainly due to a rising incidence of metastases of cutaneous squamous cell carcinomas. Except for malignant lymphomas, parotidectomy is the treatment of choice in the curative situation. In the absence of clear evidence, in the case of an intact facial nerve lateral or total parotidectomy with ipsilateral neck dissection seems to be indicated, depending on the entity of the secondary malignancy.

CONCLUSION

The differential diagnostics of squamous cell carcinoma (in) of the parotid gland can be complicated. When a squamous cell carcinoma of the parotid gland is diagnosed for the first time, a dermatological full body examination and a detailed medical history should be taken with respect to skin tumors of the head and neck region. In addition to surgical treatment of the parotid gland and neck, adjuvant radiotherapy is usually indicated.

Management of the parotid for high-risk cutaneous squamous cell carcinoma: A review from the salivary section of the American Head and Neck Society

BACKGROUND

Metastases to the parotid nodal basin in patients with high-risk cutaneous squamous cell carcinoma (HRcSCC) impact disease specific survival (DSS) and overall survival (OS).

METHODS

A writing group convened by the Salivary Section of the American Head and Neck Society (AHNS) developed contemporary, evidence-based recommendations regarding management of the parotid nodal basin in HRcSCC based on available literature, expert consultation, and collective experience. The statements and recommendations were then submitted and approved by the AHNS Salivary Committee.

RESULTS

These recommendations were developed given the wide variation of practitioners who treat HRcSCC in order to streamline management of the parotid nodal basin including indications for imaging, surgery, radiation, and systemic treatment options as well.

CONCLUSIONS

This clinical update represents contemporary optimal management of the parotid nodal basin in HRcSCC and is endorsed by the Salivary Section of the AHNS.

When is a surgical multidisciplinary approach required in the management of head and neck non-melanoma skin cancer and in advanced head and neck pathologies involving skin?

Non-melanoma Skin cancer, including cutaneous squamous cell carcinoma and basal cell carcinoma, is the most common form of malignancy in the Caucasian population, and the skin of the head and neck is the site most involved. They should not be underestimated; in particular, high-risk lesions and advanced skin cancers require accurate diagnostic work up, aggressive surgical treatment and should be managed by the head and neck surgeon, the dermatologist and the plastic surgeon. Cutaneous head-neck malignancies are often overlooked or not routinely treated with a multidisciplinary surgical approach. Similarly, for primary head and neck cancers with involvement of surrounding skin, the involvement of the dermatologist and the plastic surgeon could better define an adequate diagnosis and treatment planning. The management of these patients presents both therapeutic and ethical problems, because the poor prognosis is burdened by facial disfigurement, open malodorous wounds and intractable pain. Therefore, in patients with advanced disease that is not candidate to radical surgery, palliative surgery with flap reconstruction could take place and could be proposed to improve quality of life.

High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Clinical Review

BACKGROUND

Given the rapidly evolving nature of the field, the current state of "high-risk" head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized.

METHODS

Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC.

RESULTS

Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as "high risk" and "advanced" are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents.

CONCLUSION

Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Clinician perspectives on the factors influencing prognostic stratification by the American Joint Commission on Cancer Head and Neck Cutaneous Squamous Cell Carcinoma Staging

BACKGROUND

The eighth edition of the American Joint Committee on Cancer Staging Manual includes a staging system for head and neck cutaneous squamous cell carcinoma for the first time. The pN categories for head and neck cutaneous squamous cell carcinoma and mucosal squamous cell carcinoma are identical, despite the vastly different biological behavior of these diseases. This study aimed to survey head and neck cancer specialists' views regarding the clinical utility of the American Joint Committee on Cancer Staging Manual for head and neck cutaneous squamous cell carcinoma and to identify avenues for improvement.

DESIGN

An electronic survey of 19 questions relating to the prognostic utility of the staging system was designed based on the findings of a literature review. The survey was distributed internationally to specialists managing head and neck cutaneous squamous cell carcinoma.

RESULTS

Literature review identified 9 articles describing primary research relevant to the performance of the American Joint Committee on Cancer Staging Manual for head and neck cutaneous squamous cell carcinoma, which recognized a lack of homogeneity, monotonicity, and distinctiveness in the pN staging system. One hundred and five survey responses were received: 71% indicated that mucosal and head and neck cutaneous squamous cell carcinoma require different nodal staging categories; 63% indicated that immunosuppression should be included in the staging system; 70% thought that soft tissue metastases portend a worse prognosis compared with extranodal extension; 38% almost never saw pN3a tumors; and 40% felt that the N stage is a poor predictor of survival.

CONCLUSION

The views of head and neck cancer specialists across disciplines and countries align with evidence suggesting that head and neck cutaneous squamous cell carcinoma merits a staging system distinct from mucosal squamous cell carcinoma, that immunosuppression should be considered in prognostication, and that the use of extranodal extension should be modified.

A critical analysis of the 8th edition TNM staging for head and neck cutaneous squamous cell carcinoma with lymph node metastases and comparison to N1S3 stage and ITEM risk score: A multicenter study

BACKGROUND AND OBJECTIVES

We performed a critical analysis of the 8th edition American Joint Committee on Cancer (AJCC) staging for head and neck cutaneous squamous cell carcinoma (HNcSCC) with nodal metastases and compared the performance to the N1S3 and ITEM systems.

METHODS

Multicenter study of 990 patients with metastatic HNcSCC treated with curative intent. The end points of interest were disease-specific (DSS) and overall survival (OS). Model fit was evaluated using Harrell's Concordance Index (C-index), proportion of variation explained (PVE), Akaike information criterion, and Bayesian information criterion.

RESULTS

N1S3 and ITEM demonstrated good distribution into risk categories in contrast to the AJCC system, which classified the majority (90.6%) of patients as N2-3 and Stage IV due to the high rate of extranodal extension. The N2c and N3a categories appeared redundant. There was considerable discordance between systems in risk allocation on an individual patient basis. N1S3 was the best performed (DSS: C-index 0.62, PVE 10.9%; OS: C-index 0.59, PVE 4.5%), albeit with relatively poor predictive value.

CONCLUSIONS

The AJCC N category and tumor node metastasis stage have poor patient distribution and predictive performance in HNcSCC. The AJCC stage, N1S3, and ITEM score all provide limited prognostic information based on objective measures highlighting the need to develop a staging system specific to HNcSCC.

Prognostic indicators and outcomes following surgical management of metastatic cutaneous squamous cell carcinoma of the head and neck

Metastatic cutaneous SCC carries a poor prognosis with five-year survival of 25%-57%. The aim of this study is to examine the outcomes following surgery with adjuvant therapy for management of metastatic cSCC in a UK-based population. This is a retrospective review of patients with metastatic cSCC of the head and neck who underwent primary surgery at a regional center during a six-year period. Overall and disease specific survival were calculated using Kaplan-Meier and log-rank tests. Results were reported as hazard ratios (HR) with 95% confidence intervals. Forty-five patients met the inclusion criteria. The mean time to discovery of metastases was 9.3 months (range, 0-40 months). Only two patients (4%) had discovery of metastases after two years, with none after 3.3 years. The overall five5-year survival was 31% (95% CI 15%to 48%) with two-year survival at 48% (95% CI 31%to 63%). The median OS survival was 722 days (95% CI 607to 1359). Patients aged >80 years had a decreased OS. This is the largest UK based study documenting the overall and disease specific survival associated with metastatic cutaneous SCC of the head and neck. Our overall survival is comparable to similar studies, but remains poor. Total number of involved nodes, and lymph node ratio were not statistically significant.

Metastatic Cutaneous Squamous Cell Carcinoma Involving the Parotid Gland: Experience Outside of the Sun Belt

OBJECTIVE

To characterize a subset of patients with metastatic head and neck cutaneous squamous cell carcinoma in a tertiary North American center and describe oncologic outcomes following definitive treatment.

STUDY DESIGN

Retrospective chart review.

SETTING

National Cancer Institute-designated Comprehensive Cancer Center.

METHODS

We conducted a retrospective chart review of patients with cutaneous squamous cell carcinoma with metastases to intraparotid lymph nodes who underwent parotidectomy between 1993 and 2020. Baseline patient and tumor characteristics were assessed. Regional control, disease-specific survival, and overall survival were estimated using Kaplan-Meier method. Multivariate analysis was used to determine the relationship between adverse pathological features and survival.

RESULTS

A total of 122 patients were included. The median age was 76, 84.4% of patients were male, and 17.2% were immunosuppressed. Regional control, disease-specific survival, and overall survival were 68.5%, 70.7%, and 59.4% at 5 years, respectively. Perineural and lymphovascular invasion were predictive of worse disease-specific survival. Extracapsular spread was observed in 90.2% of patients and was not a significant predictor of outcome.

CONCLUSIONS

We found the demographics and oncologic outcomes of our cohort in the Northeast United States to be comparable with those previously reported in Australia and the Sun Belt of the United States. We noted a high rate of extracapsular spread but did not find it to be a significant predictor of recurrence or survival. Future efforts should address the impact of extracapsular spread on prognosis and adjuvant treatment decisions.

Thulium oxide nanoparticles as radioenhancers for the treatment of metastatic cutaneous squamous cell carcinoma

Metastases from cutaneous squamous cell carcinoma (cSCC) occur in 2%-5% of cases. Surgery is the standard treatment, often combined with adjuvant radiotherapy. Concurrent carboplatin treatment with post-operative radiotherapy may be prescribed, although it has not shown benefit in recent clinical trials in high-risk cSCC patients. The novel high-Z nanoparticle thulium (III) oxide has been shown to enhance radiation dose delivery to brain tumors by specific uptake of these nanoparticles into the cancerous tissue. As the dose-enhancement capacity of thulium oxide nanoparticles following radiotherapy against metastatic cSCC cells is unknown, its efficacy as a radiosensitizer was evaluated, with and without carboplatin. Novel and validated human patient-derived cell lines of metastatic cSCC were used. The sensitivity of the cells to radiation was investigated using short-term proliferation assays as well as clonogenic survival as the radiobiological endpoint. Briefly, cells were irradiated with 125 kVp orthovoltage x-rays (0-6 Gy) with and without thulium oxide nanoparticles (99.9% trace metals basis; 50 µg ml^-1) or low dose carboplatin pre-sensitization. Cellular uptake of the nanoparticles was first confirmed by microscopy and found to have no impact on short-term cell survival for the cSCC cells, highlighting the biocompatibility of thulium oxide nanoparticles. Clonogenic cell survival assays confirmed radio-sensitization when exposed to thulium nanoparticles, with the cell sensitivity increasing by a factor of 1.24 (calculated at the 10% survival fraction) for the irradiated cSCC cells. The combination of carboplatin with thulium oxide nanoparticles with irradiation did not result in significant further reductions in survival compared to nanoparticles alone. This is the first study to provide in vitro data demonstrating the independent radiosensitization effect of high-Z nanoparticles against metastatic cSCC with or without carboplatin. Further preclinical investigations with radiotherapy plus high-Z nanoparticles for the management of metastatic cSCC are warranted.

Identifying risk factors for the prognosis of head and neck cutaneous squamous cell carcinoma: A systematic review and meta-analysis

In this study, we sought to identify the potential impacts of disease characteristics on the prognosis of cutaneous squamous cell carcinoma (cSCC). We searched the PubMed, EmBase, and Cochrane Library databases from their inception until February 2020 to identify studies that investigated the prognosis of cSCC. The pooled effect estimates were applied using odds ratios (OR) and 95% confidence intervals (CI) and were calculated using the random-effects model. Forty-three studies including a total of 21,530 patients and reporting 28,627 cases of cSCC were selected for the final meta-analysis. Poor differentiation (OR, 3.54; 95% CI, 2.30–5.46; P < 0.001), perineural invasion (OR, 3.27; 95% CI, 1.60–6.67; P = 0.001), Breslow greater than 2 mm (OR, 5.47; 95% CI, 2.63–11.37; P < 0.001), diameter greater than 20 mm (OR, 4.62; 95% CI, 2.95–7.23; P < 0.001), and location on temple (OR, 3.20; 95% CI, 1.12–9.15; P = 0.030) were associated with an increased risk of recurrence, whereas immunosuppression status and location on cheek, ear, or lip were not associated with the risk of recurrence. Poor differentiation (OR, 6.82; 95% CI, 4.66–9.99; P < 0.001); perineural invasion (OR, 7.15; 95% CI, 4.73–10.83; P < 0.001); Breslow greater than 2 mm (OR, 6.11; 95% CI, 4.05–9.21; P < 0.001); diameter greater than 20 mm (OR, 5.01; 95% CI, 2.56–9.80; P < 0.001); and location on ear (OR, 2.38; 95% CI, 1.39–4.09; P = 0.002), lip (OR, 2.15; 95% CI, 1.26–3.68; P = 0.005), and temple (OR, 2.77; 95% CI, 1.20–6.40; P = 0.017) were associated with an increased risk of metastasis, whereas immunosuppression status and location on cheek did not affect the risk of metastasis. Finally, poor differentiation (OR, 5.97; 95% CI, 1.82–19.62; P = 0.003), perineural invasion (OR, 6.64; 95% CI, 3.63–12.12; P < 0.001), and Breslow greater than 2 mm (OR, 3.42; 95% CI, 1.76–6.66; P < 0.001) were associated with an increased risk of disease-specific death, whereas diameter; immunosuppression status; and location on ear, lip, and temple did not affect the risk of disease-specific death. We found that differentiation, perineural invasion, depth, diameter, and location could affect the prognosis of cSCC. The potential role of other patient characteristics on the prognosis of cSCC should be identified in further large-scale prospective studies.

Trends in parotidectomy over 30 years in an Australian tertiary care center

BACKGROUND

Nomenclature, classification, and management of parotid tumors are constantly evolving; this study was performed to identify temporal trends in histology and facial nerve sacrifice in parotidectomy during a 30-year period (1987-2018).

METHODS

Retrospective analysis of patients treated in a single tertiary-care institution during this time period was performed with analysis of temporal trends.

RESULTS

Two thousand eight hundred and fifty-seven parotidectomies were performed; pleomorphic adenoma was the most common histology (34.3%), followed by skin cancer metastases (32.3%). Significant trends noted were increasing age (P < .001), fewer parotidectomies for inflammatory lesions (P < .001), reduced incidence of mucoepidermoid carcinoma (P = .048), increasing incidence of parotidectomy for cutaneous malignancies (P < .001), and reduced facial nerve sacrifice (P = .034).

CONCLUSION

In this contemporary series of parotid pathology, metastatic cutaneous malignancies accounted for a third of cases. Despite reducing facial nerve sacrifice in parotid disease, it is still required in approximately 15% of malignancy and needs to be discussed with all patients preoperatively.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment

In order to update recommendations on treatment, supportive care, education and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer was formed. Recommendations were based on evidence-based literature review, guidelines and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable) and distant metastatic cSCC. For common primary cSCC (the most frequent cSCC type), first-line treatment is surgical excision with postoperative margin assessment or microscopically controlled sugery. Safety margins containing clinical normal-appearing tissue around the tumour during surgical excision and negative margins as reported in the pathology report are necessary to minimise the risk of local recurrence and metastasis. In case of positive margins, a re-excision shall be done, for operable cases. Lymph node dissection is recommended for cSCC with cytologically or histologically confirmed regional nodal involvement. Radiotherapy should be considered as curative treatment for inoperable cSCC, or for non-surgical candidates. Anti-PD-1 antibodies are the first-line systemic treatment for patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiation, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drug Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiation therapy. Multidisciplinary board decisions are mandatory for all patients with advanced disease who require more than surgery. Patients should be engaged with informed decisions on management and be provided with best supportive care to optimise symptom management and improve quality of life. Frequency of follow-up visits and investigations for subsequent new cSCC depend on underlying risk characteristics.

Regional Metastasis in Head and Neck Cutaneous Squamous Cell Carcinoma: An Update on the Significance of Extra-Nodal Extension and Soft Tissue Metastasis

BACKGROUND

Soft tissue metastases (STMs) are reported to predict worse prognosis than extra-nodal extension (ENE) in metastatic head and neck cutaneous squamous cell carcinoma. This study aimed to update the authors' previous analysis of STM in a larger series.

METHODS

The study analyzed 535 cases of consecutive cSCC metastatic to the parotid and/or neck treated by primary surgical resection between 1987 and 2007. A Cox proportional hazard model was used to determine the effect of STM, with adjustment for other relevant prognostic factors. Overall survival (OS) and disease-specific survival (DSS) were the primary end points.

RESULTS

Of the 535 patients, 275 (51.4%) had STM. After adjustment for the effects of age, tumor location, number of metastatic deposits, and adjuvant radiotherapy, both STM (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.08-2.22; p = 0.018) and ENE (HR, 1.56; 95% CI 1.10-2.22; p = 0.013) were shown to be independent predictors of reduced OS, with similar size of effect.

CONCLUSION

In metastatic cSCC of the head and neck, STM is an independent predictor of reduced survival and has an impact on survival similar to that of ENE.

Surgical management of the neck in patients with metastatic melanoma in parotid lymph nodes

BACKGROUND

The role and extent of neck dissection in patients with parotid metastatic cutaneous head and neck melanoma remain unclear. The aims of this study were to determine the incidence and patterns of cervical node involvement in patients with parotid metastatic melanoma, and to determine if a limited lymphadenectomy of the clinically negative neck is appropriate.

METHODS

Patients who underwent parotidectomy and neck dissection for clinically apparent parotid metastatic melanoma, irrespective of neck status, were identified from two prospectively maintained databases.

RESULTS

A total of 276 patients fulfilled the study criteria. Median follow-up was 23 months. A total of 185 necks were clinically negative, 82 were clinically positive. A total of 36 elective neck-dissection specimens harbored occult metastases; these were found in levels I (16.7%), II (58.3%), III (36.1%), IV (13.9%), and V (30.6%). Regional recurrence occurred in 32 patients with a clinically negative neck, the majority being in-transit metastases (n = 15). Only one case of recurrence could have potentially been avoided by a comprehensive lymphadenectomy.

CONCLUSIONS

In patients with clinically apparent parotid melanoma metastases, elective comprehensive neck dissection reduces failure rates in cervical nodes, and provides more accurate staging and prognostic information. However, our findings support the emerging trend for more limited elective neck dissection. Levels I and IV can probably be safely omitted.

Prognostic Factors in Metastatic Cutaneous Squamous Cell Carcinoma of the Head and Neck

Metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck poses a significant therapeutic challengedue to its aggressive biologic behavior. We conducted a retrospective study of71 patients—58 men and 13 women, aged 28 to 88 years (mean: 71)—who had been treated atour university-affiliated tertiary care medical center for metastatic cutaneous SCCover a 15-year period. In addition to demographic data, we compiled and analyzed information on tumor characteristics, the site and extent of metastasis, treatment, follow-up, and outcome. Among the tumor factors, poorly differentiated carcinoma was an independent predictor of poorer disease-free survival, and olderage was found to be an independent predictor of poorer overall survival. We found no significant difference in disease-free or disease-specific survival among patients with parotid involvement, neck involvement, or both. In our series, the site of nodal involvement appeared to have no prognostic significance in patients with metastatic cutaneous SCC of the head and neck.

Management of regional metastatic disease in cutaneous malignancy of the head and neck. 3. Merkel cell carcinoma

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes.

Cancers of the Major Salivary Gland

Salivary gland malignancies are rare tumors that comprise multiple histologic entities with diverse clinical behavior. Mucoepidermoid carcinoma is the most frequent primary salivary malignancy, followed by adenoid cystic and acinic cell carcinoma. Although most salivary malignancies are asymptomatic, presentation with a rapidly enlarging mass may be accompanied by pain, functional neurologic deficits, soft-tissue invasion, or nodal enlargement. Assessment of clinical behavior and physical exam greatly contributes to diagnostic workup. Preoperative imaging, to include ultrasound, computed tomography, or magnetic resonance imaging, may assist with surgical planning. Limitations of preoperative fine-needle aspiration cytology mean that, in some cases, definitive histologic diagnosis may not be established until therapeutic surgery is undertaken. Treatment strategies rely on oncologic resection of the primary site with negative margins as well as adjuvant radiotherapy in patients with high-risk features, such as high-grade histology, advanced T class, or perineural invasion. Regional lymphadenectomy is recommended for involved nodal basins. Patients with clinically node-negative disease at high risk for occult nodal metastases may be considered for elective lymphadenectomy or radiotherapy. Use of chemotherapy in the adjuvant setting, in combination with radiotherapy, remains controversial. The rate of objective response to palliative chemotherapy in recurrent or metastatic salivary gland malignancy remains low. In studies that include a significant proportion of adenoid cystic carcinomas, whether disease stability represents an indolent disease process or the true effect of a therapeutic drug may be difficult to discern. Recognition of genetic alterations and protein expression unique to salivary malignancies presents exciting new opportunities for molecularly targeted therapy, although the response to molecularly targeted therapy in studies has been modest thus far.

Survival Outcomes for Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck

Objectives:

Survival outcomes for advanced non-melanoma skin cancers of the head and neck treated with surgical resection are not well described in the literature. We aimed to describe outcomes for T3 and T4 cutaneoous squamous cell carcinoma of the head or neck treated with surgical resection at 1 tertiary academic medical center.

Methods:

We analyzed a retrospective cohort of patients diagnosed with T3 or T4 cutaneous squamous cell carcinoma (SCC) of the head or neck from 2005 to 2016 treated with definitive surgical resection. Survival outcomes were examined using Kaplan-Meier analysis, and multivariate analysis was completed with Cox proportional hazard model.

Results:

Forty-three patients met inclusion criteria. The mean age at diagnosis was 74.7 years (SD = 10.2), and 34 (79.1%) patients were male. Twelve (27.9%) patients were immunosuppressed. Radical resection, defined as temporal bone resection, orbital exenteration, calvarial resection, mandibulectomy, or maxillectomy, was performed in 25 (58.1%) cases. Final surgical margins were positive in 19 (44.2%) cases. Patients with tumors of the scalp/neck had a 1-year survival probability of 85.7%, and the probability of survival 1 year after a neck dissection was greater than 93%.

Conclusion:

Anatomical subsites, specifically scalp/neck tumors, tended to have worse overall survival. Positive final margins tended to indicate a worse prognosis, and overall survival and recurrence were not significantly different among patients who underwent radical surgical resection compared to soft tissue resection.

Comparison between wait-and-see policy and elective neck dissection in clinically N0 cutaneous squamous cell carcinoma of head and neck

To analyze the superiority of wait-and-see policy and elective neck dissection in treating cN0 patients with facial cutaneous cell carcinoma (cSCC).Patients with clinically negative parotid and neck metastasis disease were prospectively enrolled. Three groups were divided based on whether the patient received an operation of superficial parotidectomy or/and elective dissection, and regional control and disease-specific survival rates were compared.The occult parotid and neck metastasis rate was 20% and 16%, respectively. There was neck node metastasis without parotid metastasis in only 1 patient. All the node metastasis occurred in level II. Regional recurrence was noted in 16 (16%) patients, and 6 patients died of the disease. In the group undergoing superficial parotidectomy and elective neck dissection, 2 patients had neck node metastasis, and there was no disease-related death, further survival analysis indicated it had better regional control and disease-specific survival rates compared with the other 2 groups.Superficial parotidectomy and elective neck dissection are suggested for patients with T3-4 facial cutaneous squamous cell carcinoma.

Cancers of major salivary glands

Major salivary gland malignancies are a rare but histologically diverse group of entities. Establishing the diagnosis of a malignant salivary neoplasm may be challenging because of the often minimally symptomatic nature of the disease, and limitations of imaging modalities and cytology. Treatment is centered on surgical therapy and adjuvant radiation in selected scenarios. Systemic therapy with chemotherapeutic agents and monoclonal antibodies lacks evidence in support of its routine use.

[Lymphatic drainage of skin areas of head and neck: in vivo approach by the location of the sentinel node]

INTRODUCTION

The objective of the study was to determine the preferential territories of drainage of skin areas of the face and neck. This knowledge can guide the strategies of diagnostic (search for primary tumor skin to cervical lymphadenopathy) and treatment (determination of the extent of neck dissection to achieve in case of skin tumor).

MATERIALS AND METHODS

This is a retrospective study of the surgical procedures of sentinel node research between January 2003 and April 2011. The lymphoscintigraphic and intraoperative localization of the initial tumor site and sentinel lymph node were collected.

RESULTS AND DISCUSSION

One hundred and thirty-seven patients were included in the study. The parotid gland is a privileged territory of drainage of the head and neck skin. At cervical level, the submental region drains the lower and median part of the face (lips and chin). The posterior segments (IIb and V sector) were represented for the posterior locations of the head (ear, vertex), and cervical region.

Management of regional metastatic disease in head and neck cutaneous malignancy. 1. Cutaneous squamous cell carcinoma

This overview is the first of 2 articles on the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. In this paper we discuss cutaneous squamous cell carcinoma (SCC) and review the latest evidence for management of the regional nodes.

Head and neck cutaneous squamous cell carcinoma metastatic to cervical sublevel IIb lymph nodes occurred from primary sites involving the auricle and adjacent neck

PURPOSE

Neck dissections that include sublevel IIb increase the risk of postoperative shoulder dysfunction. The purpose of this investigation was to document the incidence of level IIb metastatic lymphatic spread in a group of patients undergoing neck dissection as part of the surgical management of cutaneous squamous cell carcinoma of the head and neck.

MATERIALS AND METHODS

A retrospective review of the pathology records taken from 1 surgeon from June 2006 through June 2013 was carried out. The predictor variable was the primary tumor site. The outcome variable was the metastatic nodal involvement according to neck level and sublevel. Secondary variables included T stage, pathologist, tumor depth, and the presence of perineural, perilymphatic, and perivascular invasion. Data analyses were by descriptive statistics.

RESULTS

Thirty-six patients with a total of 40 neck dissections met the inclusion criteria. The average primary site tumor depth was 14.7 mm, and there were 16 cases of poorly differentiated squamous cell carcinoma. Sublevel IIb was involved in 7.5% of cases, all of which occurred from lateralized primary sites of the head and neck.

CONCLUSIONS

Cutaneous squamous cell carcinoma arising from the auricle and neck sites adjacent to sublevel IIb may have increased risk of metastatic involvement of sublevel IIb nodes. Further studies with larger numbers are required to determine the risk of metastasis to sublevel IIb from midline sites of the face.

Follow-up strategies in head and neck cancer other than upper aerodigestive tract squamous cell carcinoma

Post-therapy follow-up for patients with head and neck cancer other than upper aerodigestive tract squamous cell carcinoma should meet several objectives: to detect both local, regional or distant recurrences, to evaluate acute and long-term treatment-related side effects, to guide the rehabilitation process, and to provide psychosocial support when needed. To our knowledge, there are no published reports in the literature dedicated to the follow-up of patients with these tumours. A comprehensive literature search for post-treatment follow-up strategies spanning from 1980 to 2012 was performed on several databases. This review focuses on malignant salivary gland tumors, soft tissue sarcomas, cutaneous squamous cell carcinomas, and sinonasal adenocarcinomas. Given the varying biological behavior and treatment-related factors and based on the literature, different recommendations are made on the follow-up of patients with the above-mentioned tumors.

In patients with metastatic cutaneous head and neck squamous cell carcinoma to cervical lymph nodes, the extent of neck dissection does not influence outcome

BACKGROUND

This study aimed to compare recurrence and survival in patients undergoing either selective neck dissection or modified radical neck dissection to treat metastatic cutaneous head and neck squamous cell carcinoma to the cervical lymph nodes (levels I-V) only.

METHODS

Twenty-eight year, retrospective analysis of a prospectively maintained database from a tertiary referral hospital, with a minimum follow up of two years.

RESULTS

There were 122 eligible patients: 96 males (79 per cent) and 26 (21 per cent) females (median age, 66 years). Sixty-six patients (54 per cent) underwent selective neck dissection and 56 (46 per cent) modified radical neck dissection. The former patients had a lower rate of regional recurrence compared with the latter (17 vs 23 per cent, respectively). There was no significant difference in five-year overall survival (61 vs 57 per cent, respectively) or five-year disease-free survival (74 vs 60 per cent, respectively), comparing the two groups. Overall survival and disease-free survival were significantly improved by the addition of adjuvant radiotherapy.

CONCLUSION

We found no difference in outcome in patients undergoing selective versus modified radical neck dissection. Adjuvant radiotherapy significantly improved outcome.

Concurrent primary and metastatic cutaneous head and neck squamous cell carcinoma: Analysis of prognostic factors

BACKGROUND

There is a small subgroup of patients with head and neck cutaneous squamous cell carcinoma (cSCC) in which nodal metastases present concurrently with the primary lesion. There is evidence that these tumors may represent a more aggressive subset of cSCC. The aim of this study was to determine whether alternative clinicopathologic prognostic factors should be applied to this patient cohort.

METHODS

A retrospective analysis of data from prospective databases of 2 large head and neck cancer units in Sydney, Australia, was performed. Ninety-five patients with concurrent primary and nodal metastatic head and neck cSCC were suitable for inclusion in the study.

RESULTS

Univariable analysis was performed for overall survival (OS) and disease-specific survival (DSS). OS was adversely affected by immunosuppression (p = .011) and nodal extracapsular spread (ECS) (p = .006). Similarly, immunosuppression (p = .005) and ECS (p = .005) indicated a worse outcome for DSS. ECS and immunosuppression remained significant in the multivariable analysis.

CONCLUSIONS

This study found that adverse prognostic factors were similar to the current evidence for nonconcurrent metastatic cSCC. In particular, the primary lesion had no significant influence on survival.

Assessment of second tier lymph nodes in melanoma and implications for extent of elective neck dissection in metastatic cutaneous malignancy of the parotid

BACKGROUND

The parotid is the commonest site of cutaneous metastases in the head and neck. The role and extent of neck dissection in patients with parotid metastatic cutaneous malignancy remains controversial.

METHODS

We reviewed the lymphoscintigraphy and single photon emission CT (SPECT) of patients with melanoma who had a sentinel node in the parotid to determine the second tier cervical lymph nodes.

RESULTS

Levels II and III cervical nodes make up 82% of second tier lymph nodes for the parotid, and levels IV and V, 12% and 4%, respectively. Second tier lymph nodes isolated to levels I, IV, or V, bypassing levels II and III, occurred in only 2% of cases.

CONCLUSION

The risk of harboring occult metastasis in levels I, IV, and V when levels II and III are negative is low. Levels II and III neck dissection is likely to be an effective staging procedure in patients with isolated parotid metastases.