Resident Rounds Part III: Case Report: Metastatic Cutaneous Squamous Cell Carcinoma in an African American Female

January 2017 | Volume 16 | Issue 1 | Features | 81 | Copyright © January 2017


Jennifer N. Harb MD,a Alexandra L. Owens MD,a Kathryn Mooneyham Potter MD,a Michael Montuno MD,a Reordan O. De Jesus MD,b and Sailesh Konda MDa

aDepartment of Dermatology, University of Florida College of Medicine, Gainesville, FL bDepartment of Radiology, University of Florida College of Medicine, Gainesville, FL

Currently, there is no universally validated tumor staging system, and each system selects distinctive “high-risk” fac- tors considered to be predictive of a more aggressive clinical course (Table 2). Irrespective of the staging system used, physicians should be aware of the multiple tumor features widely discussed in the literature as enhancing metastatic potential: tumor diameter, depth of invasion, poorly differenti- ated tumors, histologic features, location (head/neck, lip, ear), perineural or lymphovascular involvement, tumor recurrence, incomplete excision, multiple tumors, patient characteristics, and genetic or molecular markers.7-9,11 Our patient was found to have a poorly differentiated tumor, with perineural and bone invasion, as well as lymph node and lung metastases; all of which portend a grim prognosis. Once a HRcSCC has been identi ed, there remains an absence of established protocol regarding additional indicated work-up. Lymph node involvement by SCC increases morbidity and mor- tality, highlighting the importance of lymph node evaluation in HRcSCCs. An estimated 80% of cSCC metastasis predictably spreads to a single regional lymph node first, making sentinel lymph node biopsies (SLNB) a potentially very useful aid in ear- ly identi cation of subclinical nodal metastasis.12 According to a meta-analysis by Schmitt and colleagues, SLNBs were positive in 29.4% of T2b and 50% ofT3 tumors, compared with only 7% of BWH T2a tumors.12 This data suggests that SLNB should be considered in T2b andT3 patients. Radiographic imaging should also be considered in HRcSCCs. The NCCN recommends imaging of tumors presenting with ex- tensive disease, including involvement of deep structures (ie, bone), perineural disease, deep soft tissue involvement, or lymphovascular invasion.13These general guidelines, likely due to a paucity of data, do not clearly delineate which patients should undergo imaging. A recent study by Ruiz and colleagues evaluated the impact of imaging on the management of HRcSCC and revealed only 46% of high-stage tumors (BWHT2b/T3) underwent imaging, of which 33% had management altered due to imaging re- sults. Furthermore, those that received imaging had a lower risk of nodal metastasis and an increased 5-year disease-free survival (73%) compared with those in the non-imaging group (51%).14 In the case of our patient, imaging did in fact alter the course of the initial plan. After discovering invasive and metastatic involvement, a more aggressive and appropriate treatment plan was pursued rather than proceeding with Mohs micrographic surgery as initially planned. She was instead treated with radical excision, craniectomy, and lymph node dissection followed by adjuvant radiation therapy. Despite these aggressive measures, the tumor recurred along with new distant metastases. ConclusionEarly identification of the subset of cSCCs with high-risk of local recurrence or metastasis is of principal importance as it guides optimal management and triggers prompt treatment. Following the diagnosis and treatment of a HRcSCC, the risk of locoregional recurrence or distant metastasis is highest within the rst several years, with a risk of 75% within the first 2 years and 95% within the first 5 years.11 As such, it is imperative that physicians ensure close long-term follow up in these patients. Physicians should also be alerted to the importance of vigilant screening in patients of all skin types, including those of color. DISCLOSURES The authors have no conflicts of interest to declare. REFERENCES
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