Margin Status Predicts Outcome in Patients with Cutaneous Squamous Cell Carcinoma of the Scalp: The Westmead Hospital Experience
Main Article Content
Head and neck, Scalp, Squamous cell carcinoma, Margin status, Radiotherapy
Background/Objectives: An involved or close resection margin in the setting of cutaneous SCC (cSCC) is associated with the risk of developing recurrence. The scalp poses unique anatomical challenges when obtaining adequate resection margins and further treatment may be required. We aimed to investigate the risk of recurrence in patients with scalp cSCCs and the role of adjuvant radiotherapy.
Methods: Eligible patients with cSCC of the scalp treated with curative intent at Westmead hospital, Sydney, were identified and patient, tumor and treatment factors analyzed. Patients were categorized based on margin status and analyzed in terms of treatment delivered, local recurrence and survival.
Results: In total, 114 patients with a median age of 70 years with the majority (81%) male, were identified with a median follow up of 5.6 years. Following surgery, 52 patients (46%) had clear margins, 62 (54%) had close (≤2mm) or involved margins, with a significant difference in the 5-year disease specific mortality of 20% and 35%, respectively (p=0.05). Twenty-eight patients (25%) underwent surgery and adjuvant radiotherapy, most with a close/involved margin. There was no significant difference in the risk of developing local recurrence between the group of patients in whom a clear margin was obtained and the group in whom the margin was close/involved (p=0.23).
Conclusion: Margin status had a significant impact on disease specific mortality, but was not associated with the risk of developing local recurrence. The addition of adjuvant radiotherapy in select high-risk patients may improve outcome although this was not demonstrated in our study.
2. Ruiz ES, Koyfman SA, Que SKT, Kass J, Schmults CD. Evaluation of the utility of localized adjuvant radiation for node-negative primary cutaneous squamous cell carcinoma with clear histologic margins. J Am Acad Dermatol 2020; 82: 420–429.
3. Thompson AK, Kelley BF, Prokop LJ, Murad MH, Baum CL. Risk factors for cutaneous squamous cell carcinoma recurrence,metastasis, and disease-specific death: A systematic review and meta-analysis. JAMA Dermatology 2016; 152: 419–428.
4. Zhang J, Wang Y, Wijaya WA, Liang Z, Chen J. Efficacy and prognostic factors of adjuvant radiotherapy for cutaneous squamous cell carcinoma: A systematic review and meta-analysis. J Eur Acad Dermatology Venereol 2021. doi:10.1111/jdv.17330.
5. Newman JG, Hall MA, Kurley SJ et al. Adjuvant therapy for high-risk cutaneous squamous cell carcinoma: A 10-year review. Head Neck 2021; : 1–22.
6. Skulsky SL, O’Sullivan B, McArdle O et al. Review of high‐risk features of cutaneous squamous cell carcinoma and discrepancies between the American Joint Committee on Cancer and NCCN Clinical Practice Guidelines In Oncology. Head Neck 2017; 39: 578–594.
7. Khan K, Mykula R, Kerstein R et al. A 5-year follow-up study of 633 cutaneous SCC excisions: Rates of local recurrence and lymph node metastasis. J Plast Reconstr Aesthetic Surg 2018; 71: 1153–1158.
8. Nolan GS, Kiely AL, Totty JP et al. Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta-analysis. Br J Dermatol 2021 Jun;184(6):1033-10442021 doi:10.1111/bjd.19660.
9. Estall V, Allen A, Webb A, Bressel M, McCormack C, Spillane J. Outcomes following management of squamous cell carcinoma of the scalp: A retrospective series of 235 patients treated at the Peter MacCallum Cancer Centre. Australas J Dermatol 2017; 58: e207–e215.
10. Caparrotti F, Troussier I, Ali A, Zilli T. Localized Non-melanoma Skin Cancer: Risk Factors of Post-surgical Relapse and Role of Postoperative Radiotherapy. Curr Treat Options Oncol 2020; 21. doi:10.1007/s11864-020-00792-2.
11. Lang PG, Braun MA, Kwatra R. Aggressive squamous carcinomas of the scalp. Dermatologic Surg 2006; 32: 1163–1170.
12. Gray RJ. A class of K-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat 1988; : 1141–1154.
13. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999; 94: 496–509.
14. Nahhas AF, Scarbrough CA, Trotter S. A review of the global guidelines on surgical margins for nonmelanoma skin cancers. J Clin Aesthet Dermatol 2017; 10: 37.
15. Kiely J, Kostusiak M, Bloom O, Roshan A. Poorly differentiated cutaneous squamous cell carcinomas have high incomplete excision rates with UK minimum recommended pre-determined surgical margins. J Plast Reconstr Aesthetic Surg 2020; 73: 43–52.
16. Mo J, Miller CJ, Karakousis G, Keele L, Cohen J, Krouse RS. The scalp is a high-risk site for cutaneous squamous cell carcinoma metastasis. J Am Acad Dermatol 2021; 84: 1742–1744.
17. Howle JR, Morgan GJ, Kalnins I, Palme CE, Veness MJ. Metastatic cutaneous squamous cell carcinoma of the scalp. ANZ J Surg 2008; 78: 449–453.
18. Jenkins G, Smith AB, Kanatas AN, Houghton DR, Telfer MR. Anatomical restrictions in the surgical excision of scalp squamous cell carcinomas: Does this affect local recurrence and regional nodal metastases? Int J Oral Maxillofac Surg 2014; 43: 142–146.
19. Haehl E, Rühle A, Klink R et al. The value of primary and adjuvant radiotherapy for cutaneous squamous cell carcinomas of the head-and-neck region in the elderly. Radiat Oncol 2021; 16: 1–13.
20. Ruiz ES, Koyfman SA, Kass J, Schmults CD. Surgery and Salvage Limited-Field Irradiation for Control of Cutaneous Squamous Cell Carcinoma with Microscopic Residual Disease. JAMA Dermatology 2019; 155: 1193–1195.