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Diagnosis and Staging of Advanced/Metastatic CSCC

Insights From: Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center; Anna C. Pavlick, DO, NYU Langone Hospitals
Published: Tuesday, Dec 11, 2018



Transcript: 

Robert L. Ferris, MD, PhD: The diagnostic workup for cutaneous squamous cell carcinoma primarily begins with a primary care provider [PCP] recognizing something abnormal. The patient is then sometimes referred to a general dermatologist or medical dermatologist who tends to do the initial biopsy and assessment. Dermatologists can do a lot by eye, with pattern recognition and various tools and magnification. Ultimately, most squamous cell carcinomas of the skin are managed by dermatologists. They would then refer them on when it’s advanced, usually to a head and neck surgeon, or sometimes to a plastic surgeon.

In other cases, particularly if the skin cancer is on a very delicate area of the body like the head and neck, where most skin cancers reside and occur, then a Mohs micrographic surgeon or dermatologic oncologic surgeon is generally the person the dermatologist refers that patient to. If it’s a lesion on the nose, ear, or the eyelid, we want to keep the margins as narrow as possible. It usually begins with a dermatologist or the PCP—sometimes with a surgical subspecialist—but usually with the dermatologist who then refers the patient to a Mohs surgeon if it is in a delicate part of the anatomy or, if more advanced, on to the head and neck surgeon.

The patient populations that are at higher risk or more prone to develop aggressive skin cancers are those who have a large history of ultraviolet exposure or have immunosuppressed conditions like chronic lymphocytic leukemia, organ transplantation, pharmacologic therapies such as azathioprine, chronic steroids, or drugs for other inflammatory diseases that may dampen the immune system. The ultraviolet radiation induces a lot of DNA alterations and mutations, and one of the characteristics of skin cancers is an extremely high rate of DNA mutations—higher than lung cancer and melanoma—and so then when you remove the immune system in a high-risk patient, these can progress and become clinically significant.

Anna C. Pavlick, DO: Squamous cell carcinoma is predominantly found in the male population. Most of the time it’s found on the scalp in men for the simple reason that they have excessive sun exposure to their scalp and ears. We know that cutaneous squamous cell carcinoma is due to excessive UV radiation, or sun exposure. Patients that also have an increased incidence of CSCC are those who are immuno-compromised, meaning patients who are on chronic steroids for either autoimmune diseases, patients with chronic lymphocytic leukemia, transplant patients, those who have had larger squamous cells that went on to get radiation, and those patients who are at risk of developing recurrent disease or metastatic disease. We know that squamous cell commonly can invade nerves, and so many times when patients will present with a numbness or a tingling around their lesion, we’re concerned that the cancer has started to track along the nerve. Those patients are more at risk of recurrent disease.


The imaging for locally advanced or metastatic disease really depends upon where the recurrence is or where the metastatic disease is. We commonly use CAT [computed axial tomography] scans for the chest, abdomen, and pelvis to evaluate for lung disease or liver disease. Sometimes if patients are complaining about back pain or bone pain, we’ll do an MRI [magnetic resonance imaging] of the spine. And many times when patients have multiple tumors on their scalp or on their head and neck, we’re going to do MRIs to better evaluate if these tumors have infiltrated not only the skin but the muscle and bone.

CSCC is very commonly taken care of by a patient’s dermatologist. It’s either locally excised or excised with the Mohs procedure. When it comes to doing a sentinel lymph node, they are commonly done by surgical oncologists because they’re going to have a wide local excision at the time they inject the area and follow the Isosulfan blue dye and radio activity up to the sentinel node so that they can pull it out to determine whether there’s cancer. These are now procedures that are commonly done in the dermatologist’s office—and again, most of the squamous cell cancers that present are very manageable and curable in the dermatologist’s office. The jury is out as to when you have a very large squamous cell cancer of the skin. Do you do a sentinel node, or not? We don’t know because there’s just not enough of them, which is probably a good thing.

Transcript Edited for Clarity 
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Transcript: 

Robert L. Ferris, MD, PhD: The diagnostic workup for cutaneous squamous cell carcinoma primarily begins with a primary care provider [PCP] recognizing something abnormal. The patient is then sometimes referred to a general dermatologist or medical dermatologist who tends to do the initial biopsy and assessment. Dermatologists can do a lot by eye, with pattern recognition and various tools and magnification. Ultimately, most squamous cell carcinomas of the skin are managed by dermatologists. They would then refer them on when it’s advanced, usually to a head and neck surgeon, or sometimes to a plastic surgeon.

In other cases, particularly if the skin cancer is on a very delicate area of the body like the head and neck, where most skin cancers reside and occur, then a Mohs micrographic surgeon or dermatologic oncologic surgeon is generally the person the dermatologist refers that patient to. If it’s a lesion on the nose, ear, or the eyelid, we want to keep the margins as narrow as possible. It usually begins with a dermatologist or the PCP—sometimes with a surgical subspecialist—but usually with the dermatologist who then refers the patient to a Mohs surgeon if it is in a delicate part of the anatomy or, if more advanced, on to the head and neck surgeon.

The patient populations that are at higher risk or more prone to develop aggressive skin cancers are those who have a large history of ultraviolet exposure or have immunosuppressed conditions like chronic lymphocytic leukemia, organ transplantation, pharmacologic therapies such as azathioprine, chronic steroids, or drugs for other inflammatory diseases that may dampen the immune system. The ultraviolet radiation induces a lot of DNA alterations and mutations, and one of the characteristics of skin cancers is an extremely high rate of DNA mutations—higher than lung cancer and melanoma—and so then when you remove the immune system in a high-risk patient, these can progress and become clinically significant.

Anna C. Pavlick, DO: Squamous cell carcinoma is predominantly found in the male population. Most of the time it’s found on the scalp in men for the simple reason that they have excessive sun exposure to their scalp and ears. We know that cutaneous squamous cell carcinoma is due to excessive UV radiation, or sun exposure. Patients that also have an increased incidence of CSCC are those who are immuno-compromised, meaning patients who are on chronic steroids for either autoimmune diseases, patients with chronic lymphocytic leukemia, transplant patients, those who have had larger squamous cells that went on to get radiation, and those patients who are at risk of developing recurrent disease or metastatic disease. We know that squamous cell commonly can invade nerves, and so many times when patients will present with a numbness or a tingling around their lesion, we’re concerned that the cancer has started to track along the nerve. Those patients are more at risk of recurrent disease.


The imaging for locally advanced or metastatic disease really depends upon where the recurrence is or where the metastatic disease is. We commonly use CAT [computed axial tomography] scans for the chest, abdomen, and pelvis to evaluate for lung disease or liver disease. Sometimes if patients are complaining about back pain or bone pain, we’ll do an MRI [magnetic resonance imaging] of the spine. And many times when patients have multiple tumors on their scalp or on their head and neck, we’re going to do MRIs to better evaluate if these tumors have infiltrated not only the skin but the muscle and bone.

CSCC is very commonly taken care of by a patient’s dermatologist. It’s either locally excised or excised with the Mohs procedure. When it comes to doing a sentinel lymph node, they are commonly done by surgical oncologists because they’re going to have a wide local excision at the time they inject the area and follow the Isosulfan blue dye and radio activity up to the sentinel node so that they can pull it out to determine whether there’s cancer. These are now procedures that are commonly done in the dermatologist’s office—and again, most of the squamous cell cancers that present are very manageable and curable in the dermatologist’s office. The jury is out as to when you have a very large squamous cell cancer of the skin. Do you do a sentinel node, or not? We don’t know because there’s just not enough of them, which is probably a good thing.

Transcript Edited for Clarity 
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