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Diagnostic Workup for cSCC and AJCC Guidelines

Insights From: Robert L. Ferris, MD, PhD, UPMC Hillman Cancer Center; Anna C. Pavlick, DO, NYU Langone Hospitals; Todd E. Schlesinger, MD, FAAD, FASMS, Dermatology & Laser Center of Charleston
Published: Wednesday, Feb 06, 2019



Transcript: 

Todd E. Schlesinger, MD, FAAD, FASMS: The imaging modalities that I consider in patients with high-risk cSCC really vary based on the tumor location and tumor type. The most common imaging modalities that are used are ultrasounds, computed tomography, CT scanning, magnetic resonance imaging, MRI scanning, and even PET CT, or plain PET, positron emission tomography scanning, or various combinations thereof.

Now as a dermatologist, I’m usually not the one to order most of these scans. They’re typically ordered by our medical oncology colleagues. But it is not impossible for our clinic to directly order these scans and follow along with the patients ourselves.

Robert L. Ferris, MD, PhD: The AJCC [American Joint Committee on Cancer] Staging System is updated periodically, based on greater experience and in particular, experience not only with the disease but sort of playing out and living with the prior staging system. So, one of the problems with the AJCC 7th edition, the prior version was that it didn’t really create a category that adequately encompassed the aggressive advanced cases. And, in that case, then we don’t have good record keeping. We don’t monitor them if we don’t have a good staging category. You need to have enough of a critical mass in that category that a registry can monitor those patients. And so, for instance, the T2 category and T3 category are now more populated and more appropriately encompass the groups that we want to follow.

T1, stage I cancers I think most clinicians understand those can be dealt with in a relatively straightforward way. Those in the AJCC 8th edition have no high-risk features and they’re less than 2 cm in diameter. Those are pretty straightforward. The AJCC 8th edition now segregates 2 to 4 cm as a T2, and as unlike in former staging systems where some of the high-risk features were not sufficient to bump that patient up to a higher stage, now the AJCC 8th edition allows for the risk features, such as bone invasion, perineural invasion, larger diameter, immunosuppressed status, and things like that. And those high-risk features now allow upstaging to say a T3, stage III, even if the diameter is not greater than 4 cm. And so, it gives us the ability to characterize and quantify the more advanced stage patients.

Another feature, as we talked about earlier, is the nodal metastasis which is a feature of advanced stage cutaneous squamous cell carcinoma, and the new AJCC 8th edition has diameter for node metastases, 0 to 3, 3 to 6 for N1 and N2. But it now also includes extracapsular spread or extranodal extension of tumor cells as one of the risk features that increases the stage to an N2c or an N3. So much like the T staging, the N staging has diameter—2 centimeter, 0 to 2, 2 to 4 for the T category, 0 to 3, 3 to 6 for the nodal N category, but then it adds a qualitative risk factor, bone invasion or perineural invasion for the primary tumor, and extranodal extension for the lymph node. And that upstages those patients.

The 8th edition AJCC staging system has been out for about a year. Publications have begun and now come out indicating that there are some advantages, that it is better than the 7th edition. I think, ultimately, we’re going to need a bit more time. Clearly, the 8th edition has a better advanced and aggressive skin cancer category. And, with that, I think now that we have new treatments, time will tell if this adequately quantifies that population that is eligible for adjuvant therapy or new immunotherapies.

Todd E. Schlesinger, MD, FAAD, FASMS: Defining locally advanced cSCC versus borderline resectable tumors can be a difficult challenge. There are many factors that are involved such as the size of the tumor, the ability to see the margin, the location of the tumor that may be near critical structure—the eye, the nose, the ear, around the lip. Things like this can affect whether we consider a tumor to be resectable or not. The factors of the patient, the patient’s health status, their desire to have surgery, all these things play into whether we would decide a tumor is resectable or not.

The other thing is the skill of the surgeon. Every surgeon has different skills, and every surgeon has a different comfort level. So oftentimes the resectability of the tumor is also dependent on the skills of the surgeon that’s looking at that tumor.

Robert L. Ferris, MD, PhD: For advanced cutaneous squamous cell carcinoma, the surgeon is often confronted with a treatment decision to decide really is this a surgical candidate? Is this a tumor that is curable? Should we take a different path and integrate some new or novel approach? And what is the risk of nodal or distant metastasis? Locally advanced disease is generally assessed by the T and the N, whether it is greater than 2 cm or in fact greater than 3, greater than 4 cm and is therefore a T3.

For nodal metastasis, many of these are occult. If a skin cancer presents with nodal metastasis, we know that’s an aggressive case, it’s not necessarily unresectable. For one or two metastatic lymph nodes, a parotidectomy or a regional nodal dissection, like a neck dissection if it occurs in the head and neck which up to two-thirds do. And so, the surgeon is making an assessment what is the likelihood of an R0 negative margin resection. So minor bone invasion, certainly a possible feature that would put that patient in a discussion where imaging would need to assess, is this a candidate for surgery or is that person borderline resectable?

If it’s on the scalp and there’s minor external cortical invasion, that can often be managed surgically and get clear margins. If it’s full thickness bone invasion, and we’re talking about a craniotomy, if there’s invasion around the orbit and we start to remove major structures, particularly if the patient is not very robust a and fit or they’re frail, which is many of these patients are, then we have to re-access resectability in terms of the size of the tumor, the location to important structures, and whether this patient could tolerate a major surgery with some sort of reconstruction.

Transcript Edited for Clarity
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Transcript: 

Todd E. Schlesinger, MD, FAAD, FASMS: The imaging modalities that I consider in patients with high-risk cSCC really vary based on the tumor location and tumor type. The most common imaging modalities that are used are ultrasounds, computed tomography, CT scanning, magnetic resonance imaging, MRI scanning, and even PET CT, or plain PET, positron emission tomography scanning, or various combinations thereof.

Now as a dermatologist, I’m usually not the one to order most of these scans. They’re typically ordered by our medical oncology colleagues. But it is not impossible for our clinic to directly order these scans and follow along with the patients ourselves.

Robert L. Ferris, MD, PhD: The AJCC [American Joint Committee on Cancer] Staging System is updated periodically, based on greater experience and in particular, experience not only with the disease but sort of playing out and living with the prior staging system. So, one of the problems with the AJCC 7th edition, the prior version was that it didn’t really create a category that adequately encompassed the aggressive advanced cases. And, in that case, then we don’t have good record keeping. We don’t monitor them if we don’t have a good staging category. You need to have enough of a critical mass in that category that a registry can monitor those patients. And so, for instance, the T2 category and T3 category are now more populated and more appropriately encompass the groups that we want to follow.

T1, stage I cancers I think most clinicians understand those can be dealt with in a relatively straightforward way. Those in the AJCC 8th edition have no high-risk features and they’re less than 2 cm in diameter. Those are pretty straightforward. The AJCC 8th edition now segregates 2 to 4 cm as a T2, and as unlike in former staging systems where some of the high-risk features were not sufficient to bump that patient up to a higher stage, now the AJCC 8th edition allows for the risk features, such as bone invasion, perineural invasion, larger diameter, immunosuppressed status, and things like that. And those high-risk features now allow upstaging to say a T3, stage III, even if the diameter is not greater than 4 cm. And so, it gives us the ability to characterize and quantify the more advanced stage patients.

Another feature, as we talked about earlier, is the nodal metastasis which is a feature of advanced stage cutaneous squamous cell carcinoma, and the new AJCC 8th edition has diameter for node metastases, 0 to 3, 3 to 6 for N1 and N2. But it now also includes extracapsular spread or extranodal extension of tumor cells as one of the risk features that increases the stage to an N2c or an N3. So much like the T staging, the N staging has diameter—2 centimeter, 0 to 2, 2 to 4 for the T category, 0 to 3, 3 to 6 for the nodal N category, but then it adds a qualitative risk factor, bone invasion or perineural invasion for the primary tumor, and extranodal extension for the lymph node. And that upstages those patients.

The 8th edition AJCC staging system has been out for about a year. Publications have begun and now come out indicating that there are some advantages, that it is better than the 7th edition. I think, ultimately, we’re going to need a bit more time. Clearly, the 8th edition has a better advanced and aggressive skin cancer category. And, with that, I think now that we have new treatments, time will tell if this adequately quantifies that population that is eligible for adjuvant therapy or new immunotherapies.

Todd E. Schlesinger, MD, FAAD, FASMS: Defining locally advanced cSCC versus borderline resectable tumors can be a difficult challenge. There are many factors that are involved such as the size of the tumor, the ability to see the margin, the location of the tumor that may be near critical structure—the eye, the nose, the ear, around the lip. Things like this can affect whether we consider a tumor to be resectable or not. The factors of the patient, the patient’s health status, their desire to have surgery, all these things play into whether we would decide a tumor is resectable or not.

The other thing is the skill of the surgeon. Every surgeon has different skills, and every surgeon has a different comfort level. So oftentimes the resectability of the tumor is also dependent on the skills of the surgeon that’s looking at that tumor.

Robert L. Ferris, MD, PhD: For advanced cutaneous squamous cell carcinoma, the surgeon is often confronted with a treatment decision to decide really is this a surgical candidate? Is this a tumor that is curable? Should we take a different path and integrate some new or novel approach? And what is the risk of nodal or distant metastasis? Locally advanced disease is generally assessed by the T and the N, whether it is greater than 2 cm or in fact greater than 3, greater than 4 cm and is therefore a T3.

For nodal metastasis, many of these are occult. If a skin cancer presents with nodal metastasis, we know that’s an aggressive case, it’s not necessarily unresectable. For one or two metastatic lymph nodes, a parotidectomy or a regional nodal dissection, like a neck dissection if it occurs in the head and neck which up to two-thirds do. And so, the surgeon is making an assessment what is the likelihood of an R0 negative margin resection. So minor bone invasion, certainly a possible feature that would put that patient in a discussion where imaging would need to assess, is this a candidate for surgery or is that person borderline resectable?

If it’s on the scalp and there’s minor external cortical invasion, that can often be managed surgically and get clear margins. If it’s full thickness bone invasion, and we’re talking about a craniotomy, if there’s invasion around the orbit and we start to remove major structures, particularly if the patient is not very robust a and fit or they’re frail, which is many of these patients are, then we have to re-access resectability in terms of the size of the tumor, the location to important structures, and whether this patient could tolerate a major surgery with some sort of reconstruction.

Transcript Edited for Clarity
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