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cSCC: cutaneous squamous cell carcinoma EMA: epithelial membrane antigen IHC: immunohistochemistry MMS: Mohs micrographic surgery PNI: perineural invasion RT: radiation therapy INTRODUCTION Perineural invasion (PNI), the infiltration of tumor within the perineural space, is an independent risk factor for adverse outcomes in cutaneous squamous cell carcinoma (cSCC) including recurrence, metastasis, and death. During microscopically controlled excision, histopathologic features seen on intraoperative tissue sections can present challenges in assessing the presence of PNI. Benign findings such as normal perineurium may mimic PNI in routine sections. Conversely, subtle PNI may be mistaken for benign findings. Immunohistochemistry (IHC) may be more accurate than routine sections in diagnosing PNI, with significant implications for staging, prognosis, and management. We present a case in which IHC proved essential in identifying cSCC with PNI, affecting the course of therapy.

Cutaneous squamous cell carcinoma with subtle perineural invasion detected with cytokeratin and epithelial membrane antigen immunohistochemistry