Regarding ACR Appropriateness Criteria® aggressive nonmelanomatous skin cancer of the head and neck

Nonmelanoma skin cancer of the head and neck is an ever-increasing public health problem. The most common histologic types are squamous and basal cell carcinomas. The majority of these tumors can be managed with local excision with a high probability of tumor control and cure. A subset of these tumors, however, is aggressive, as defined by deep invasion, neurotropic extension, and regional lymph node metastasis. Surgery alone is inadequate for aggressive nonmelanoma skin cancer, and many patients with such lesions receive surgical resection followed by adjuvant radiation to the primary site and regional lymph node basins. A multidisciplinary team comprising surgeons, radiation oncologists, and, in some cases, medical oncologists is the optimum collaborative approach. Squamous cell carcinoma, when associated with adverse clinical features, such as invasion >6 mm; involvement of muscle, cartilage, or bone; clinical perineural invasion; or regional metastasis, is associated with a significant locoregional recurrence rate and mortality of at least 30%. Surgery remains the mainstay of treatment for patients with aggressive tumors, and, as highlighted by the authors, the addition of adjuvant radiotherapy improves locoregional control and survival. The use of Mohs surgery for aggressive tumors is controversial and may be at odds with the known biological behavior of these tumors. Advocating narrow-margin surgery or a tissue-sparing approach is not consistent with oncologic principles for the surgical management of aggressive malignant neoplasms. Aggressive cutaneous squamous cell carcinoma of the head and neck should be managed with en bloc surgical resection analogous to surgical management of malignancies of the upper aerodigestive tract. Given the biological behavior of cutaneous squamous cell carcinoma, tissue-sparing and narrowmargin surgery is not consistent with the behavior of these tumors. En bloc tumor resection followed by thorough pathologic assessment of the adequacy of tumor resection is critical for a favorable outcome. The pathologist should not only assess the specimen margins but also provide a detailed synoptic pathology report that includes the histologic diagnosis, morphologic variant, presence or absence of perineural invasion, peritumoral inflammation, lymphovascular invasion, and status of regional lymph nodes if removed. A detailed pathology report is essential for deciding upon the need for adjuvant radiation. It is imperative that aggressive cutaneous malignancies are treated in a manner consistent with their biological behavior and their potential lethality. Aggressive surgical resection and the appropriate use of adjuvant radiotherapy will afford these patients optimum locoregional control and survival.