Risk stratification for metastasis from cutaneous squamous cell carcinoma of the head and neck

Background: The purpose of the study was to develop a system of risk stratification, based on clinical and histological factors that would aid prediction of metastasis from cutaneous squamous cell carcinoma (SCC) of the head and neck. Method: The method used was a retrospective case control study comparing clinical and histological parameters of 78 patients who developed metastasis with 92 patients who did not develop metastasis over a 5‐year period. Results: The two ‘absolute’ (highest) risk factors for development of metastatic disease are poor histological differentiation and perineural/lymphovascular infiltration. The three ‘relative’ risk factors are moderate histological differentiation, diameter ≥20 mm and Clark level 5. Risk stratification: High‐risk lesions have either one of the absolute risk factors or all three of the relative risk factors with a predicted incidence of metastasis of 37%. Intermediate risk lesions have two of three relative risk factors and a predicted incidence of metastasis of 5%. Low‐risk lesions have one or none of the relative risk factors and a predicted incidence of meatstasis of 0.3%. Conclusion: Ongoing management of patients with histo‐pathologically proven invasive SCC of the head and neck should be based upon risk stratification for metastasis.     

Skin metastases in squamous cell carcinoma of the head and neck.

Distant metastases in squamous cell carcinoma of the head and neck (SCCHN) are most often to the lung, liver, and bone. SCCHN rarely metastasizes to skin sites. OBJECTIVE: To ascertain the significance of skin metastases (SM) on the prognosis of patients with SCCHN. METHODS: A retrospective review of all patients between 1987 and 1999 with SCCHN was conducted. Patients in whom SM developed were identified. Data pertaining to demographics, primary tumor staging, SM development, and outcome were investigated. RESULTS: In 798 consecutive patients diagnosed with SCCHN between 1987 and 2000, 19 developed SM. The average time of onset of the SM was 17.65 months. The average survival time was 7.2 months after the development of SM. The overall survival time of patients who developed SM from the initial presentation of the primary tumor was 24.85 months. The 1-year survival rate from the time of development of SM was 0%. CONCLUSIONS: Metastasis to skin sites is an uncommon feature of SCCHN. SM may represent the first clinical evidence of impending loco-regional recurrence or distant metastasis. The development of SM is an ominous sign associated with an extremely poor prognosis, similar to the development of distant metastasis at more typical sites. Both the development of SM and survival of patients developing SM are independent of primary tumor stage. Current treatment options of SM are limited in their efficacy.     

Skin metastases from head and neck squamous cell carcinoma: incidence and impact.

BACKGROUND: Squamous cell carcinoma (SCC) of the upper aerodigestive tract rarely metastasizes to the skin. This study was designed to review the incidence of skin metastases, to identify associated risk factors, and to investigate the prognostic significance of skin metastases. METHODS: A cohort of 2491 patients treated for SCC originating in the upper aerodigestive tract were evaluated retrospectively. Patients who developed skin metastases were evaluated with respect to tumor stage, treatment, and outcome. Patients with skin metastases were compared with patients who developed distant metastases at other sites and with those who did not develop distant metastases. RESULTS: Skin metastases developed in 19 (0.763%) patients. The median time to occurrence was 6 months. Ninety percent of patients died of disease within a median of 3 months (1 to 16 months) following diagnosis. The development of skin metastasis is most closely related to the presence of two or more cervical metastases and/or extracapsular spread of tumor in the cervical metastases. Similar risk factors were identified for the development of distant metastases to other sites. CONCLUSION: Metastasis to skin is a rare occurrence which has prognostic significance similar to distant metastasis to other areas.     

Resection of pulmonary metastases from squamous carcinoma of the head and neck

The purpose of this study was to determine the survival results and identify favorable selection factors for a group of patients who were found to have metastatic disease from the upper aerodigestive tract to the lung and subsequently underwent pulmonary resection. The medical records of 44 patients treated at our institution were reviewed. The cumulative 5-year survival rate after pulmonary resection was 43 percent. The optimal interval between diagnosis of the primary tumor and the development of pulmonary metastases was 13 to 24 months (p less than 0.005). The most favorable primary site was the larynx. No significant prognostic effect was noted for single versus multiple metastases or T-stage of the primary tumor. The presence of intervening locoregional recurrence prior to pulmonary diagnosis likewise had no significant effect on the survival rate. The initial presence of nodal metastases and primary tumor in the oral cavity had a poor outcome. The worst prognostic indicator was the presence of mediastinal disease (p less than 0.001). We have concluded that aggressive surgical treatment for isolated pulmonary metastases from the upper aerodigestive tract in the absence of mediastinal involvement is therapeutically beneficial. Selection criteria for resection should include site and stage of primary disease, locoregional control, interval from primary to pulmonary diagnosis, extent of pulmonary disease and mediastinal involvement, and the general medical condition of the patient.     

Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck

A consecutive series of 111 patients treated between 1964 and 1989 with primary cutaneous malignant melanoma of the head and neck and histologically proven regional metastases was reviewed to determine the patterns of nodal metastases. The primary sites were grouped in the following categories: face (34), anterior scalp (25), anterior neck (16), posterior scalp (15), ear (11), and posterior neck (10). All patients underwent radical neck dissection: 80 of the procedures were therapeutic and 31 elective. A total of 106 specimens were positive for metastases. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases (14 of 20 in therapeutic parotidectomies and 19 of 37 in elective parotidectomies). Based on the incidence of involvement of the parotid gland and the patterns of lymph node metastases from levels I through V, three observations are made. Patients undergoing regional lymphadenectomy for primary melanomas on the ear, face, and anterior scalp should be considered for parotidectomy. The use of selective limited neck dissection for elective regional lymphadenectomy appears justified based on the location of the primary site. In patients undergoing therapeutic neck dissection, a complete neck dissection should be performed due to the unpredictable distribution of lymph node metastases to the cervical lymph nodes.     

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence‐based approach. © 2014 Wiley Periodicals, Inc. Head Neck 37: 915–926, 2015     

Distant metastases after definitive radiotherapy for squamous cell carcinoma of the head and neck

PURPOSE: To analyze parameters that influence the risk of distant metastases after definitive radiotherapy. METHODS: Between 1983 and 1997, 873 patients were treated with definitive radiotherapy and had follow-up for 2 years or more. Univariate and multivariate analyses were performed to evaluate risk factors that might influence the risk of distant metastases. RESULTS: The 5-year distant metastasis-free survival rate was 86%. Univariate analyses revealed that the risk of distant metastases was significantly influenced by gender (p =.0092), primary site (p =.0023), T stage (p <.0001), N stage (p <.0001), overall stage (p <.0001), level of nodal metastases in the neck (p <.0001), histologic differentiation (p =.0096), control above the clavicles (p <.0001), and time to locoregional recurrence (p <.0001). Multivariate analysis of freedom from distant metastases revealed that gender (p =.0390), T stage (p <.0001), N stage (p =.0060), nodal level (p <.0001), and locoregional control (p <.0001) significantly influenced this end point. Multivariate analysis revealed that gender (p =.0049), T stage (p <.0001), N stage (p <.0001), and locoregional control (p <.0001) significantly influenced cause-specific survival. CONCLUSIONS: The risk of distant metastases after definitive radiotherapy is 14% at 5 years and is significantly influenced by gender, T stage, N stage, nodal level, and locoregional control.     

Intracranial metastases in patients with squamous cell carcinoma of the head and neck.

BACKGROUND: Intracranial metastases are rarely clinically diagnosed in patients with head and neck squamous cell carcinoma. Only 7 patients with metastases to the cavernous sinus from head and neck squamous cell carcinomas have been reported. METHODS: A retrospective study revealed 13 patients with intracranial metastases of head and neck squamous cell carcinoma. In a 53-year-old woman a cavernous sinus metastasis of a laryngeal carcinoma was histologically diagnosed by using a CT-guided surgical navigation system and was treated with stereotactic radiotherapy. RESULTS: The mean survival was 4.3 months. Predictive factors for longer survival were absence of extracranial disease, age younger than 60 years, and treatment with radiotherapy. CONCLUSIONS: The prognosis for patients with intracranial disease is poor. The current development of computer-assisted stereotactic navigation and stereotactic radiotherapy may facilitate surgical diagnostic exploration and improve treatment, especially in patients without extracranial disease.     

Patterns of lymph node spread of cutaneous squamous cell carcinoma of the head and neck

BACKGROUND: Among patients with cutaneous squamous cell carcinoma (SCC) of the head and neck, recent studies have shown that those with involvement of the parotid gland also have a high incidence of neck node involvement. Treatment of the neck by either surgery or radiotherapy is therefore recommended among patients with parotid SCC, even if clinical examination is negative. The aim of this study was first to analyze patterns of metastatic spread in the parotid and cervical lymph nodes and then to correlate the pattern of involved nodes with the primary cutaneous site in order to guide the appropriate extent of surgery, should neck dissection be used to treat the neck in patients with parotid SCC. METHODS: A cohort of 209 patients with cutaneous SCC of the head and neck and clinically evident regional metastatic disease was reviewed retrospectively from 3 Australian institutions. The distribution of involved nodes was obtained from pathology reports; the anatomic sites of primary cutaneous cancers were then correlated with these findings. RESULTS: Among 209 patients, 171 (82%) had clinical parotid involvement. Of these, 28 had clinical neck disease, whereas 143 had parotid disease alone. Thirty-eight (18%) patients had neck disease only. A total of 199 patients were treated surgically, whereas 10 received radiotherapy alone. Surgery included 172 parotidectomies and 151 neck dissections (93 of which were elective). Primary sites were cheek (21.7%), pinna (20.4%), temple (15.8%), forehead (15.8%), postauricular region (5.9%), neck (5.3%), anterior scalp (5.3%), posterior scalp (3.3%), periorbital (3.3%), nose (2.6%), and chin (0.6%). Among pathologically positive necks, level II was most frequently involved (79%). Level IV (13%) and level V (17%) were only involved in extensive lymph node disease, the exception being for isolated level V metastases from the posterior scalp. CONCLUSIONS: Primary sites were mainly localized to the lateral aspect of the head. Among patients with cutaneous SCC involving the parotid and neck, level II was the most commonly involved neck level. The distribution of involved nodes suggests that in a patient with parotid involvement and a clinically negative neck with an anterolateral primary, a supraomohyoid neck dissection, always including the external jugular lymph node(s) would be appropriate. In the case of a posterior primary, level V should be dissected as well. In patients with parotid SCC and a clinically positive neck, a comprehensive neck dissection is recommended.