Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Advanced Squamous and Basal Cell of the Skin of the Head and Neck Skin cancer causes significant morbidity and mortality in the United States. It is estimated that there are about 500,000 new cases and about 2,000 deaths due to nonmelanoma skin cancer each year. These lesions are associated with sun exposure and occur on the nose, ear and forehead most commonly. The incidence varies with geography, climate, and skin color. The incidence is about twice as high in southern cities as in some northern cities and fair-skinned persons are especially susceptible. With the increase in sun exposure from occupational and recreational activities the incidence is increasing and the initial age of presentation is decreasing. Basal and squamous cell carcinomas make up about 90% of skin cancers with basal cell being the most common. Most of these can be treated easily with a high cure rate; however, there are some lesions that are much more aggressive. Advanced skin cancer may be arbitrarily defined as tumors > 2cm, invasion of bone muscle, or nerves, lymph node metastasis, or lesions that require removal of a cosmetic or functional unit. Basal Cell carcinoma occurs in several different forms. These include the nodular, morphea-like, superficial multicentric, pigmented, and basosquamous types. The nodular type is the most common, and it classically is nodular in shape and may have an ulcerated center. The morphea-like basal cell carcinoma is often not clinically impressive, but is especially dangerous because of its indistinct borders. This makes this lesion prone to incomplete excision and recurrence. The superficial multicentric basal cell carcinoma presents as an eczematous patch that advances peripherally without minimal deep invasion. These lesions are found predominantly on the trunk and play a limited role in the head and neck. Squamous cell carcinomas of the skin typically have elevated and rolled edges with central ulceration. Several factors influence the prognosis of squamous cell carcinoma of the skin. The most obvious is the size of the lesion and depth of invasion. The site of origin also influences the prognosis. Lesions arising outside actinic damage or within burns have a worse prognosis. Several cofactors are important as well. A history of radiation, arsenic, and chemical exposure worsens the prognosis as well. The presence of lymph node metastasis and perineural invasion are very important as well. Another important factor in skin cancer is the location of the lesion. The periauricular and midface areas are the high risk areas and lesions in this area are much more likely to be incompletely excised and more likely to recur. Several studies have been undertaken to define these high risk areas. Panje and Ceilley reviewed the tumor maps of 150 patients undergoing resection of epithelial malignancies of the midface by Mohs' micrographic surgery and correlated this with the midface development. They noted several consistent patterns of spread in the midface. Lesions of the supratip and columella tend to invade along the septum and spread to the premaxilla and upper lip. Tumors on the nasal dorsum tend to spread in a cranial caudal direction. Lesions of the nasal ring tend to develop through and through defects. Nasolabial fold lesions tend to spread deeply toward the pyriform aperture and internal nose. Glabellar and nasal root areas tend to spread laterally in the intercanthal area. Cheek lesions tend to spread onto the cheek and into the lower lid and spread to the nose later. A similar study was done by Bailin and Levine in 145 patients undergoing Mohs Surgery for cutaneous carcinomas of the periauricular areas. They also characterized patterns of spread and correlated this with embryology as well. They found that preauricular tumors spread toward the tragus and the anterior superior aspect of the helix. Once the lesion reaches the tragus spread tends to occur downward into the parotid gland to involve the deeper structures. Lesions that arise in the postauricular area spread toward the ear into the postauricular sulcus. Lesions that arise on the helix spread along the helix before moving onto other structures. Likewise, lesions on the antihelix spread along itself and into the concha before spreading onto the helix. Knowledge of these patterns of spread is important since it may influence treatment and reconstruction. The evaluation of patients with advanced basal and squamous cell carcinoma of the skin begins with a thorough history and physical exam. It is important to obtain a complete history relating the onset and rate of growth of the lesion. History of sun, radiation, arsenic, and chemical exposure should be obtained. Likewise, history of burns or trauma to the affected areas is important as well. Symptoms of perineural invasion should be sought. A careful physical examination should be performed evaluating the full extent of the primary lesion as well as diagnosing other small lesions. Special attention should be given to high risk areas. Cranial nerves should be carefully examined to rule out any perineural involvement. An early study by Warren and Hoerr noted a 30% incidence of other malignancies in patients presenting with skin cancer. Therefore, these patients should receive a complete physical exam looking for other malignancies. Large extensive lesions may require radiographic examination such as MRI or CT to evaluate the extent of the lesion. CT can be used to assess bony involvement and MRI is best to assess soft tissue di sease. Cutaneous malignancies may be treated by several different methods. These include surgical excision, cryosurgery, electrosurgery, Mohs' chemosurgery, and radiation therapy. For simple uncomplicated basal cell carcinomas each of these techniques offer greater than 90% cure rate. However, for advanced lesions cryosurgery, electrosurgery,and radiation therapy are limited by their inability to obtain surgically clear margins. Mohs' chemosurgery is a technique that has gained popularity in the treatment of skin lesions. This technique is useful in obtaining complete resection with minimal tissue loss. Mohs' chemosurgery was developed by Frederick E. Mohs as a medical student in the 1930's. At that time he developed a technique for in vivo fixation of tissue and used this technique to excise rat skin tumors with complete microscopic control of resection margins. He was trained in general surgery and began to use this technique to resect skin lesions. He reported his initial results in 440 cases of skin cancer in 1941. He reported a cure rate of 99% for primary BCC and 96% in recurrent BCC. His original technique was limited by the need to wait 24 hours between resections and the pain caused by the fixative. Also, the fixative itself caused sloughing of tissue that contributed to tissue loss defeating the purpose of the technique. In 1953, he modified his technique for eyelid carcinomas to avoid these problems and performed direct serial resections under local anesthesia until the tumor was resected. It is this technique that is used today. The main difference between this technique and conventional surgical margins is the horizontal sectioning used in Mohs' chemosurgery versus the vertical sectioning used to examine traditional surgical margins. Use of this technique is limited in advanced lesions since this technique cannot be used on bone and is less effective for lesions that invade into deeper tissue planes. Also, the time and cost in very large lesions may be prohibitive as well. For advanced basal and squamous cell carcinomas of the head and neck wide local excision with frozen section control of the margins is another treatment option. Adequate margins must be taken and for basal cell carcinomas this about 5 mm and for large SCC about 12 cm margins are adequate. Regional lymphadenectomy is performed if their is evidence of metastatic disease or is necessary to remove the primary tumor. Surgical reconstruction is an important consideration and the reconstruction is often dictated by the resection. Lesions that are prone to recur are best closed with a skin graft if possible. Adequate resection should never be compromised to facilitate reconstruction. Weber et al reviewed the results using this technique at MDACC for advanced BCC in 89 patients. They had 8% with positive margins and one patient with histologically proven lymph node metastasis. Only one patient had a local recurrence and this was the patient with lymph node metastasis who was cured by repeat resection. He also reviewed the ex-perience using this technique for advanced SCC of the head and neck in 45 patients. Eight-een percent had positive margins, 11% had perineural invasion and 31% of these patients had local recurrences. Several factors correlated with a higher rate of recurrence these include size > 2 cm, perineural invasion, deep invasion, or lymph node metastasis the recurrence rate was 70%. For patients without these findings the recurrence rate was 20%. Patients with perineural invasion, positive margins, lymph node metastasis were treated with radiation therapy. Twenty-two percent of the patients in this series were either alive with disease or dead with disease at the time of review. This experience demonstrates the severity of disease and difficulty in treating these patients. Radiotherapy may be used to treat patients who are poor surgical candidates, have multiple lesions, or have tumors in locations that resection would cause significant morbidity. Such sites include the eyelids and medial canthal area. Current techniques use low energy electrons with a 5-10 mm margin of normal tissue. Doses vary with the size of tumor. Complications include local inflammation and possible cataract formation in lesions around the eye. Using radiotherapy, Sinesi et al obtained an 89.4% local control rate in lesions of the lower lid. Advanced basal and squamous cell carcinomas of the skin of the head and neck are challenging lesions for the head and neck surgeon. Unlike smaller skin cancers, these lesions cause significant morbidity and mortality. Successful management begins with careful assessment of the lesion. The majority of lesions are treated with wide surgical excision, but radiotherapy may be used primarily in certain cases. Careful follow up is necessary to detect other lesions and detect recurrences. Case Presentation A 61-year-old white male was referred to the Otolaryngology Clinic by Dermatology with a large ulcerative skin lesion on his right cheek. Biopsy revealed invasive squamous cell carcinoma. On initial evaluation he stated the lesion had been present for three months and had been growing rapidly. He denied parasthesia, hypesthesia, or other head and neck complaints. Physical exam revealed a raised ulcerated lesion that measured 4 cm x 5 cm. There was no palpable adenopathy and all cranial nerves were intact. An MRI scan was obtained which revealed a deeply invasive skin tumor that invaded the parotid gland and masseter muscle. He was taken to the operating room and underwent wide local excision of the lesion with radical parotidectomy and supraomohyoid neck dissection. The facial nerve was repaired using the sural nerve as a cable graft. The soft tissue defect was closed with a lateral arm free flap by the plastic surgery service. His postoperative course has been uneventful. Bibliography Ahn ST, Hruza GJ, Mustoe TA: Microvascular free tissue reconstruction following Mohs' micrographic surgery for advanced head and neck skin cancer. Head Neck 13:145-52, 1991. Andrade R, Gumport SL, Popkin G, et al: Cancer of the skin, in Thawley SE, Panje WR (eds): Comprehensive Management of Head and Neck Tumors, Vol. 2. Philadelphia, WB Saunders, 1976, pp 899-949. Bailin PL, Levine HL, et al: Cutaneous carcinoma of the auricular and periauricular region. Arch Otolaryngol 106:692-696, 1980. Brownstein MH, Rabinowitz AD: The precursors of cutaneous squamous cell carcinoma. Int J Derm 18:1-16, 1979. Buchanan RB, Carruth JA, McKenzie AL, et al: Photodynamic therapy in the treatment of malignant tumours of the skin and head and neck. Eur J Surg Oncol 15:400-6, 1989. Chuang TY, Popescu NA, Su WP, et al: Squamous cell carcinoma. A population-based incidence study in Rochester, Minn. Arch Dermatol 126:185-8, 1990. Clouston PD, Sharpe DM, Corbett AJ, et al: Perineural spread of cutaneous head and neck cancer: Its orbital and central neurologic complications. Arch Neurol 47:73-7, 1990. Cottle WI: Perineural invasion by squamous cell carcinoma. J Dermatol Surg Oncol 8:589-600, 1982. Darmstadt GL, Steinman HK: Mohs' micrographic surgery of the head and neck. West J Med 152:153-8, 1990. Gallagher RP, Ma B, McLean DI, et al: Trends in basal cell carcinoma, squamous cell carcinoma, and melanoma of the skin from 1973 through 1987. J Am Acad Dermatol 23:413-21. Goepfert HG, Dichtel WJ, Medina JE, et al: Perineural invasion in squamous cell skin carcinoma of the head and neck. Am J Surg 148:542-547, 1984. Griffiths RW: Skin malignancy and the reconstructive plastic surgeon. Ann R Coll Surg Engl 71:150-8, 1989. Hanke CW, Weisberger EC: Invasion of parotid gland by basal cell carcinoma: implications for therapy. J Dermatol Surg Oncol 12:849-52, 1986. Harwick RD: Cervical metastases from an occult primary site. Semin Surg Oncol 7:2-8, 1991. Hauben DJ, Zirkin H, Mahler D, Sacks M: The biologic behavior of basal cell carcinoma: Part I. Plast Reconstr Surg 69:103-109, 1982. Hruza GJ: Mohs micrographic surgery. Otolaryngol Clin North Am 23:845-864, 1990. Immerman SC, Scanlon EF, Christ M, et al: Recurrent squamous cell carcinoma of the skin. Cancer 51:1537-1540, 1983. Jackson GL, Ballantyne AJ: Role of parotidectomy for skin cancer of the head and neck. Am J Surg 142:464-469, 1981. Jackson RJ, Adams RH: Horrifying basal cell carcinoma: A study of 33 cases and a comparison with 435 non-horror cases and a report on four metastatic cases. J Surg Oncol 5:431-463, 1973. Kaspar TA, Wagner RF, Jablonska S, et al: Prognosis and treatment of advanced squamous cell carcinoma (SCC) secondary to epidermodysplasia verruciformis: a worldwide analysis of 11 patients. J Dermatol Surg Oncol 17:237-40, 1991. Keller GS, Doiron DR, Fisher GU: Photodynamic therapy in otolaryngology head and neck surgery. Arch Otolaryngol 111:758-61, 1985. Koplin L, Zarem HA: Recurrent basal cell carcinoma: A review concerning the incidence behavior, and management of recurrent basal cell carcinoma, with emphasis on the incompletely excised lesion. Plast Reconst Surg 65:656-64, 1980. Lang PG, Maize JC: Histologic evolution of recurrent basal cell carcinoma and treatment implications. J Am Acad Dermatol 14:186-96, 1986. Larson DL, Rodin AE, Roberts DK, et al: Perineural lymphatics: myth or fact. Am J Surg 112:488-492, 1966. Levine H: Cutaneous carcinoma of the head and neck: management of massive and previously uncontrolled lesions. Laryngoscope 93:87-105, 1983. Levine HL, Bailin PL: Basal cell carcinoma of the head and neck: Identification of the high-risk patient. Laryngoscope 90:955-961, 1980. Levine HL, Ratz JL, Bailin P: Squamous cell carcinoma of the head and neck. Selective management according to site and stage-skin. Otolaryngol Clin North Am 18:499-503, 1985. Lund HZ: How often does squamous cell carcinoma of the skin metastasize? Arch Dermatol 92:635-37, 1965. Mendenhall WM, Parsons JT, Mendenhall NP, et al: Carcinoma of the skin of the head and neck with perineural invasion. Head Neck 11:301-308, 1989. Mendenhall WM, Parsons JT, Mendenhall NP, et al: T2-T4 carcinoma of the skin of the head and neck treated with radical irradiation. Int J Radiat Oncol Biol Phys. 13:975-81, 1987. Modlin JJ: Cancer of the skin - surgical treatment. Miss Med 51:364-67, 1954. Mohle J, Nickoloff BJ: Fatal cutaneous squamous cell carcinoma in a forty-three year old male. J Dermatol Surg Oncol 12:276-9, 1986. Mohs FE: Chemosurgery microscopically controlled method of cancer excision. Arch Surg 42:279-295, 1941. Moller R, Reymann F, Hou-Jensen K: Metastases in dermatological patients with squamous cell carcinoma. Arch Dermatol 115:703-705, 1979. Mordick TG, Hamilton R, Dzubow LM: Delayed reconstruction following Mohs' chemosurgery for skin cancers of the head and neck. Am J Surg 160:447-9, 1990. Mosborg DA, Crane RT, Tami TA, et al: Burn scar carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 114:1038-40, 1988. Panje WR, Ceilley RI: The influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope 89:1914-1920, 1979. Richmond JD, Davie RM: The significance of incomplete excision in patients with basal cell carcinoma. Br J Plast Surg 40:63-7, 1987. Ron E, Modan B, Preston D, Alfandary E, et al: Radiation-induced skin carcinomas of the head and neck. Radiat Res 125:318-25, 1991. Scanlon EF, Volkmer DD, Oviedo MA, et al: Metastatic basal cell carcinoma. J. Surg Oncol 15:171-180, 1980. Schmidt JJ, Grande DJ, Bankoff MS: Use of computed tomography in the preoperative evaluation of patients with head and neck tumors. J Dermatol Surg Oncol 12:375-379, 1986. Silverberg E, Lubera JA: Cancer statistics, 1988. CA 38:5-22, 1988. Weber RS, Lippman SM, McNeese MD: Advanced basal and squamous cell carcinomas of the skin of the head and neck. Cancer Treat Res 52:61-81, 1990. Whitaker DC: Clinical evaluation of tumors of the skin, in Thawley SE, Panje WR (eds): Comprehensive Management of Head and Neck Tumors, Vol. 2. Philadelphia, WB Saunders, 1976, pp 899-949. Wolf DJ, Zitelli JA: Surgical margins for basal cell carcinoma. Arch Dermatol 123:340- 344, 1987. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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