What are the guideline sources, guidelines and references for Cutaneous squamous cell carcinoma ?
Guideline sources The following summarized guidelines for the evaluation and management of cutaneous squamous cell carcinoma (CSCC) are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2023; 2018), the American Society of Plastic Surgeons (ASPS 2021), the British Association of Dermatologists (BAD 2021), the European Association of Dermato-Oncology (EADO/EORTC 2020), the American Society for Radiation Oncology (ASTRO 2020), the British Photodermatology Group (BPG/BAD 2019), and the American Academy of Dermatology (AAD 2018). 1 2 3 4 5 6 7 8 Calculator Calculator Calculator Brigham and Women's Hospital t Eastern Cooperative Oncology G Karnofsky Guidelines https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 1/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway 1. Screening and diagnosis Indications for screening: As per USPSTF 2023 guidelines, insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults. I As per USPSTF 2018 guidelines, insufficient evidence to assess the balance of benefits and harms of counseling adult persons about skin self-examination to prevent skin cancer. I 2. Classification and risk stratification Staging: use the Brigham and Women's Hospital tumor classification system to obtain the most accurate prognostication of patients with localized cutaneous SCC. B Risk classification: document the risk status of cutaneous SCC as low risk, high risk, or very high risk in the patient notes. E 3. Diagnostic investigations Imaging for staging: As per BAD 2021 guidelines, do not obtain routine imaging of the draining nodal basin in patients with cutaneous SCC without suspected or clinically detectable regional nodal involvement. D Show 3 more As per ASTRO 2020 guidelines, consider obtaining imaging to guide the need for and target of lymph node basin radiotherapy in patients with cutaneous SCC at high risk of regional nodal metastasis. E 4. Diagnostic procedures Skin biopsy: As per BAD 2021 guidelines, obtain histological confirmation of cutaneous SCC lesions in case of diagnostic uncertainty before planning definitive treatment. Perform full-thickness incisional biopsy to collect a representative tumor sample, ideally incorporating both the peripheral and the deep margins. A Show 3 more As per EADO 2020 guidelines: Perform an excision to obtain histological confirmation of peripheral and deep excision margins. B Consider performing a punch or incisional biopsy (with planned subsequent complete excision) for histological confirmation of large tumors or tumors on high-risk sites. B https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 2/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway As per AAD 2018 guidelines, perform punch biopsy, shave biopsy, or excisional biopsy depending on the characteristics of the suspected malignancy (morphology, location) and the physician's judgment. B Show 4 more Sentinel lymph node biopsy: As per BAD 2021 guidelines: Consider performing sentinel lymph node biopsy only in specific, high-risk cases of primary cutaneous SCC in the context of a clinical trial or specialist skin cancer multidisciplinary team. E Obtain US-guided FNA cytology in patients with cutaneous SCC with clinically suspicious nodes. Consider repeating US-guided FNA cytology in case of negative results but remaining suspicion, although core or open-biopsy histology may be required. E As per ASTRO 2020 guidelines, consider performing sentinel lymph node biopsy to guide the need for and target of lymph node basin radiotherapy in patients with cutaneous SCC at high risk of regional nodal metastasis. E 5. Medical management Management of local disease, general principles: As per BAD 2021 guidelines: Take into consideration the risk factors for the patient and the margin, site, and tumor stage in patients with cutaneous SCC with 1 clear-but-close margins (< 1 mm). Consider offering observation in immunocompetent patients with cutaneous SCC with a low-risk tumor. B Offer active treatment in immunosuppressed patients with cutaneous SCC with 1 clear-but- close (< 1 mm) or involved margins with structured follow-up and surveillance. E As per AAD 2018 guidelines, develop a treatment plan taking into consideration recurrence rate, preservation of function, patient expectations, and potential adverse effects. B Management of local disease, topical therapies: As per BAD 2021 guidelines, insufficient evidence to recommend topical therapies in the treatment of cutaneous SCC. I As per AAD 2018 guidelines, do not offer topical therapies (imiquimod or 5-fluorouracil) in patients with cutaneous SCC. D Management of local disease, curettage and cautery: As per BAD 2021 guidelines: Consider performing curettage and cautery with curative intent in immunocompetent patients with small (< 1 cm), well-defined, nonrecurrent, clinically low-risk cutaneous SCC. C Review the histology of cutaneous SCC removed by curettage and cautery to identify high-risk or very high-risk features and, if identified, discuss with an appropriate multidisciplinary team regarding further management. E https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 3/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway As per EORTC/EADO 2020 guidelines, consider performing curettage and electrodesiccation in patients with small-sized and/or multiple invasive cutaneous SCCs in low-risk areas where surgery is impossible or has unacceptable consequences. C As per AAD 2018 guidelines, consider performing curettage and electrodesiccation in patients with low-risk primary cutaneous SCC in non-terminal hair-bearing locations. C Management of local disease, surgical excision: As per BAD 2021 guidelines, perform standard surgical excision as the first-line treatment option in patients with resectable primary cutaneous SCC. A Show 5 more As per EORTC/EADO 2020 guidelines, perform an excision with histological control as standard therapy aiming for complete excision (R0) with histological confirmation of peripheral and deep excision margins. B Show 4 more As per AAD 2018 guidelines: Perform standard excision with a 4-6 mm margin to a depth of the mid-subcutaneous adipose tissue with histologic margin assessment in patients with low-risk primary cutaneous SCC. B Consider performing standard excision in selected patients with high-risk tumors. Exercise strong caution when selecting a treatment modality for high-risk tumors without a complete margin assessment. C Management of local disease, Mohs micrographic surgery: As per BAD 2021 guidelines: Perform Mohs micrographic surgery in patients with cutaneous SCC with 1 involved margins or close margins (< 1 mm) where patient or tumor factors confer higher risk. A Consider performing Mohs micrographic surgery in selected patients with cutaneous SCC following specialist skin cancer multidisciplinary team discussion, particularly where tumor margins are difficult to delineate or in sites where tissue conservation is important for function. C As per EORTC/EADO 2020 guidelines, perform Mohs micrographic surgery/micrographically controlled surgery in patients with cutaneous SCC with high-risk factors. B As per AAD 2018 guidelines, perform Mohs micrographic surgery in patients with high-risk cutaneous SCC. B Management of local disease (elective lymph node dissection): do not perform elective lymph node dissection in patients with cutaneous SCC. D Management of local disease, cryotherapy: As per BAD 2021 guidelines, insufficient evidence to recommend cryotherapy in the treatment of cutaneous SCC. I As per EORTC/EADO 2020 guidelines, consider offering cryotherapy in patients with small- sized and/or multiple invasive cutaneous SCCs in low-risk areas where surgery is impossible or has unacceptable consequences. C https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 4/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway As per AAD 2018 guidelines, consider performing cryosurgery in patients with low-risk cutaneous SCC when more effective therapies are contraindicated or impractical. C Management of local disease, laser therapy: As per BAD 2021 guidelines, insufficient evidence to recommend CO laser therapy in the treatment of cutaneous SCC. I As per EORTC/EADO 2020 guidelines, consider offering laser therapy in patients with small- sized and/or multiple invasive cutaneous SCCs in low-risk areas where surgery is impossible or has unacceptable consequences. C As per AAD 2018 guidelines, insufficient evidence to recommend laser therapies or electronic surface brachytherapy in patients with cutaneous SCC. I Management of local disease, photodynamic therapy: As per EORTC/EADO 2020 guidelines, consider offering photodynamic therapy in patients with small-sized and/or multiple invasive cutaneous SCCs in low-risk areas where surgery is impossible or has unacceptable consequences. C As per BPG/BAD 2019 guidelines, consider offering photodynamic therapy as a treatment option in patients with microinvasive cutaneous SCC if surgery is contraindicated. C As per AAD 2018 guidelines, do not offer photodynamic therapy in patients with cutaneous SCC. D Management of local disease (adjuvant radiotherapy): consider offering adjuvant radiotherapy in patients with cutaneous SCC with clear-but-close (< 1 mm) pathological excision margins following a discussion at a skin cancer multidisciplinary team involving a clinical oncologist. C Show 3 more Management of local disease, definitive radiotherapy: As per BAD 2021 guidelines: Offer primary radiotherapy as treatment option in selected patients with cutaneous SCC, factoring in patient preference, following appropriate discussion at skin cancer multidisciplinary team and/or with a clinical or radiation oncologist. A Offer primary radiotherapy in patients with cutaneous SCC when surgery is not feasible or would be challenging or likely to result in an unacceptable functional or esthetic outcome. A As per ASTRO 2020 guidelines, offer definitive radiotherapy as a curative treatment modality in patients with cutaneous SCC unable to undergo or declining surgical resection. B Show 3 more As per AAD 2018 guidelines, consider offering radiotherapy, such as superficial radiotherapy, brachytherapy, external electron beam therapy, C and other traditional radiotherapy forms in patients with low-risk tumors if surgical therapy is not feasible or preferred, recognizing that the cure rate may be lower. C Management of locally advanced/metastatic disease, general principles: As per BAD 2021 guidelines: https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 5/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway Discuss cases of cutaneous SCC with symptomatic perineural invasion and/or radiological evidence of perineural invasion at a specialist skin cancer multidisciplinary. Consider obtaining skull base or head and neck multidisciplinary team opinion if the case is discussed at a skin multidisciplinary team. A Compose an individualized specialist skin cancer multidisciplinary team, multimodality, and imaging treatment plan for patients with any of the following: regional lymph node metastasis immunocompromised state and locally advanced and/or metastatic cutaneous SCC in-transit metastases from cutaneous SCC metastatic cutaneous SCC with further locoregional relapse following lymphadenectomy. A As per AAD 2018 guidelines, provide multidisciplinary consultation and management in patients with locoregional or distant metastases, particularly in patients with immunosuppression. Consider providing such consultation in patients with locally advanced disease without known metastases in some cases. B Management of locally advanced/metastatic disease, surgical resection: As per BAD 2021 guidelines: Consider performing surgical resection (with or without adjuvant radiotherapy) or primary radiotherapy in patients with locally recurrent cutaneous SCC. E Perform aggressive surgical excision of the involved nerve as the first step, where technically possible, followed by consideration of adjuvant radiotherapy in patients with cutaneous SCC with perineural invasion. A As per AAD 2018 guidelines, perform surgical resection, with or without adjuvant radiotherapy and possible systemic therapy, for regional lymph node metastases. Consider offering combination chemoradiotherapy in patients with inoperable disease. B Management of locally advanced/metastatic disease, lymph node dissection, general principles: As per BAD 2021 guidelines: Perform therapeutic regional lymphadenectomy in patients with cutaneous SCC with regional lymph node metastasis. A Consider performing regional lymphadenectomy or regional lymph node basin irradiation for disease control in selected patients, even in the presence of distant metastases, especially in patients undergoing multimodality treatment. E Perform regional lymphadenectomy by a designated surgeon of the specialist skin cancer multidisciplinary team pathway compliant with prevailing multispecialty guidance. A As per ASTRO 2020 guidelines, perform therapeutic lymphadenectomy followed by adjuvant radiotherapy in patients with cutaneous SCC metastasized to clinically apparent regional lymph nodes, except for patients having a single, small (< 3 cm) cervical lymph node harboring carcinoma without extracapsular extension. B As per EORTC/EADO 2020 guidelines, perform regional therapeutic lymph node dissection in clinically or radiologically detected lymph node metastasis confirmed with cytology or biopsy. B Show 2 more https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 6/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway Management of locally advanced/metastatic disease (lymph node dissection, head and neck region): perform therapeutic regional lymphadenectomy in patients with head and neck cutaneous SCC with regional lymph node metastasis. A Show 4 more Management of locally advanced/metastatic disease (lymph node dissection, non-head and neck region): perform therapeutic regional lymphadenectomy in patients with non-head and neck cutaneous SCC with regional lymph node metastases in axillary, inguinofemoral, or other peripheral draining nodes. A Show 3 more Management of locally advanced/metastatic disease, adjuvant radiotherapy: As per BAD 2021 guidelines: Offer adjuvant radiotherapy following therapeutic regional lymphadenectomy in patients with cutaneous SCC with high-risk pathology ( pN1; such as 2 nodes, large nodes, and extracapsular extension). A Consider offering adjuvant radiotherapy following surgical excision of the involved nerve in patients with cutaneous SCC with perineural invasion. B As per ASTRO 2020 guidelines, consider offering postoperative radiotherapy in patients with cutaneous SCC with close or positive margins that cannot be corrected with further surgery (secondary to morbidity or adverse cosmetic outcome). B Show 6 more As per EORTC/EADO 2020 guidelines: Consider offering adjuvant radiotherapy in patients with cutaneous SCC of the head and neck with regional nodal metastases and extracapsular extension. C Consider offering postoperative radiotherapy after surgical excision of tumors with positive margins if re-excision is not possible. C Management of locally advanced/metastatic disease, definitive radiotherapy: As per BAD 2021 guidelines, consider offering conformal radiotherapy including the entire course of the involved nerve in patients with cutaneous SCC with symptomatic perineural invasion and/or radiological evidence of perineural invasion if surgery is inappropriate, after carefully weighing the benefits and side effects from radiotherapy to such an extensive radiotherapy treatment field. C As per ASTRO 2020 guidelines, consider offering elective lymph node basin irradiation only in patients with cutaneous SCC at high risk of regional nodal metastasis (thickness > 6 mm) undergoing radiotherapy to the primary site with an overlap of the adjacent nodal basin. C Show 3 more As per EORTC/EADO 2020 guidelines, consider offering primary radiotherapy as an alternative to surgery in patients with inoperable or difficult-to-operate tumors or in the absence of consent to surgical excision. C Management of locally advanced/metastatic disease, systemic therapy: As per BAD 2021 guidelines: https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 7/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway Consider offering immune checkpoint inhibitors in patients with locally advanced cutaneous SCC if curative surgery or radiotherapy is not reasonable and in patients with metastatic cutaneous SCC, except patients with organ transplants or having significant autoimmune conditions. C Consider offering systemic chemotherapy or epidermal growth factor receptor inhibitors in patients with metastatic cutaneous SCC with contraindications to immune checkpoint inhibitors. C As per ASTRO 2020 guidelines: Do not offer concurrent carboplatin in addition to adjuvant radiotherapy in patients with resected locally advanced cutaneous SCC. D Consider offering concurrent drug therapies in addition to definitive radiotherapy in patients with unresected locally advanced cutaneous SCC. C As per EORTC/EADO 2020 guidelines, offer a PD-1 antibody as first-line therapy in patients with locally advanced or metastatic cutaneous SCC ineligible for curative surgery or radiotherapy. B Show 2 more As per AAD 2018 guidelines, consider offering epidermal growth factor inhibitors and cisplatin, as a single agent or in combination therapy, in patients with metastatic disease. C Management of locally advanced/metastatic disease (laser therapy): insufficient evidence to recommend laser therapies or electronic surface brachytherapy in patients with cutaneous SCC. I Management of locally advanced/metastatic disease, photodynamic therapy: As per BPG/BAD 2019 guidelines, do not offer photodynamic therapy as a treatment option in patients with invasive cutaneous SCC. As per AAD 2018 guidelines, do not offer photodynamic therapy in patients with cutaneous SCC. D Management of locally advanced/metastatic disease, palliative care: As per BAD 2021 guidelines: Consider offering electrochemotherapy in patients with locally advanced cutaneous SCC in palliative settings if other local or systemic therapies are not appropriate. E Consider offering best supportive care in elderly and frail patients with metastatic cutaneous SCC since responses to systemic therapy are generally short-lived, and chemotherapy is poorly tolerated. C As per EORTC/EADO 2020 guidelines: Assess nutritional, psychological, social, and existential needs to improve the overall quality of life in the palliative setting. B Provide supportive care to all patients with skin cancer, including reduction of symptoms, prevention/treatment of infection, control of bleeding, and adequate pain management. B https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 8/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway As per AAD 2018 guidelines, provide palliative and best supportive care to optimize symptom management and maximize the quality of life in patients with advanced disease. B 6. Patient education Pretreatment counseling: Discuss the risks and benefits of all treatment options (outcomes, function, cosmesis) with patients with cutaneous SCC and their families/carers and ensure making treatment decisions together. E Inform younger patients with cutaneous SCC (age < 60 years), especially organ transplant recipients, about the very low risk of radiation-induced, in-field malignancy in the future. Take this risk into account when making any treatment decision. E 7. Preventative measures Primary prevention: As per AAD 2018 guidelines: Counsel persons with fair skin types aged 6 months to 24 years and parents of young children about minimizing exposure to UV radiation to reduce the risk of skin cancer. B Offer counseling selectively in adults > 24 years with fair skin types about minimizing exposure to UV radiation to reduce the risk of skin cancer, taking into consideration the presence of risk factors for skin cancer. B Primary prevention (EDA): consider offering field photodynamic therapy as prophylaxis to reduce the emergence of new lesions in patients with actinic keratosis or non-melanoma skin cancer, including patients with organ transplantation. C Secondary prevention: do not offer topical and oral retinoids, such as tretinoin, D retinol, D acitretin, D and isotretinoin D , to reduce the incidence of keratinocyte cancers in patients with a history of cutaneous SCC, unless they are solid organ transplant recipients. Consider offering acitretin only in solid organ transplant recipients. D Show 2 more 8. Follow-up and surveillance Skin reconstruction after tumor resection (timing): consider performing reconstructive surgery in a delayed (asynchronous) fashion in adult patients after skin cancer resection. C Skin reconstruction after tumor resection (perioperative antibiotics): consider discussing the management of antibiotics with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 3 more https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 9/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway Skin reconstruction after tumor resection (perioperative antithrombotics): consider discussing the management of anticlotting agents with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 2 more Skin reconstruction after tumor resection (perioperative analgesics): consider discussing the management of pain with adult patients undergoing reconstruction after skin cancer resection when relevant. C Show 2 more Skin reconstruction after tumor resection (follow-up): consider obtaining postoperative follow- up assessment in adult patients undergoing reconstruction after skin cancer resection. C Surveillance after curative-intent therapy: As per BAD 2021 guidelines, do not obtain a routine discussion at a multidisciplinary team for cases of T1 cutaneous SCC excised with histologically clear margins of at least 1 mm without other high-risk factors. D Show 5 more As per EADO 2020 guidelines: Perform regular clinical examinations, including inspection of the entire skin and inspection and palpation of the excision site, the in-transit route, and the regional lymph nodes, during follow-up of all patients. B Decide on the frequency of follow-up visits and imaging depending on underlying risk characteristics of cutaneous SCC, including low-risk or high-risk common primary, advanced or regional disease, immunosuppression setting. B Surveillance for future malignancies: As per BAD 2021 guidelines, educate patients with cutaneous SCC on self-examination (skin and lymph nodes) and sun protection by providing appropriate verbal and written information. E As per EADO 2020 guidelines, obtain surveillance for recurrences and development of new non- melanoma skin cancer and melanoma in patients with a history of cutaneous SCC. B As per AAD 2018 guidelines: Counsel patients with a history of cutaneous SCC on skin self-examination and sun protection. B Obtain screening for new keratinocyte cancers (basal cell carcinoma or cutaneous SCC) and melanoma on at least an annual basis after diagnosis of first SCC. A References 1. Andrew Chen, John G Albertini, Jeremy S Bordeaux et al. Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection. Plast Reconstr Surg. 2021 May 1;147 5 812e-829e. Open https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 10/11 6/23/23, 3:36 AM Cutaneous squamous cell carcinoma Pathway 2. Alexander J Stratigos, Claus Garbe, Clio Dessinioti et al. European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment. Eur J Cancer. 2020 Mar;128 83 102. Open 3. Work Group, Invited Reviewers, John Y S Kim et al. Guidelines of care for the management of cutaneous squamous cell carcinoma. J Am Acad Dermatol. 2018 Mar;78 3 560 578. Open 4. S G Keohane, J Botting, P G Budny et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma 2020. Br J Dermatol. 2021 Mar;184 3 401 414. Open 5. T H Wong, C A Morton, N Collier et al. British Association of Dermatologists and British Photodermatology Group guidelines for topical photodynamic therapy 2018. Br J Dermatol. 2019 Apr;180 4 730 739. Open 6. Anna Likhacheva, Musaddiq Awan, Christopher A Barker et al. Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive Summary of an American Society for Radiation Oncology Clinical Practice Guideline. Pract Radiat Oncol. Jan-Feb 2020;10 1 8 20. Open 7. US Preventive Services Task Force, Grossman DC, Curry SJ et al. Behavioral Counseling to Prevent Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Mar 20;319 11 1134 1142. Open 8. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2023 Apr 18;329 15 1290 1295. Open 9. Ashish Sharma, Andrew J Birnie, Cristina Bordea et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma in situ Bowen disease) 2022. Br J Dermatol. 2023 Feb 10;188 2 186 194. Open 10. C A Morton, R M Szeimies, N Basset-Seguin et al. European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 1 treatment delivery and established indications - actinic keratoses, Bowen's disease and basal cell carcinomas. J Eur Acad Dermatol Venereol. 2019 Dec;33 12 2225 2238. Open 11. Anokhi Jambusaria-Pahlajani, Peter A Kanetsky, Pritesh S Karia et al. Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol. 2013 Apr;149 4 402 10. Open https://web.pathway.md/diseases/recYAu9FO4o5hoaAg 11/11