Quick Reference Guide to TNM Staging of Head and Neck Cancer and Neck Dissection Classification

B. Nonmelanoma Skin Cancer of the Head and Neck Nonmelanoma skin cancer (NMSC) of the head and neck include the ana- tomic subsites of the vermillion lip, external ear, face, scalp, and neck. There are approximately 82 different histologic subtypes of nonmelanoma skin carcinoma. While Merkel Cell Carcinoma (MCC) has its own staging system, this staging system applies to all other NMSC, excluding basal cell carcinoma (BCC), as this has no well-defined staging system. The clinical staging of cutaneous squamous cell carcinoma (CSCC) relies on clinical examination in evaluation of the primary lesion and palpation of the neck for potential regional metastasis. Imaging studies, such as CT, MRI, PET/ CT can be considered in the setting of advanced primary disease (e.g. T3, T4) or palpable lymphadenopathy. These imaging studies may be helpful in evaluating local extent of the primary, involvement of adjacent structures, and the existence of perineural spread. Imaging for distant metastasis via CXR, PET/CT, CT chest may be considered in clinically stage III or IV disease. Patients who are immunosuppressed are a high risk of CSCCs. Overall, immunocompromised patients with CSCC have a higher recurrence rate and a higher rate of metastasis. Strong consideration was given for immunosup- pression as an independent prognostic factor. However, in reviewing studies with multivariate analysis, only one shows immunosuppression being an independent poor prognostic factor. In this study by Brantsch, et al, the authors reviewed retrospectively 615 patients treated surgically for CSCC, reporting that on multivariate analysis, key prognostic factors for metastasis included increased tumor thickness, immunosuppression, localization at the ear, and increased horizontal size. However, since other studies with multivar- iate analysis did not replicate these results, immunosuppression was omitted in the staging system. The mainstay of treatment remains surgical resection, when feasible. Neck dissection is recommended in the setting of known nodal disease. Adjuvant radiation therapy may be advised in advanced stage disease or in the setting of poor histologic features. The use of chemotherapy, either in the neoadju- vant or adjuvant setting is not well defined in cutaneous squamous cell cancer. While implementation of cytotoxic chemotherapy or immunotherapy can be considered in certain patients with advanced, recurrent, or metastatic disease, it is typically offered in the context of a clinical trial.

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