Original Article
Oncologic Outcomes of Invasive Squamous Cell Carcinoma of the Scalp Requiring Resection of Cranial Bone Ronald Walker2
Mark Varvares3
1 Department of Otolaryngology, Loyola University Stritch School of
Medicine, Maywood, Illinois, United States 2 Department of Otolaryngology, Saint Louis University School of Medicine, Saint Louis, Missouri, United States 3 Department of Otolaryngology, The Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
Address for correspondence Mark Varvares, MD, The Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243, Charter St., Boston, MA 02114, United States (e-mail: [email protected]).
J Neurol Surg A
Abstract
Keywords
► squamous cell carcinoma ► scalp cancer ► head and neck cancer ► survival outcomes ► periosteal invasion
Objectives To identify the recurrence rates and survival outcomes of patients with invasive squamous cell carcinoma of the scalp. Methods This study was a retrospective chart review of eight patients that had squamous cell carcinoma of the scalp with either periosteal or skull invasion on clinical and/or radiographic evaluation. Results The disease-free survival was 62.5% (5/8 patients) with a local control rate of 75% (6/8 patients) for the entire group. The two patients with full-thickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). The disease-free survival of the fullthickness group was 50% (1/2 patients ), and the disease-free survival of the outer cortex removal patients was 66.7% (4/6 patients). Conclusion Despite the invasive nature of this disease, a high degree of local control can be achieved in this high-risk group with multiple comorbidities using outer cortex drilldown, and, in properly selected patients, full-thickness calvarial resection. We conclude that for patients without evidence of medullary involvement that outer table drilldown offers a well-tolerated approach with reasonable oncologic control.
Background The incidence of cutaneous malignancies is rising in the United States with one in five individuals developing skin cancer in their lifetime. The predominant malignancies are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Most of these lesions are confined to the skin and can be easily handled by simple excision or by Mohs micrographic surgery (MMS).1 However, it has been estimated that in the Sun Belt region of the central and southern United States, deaths from cutaneous SCC are as common as deaths from many more feared cancers including
received February 18, 2015 accepted after revision September 14, 2015
leukemia, non-Hodgkin lymphoma, renal cancer, and bladder cancer.2 MMS is the treatment of choice for most nonmelanoma skin cancers. During MMS, layers of cancer containing skin are progressively removed and the peripheral and deep margins microscopically examined to ensure they are cancer free. The mainstay of MMS is to remove the skin malignancies in their entirety while preserving as much of the surrounding healthy tissue as possible. This technique better ensures the removal of all malignant cells and reduces recurrence rates and the need for additional procedures. Additionally, MMS is almost always able to be performed on an outpatient basis under local anesthesia.1
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1567859. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Andrea Ziegler1
Zeigler et al.
The head and neck region is a common site affected by skin cancer. Skin cancer in this area tends to be more challenging to excise due to the complexity of the local anatomy. The scalp region of the head and neck, in particular, is a commonly afflicted site. When neglected or when patients fail prior attempts of treatment, these skin cancers can grow to involve a significant area of the scalp and potentially invade into underlying periosteum, calvarium, dura, and even cerebrum.3 Unfortunately, skin cancers that invade underlying tissue are often not amenable to cure with MMS. It is well established that cutaneous SCCs of the head and neck are more aggressive and have a higher rate of metastasis than BCCs, with metastatic rates of 2 to 5% and 0.28 to 0.55%, respectively.4 The local recurrence rates, however, have been reported with a wide range. This is particularly true for SCCs, with recurrence rates varying from 3% to 7% for superficial lesions of the head and neck and increasing to 10 to 50% for more invasive lesions.5–9 Multiple risk factors have been identified that increase the likelihood of recurrence including the presence of perineural invasion, size >1 cm, depth >6 mm, prior irradiation, prior treatment for cutaneous malignancy, immunosuppression, or poorly differentiated lesions.10–12 Despite this knowledge, it remains difficult to determine what extent of local surgery should be undertaken when there is either periosteal invasion (clinical fixation to underlying skull without radiographic evidence of cortical bone invasion) or frank bone invasion seen on preoperative imaging. Given that most of the patients that present with this disease entity are elderly and may not tolerate a fullthickness calvarial resection, we wanted to evaluate the oncologic outcomes and complication profiles of a series of patients recently treated at our institution with either fullthickness calvarial resection or outer table drilldown. The goal of this study was to define more accurately the recurrence rates specifically in the subset of patients with invasive SCC of the scalp requiring cranial bone resection and what depth of bone resection is required to result in an acceptable rate of local recurrence.
Materials and Methods This study was conducted with approval from the Saint Louis University internal review board. Data were collected by retrospective medical record review. A list of patients was generated using the International Classification of Disease, 9th edition, codes for cutaneous malignancies of the head and neck that provided 669 such patients that were treated at Saint Louis University Hospital. Patients included in the study were those with invasive SCC of the scalp requiring resection of the calvarium. Of the 669 patients reviewed, 10 met the criteria for our study. Two were excluded from review because they did not follow up at Saint Louis University Hospital. Collected variables included age, sex, pathologic diagnosis, tumor stage, presence of radiation treatment, prior local treatment, and extent of surgical resection. Clinical outcomes measured included local recurrence, time to local recurrence, regional recurrence, time to regional recurrence, and survival Journal of Neurological Surgery—Part A
outcomes. Local recurrence was defined as recurrence in the original tumor bed with the same histopathologic features of the primary tumor. Regional recurrence was defined as tumor in draining lymph nodes with the same histopathologic features of the primary tumor.
Surgical Technique The procedures performed in this study group varied based on the extent of resection required to obtain clear margins on pathology. Most of the cases of periosteal invasion were noted preoperatively with clinical fixation of the lesion against the underlying skull without outer cortical bone irregularities on computed tomography (CT) scan. The remaining cases had radiographic evidence of calvarial bone involvement and intraoperative findings of pitting and irregularity of the cortical bone on direct visualization. Surgical resection began with wide field excision of skin. This was sent for frozen section with pathology to evaluate for the presence of malignant cells at the lateral and deep margins. In patients with known or suspected periosteal invasion or a positive deep margin on frozen section, the resection involved removal of the outer cortex of the calvarium by drilling of the outer table down to the diploe. Full-thickness resection was performed on patients with extensive calvarial invasion on preoperative imaging. Two patients warranted dura biopsies, both of which were negative. Therefore, no patients in this study required dural resection.
Results The average age of patients was 81 years. Six patients had the outer cortex of skull drilled down, and two had full-thickness resection down to the dura. Lesions were fairly evenly divided over the scalp with three located at the vertex, two on the occipital scalp, two over the frontal scalp, and one located laterally over the parietal scalp. Four of these patients developed recurrence of disease, two local (25%) and two (25%) regional recurrences. One of the patients with regional recurrence had positive margins on final pathology after the frozen section was reported with negative margins. All other patients achieved negative margins with resection. The other case of regional recurrence occurred in the parotid in a patient with clear margins. Two patients had prior radiation to the head and neck, and one developed regional recurrence. Three patients had postoperative radiation, and two developed recurrence, one local and one regional. The follow-up length ranged from 6 to 42 months with a median of 10 months and an average length of follow-up of 16 months. The disease-free survival was 62.5% (5/8 patients) with a local control rate of 75%. The two patients with fullthickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). Unfortunately, we were unable to determine if the recurrences in the drilldown group were related to a recurrence in the bone or the soft tissue cutaneous resection margin. The disease-free survival of the full-thickness group was 50% (1/2 patients); one patient
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Invasive Squamous Cell Carcinoma of the Scalp
Abbreviations: DOD, dead of disease; NED, no evidence of disease; SCC, squamous cell carcinoma; WLE, wide local excision. a Negative margins on frozen pathology.
85 8
Journal of Neurological Surgery—Part A
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
DOD Regional at 6 mo WLE, Mohs Postoperative Full thickness Negative T4N0M0 SCC
88 7
F
NED None Mohs None Full thickness Negative T4N0M0 SCC
Local at 4 mo none Postoperative Outer cortex Negative T3N2bM0 SCC 84
M
Zeigler et al.
6
69 5
M
Alive with NED after radiation and additional resection
DOD Regional at 4 mo WLE, Mohs 2
89 4
M
SCC
T4N0M0
Positive
Outer cortex
Prior
Deceased with NED None Mohs
a
Postoperative Outer cortex Negative T2N0M0 SCC
83 3
M
NED None WLE, Mohs None Outer cortex Negative T3N0M0 SCC
60 2
M
Local at 23 mo Mohs None Outer cortex Negative T3N0M0 SCC
NED None WLE Prior Outer cortex Negative T3N0M0 SCC 77 1
M
Recurrence Prior treatment Radiation Extent of resection Margins Stage Pathology Sex Age, y Patient
Table 1 Information for patients who underwent resection of the calvarium
Fortunately, the incidence of invasive cutaneous malignancies of the scalp remains relatively low. However, the incidence of these lesions will likely rise with the continued increasing incidence of skin cancer in the United States. The patients in our study displayed many of the known risk factors for increased recurrence. Most of the patients had a history of multiple cutaneous malignancies and failed local therapy, and all had a tumor size >1 cm. Unfortunately, the number of these risk factors did not strongly correlate with those patients who recurred versus the patients who remained disease free. There are few reports focusing specifically on the recurrence rates of invasive scalp malignancies. Donald et al studied 52 patients with invasive scalp cancer. Their study focused on the surgical approach to resection, but they reported similar results to ours with a local control rate of 77.8% among 36 patients who were followed for at least 2 years or until death. However, the local control rate was not stratified based on depth of invasion and included patients with superficial, intermediate, and deep invasion.3 A study by Panizza et al of 21 patients with large nerve perineural invasion of head and neck squamous cell carcinoma reported a local recurrence rate of 23.8%. This was not specific to the scalp and only included the subset of cases with perineural invasion.9 Although difficult to treat, invasive cutaneous malignancies of the scalp can be eradicated in many instances with proper excision and management. Preoperative imaging is crucial in these tumors to evaluate the extent of invasion so that appropriate surgical planning can be accomplished. In general, CT is superior for detecting evidence of cortical bone involvement and can be used in the preoperative assessment to help determine the degree of bony resection necessary to achieve a complete resection. It is thought that the best chance at eradicating disease is to obtain negative margins in the absence of metastatic disease. This idea is strongly supported by the repeated low recurrence rates observed following MMS, because as discussed earlier, it is microscopically guided to ensure obtainment of tumor-free margins. A large prospective cohort study by Chren et al reported a local recurrence rate of just 2.1% following MMS for cutaneous BCC and SCC.13 This raises the question regarding the therapeutic advantage of full-thickness calvarial resection to minimize local recurrence in patients with clinical periosteal invasion with no evidence of cortical invasion. If negative margins can be obtained with removal of the outer cortex of the calvarium alone, full-thickness resection may not be of benefit. Potential
Status
Discussion
F
succumbed to regional recurrence of the disease. The diseasefree survival of the outer cortex removal patients was 66.7% (4/6 patients) with one patient deceased due to regional recurrence (patient mentioned earlier with positive final margins) and one patient deceased due to other medical comorbidities unrelated to the surgery. ►Table 1 shows the patient-specific information.
Alive with NED after WLE and further calvarial removal after recurrence
Invasive Squamous Cell Carcinoma of the Scalp
Zeigler et al.
complications following a full-thickness craniectomy include bleeding, seroma or hematoma formation, cerebrospinal fluid leak, seizure, stoke, pneumocephalus, or meningitis. A study by Abo Sedira et al followed 12 patients with full-thickness calvarial resection and noted complications in 3 patients— one case each of wound infection, flap failure, and convulsions.14 In comparison, the potential complications following removal of the outer cortex of the skull are minimal. Invasive cutaneous malignancies of the scalp are a disease that frequently affects the elderly, a population that has several additional significant medical comorbidities. This study developed out of the concept that surgical planning must remain mindful of the potential morbidity and mortality associated with more aggressive resection. The treating clinician must strike a balance and appreciate the risk assessment of the more aggressive surgical approach with its associated morbidity and mortality versus the potentially inferior oncologic outcome of the less aggressive surgical resection. The ability to predict the oncologic outcome of a less aggressive approach (outer table drilldown) in achieving local control at the primary site of resection and disease-free survival would be valuable information when planning a surgical resection in this group of patients. Demonstrating these issues, the two patients with full-thickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). However, the disease-free survival of the full-thickness group was 50% (1/2 patients) because one patient succumbed to regional recurrence of the disease. The disease-free survival of the outer cortex removal patients was 66.7% (4/6 patients) with one patient deceased due to regional recurrence and one patient deceased due to other medical comorbidities unrelated to the surgery. The major drawbacks of this study are the small sample size and the retrospective design. Unfortunately, the patient population size of our group is too small to make statistically significant conclusions. Larger patient populations are needed to further define the effectiveness of full-thickness resections compared with outer cortex removal. This could be achieved through a larger retrospective or prospective multicenter observational study.
disease-free survival in the outer cortex drilldown group compared with the full-thickness resection group. We conclude that for patients in our study with periosteal involvement and without evidence of calvarial cortical involvement, outer table drilldown offers a well-tolerated approach with reasonable oncologic control.
References 1 Akcam TM, Gubisch W, Unlu H. Nonmelanoma skin cancer of the
2
3
4
5
6
7
8
9
10
11
Conclusion Cutaneous SCC involving the scalp with periosteal or calvarial involvement offers a significant management challenge to the treating clinician. Despite the aggressive nature of this disease, it appears that a high degree of local control can be achieved in this group with multiple complex comorbidities using either outer cortex drilldown in properly selected patients or full-thickness calvarial resection. Although there was not the ability to determine statistical significance due to the small series size, there was no worse
Journal of Neurological Surgery—Part A
12
13
14
head and neck: surgical treatment. Facial Plast Surg Clin North Am 2012;20(4):455–471 Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013; 68(6):957–966 Donald PJ, Boggan J, Farwell DG, Enepekides DJ. Skull base surgery for the management of deeply invasive scalp cancer. Skull Base 2011;21(6):343–350 Brougham ND, Dennett ER, Cameron R, Tan ST. The incidence of metastasis from cutaneous squamous cell carcinoma and the impact of its risk factors. J Surg Oncol 2012;106(7):811–815 Mendenhall WM, Amdur RJ, Williams LS, Mancuso AA, Stringer SP, Price Mendenhall N. Carcinoma of the skin of the head and neck with perineural invasion. Head Neck 2002;24(1):78–83 Solares CA, Lee K, Parmar P, O’Rourke P, Panizza B. Epidemiology of clinical perineural invasion in cutaneous squamous cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 2012;146(5): 746–751 Aspoas AR, Wilson GR, McLean NR, Mendelow AD, Crawford PJ. Microvascular reconstruction of complex craniofacial defects. Ann R Coll Surg Engl 1997;79(4):278–283 McCombe D, Donato R, Hofer SOP, Morrison W. Free flaps in the treatment of locally advanced malignancy of the scalp and forehead. Ann Plast Surg 2002;48(6):600–606 Panizza B, Solares CA, Redmond M, Parmar P, O’Rourke P. Surgical resection for clinical perineural invasion from cutaneous squamous cell carcinoma of the head and neck. Head Neck 2012; 34(11):1622–1627 Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol 1992;26(6):976–990 Farasat S, Yu SS, Neel VA, et al. A new American Joint Committee on Cancer staging system for cutaneous squamous cell carcinoma: creation and rationale for inclusion of tumor (T) characteristics. J Am Acad Dermatol 2011;64(6):1051–1059 Brantsch KD, Meisner C, Schönfisch B, et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008;9(8):713–720 Chren MM, Linos E, Torres JS, Stuart SE, Parvataneni R, Boscardin WJ. Tumor recurrence 5 years after treatment of cutaneous basal cell carcinoma and squamous cell carcinoma. J Invest Dermatol 2013;133(5):1188–1196 Abo Sedira M, Amin AA, Rifaat MA, El-Sebai HI, El-Badawy MA, Aboul Kassem HA. Locally advanced tumors of the scalp: the Egyptian National Cancer Institute experience. J Egypt Natl Canc Inst 2006;18(3):250–257
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Invasive Squamous Cell Carcinoma of the Scalp
Oncologic Outcomes of Invasive Squamous Cell Carcinoma of the Scalp Requiring Resection of Cranial Bone Ronald Walker2
Mark Varvares3
1 Department of Otolaryngology, Loyola University Stritch School of
Medicine, Maywood, Illinois, United States 2 Department of Otolaryngology, Saint Louis University School of Medicine, Saint Louis, Missouri, United States 3 Department of Otolaryngology, The Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
Address for correspondence Mark Varvares, MD, The Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243, Charter St., Boston, MA 02114, United States (e-mail: [email protected]).
J Neurol Surg A
Abstract
Keywords
► squamous cell carcinoma ► scalp cancer ► head and neck cancer ► survival outcomes ► periosteal invasion
Objectives To identify the recurrence rates and survival outcomes of patients with invasive squamous cell carcinoma of the scalp. Methods This study was a retrospective chart review of eight patients that had squamous cell carcinoma of the scalp with either periosteal or skull invasion on clinical and/or radiographic evaluation. Results The disease-free survival was 62.5% (5/8 patients) with a local control rate of 75% (6/8 patients) for the entire group. The two patients with full-thickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). The disease-free survival of the fullthickness group was 50% (1/2 patients ), and the disease-free survival of the outer cortex removal patients was 66.7% (4/6 patients). Conclusion Despite the invasive nature of this disease, a high degree of local control can be achieved in this high-risk group with multiple comorbidities using outer cortex drilldown, and, in properly selected patients, full-thickness calvarial resection. We conclude that for patients without evidence of medullary involvement that outer table drilldown offers a well-tolerated approach with reasonable oncologic control.
Background The incidence of cutaneous malignancies is rising in the United States with one in five individuals developing skin cancer in their lifetime. The predominant malignancies are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Most of these lesions are confined to the skin and can be easily handled by simple excision or by Mohs micrographic surgery (MMS).1 However, it has been estimated that in the Sun Belt region of the central and southern United States, deaths from cutaneous SCC are as common as deaths from many more feared cancers including
received February 18, 2015 accepted after revision September 14, 2015
leukemia, non-Hodgkin lymphoma, renal cancer, and bladder cancer.2 MMS is the treatment of choice for most nonmelanoma skin cancers. During MMS, layers of cancer containing skin are progressively removed and the peripheral and deep margins microscopically examined to ensure they are cancer free. The mainstay of MMS is to remove the skin malignancies in their entirety while preserving as much of the surrounding healthy tissue as possible. This technique better ensures the removal of all malignant cells and reduces recurrence rates and the need for additional procedures. Additionally, MMS is almost always able to be performed on an outpatient basis under local anesthesia.1
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1567859. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Andrea Ziegler1
Zeigler et al.
The head and neck region is a common site affected by skin cancer. Skin cancer in this area tends to be more challenging to excise due to the complexity of the local anatomy. The scalp region of the head and neck, in particular, is a commonly afflicted site. When neglected or when patients fail prior attempts of treatment, these skin cancers can grow to involve a significant area of the scalp and potentially invade into underlying periosteum, calvarium, dura, and even cerebrum.3 Unfortunately, skin cancers that invade underlying tissue are often not amenable to cure with MMS. It is well established that cutaneous SCCs of the head and neck are more aggressive and have a higher rate of metastasis than BCCs, with metastatic rates of 2 to 5% and 0.28 to 0.55%, respectively.4 The local recurrence rates, however, have been reported with a wide range. This is particularly true for SCCs, with recurrence rates varying from 3% to 7% for superficial lesions of the head and neck and increasing to 10 to 50% for more invasive lesions.5–9 Multiple risk factors have been identified that increase the likelihood of recurrence including the presence of perineural invasion, size >1 cm, depth >6 mm, prior irradiation, prior treatment for cutaneous malignancy, immunosuppression, or poorly differentiated lesions.10–12 Despite this knowledge, it remains difficult to determine what extent of local surgery should be undertaken when there is either periosteal invasion (clinical fixation to underlying skull without radiographic evidence of cortical bone invasion) or frank bone invasion seen on preoperative imaging. Given that most of the patients that present with this disease entity are elderly and may not tolerate a fullthickness calvarial resection, we wanted to evaluate the oncologic outcomes and complication profiles of a series of patients recently treated at our institution with either fullthickness calvarial resection or outer table drilldown. The goal of this study was to define more accurately the recurrence rates specifically in the subset of patients with invasive SCC of the scalp requiring cranial bone resection and what depth of bone resection is required to result in an acceptable rate of local recurrence.
Materials and Methods This study was conducted with approval from the Saint Louis University internal review board. Data were collected by retrospective medical record review. A list of patients was generated using the International Classification of Disease, 9th edition, codes for cutaneous malignancies of the head and neck that provided 669 such patients that were treated at Saint Louis University Hospital. Patients included in the study were those with invasive SCC of the scalp requiring resection of the calvarium. Of the 669 patients reviewed, 10 met the criteria for our study. Two were excluded from review because they did not follow up at Saint Louis University Hospital. Collected variables included age, sex, pathologic diagnosis, tumor stage, presence of radiation treatment, prior local treatment, and extent of surgical resection. Clinical outcomes measured included local recurrence, time to local recurrence, regional recurrence, time to regional recurrence, and survival Journal of Neurological Surgery—Part A
outcomes. Local recurrence was defined as recurrence in the original tumor bed with the same histopathologic features of the primary tumor. Regional recurrence was defined as tumor in draining lymph nodes with the same histopathologic features of the primary tumor.
Surgical Technique The procedures performed in this study group varied based on the extent of resection required to obtain clear margins on pathology. Most of the cases of periosteal invasion were noted preoperatively with clinical fixation of the lesion against the underlying skull without outer cortical bone irregularities on computed tomography (CT) scan. The remaining cases had radiographic evidence of calvarial bone involvement and intraoperative findings of pitting and irregularity of the cortical bone on direct visualization. Surgical resection began with wide field excision of skin. This was sent for frozen section with pathology to evaluate for the presence of malignant cells at the lateral and deep margins. In patients with known or suspected periosteal invasion or a positive deep margin on frozen section, the resection involved removal of the outer cortex of the calvarium by drilling of the outer table down to the diploe. Full-thickness resection was performed on patients with extensive calvarial invasion on preoperative imaging. Two patients warranted dura biopsies, both of which were negative. Therefore, no patients in this study required dural resection.
Results The average age of patients was 81 years. Six patients had the outer cortex of skull drilled down, and two had full-thickness resection down to the dura. Lesions were fairly evenly divided over the scalp with three located at the vertex, two on the occipital scalp, two over the frontal scalp, and one located laterally over the parietal scalp. Four of these patients developed recurrence of disease, two local (25%) and two (25%) regional recurrences. One of the patients with regional recurrence had positive margins on final pathology after the frozen section was reported with negative margins. All other patients achieved negative margins with resection. The other case of regional recurrence occurred in the parotid in a patient with clear margins. Two patients had prior radiation to the head and neck, and one developed regional recurrence. Three patients had postoperative radiation, and two developed recurrence, one local and one regional. The follow-up length ranged from 6 to 42 months with a median of 10 months and an average length of follow-up of 16 months. The disease-free survival was 62.5% (5/8 patients) with a local control rate of 75%. The two patients with fullthickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). Unfortunately, we were unable to determine if the recurrences in the drilldown group were related to a recurrence in the bone or the soft tissue cutaneous resection margin. The disease-free survival of the full-thickness group was 50% (1/2 patients); one patient
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Invasive Squamous Cell Carcinoma of the Scalp
Abbreviations: DOD, dead of disease; NED, no evidence of disease; SCC, squamous cell carcinoma; WLE, wide local excision. a Negative margins on frozen pathology.
85 8
Journal of Neurological Surgery—Part A
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
DOD Regional at 6 mo WLE, Mohs Postoperative Full thickness Negative T4N0M0 SCC
88 7
F
NED None Mohs None Full thickness Negative T4N0M0 SCC
Local at 4 mo none Postoperative Outer cortex Negative T3N2bM0 SCC 84
M
Zeigler et al.
6
69 5
M
Alive with NED after radiation and additional resection
DOD Regional at 4 mo WLE, Mohs 2
89 4
M
SCC
T4N0M0
Positive
Outer cortex
Prior
Deceased with NED None Mohs
a
Postoperative Outer cortex Negative T2N0M0 SCC
83 3
M
NED None WLE, Mohs None Outer cortex Negative T3N0M0 SCC
60 2
M
Local at 23 mo Mohs None Outer cortex Negative T3N0M0 SCC
NED None WLE Prior Outer cortex Negative T3N0M0 SCC 77 1
M
Recurrence Prior treatment Radiation Extent of resection Margins Stage Pathology Sex Age, y Patient
Table 1 Information for patients who underwent resection of the calvarium
Fortunately, the incidence of invasive cutaneous malignancies of the scalp remains relatively low. However, the incidence of these lesions will likely rise with the continued increasing incidence of skin cancer in the United States. The patients in our study displayed many of the known risk factors for increased recurrence. Most of the patients had a history of multiple cutaneous malignancies and failed local therapy, and all had a tumor size >1 cm. Unfortunately, the number of these risk factors did not strongly correlate with those patients who recurred versus the patients who remained disease free. There are few reports focusing specifically on the recurrence rates of invasive scalp malignancies. Donald et al studied 52 patients with invasive scalp cancer. Their study focused on the surgical approach to resection, but they reported similar results to ours with a local control rate of 77.8% among 36 patients who were followed for at least 2 years or until death. However, the local control rate was not stratified based on depth of invasion and included patients with superficial, intermediate, and deep invasion.3 A study by Panizza et al of 21 patients with large nerve perineural invasion of head and neck squamous cell carcinoma reported a local recurrence rate of 23.8%. This was not specific to the scalp and only included the subset of cases with perineural invasion.9 Although difficult to treat, invasive cutaneous malignancies of the scalp can be eradicated in many instances with proper excision and management. Preoperative imaging is crucial in these tumors to evaluate the extent of invasion so that appropriate surgical planning can be accomplished. In general, CT is superior for detecting evidence of cortical bone involvement and can be used in the preoperative assessment to help determine the degree of bony resection necessary to achieve a complete resection. It is thought that the best chance at eradicating disease is to obtain negative margins in the absence of metastatic disease. This idea is strongly supported by the repeated low recurrence rates observed following MMS, because as discussed earlier, it is microscopically guided to ensure obtainment of tumor-free margins. A large prospective cohort study by Chren et al reported a local recurrence rate of just 2.1% following MMS for cutaneous BCC and SCC.13 This raises the question regarding the therapeutic advantage of full-thickness calvarial resection to minimize local recurrence in patients with clinical periosteal invasion with no evidence of cortical invasion. If negative margins can be obtained with removal of the outer cortex of the calvarium alone, full-thickness resection may not be of benefit. Potential
Status
Discussion
F
succumbed to regional recurrence of the disease. The diseasefree survival of the outer cortex removal patients was 66.7% (4/6 patients) with one patient deceased due to regional recurrence (patient mentioned earlier with positive final margins) and one patient deceased due to other medical comorbidities unrelated to the surgery. ►Table 1 shows the patient-specific information.
Alive with NED after WLE and further calvarial removal after recurrence
Invasive Squamous Cell Carcinoma of the Scalp
Zeigler et al.
complications following a full-thickness craniectomy include bleeding, seroma or hematoma formation, cerebrospinal fluid leak, seizure, stoke, pneumocephalus, or meningitis. A study by Abo Sedira et al followed 12 patients with full-thickness calvarial resection and noted complications in 3 patients— one case each of wound infection, flap failure, and convulsions.14 In comparison, the potential complications following removal of the outer cortex of the skull are minimal. Invasive cutaneous malignancies of the scalp are a disease that frequently affects the elderly, a population that has several additional significant medical comorbidities. This study developed out of the concept that surgical planning must remain mindful of the potential morbidity and mortality associated with more aggressive resection. The treating clinician must strike a balance and appreciate the risk assessment of the more aggressive surgical approach with its associated morbidity and mortality versus the potentially inferior oncologic outcome of the less aggressive surgical resection. The ability to predict the oncologic outcome of a less aggressive approach (outer table drilldown) in achieving local control at the primary site of resection and disease-free survival would be valuable information when planning a surgical resection in this group of patients. Demonstrating these issues, the two patients with full-thickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). However, the disease-free survival of the full-thickness group was 50% (1/2 patients) because one patient succumbed to regional recurrence of the disease. The disease-free survival of the outer cortex removal patients was 66.7% (4/6 patients) with one patient deceased due to regional recurrence and one patient deceased due to other medical comorbidities unrelated to the surgery. The major drawbacks of this study are the small sample size and the retrospective design. Unfortunately, the patient population size of our group is too small to make statistically significant conclusions. Larger patient populations are needed to further define the effectiveness of full-thickness resections compared with outer cortex removal. This could be achieved through a larger retrospective or prospective multicenter observational study.
disease-free survival in the outer cortex drilldown group compared with the full-thickness resection group. We conclude that for patients in our study with periosteal involvement and without evidence of calvarial cortical involvement, outer table drilldown offers a well-tolerated approach with reasonable oncologic control.
References 1 Akcam TM, Gubisch W, Unlu H. Nonmelanoma skin cancer of the
2
3
4
5
6
7
8
9
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Conclusion Cutaneous SCC involving the scalp with periosteal or calvarial involvement offers a significant management challenge to the treating clinician. Despite the aggressive nature of this disease, it appears that a high degree of local control can be achieved in this group with multiple complex comorbidities using either outer cortex drilldown in properly selected patients or full-thickness calvarial resection. Although there was not the ability to determine statistical significance due to the small series size, there was no worse
Journal of Neurological Surgery—Part A
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Invasive Squamous Cell Carcinoma of the Scalp
