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  • Presentation

Radiologic Staging and Surveillance: High-Risk cSCC - A Practical and Guidelines-Focused Approach

Description

In a presentation on the radiologic staging and surveillance of high-risk cutaneous squamous cell carcinoma (cSCC), Dr. Addison Demermo emphasizes a practical approach based on NCCN guidelines. He introduces the KISS principle (Keep It Simple Surgeon) to streamline imaging processes, arguing that tailored imaging should consider patient specifics to enhance detection while minimizing costs and patient inconvenience. Key recommendations include utilizing high-resolution ultrasound for nodal surveillance, which offers greater sensitivity compared to clinical examinations, and can change management in about a third of cases. He highlights the importance of MRI for brain imaging when there's potential calvarial involvement, using case examples to illustrate these points. Furthermore, Dr. Demermo underscores that not all cases fit neatly into established staging criteria, advocating for personalized risk assessments. He advises regular imaging intervals for high-risk patients for early detection of recurrence, reiterating the significance of balancing simplicity with the complexities presented by individual patient cases. His concluding messages urge clinicians to conduct thorough examinations with imaging, particularly using ultrasound, and to remain vigilant about potential metastasis, suggesting a comprehensive and adaptable strategy for managing high-risk cSCC.

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Conclusions

  • The KISS approach promotes simplicity and flexibility in radiologic imaging for high-risk cutaneous squamous cell carcinoma (cSCC).
  • Ultrasound should be considered the primary tool for high-risk cSCC surveillance as it is safe, sensitive, and cost-effective.
  • Routine imaging is recommended for higher-stage tumors (T2b and T3) due to the significant reduction in poor outcomes when imaging is performed, especially perioperatively.
  • High-resolution ultrasound can detect more metastases than a clinical exam, improving surveillance efficacy.
  • Minor risk factors for poor outcomes in T1 and T2a tumors necessitate tailored imaging and management strategies.
  • Brain MRI should be considered in cases with suspected calvarial involvement to rule out deeper disease which may not be evident through other imaging.
  • Cross-sectional imaging may be necessary for patients with very high-risk tumors to rule out distant metastasis before highly morbid treatments.
  • The established guidelines support imaging frequency and modality recommendations based on individual risk assessments and clinical evidence.
  • Ruiz ES, Karia PS, Morgan FC, Schmults CD. The positive impact of radiologic imaging on high-stage cutaneous squamous cell carcinoma management. J Am Acad Dermatol. 2017 Feb;76(2):217-225. doi: 10.1016/j.jaad.2016.08.051.
  • Libson K, Sheridan C, Carr DR, Shahwan KT. Use of Imaging in Cutaneous Squamous Cell Carcinoma to Detect High-Risk Tumor Features, Nodal Metastasis, and Distant Metastasis: A Systematic Review. Dermatol Surg. 2024 Aug 1;50(8):705-709. doi: 10.1097/DSS.0000000000004191. Epub 2024 Apr 16. PMID: 38624106.
  • Gibson FT, Murad F, Granger E, Schmults CD, Ruiz ES. Perioperative imaging for high-stage cutaneous squamous cell carcinoma helps guide management in nearly a third of cases: A single-institution retrospective cohort. J Am Acad Dermatol. 2023 May;88(5):1209-1211. doi: 10.1016/j.jaad.2023.01.012. Epub 2023 Jan 18. PMID: 36681240.
  • Tokez S, Koekelkoren FHJ, Baatenburg de Jong RJ, Grünhagen DJ, Mooyaart AL, Nijsten T, van der Lugt A, Wakkee M. Assessment of the Diagnostic Accuracy of Baseline Clinical Examination and Ultrasonographic Imaging for the Detection of Lymph Node Metastasis in Patients With High-risk Cutaneous Squamous Cell Carcinoma of the Head and Neck. JAMA Dermatol. 2022 Feb 1;158(2):151-159.
  • Shahwan, Kathryn T. et al. Identifying the Impact of Minor Risk Factors in Brigham and Women's Hospital Stage T1 Cutaneous Squamous Cell Carcinomas on Risk of Poor Outcomes: A Retrospective Cohort Study. JAAD. IN PRESS. Accessed: 3/4/2025.
  • Gupta N, Weitzman RE, Murad F, Koyfman SA, Smile TD, Chang MS, Maher JM, Schmults CD, Vidimos AT, Ruiz ES. Identifying Brigham and Women's Hospital stage T2a cutaneous squamous cell carcinomas at risk of poor outcomes. J Am Acad Dermatol. 2022 Jun;86(6):1301-1308.