Cutaneous Squamous Cell Carcinoma Takes the Stage

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Cutaneous Squamous Cell Carcinoma Takes the Stage

Highlights of the new risk-stratification scheme, with a focus on tumor characteristics

Staging is critically important for establishing cancer prognosis and treatment algorithms. The American Joint Commission on Cancer (AJCC) initiated staging systems for Merkel cell carcinoma and cutaneous squamous cell carcinoma (cSCC) because of their potential to metastasize. This "TNM" staging scheme synthesizes characteristics of the primary tumor (T), lymph nodes (N), and metastasis (M) to determine stage. This report from the cSCC staging committee focuses on T characteristics, as most cSCCs present as small primary tumors, and briefly discusses changes in N and M grading. (Changes to N criteria will be described elsewhere. Penile, vulvar, and eyelid SCC are staged separately.)

The new T grading system establishes clinical size >2 cm as a key delineator, along with high-risk features (>2-mm thickness, Clark level >IV, perineural invasion, primary location on the ear or nonglabrous lip, poorly differentiated or undifferentiated histology); invasion of maxilla, mandible, orbit, or temporal bone; and invasion of axial or appendicular skeleton or perineural invasion of the skull base. N grading includes number, size, and location (ipsilateral vs. contralateral) of involved nodes; M grading details presence or absence of distant metastasis. These features are summarized in the attached table.

Comment: These important changes are welcome additions to the AJCC staging manual. Though cSCC is common, study of the behavior and treatment of high-risk cSCC has been fragmented, and multiple features have not often been considered simultaneously. In this scheme, many high-risk features are grouped together, suggesting that their precise relative contributions to risk are not well understood. However, this system should enable studies to further stratify and incorporate other risk factors, such as immunosuppression. Of note, keratoacanthomas often grow larger than these size cutoffs, although they usually have a benign course. Because the distinction between keratoacanthoma and well-differentiated cSCC has been controversial, this issue also needs further study.

— Kenneth Y. Tsai, MD, PhD

Published in Journal Watch Dermatology March 11, 2011

Citation(s):

Farasat S 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 Jan 21; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.jaad.2010.08.033)

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