The study involved twelve patients who were diagnosed with CSCC and underwent lymph node dissection at Hospital Kuala Lumpur, Malaysia between January 1st, 2013 and December 31st 2019. Among the patients, 75% were male, and two-thirds had medical comorbidities such as diabetes mellitus or hypertension. The racial distribution of the patients showed that 50% (n = 6) were Malay, 41.7% (n = 5) were Chinese, and 8.3% (n = 1) were Indian.
Table 1.0
Demographics for lymph node dissection cohort 2013–2019
Age Mean (range) | 56.9 years ± 19.8 years |
Gender Male, n (%) Female, n (%) | 9 (75%) 3 (25%) |
Indication Macroscopic (clinically palpable), n (%) Microscopic (radiologically detected), n (%) | 2 (16.7%) 10 (83.3%) |
Region of lymph node dissection N = 13 Neck, n (%) Sentinel lymph node biopsy Supraomohyoid neck dissection Modified radical neck dissection Axillary nodes (%) Inguinal nodes (%) Parotid nodes (%) | 8 (61.5%) 1 (7.7%) 2 (15.4%) 5 (38.5%) 3 (23.1%) 1 (7.7%) 1 (7.7%) |
During clinical examinations, it was observed that two patients exhibited palpable lymph node enlargement. One patient presented with enlargement at the neck, while the other had enlargement at the inguinal region. Out of the two regions examined, only the lymph nodes in the inguinal area revealed evidence of malignancy. Neck dissections are the most frequently performed lymph node dissections at our institution, n = 8. From a group of eight patients, including one individual who underwent neck sentinel lymph node biopsy, there was no instances of malignancy detected in any of the removed lymph nodes. Table 2.0 shows the clinicopathological features of the primary tumor with number of lymph nodes harvested.
Table 2.0
Clinicopathological features of cutaneous squamous cell carcinoma and type of lymph node dissection done.
Case number | Histological tumor size | Location | Differentiation | Perineural involvement | Lymphovascular invasion | Margin | Type of lymph node surgery | Lymph nodes found | Positive lymph nodes with malignancy |
1 | 30mmx25mm | Cheek | Well | No | No | Clear | Supraomohyoid neck dissection | 16 | 0 |
2 | 55mmx40mm | Cheek | Well | No | No | Clear | Modified radical neck dissection | 19 | 0 |
3 | 55mmx50mm | Cheek | Moderate | No | No | Clear | Modified radical neck dissection | 14 | 0 |
4 | 90mmx90mm | Arm | Well | No | No | Clear | Axillary level 2 | 26 | 1 |
5 | 100mmx100mm | Scalp | Well | No | No | Clear | Modified radical neck dissection | 40 | 0 |
20mmx20mm | Cheek | Well | No | No | Clear | Parotid nodes | 11 | 0 |
6 | 30mmx60mm | Scalp | Moderate | No | No | Close | Sentinel lymph node of neck | 3 | 0 |
7 | 120mmx85mm | Gluteal | Well | Yes | No | Clear | Inguinal dissection | 34 | 6 |
8 | 33mmx20mm | Neck | Well | No | No | Clear | Modified radical neck dissection | 23 | 0 |
9 | 80mmx60mm | Arm | Well | No | No | Clear | Axillary level 2 | 37 | 0 |
10 | 80mmx70mm | Temple | Moderate | No | No | Clear | Modified radical neck dissection | 32 | 0 |
11 | 70mmx70mm | Forearm | Well | No | No | Clear | Axillary level 2 | 20 | 0 |
12 | 32mmx40mm | Lips | well | No | No | Clear | Supraomohyoid neck dissection | 20 | 0 |
Computed tomography (CT) imaging is employed at our facility to exclude the possibility of undetected clinical lymph node involvement and distant metastasis. Typically, our CT images provide information regarding the identification of structures resembling lymph nodes, accompanied by their respective size, if relevant. There was no evidence of malignancy in the lymph nodes that were dissected by the pathologist among the ten patients who exhibited occult lymph node involvement in CT imaging. Even though most patients receive a stage III diagnosis, a significant proportion of individuals did not exhibit any indications of lymph node involvement. Table 2.0 displays the specific type of lymph node surgical procedure that was executed on the patients. The selection of surgical procedures is predominantly based on the primary lymph node basin for drainage and the clinical expertise of the surgeon.
Table 2.0: Clinicopathological features of cutaneous squamous cell carcinoma and type of lymph node dissection done.
On average, patients who underwent lymph node dissection required a hospital stay of approximately 19 days, with the maximum duration around 27 days. In our patient cohort, recurring surgical procedures often necessitated by persistent lymph dissection site drainage, cellulitic alterations in the neck area, and wound dehiscence at the flap site.
In 2017, Case 5 received a diagnosis of Stage III CSCC of the scalp. A sentinel biopsy of neck nodes yielded negative results. The individual displayed two instances of risky characteristics as per the NCCN categorization, namely the dimensions and depth of the cancer. Three years later, he was diagnosed with a CSCC on his cheek, which required surgical intervention. He had wide local excision of the tumor, modified radical neck dissection performed, excision of both superficial and deep parotid glands with lymph nodes dissected. The results of the procedure indicated the absence of any malignant cells in the harvested nodes. Regrettably, the individual experienced facial nerve palsy after the procedure, resulting in significant impairment. Adjuvant radiotherapy or chemotherapy was not administered to this patient.
In Case 7, an inguinal dissection procedure was performed in 2017, which resulted in the detection of positive nodes. During his first presentation to us, he had a palpable inguinal node. The patient experienced locoregional recurrence within 15 months of his initial surgery and, despite receiving chemotherapy, ultimately passed away from the disease 6 months later. The mentioned patient exhibited four high-risk characteristics, namely, tumour size, tumour depth, high risk site, and presence of perineural invasion from the primary tumor.
Axillary level 2 lymph node dissection was performed on three patients, and the results indicated the absence of malignancy in all cases. There were no instances of recurrence observed among these patients during their 5-year follow-up period. Nevertheless, a patient developed lymphoedema several months post-surgery.
Among the cohort of twelve patients, six individuals had undergone adjuvant radiotherapy. Two patients received radiotherapy within two to three months following surgery, three patients received radiotherapy four months after surgery, and one patient received radiotherapy more than six months after surgery. All patients were administered a total dose of 60 Gy, delivered in 30 fractions over a period of 6 weeks, following consultation with the oncologist.
The patient cohort was monitored for a minimum of 5 years, during which 2 patients experienced recurrence, as previously noted. The remaining individuals are free from the cancer.
Table 3.0
Clinical stage of cutaneous squamous cell carcinoma
Case number | Location | Tumor staging | Lymph node | Distant Metastasis | Stage |
1 | Cheek | T2 | N0 | M0 | II |
2 | Cheek | T3 | N0 | M0 | III |
3 | Cheek | T3 | N0 | M0 | III |
4 | Arm | T3 | N1 | M0 | III |
5 | Scalp | T3 | N0 | M0 | III |
Cheek | T2 | N0 | M0 | II |
6 | Scalp | T2 | N0 | M0 | II |
7 | Gluteal | T3 | N1 | M1 | IV |
8 | Neck | T2 | N0 | M0 | II |
9 | Arm | T3 | N0 | M0 | III |
10 | Temple | T3 | N0 | M0 | III |
11 | Forearm | T3 | N0 | M0 | III |
12 | Lips | T2 | N0 | M0 | II |