Abstract
Purpose: Post-operative radiotherapy (PORT) for resected cutaneous squamous cell carcinoma (CSCC) with perineural invasion (PNI) is controversial. Therefore, we conducted a survey to review treatment recommendations among Radiation Oncologists (ROs) in the management of CSCC with PNI. Materials & Methods: In March 2011, we contacted all ROs and trainees in the US through email addresses listed in the 2009 ASTRO directory. Our web-based survey presented clinical vignettes involving Mohs micrographically resected CSCC with microscopic PNI (mPNI) or clinical PNI (cPNI). For each vignette, ROs were asked to indicate if PORT was appropriate and to further specify the dose and volume to treat. Results: Three hundred fifty two responses were completed and analyzed. The majority of ROs (72%) had over 10 years of post residency experience. 64% of the sampled ROs had a special interest in treating head and neck cancers, and 64% treated 4 or more cases per year. Approximately 95% recommended PORT for cPNI whereas 59% recommended PORT for mPNI. Post residency experience (10+ yrs vs. = 0.005) and for mPNI of deep subcutaneous non-named nerve involvement (80% vs. 60%, p = 0.001). ROs treating 8 or more cases per year (vs. = 0.01). Conclusions: Our study demonstrates significant variability among ROs in the management of CSCC with mPNI. For cases of cPNI, an overwhelming majority recommended PORT. In cases of mPNI, there was no consensus for recommending PORT, although experienced practitioners had a lower threshold for offering treatment. These results indicate the need for prospective clinical studies to clarify the role of PORT in CSCC patients with mPNI.
Highlights
An estimated 700,000 new cases of cutaneous squamous cell carcinoma (CSCC) are diagnosed each year in the US, and the incidence is rising [1]-[3]
These results indicate the need for prospective clinical studies to clarify the role of Post-operative radiotherapy (PORT) in CSCC patients with microscopic PNI (mPNI)
The results of this study demonstrate wide variability without a clear consensus in the management of CSSC with mPNI among U.S based Radiation Oncologists (ROs)
Summary
An estimated 700,000 new cases of cutaneous squamous cell carcinoma (CSCC) are diagnosed each year in the US, and the incidence is rising [1]-[3]. Perineural invasion (PNI), tumor diameter (>2 cm), deep invasion, poorly differentiated histology, and immunosuppression have been identified as negative prognostic factors for CSCC, and are often associated with a higher risk of recurrence, metastasis, and death [4]-[8]. PNI is reported in approximately 5% - 10% of CSCC patients, and has been associated with other high-risk disease characteristics [10]-[12]. PNI has been reported as an important independent negative prognostic factor for recurrence and survival [4] [6] [13] [14]. In a 2010 study of 315 patients with CSCC of the head and neck, Kygirdis et al reported a 5-year recurrence free survival (RFS) of 26% and a 5-year overall survival rate of 45% in patients with PNI (compared to 82% and 76% in patients without PNI, respectively) [15]
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