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Regional Lymphatic Dissemination of Squamous Cell Carcinoma of the Face

Peterson, Emily M.D.; Murphy, Robert X. Jr M.D., M.S.; Risch, Victor R. M.D., Ph.D.; Hallock, Geoffrey G. M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 21e-22e
doi: 10.1097/PRS.0b013e318194d1bc
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Sir:

Although lymphatic spread of squamous cell carcinoma is well described in the oncology and dermatology literature, reports of local dissemination via lymphatics are rare. We describe an immunocompromised patient with aggressive local spread of squamous cell carcinoma in the head and neck, presumably through the dermal lymphatics.

The patient, a 68-year-old man receiving chronic immunosuppression secondary to renal transplantation for polycystic kidney disease, had a forehead lesion that proved to be a poorly differentiated invasive squamous cell carcinoma with perineural invasion. Over the next 16 months he underwent three resections of contiguous lesions with negative margins. After his third resection, he had a 1-cm scaly lesion on the right side of his forehead, with a series of nodular lesions extending to his left eyebrow, multiple nodules anterior to the pinna, and extensive dermal lymphatic involvement along the lateral canthus of his left eye extending to the mandibular ramus. No adenopathy was noted on clinical examination or computed tomography scans of his head, chest, abdomen, and pelvis.

After clinical diagnosis of squamous cell carcinoma with dermal lymphatic involvement, the patient received two 3-month courses of radiation to the right side of his forehead and left brow and seven weekly cycles of chemotherapy with Taxotere. He developed a nonhealing radiation wound, which proved to be squamous cell carcinoma with perineural invasion, and several new lesions, one of which had dermal lymphatic involvement on pathologic and physical examinations. Lymph node biopsy and dissection were not performed.

The patient underwent two major hemifacial excisions, with microsurgical reconstruction of his tumor-laden radiation wound (Fig. 1). During his last complicated hospitalization, new lesions appeared on his face and his right leg.

Fig. 1.
Fig. 1.:
Microsurgical reconstruction was performed using an anterolateral thigh perforator flap. Six months later, multiple new squamous cell carcinomas of his face and right leg were identified and excised.

Squamous cell carcinoma is a locally invasive tumor, but metastatic potential exists, particularly when tumors are found on the head or neck, at sites of chronic inflammation, in previously irradiated areas, or in immunocompromised patients. The rate of metastasis is generally reported to be 3 to 10 percent, with reports of up to 30 percent.1,2 Tumor spreads via the lymphatics, circulatory system, or interstitium. Regional lymph nodes are the most common site of metastasis (85 percent), but squamous cell carcinoma can also metastasize to the liver, lung, brain, and bone.3 Depth of invasion and degree of cytologic atypia are associated with a greater likelihood of metastasis and recurrence. Perineural invasion portends a worse prognosis. Squamous cell carcinoma in the immunosuppressed patient commonly recurs with perineural, dermal lymphatic, and regional lymph node involvement.4

A recent study noted that 87 percent of participants had head and neck lesions, with 20 percent on the forehead, 20 percent on the face, and 17 percent on the cheek. Roughly 10 percent of head and neck patients developed delayed regional lymphatic recurrences of previously excised squamous cell carcinoma, and eight patients with midfacial squamous cell carcinoma actually presented with regional lymphatic failure despite normal immune function.5

Surgery is the treatment of choice for both local and metastatic squamous cell carcinoma confined to regional lymph nodes,3 with chemotherapy and radiation reserved for diffuse metastatic disease. Patients at risk for local lymphatic spread of their squamous cell carcinoma, specifically the immunosuppressed, deserve early referral to a radiation oncologist, chemotherapist, and surgeon, to eradicate or slow disease progression.

Emily Peterson, M.D.

Robert X. Murphy, Jr., M.D., M.S.

Victor R. Risch, M.D., Ph.D.

Geoffrey G. Hallock, M.D.

Lehigh Valley Hospital

Allentown, Pa.

REFERENCES

1. Dinehart SM, Pollack SV. Metastases from squamous cell carcinoma of the skin and lip: An analysis of twenty-seven cases. J Am Acad Dermatol. 1989;21:241–248.
2. Moller R, Reymann F, Hou-Jensen K. Metastases in dermatological patients with squamous cell carcinoma. Arch Dermatol. 1979;115:703–705.
3. Preston DS, Stern RS. Nonmelanoma cancers of the skin. N Engl J Med. 1992;327:1649–1662.
4. Miller A. CLL and squamous cell of the auricle. Turkish J Haematol. 2003;20:251.
5. Clayman GL, Lee JJ, Holsinger FC, et al. Mortality risk from squamous cell skin cancer. J Clin Oncol. 2005;23:759–765.

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©2009American Society of Plastic Surgeons