Cutaneous head and neck basal and squamous cell carcinomas with perineural invasion
Department of Radiation Oncology, University of Florida, Gainesville, FL, USA.Oral Oncology (Impact Factor: 3.61). 03/2012; 48(10):918-22. DOI: 10.1016/j.oraloncology.2012.02.015
Perineural invasion (PNI) occurs in 2% to 6% of cutaneous head and neck basal and squamous cell carcinomas (SCCs) and is associated with mid-face location, recurrent tumors, high histologic grade, and increasing tumor size. Patients may be asymptomatic with PNI appreciated on pathologic examination of the surgical specimen (microscopic), or may present with cranial nerve (CN) deficits (clinical). The V and VII CNs are most commonly involved. Magnetic resonance imaging (MRI) may be obtained to detect and define the extent of PNI; computed tomography (CT) or ultrasound-guided fine needle aspiration cytology (UGFNAC) may assist with detecting or excluding regional lymph node metastases. Patients with apparently resectable cancers undergo surgery, usually followed by postoperative radiotherapy (RT). Patients with unresectable cancers are treated with definitive RT. Moreover, RT may be considered if significant functional or cosmetic impairment is expected after surgical treatment. The 5-year outcomes after treatment for clinically unsuspected microscopic compared with clinical PNI are: local control, 80% and 55%; cause-specific survival, 75% and 65%; and overall survival, 55% and 50%, respectively. The incidence of grade ⩾3 complications is higher after treatment for clinical PNI versus microscopic PNI; approximately 35% compared with 15%, respectively. Proton beam RT may be used to reduce the risk of late complications by reducing RT dose to the visual apparatus and central nervous system (CNS).
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ABSTRACT: Perineural invasion of head and neck skin cancer is a poorly understood and often misdiagnosed pathological entity. Incidental or microscopic perineural invasion is identified by the pathologist and often leads to confusion as to how the patient should be further treated. The less common but more aggressive clinical perineural spread presents with a clinical deficit, which is too commonly misinterpreted by the clinician. This review will try to clarify the terminology that exists in the literature and explore the mechanisms of invasion and spread. It will look at the recent advances in diagnosis and comment on the limitations inherent in current classification schemes. A review of outcomes will be included and current treatment strategies utilized discussed.
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ABSTRACT: Purpose: To update our experience treating cutaneous squamous cell carcinoma (SCC) and basal cell carcinomas (BCC) of the head and neck with incidental perineural invasion (PNI) using Mohs resection followed by radiotherapy (RT). We compare outcomes between head and neck patients with incidental PNI who received Mohs surgery and those who did not. Materials and methods: From 1987 to 2009, 36 patients were treated with Mohs resection followed by postoperative RT; 82 patients were treated with resection other than Mohs followed by postoperative RT. Results: The 5-year overall survival and cause-specific survival rates for patients who received Mohs resection plus RT and those who received a non-Mohs resection plus RT were 53% versus 56% (p=0.809) and 84% versus 68% (p=0.0329), respectively. The 5-year local control rates for Mohs and non-Mohs patients were 86% versus 76% (p=0.0606), respectively. The 5-year local-regional control and freedom from distant metastases rates for the Mohs group were 77% and 92%, respectively. The 5-year overall neck control, neck control with elective neck RT, and neck control without elective RT treatment rates for the Mohs group were 91%, 100%, and 82% (p=0.0763), respectively. The rate of grade 3 or higher complication in the Mohs group was 22%, which included bone exposure (N=3), cataract (N=2), chronic non-healing wound (N=2), wound infection (N=1), fistula (N=1), and/or radiation retinopathy (N=1). Conclusions: Mohs surgery appears to result in improved local control and cause-specific survival in patients with incidental PNI who receive postoperative RT. Elective nodal RT improves regional control in patients with SCC.
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