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A need exists to tailor the extent of surgical margins and parotid/neck management to different histotypes for NMSCs, the most common malignant tumors that affect the head and neck.

Although NMSCs are among the most common malignant tumors that affect the head and neck worldwide, the authors of an article published in Current Opinion in Otolaryngology & Head and Neck Surgery emphasized there is a lack of high-level evidence for their management, particularly for those in more advanced stages.

“The need to tailor the extent of surgical margins and parotid/neck management to different histotypes, considering the varying risk factors for recurrence, is beginning to emerge in the literature,” said Vittorio Rampinelli, MD, PhD, and colleagues.

Typical Management Factors

Therapeutic management of each type of NMSC is determined based on various factors. However, surgical excision is a standard treatment regardless of patient age or anatomical location of the tumor.

An effective management path considers a patient’s age, comorbidities, cosmetic expectations, and QOL. For example, if ablation is determined to be the most effective strategy, the functionality and esthetics of the anatomical structures should also be considered.

For older patients with head and neck NMSCs, treatment courses must consider epidemiologic association of skin tumors with the last decades of life. Increased age can increase risk for postoperative complications.

An additional complication to NMSC treatments is inadequate high-level evidence to guide management.

“As a consequence, different professionals face this disease with nonuniform indications and competencies,” Dr. Rampinelli and colleagues noted. “Therefore, it is necessary to integrate the diverse expertise among specialists within a broad multidisciplinary team to work together and share a common clinical reasoning.”

Squamous Cell Carcinoma

Common primary SCC is nonmetastatic and is further categorized as either low-risk or high-risk for recurrence. Advanced SCC is categorized as locally advanced or metastatic.

“Locally advanced SCCs, at the extreme of the pathologic spectrum, may end up as ‘nonresectable’ tumors due to factors like multiple recurrences and extensive or critical extension to bone and/or major vessels. Treatment of tumors in this category could potentially lead to unacceptable functional or cosmetic consequences,” the authors wrote.

Strategies among specialists vary, underscoring how a multidisciplinary board could be pivotal to optimizing treatment decisions.

The authors of the article broke down SCC management into three categories: risk stratification, surgical margin adequacy, and neck management.

1. Risk Stratification

The main objective of oncologic surgery for NMSCs, particularly head and neck SCCs, is to achieve clear resection margins. Different scores have been developed to help stratify risk pertaining to the adequacy of tumor margins, though these vary widely in application due to limited scientific evidence to support their efficacy. Identification and biopsy of clinically high-risk lesions are crucial for planning optimal treatment strategies to avoid inadequate resections or aggressive subsequent treatments.

2. Surgical margin adequacy

Treatment of invasive SCC typically involves surgical excision with clear margins confirmed through postoperative histologic assessment. Intraoperative techniques like frozen sections aid in margin assessment, although they carry a risk for false negatives, necessitating final analysis with paraffin-embedded sections.

Micrographically controlled surgeries such as Mohs surgery and 3D histology are effective for high-risk SCCs but are limited by their complexity and suitability for large lesions needing immediate reconstruction.

Margin widths vary based on risk, with low-risk SCCs often treated within 4 mm to 6 mm margins, while high-risk cases may require 6 mm to 13 mm. Surgical planning in the head and neck region must consider the challenges of preserving critical structures and achieving oncologic safety, often requiring advanced techniques and complex reconstructions.

Specific challenges and treatment strategies vary by site, such as the scalp and nose, where considerations include bone involvement and aesthetic outcomes. Eyelid and orbital SCCs require meticulous treatment due to proximity to vital structures, with orbital invasion necessitating aggressive management like orbital exenteration.

3. Neck Management

Cutaneous SCCs often metastasize to regional lymph nodes post-treatment, significantly impacting mortality rates despite initial low reported rates (2.3% to 5.2%). Understanding lymphatic drainage patterns is crucial, especially in the head and neck, where drainage pathways can be unpredictable due to prior surgeries altering normal flow.

Key factors influencing metastatic risk include tumor location and clinicopathological features. Parotid involvement is common (82% in cases of regional metastasis), with level II nodes most frequently affected (79% of positive cases), followed by levels IV and V in more extensive disease. Surgical management includes comprehensive neck dissection for clinically positive nodes, with variability in elective dissection recommendations due to uncertain occult metastasis rates (0% to 37%). Prophylactic neck dissection may benefit cases with high-risk features, particularly when tumors are contiguous with or near the parotid gland or require extensive reconstruction (Figure).

“This comprehensive review underscores the importance of individualized care, the need for continued research, and the value of a multidisciplinary approach in managing the complex spectrum of NMSCs of the head and neck,” Dr. Rampinelli and colleagues concluded.