2017 Section 7 Green Book

Original Investigation Research

Sentinel Lymph Node Biopsy for Cutaneous Squamous Cell Carcinoma on the Head and Neck

up after the immediate postoperative period, and overall small numbers despite being the largest single institution report. The purpose of our study was to review our institutional experi- ence utilizing SLNB for cutaneous SCC on the head and neck to provide a basis to optimize future prospective analyses over a long period of time with long-term follow-up. We included outcomes data, although not complete, for all patients to add to the current body of literature on the subject, acknowledg- ing that, owing to the limited follow up for some of our pa- tients, the rates of recurrence and false-omission may be un- derestimates. Despite these limitations, our study provides unique data, particularly with regard to histologic processing of the SLNB specimens, and additional evidence to justify fu- ture investigation incorporating prospectively-collected, ho- mogeneous, comprehensive data sets based on standardized treatment algorithms. Conclusions Rigorous studywith optimal methodology is necessary to im- prove surgical and histopathologic protocols for SLNB for cu- taneous SCC and to advance our understanding of what role SLNB may play with respect to improved staging for patients at high risk of nodal metastasis. Further work will be neces- sary to determine if early identification and intervention leads to improved outcomes for these patients.

months. One nodal recurrence occurred after a positive SLNB, another after a failed SLNB. The overall rate of nodal disease was 14% (7 positive SLNB, 1 nodal recurrence). Predictors of nodal disease were multiple high-risk factors ( P = .008), PNI ( P = .05), and ALI ( P = .05). 32 The lack of a cutaneous SCC National Tumor Registry im- pedes large retrospective multi institutional analysis of prog- nostic factors. Risk factors associated with a higher rate of lo- cal recurrence andmetastases are currently defined based on low-moderate evidence and expert consensus. 7,33,34 We evalu- ated our data using effect size to aid in comparison of the rela- tive size of effect of each NCCN high-risk feature with regard to the presence of nodal disease and found that presence of ALI, presence of PNI, and a large clinical size had a large ef- fect on the development of nodal disease. The large width of the CIs around the estimates of the false-negative and false- omission rates, however, exposes the small sample size and demonstrates the variability of these estimates. Until higher level evidence is produced, our results, which are relatively consistent with the literature, suggest that utilization of the NCCN guidelines may facilitate appropriate patient selection for future study design and current consideration for SLNB. 7 Limitations Limitations of our study include a retrospective design asso- ciated with missing data of some variables of interest, rela- tively short follow up including some patients lost to follow

ARTICLE INFORMATION Accepted for Publication: June 3, 2016.

9 . Ross AS, Schmults CD. Sentinel lymph node biopsy in cutaneous squamous cell carcinoma: a systematic review of the English literature. Dermatol Surg . 2006;32(11):1309-1321 . 10 . Eastman AL, Erdman WA, Lindberg GM, Hunt JL, Purdue GF, Fleming JB. Sentinel lymph node biopsy identifies occult nodal metastases in patients with Marjolin’s ulcer. J Burn Care Rehabil . 2004;25(3):241-245 . 11 . Hatta N, Morita R, Yamada M, Takehara K, Ichiyanagi K, Yokoyama K. Implications of popliteal lymph node detected by sentinel lymph node biopsy. Dermatol Surg . 2005;31(3):327-330 . 12 . Stadelmann WK, Javaheri S, Cruse CW, Reintgen DS. The use of selective lymphadenectomy in squamous cell carcinoma of the wrist: a case report. J Hand Surg Am . 1997;22(4):726-731 . 13 . Weisberg NK, Bertagnolli MM, Becker DS. Combined sentinel lymphadenectomy and mohs micrographic surgery for high-risk cutaneous squamous cell carcinoma. J Am Acad Dermatol . 2000;43(3):483-488 . 14 . Weber F, Bauer JW, Sepp N, et al. Squamous cell carcinoma in junctional and dystrophic epidermolysis bullosa. Acta Derm Venereol . 2001;81 (3):189-192 . 15 . Ardabili M, Gambichler T, Rotterdam S, Altmeyer P, Hoffmann K, Stücker M. Metastatic cutaneous squamous cell carcinoma arising from a previous area of chronic hypertrophic lichen planus. Dermatol Online J . 2003;9(1):10 . 16 . Ozçelik D, Tatlidede S, Hacikerim S, Uğurlu K, Atay M. The use of sentinel lymph node biopsy in squamous cell carcinoma of the foot: a case report. J Foot Ankle Surg . 2004;43(1):60-63 .

cancer (keratinocyte carcinomas) in the U.S. population, 2012. JAMA Dermatol . 2015;151(10): 1081-1086 . 2 . Stratigos A, Garbe C, Lebbe C, et al; European Dermatology Forum (EDF); European Association of Dermato-Oncology (EADO); European Organization for Research and Treatment of Cancer (EORTC). Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. Eur J Cancer . 2015;51(14):1989-2007 . 3 . Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol . 2013;68(6):957-966 . 4 . Coit DG, et al. NCCN Clinical Practice Guidelines in Oncology: Melanoma. Version I.2016. https://www.nccn.org/. Accessed June 1, 2016. 5 . Bichakjian CK, et al. NCCN Clinical Practice Guidelines in Oncology: Merkel Cell Carcinoma. Version I.2016. https://www.nccn.org/. Accessed June 1, 2016. 6 . Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med . 2014;370(7):599-609 . 7 . Bichakjian CK, et al NCCN Clinical Practice Guidelines in Oncology: Squamous Cell Skin Cancer. Version I.2016. https://www.nccn.org/. Accessed June 1, 2016. 8 . Wilson DB. Practical Meta-Analysis Effect Size Calculator. http://www.campbellcollaboration.org /resources/effect_size_input.php. Accessed June 1, 2016.

Published Online: July 20, 2016. doi: 10.1001/jamaoto.2016.1927 .

Author Contributions: Alison B. Durham had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Durham, Lowe, Malloy, Bradford, Johnson, McLean. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Durham, Lowe, Malloy, Chubb. Critical revision of the manuscript for important intellectual content: Durham, Lowe, Malloy, McHugh, Bradford, Johnson, McLean. Statistical analysis: Chubb. Administrative, technical, or material support: Durham, McLean. Study supervision: Lowe, Malloy, Bradford, Johnson, McLean. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Previous Presentation: This study was presented at the American Head and Neck Society Ninth International Conference on Head and Neck Cancer; July 20, 2016; Seattle, Washington. REFERENCES 1 . Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence estimate of nonmelanoma skin

(Reprinted) JAMA Otolaryngology–Head & Neck Surgery Published online July 20, 2016

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