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Cutaneous squamous cell carcinoma

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of cutaneous squamous cell carcinoma are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the German Society of Dermatology (DDG/DKG/DeCOG 2023), the U.S. Preventive Services Task Force (USPSTF 2023,2018), the American Society of Plastic Surgeons (ASPS 2021), the British Association of Dermatologists ...
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Screening and diagnosis

Indications for screening: as per USPSTF 2023 guidelines, insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults.
I
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Classification and risk stratification

Staging: as per DDG/DeCOG/DKG 2023 guidelines, use the current UICC/AJCC TNM system to classify CSCC based on histologic and clinical parameters.
E
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  • Risk assessment

Diagnostic investigations

Physical examination: as per DDG/DeCOG/DKG 2023 guidelines, perform a physical examination with inspection of the entire skin in patients with suspected CSCC.
E
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  • Diagnostic imaging

  • Imaging for staging

Diagnostic procedures

Skin biopsy: as per DDG/DeCOG/DKG 2023 guidelines, consider performing complete resection without prior probing biopsy if the clinical picture is clear for CSCC.
E
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  • Sentinel lymph node biopsy

Medical management

Management of local disease, general principles
As per BAD 2021 guidelines:
Take into consideration the risk factors for the patient and the margin, site, and tumor stage in patients with CSCC with ≥ 1 clear-but-close margins (< 1 mm). Consider offering observation in immunocompetent patients with CSCC with a low-risk tumor.
B
Offer active treatment in immunosuppressed patients with CSCC with ≥ 1 clear-but-close (< 1 mm) or involved margins with structured follow-up and surveillance.
E
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  • Management of local disease (topical therapies)

  • Management of local disease (curettage and cautery)

  • Management of local disease (surgical excision)

  • Management of local disease (wound closure)

  • Management of local disease (Mohs micrographic surgery)

  • Management of local disease (elective lymph node dissection)

  • Management of local disease (cryotherapy)

  • Management of local disease (laser therapy)

  • Management of local disease (photodynamic therapy)

  • Management of local disease (adjuvant radiotherapy)

  • Management of local disease (definitive radiotherapy)

  • Management of locally advanced/metastatic disease (general principles)

  • Management of locally advanced/metastatic disease (surgical resection)

  • Management of locally advanced/metastatic disease (lymph node dissection, general principles)

  • Management of locally advanced/metastatic disease (lymph node dissection, head and neck region)

  • Management of locally advanced/metastatic disease (lymph node dissection, non-head and neck region)

  • Management of locally advanced/metastatic disease (systemic therapy)

  • Management of locally advanced/metastatic disease (adjuvant radiotherapy)

  • Management of locally advanced/metastatic disease (definitive radiotherapy)

  • Management of locally advanced/metastatic disease (laser therapy)

  • Management of locally advanced/metastatic disease (photodynamic therapy)

  • Management of locally advanced/metastatic disease (palliative care)

Specific circumstances

Patients with keratoacanthoma: as per AAFP 2024 guidelines, perform excision of lesions suspicious for keratoacanthoma with a 5 mm margin due to the difficulty in distinguishing keratoacanthomas from CSCC.
B
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Patient education

Pretreatment counseling
As per BAD 2021 guidelines:
Discuss the risks and benefits of all treatment options (outcomes, function, cosmesis) with patients with CSCC and their families/carers and ensure making treatment decisions together.
E
Inform younger patients with CSCC (age < 60 years), especially organ transplant recipients, about the very low risk of radiation-induced, in-field malignancy in the future. Take this risk into account when making any treatment decision.
E
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Preventative measures

Primary prevention
As per USPSTF 2018 guidelines:
Counsel persons with fair skin types aged 6 months to 24 years and parents of young children about minimizing exposure to UV radiation to reduce the risk of skin cancer.
B
Offer counseling selectively in adults > 24 years with fair skin types about minimizing exposure to UV radiation to reduce the risk of skin cancer, taking into consideration the presence of risk factors for skin cancer.
B
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  • Primary prevention (EDA)

  • Secondary prevention

Follow-up and surveillance

Skin reconstruction after tumor resection, timing: as per ASPS 2021 guidelines, consider performing reconstructive surgery in a delayed (asynchronous) fashion in adult patients after skin cancer resection.
C
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  • Skin reconstruction after tumor resection (perioperative antibiotics)

  • Skin reconstruction after tumor resection (perioperative antithrombotics)

  • Skin reconstruction after tumor resection (perioperative analgesics)

  • Skin reconstruction after tumor resection (follow-up)

  • Surveillance after curative-intent therapy

  • Surveillance for future malignancies