Most of us who treat cutaneous squamous cell carcinoma (cSCC) have had patients who develop nodal metastasis. However, such metastases are rare, with risks from single-institution cohorts hovering around 4.0%.1,2 For most dermatologists in practice, the number is likely lower. This rarity makes it difficult for physicians to select out the few patients who may need nodal staging from the multitude of patients with cSCC we see daily. If we use the 10% or greater risk generally considered appropriate for melanoma, the challenge of identifying who is in that 10% group remains because there is little firm prognostic data available for cSCC. Assuming we could accurately identify which patients have that 10% risk, we are still not sure how best to evaluate lymph node basins because there are no controlled studies of nodal staging modalities in cSCC. A survey study of Mohs surgeons reported that there is no consensus as to the best way to radiologically stage nodal basins and that more than 20% of respondents did not perform any nodal staging of patients they thought had a 10% risk of nodal metastasis.3 Thus, the only thing that is clear is that we are presently unclear. Schmitt and colleagues4 are therefore to be congratulated for their study in this issue of JAMA Dermatology because it is the first to use a systematic approach to begin to shed some light on this very gray area.
Karia PS, Schmults CD. Screening for Nodal Metastasis and Its ChallengesNodal Needles in the SCC Haystack. JAMA Dermatol. 2014;150(1):16-17. doi:10.1001/jamadermatol.2013.6690