Certain factors may indicate a greater risk for recurrence or metastasis1-4

Guidelines identify a number of features of cutaneous squamous cell carcinoma (CSCC) that correlate with greater likelihood of disease recurrence, metastasis, and death in patients who initially present with localized disease. Patients with even a single risk factor are deemed high risk and should be managed more aggressively than those at low risk for recurrence or metastasis.1,3,5

Are you STOPPING to assess for high risk for disease progression?1,4

Some of the risk factors identified in guidelines include:

Size ≥10 mm on cheeks, forehead, scalp, neck, and pretibial; ≥20 mm on trunk and extremitiesa

Thickness ≥2 mm or Clark level IV or V OR invasion into deep reticular dermis or subcutaneous fat

Origin of lesion on “mask areas” of the face,b scars, hands, feet, and genitalia

Poorly differentiated

Perineural, lymphatic, or vascular involvement


Neurologic symptoms

Growth in desmoplastic or infiltrative pattern

a Excluding pretibial, hands, feet, nail units, and ankles.

b Central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear.

Though the rate of nodal or distant metastasis of CSCC is approximately 2%-4%, the presence of any single risk factor increases the metastatic potential up to6-8:


Increasing numbers of coincident risk factors correlate with worse prognosis and survival.9

For certain high-risk patients, guidelines recommend1,3,5,10,11:

A more aggressive treatment approach to CSCC

A more aggressive
treatment approach

More frequent follow-up in CSCC

More frequent follow-up

Multidisciplinary team assessment and consideration of multiple modalities in CSCC

Multidisciplinary team
assessment and consideration
of multiple modalities

All of the risk factors identified here have a bearing on the potential for recurrence, metastasis, and poor outcomes.

References: 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Squamous Cell Skin Cancer V.2.2018. © National Comprehensive Cancer Network, Inc. 2017. All rights reserved. Accessed March 8, 2018. To view the most recent and complete version of the guideline, go online to NCCN.org. 2. Jennings L, Schmults CD. Management of high-risk cutaneous squamous cell carcinoma. J Clin Aesthet Dermatol. 2010;3(4):39-48. 3. Stratigos A, Garbe C, Lebbe C, et al, on behalf of European Dermatology Forum, European Association of Dermato-Oncology, and European Organization for Research and Treatment of Cancer. Diagnosis and treatment of invasive squamous cell carcinoma of the skin: European consensus-based interdisciplinary guideline. Eur J Cancer. 2015;51(14):1989-2007. 4. Califano JA, Lydiatt WM, Nehal KS, et al. Cutaneous squamous cell carcinoma of the head and neck. In: Amin MB, Edge SB, Greene FL, et al, eds. AJCC Cancer Staging Manual. 8th ed. Springer; 2017:171-181. 5. Baum CL, Wright AC, Martinez J-C, et al. A new evidence-based risk stratification system for cutaneous squamous cell carcinoma into low, intermediate, and high risk groups with implications for management. J Am Acad Dermatol. In press. 6. Burton KA, Ashack KA, Khachemoune A. Cutaneous squamous cell carcinoma: a review of high-risk and metastatic disease [published online June 29, 2016]. Am J Clin Dermatol. 2016;17(5):491-508. doi:10.1007/s40257-016-0207-3. 7. 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. 8. Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip: implications for treatment modality selection. J Am Acad Dermatol. 1992;26(6):976-990. 9. Karia PS, Jambusaria-Pahlajani A, Harrington DP, Murphy GF, Qureshi AA, Schmults CD. Evaluation of American Joint Committee on Cancer, International Union Against Cancer, and Brigham and Women’s Hospital tumor staging for cutaneous squamous cell carcinoma. J Clin Oncol. 2014;32(4):327-334. 10. Harwood C. Guidelines for the treatment and referral of squamous cell carcinoma (SCC) of the skin. London Cancer. http://www.londoncancer.org/media/76391/london-cancer-scc-guidelines-2013-v1.0.pdf. Published August 2013. Updated August 2014. Accessed January 29, 2018. 11. Motley R, Kersey P, Lawrence C. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Plast Surg. 2003;56(2):85-91.