Is radiologic imaging necessary in management of cutaneous SCC?

Radiologic imaging of high-risk cutaneous squamous cell carcinoma (sSCC) tumours displays unforeseen results such as local invasion and nodal metastasis, which result in changes in management in nearly half of these cases, reveals a study.

“Radiologic imaging, especially of the local site and nodal basins, should be considered in high-risk cSCC to aid staging and management planning,” the investigators said.

A total of 394 patients with primary Brigham and Women's Hospital (BWH) stage T2a high, T2b, T3, and recurrent cSCC tumours were included in this retrospective cohort analysis of invasive cSCC at the Cleveland Clinic, Cleveland, Ohio, US, over a 25-year period. Of these, 138 were stratified into imaged and 256 to nonimaged cohorts.

Imaged tumours tended to be BWH T2b/T3, located on the head and neck or trunk, moderately or poorly differentiated, and have a larger diameter, depth beyond fat, and perineural involvement than nonimaged tumours (p<0.001 for all). [J Am Acad Dermatol 2025;93:360-367]

Almost half (49 percent) of the imaged tumours showed unexpected imaging findings, particularly local invasion beyond clinical expectations (23 percent) and nodal metastasis (18 percent). Imaging results led to changes in clinical management in 47 percent of patients, often by altering the surgical approach.

“Even among a more favourable subgroup of patients where imaging was deferred, the 5-year disease-related outcome (DRO) event rate was still substantial (25 percent),” according to the investigators. 

“These findings reinforce the need for consistent imaging, particularly of the local site and nodal basins, in the evaluation of all high-risk cSCCs to aid accurate staging and treatment planning,” they added. 

Abnormal findings

A previous study of 113 BWH stage T2b and T3 tumours from 103 patients noted abnormal findings on imaging in 65 percent of patients, resulting in changes in management in 33 percent. [J Am Acad Dermatol 2017;76:217-225]

Another study at the same institution, involving 99 BWH T2b and T3 tumours from 93 patients, had imaging that revealed unpredicted results in 38 percent of patients and altered management 30 percent of the time. [J Am Acad Dermatol 2023;88:1209-1211]

“Our study expanded inclusion criteria to incorporate BWH stage T2a high tumours and recurrent tumours, as these groups also represent higher risk cSCC tumours likely to benefit from baseline imaging, which may explain the greater proportion of cases where management was altered in the present study,” the investigators said.

“BWH stage T2a high tumours are a subset of BWH T2a tumours with higher-risk features that have been shown to lead to significantly worse outcomes compared to the broader T2a group,” they added. [J Am Acad Dermatol 2022;86:1301-1308]

The present analyses revealed similar findings, indicating utility in radiologic imaging for both primary and recurrent cSCC tumours.

“Subsequent studies should validate these findings in larger, multi-institutional cohorts to develop optimal imaging guidelines for cSCC,” the investigators said.

“Radiologic imaging is not routinely performed to assess high-risk cSCC as data on its utility are limited,” they noted.