Locally advanced cSCC of the scalp with named-nerve PNI

Locally advanced cSCC of the scalp with named-nerve PNI — MDT, MRI, adjuvant RT and consideration of cemiplimab

Learning points

• BWH T-staging outperforms AJCC 8 in most cohorts and is recommended by BAD 2020.
• PNI is high-risk if ANY ONE of: nerve calibre ≥ 0.1 mm; PNI deeper than dermis; PNI of a named nerve.
• MRI with fat-saturation is the imaging modality of choice for suspected perineural spread along named nerves (e.g. supraorbital branch of trigeminal).
• Adjuvant radiotherapy is strongly indicated for large-calibre / named-nerve PNI, multiply recurrent disease, close / positive margins where re-excision is not feasible, and node-positive disease.
• NICE TA802 (29 June 2022) recommends cemiplimab for metastatic or locally advanced cSCC not suitable for curative surgery or curative radiotherapy.
• Bone invasion is automatic BWH T3 — highest metastatic and disease-specific mortality tier.