From the Guidelines
Elective nodal radiotherapy is not indicated for this patient with pT2N0M0 G1-2 squamous cell carcinoma of the left lower lip. The patient's tumor has a depth of invasion of 3mm, with no lymphovascular invasion (LVI) or perineural invasion (PNI), and was completely excised with clear margins for the invasive component, although there is a positive margin for intraepidermal carcinoma (IEC) at the 9 o'clock position 1. According to the guidelines of care for the management of cutaneous squamous cell carcinoma, primary radiation therapy can be used in special situations, but there is limited evidence regarding the use of traditional variants of brachytherapy for the treatment of cSCC 1. Key points to consider in this case include:
- The patient's tumor is relatively thin, with a depth of invasion of 3mm, which may be more responsive to radiation therapy if needed 1.
- The absence of adverse pathological features such as deep invasion (>5mm), PNI, or LVI, which are associated with a higher risk of regional nodal spread.
- The CT imaging confirms the absence of nodal involvement or metastatic disease.
- The primary concern is the positive margin for IEC, which requires re-excision or targeted radiotherapy to the primary site rather than elective nodal treatment. Given these factors, the risk of occult nodal metastasis is low, and elective nodal radiotherapy would expose the patient to potential toxicity without clear benefit, making it unnecessary in this case 1.
From the Research
Patient Overview
- The patient has a pT2N0M0 G1-2 SCC of the left lower lip.
- The patient underwent excision on 21/2/25, with a 16 mm SCC and a depth of invasion (DOI) of 3 mm.
- The margins were clear for invasive cancer, but there was a positive margin for intraepidermal carcinoma.
- There was no lymphovascular invasion (LVI) or perineural invasion (PNI).
- A CT scan of the brain and neck showed no evidence of metastatic disease or nodal involvement.
Elective Nodal Radiotherapy
- The decision to use elective nodal radiotherapy (ENI) depends on various factors, including the risk of nodal involvement and the potential benefits and risks of treatment.
- According to 2, ENI can attenuate the combinatorial efficacy of stereotactic radiation therapy and immunotherapy.
- However, 3 suggests that de-escalating ENI dose and volume may be a viable approach, and that omitting ENI altogether may be considered in certain cases.
- The patient's low risk of nodal involvement, as indicated by the absence of LVI and PNI, and the clear margins for invasive cancer, may argue against the use of ENI.
- Additionally, 4 found that LVI and PNI are risk factors for inguinal lymph node metastases in men with T1G2 penile cancer, but this may not be directly applicable to the patient's case.
Treatment Considerations
- The patient's treatment plan should be individualized based on their specific risk factors and disease characteristics.
- The use of ENI should be carefully considered, weighing the potential benefits against the potential risks and side effects.
- Alternative treatment approaches, such as observation or adjuvant therapy, may be considered depending on the patient's overall health and disease status.
- Further research, such as 5 and 6, may provide additional insights into the role of ENI in different cancer types and treatment contexts.