Does a 75-year-old patient require further management after complete excision of a poorly differentiated squamous cell carcinoma from the neck with 2mm minimum clearance, perineural involvement, and a 0.05mm nerve width?

From the Guidelines

A 75-year-old patient with completely excised poorly differentiated squamous cell carcinoma from the neck requires further management despite the complete excision, and adjuvant radiation therapy is recommended. This recommendation is based on several high-risk features present in this case, including poor differentiation of the tumor, close surgical margins (2mm is considered close for SCC) 1, and perineural invasion. Perineural involvement, even with a small nerve width of 0.05mm, significantly increases the risk of local recurrence and reduces disease-specific survival. According to the most recent and highest quality study, adjuvant radiation therapy should be considered for patients with close margins (< 5mm) and/or extracapsular spread of disease 1.

Some key points to consider in the management of this patient include:

• The patient's age of 75 is not a contraindication to adjuvant therapy, though performance status and comorbidities should be considered when finalizing the treatment plan.
• Regular follow-up examinations every 3 months for the first two years are necessary, including complete head and neck examination and consideration of imaging studies.
• The patient should be referred to radiation oncology within 6 weeks of surgery for optimal outcomes.
• Adjuvant cisplatin-based chemoradiation therapy (CRT) may be considered if the patient has other high-risk features, such as extracapsular extension or microscopically involved resection margins 1.

However, the current evidence suggests that adjuvant RT alone may be sufficient for patients with close margins and no extracapsular extension 1. Therefore, adjuvant radiation therapy to the surgical bed and regional lymph nodes, typically delivered at doses of 60-66 Gy over 6-7 weeks, is the recommended treatment plan.

From the Research

Perineural Involvement and Further Management

• The presence of perineural involvement in a poorly differentiated squamous cell carcinoma is a significant factor in determining the need for further management 2, 3.
• Perineural invasion (PNI) is associated with poor clinical outcomes, including increased local recurrence and poor prognosis 3, 4.
• In the case of a 75-year-old patient with complete excision of a poorly differentiated squamous cell carcinoma from the neck, perineural involvement with a 0.05mm nerve width may indicate a higher risk of local recurrence and metastasis 2, 5.

Radiation Therapy and Perineural Involvement

• Radiation therapy may be effective in controlling perineural invasion by modulating the nerve microenvironment and impairing cancer cell viability 4.
• The use of radiation therapy for PNI and perineural tumor spread (PNTS) can improve local control and reduce devastating failures at the skull base 3.

Considerations for Further Management

• Given the patient's age and the presence of perineural involvement, further management may be necessary to prevent local recurrence and metastasis 2, 3.
• The decision for further management should be based on a multidisciplinary approach, taking into account the patient's overall health, tumor characteristics, and the potential benefits and risks of additional treatment 2, 3.
• Regular follow-up and monitoring for signs of recurrence or metastasis are crucial in managing patients with poorly differentiated squamous cell carcinoma and perineural involvement 2, 6.