What is the recommended management for a 58-year-old male patient with multiple suspicious lesions and a diagnosis of squamous cell carcinoma (SCC) based on a skin biopsy?

Management of Multiple Suspicious Lesions with Squamous Cell Carcinoma

For a 58-year-old male with multiple suspicious lesions and confirmed squamous cell carcinoma (SCC), surgical excision with histologically confirmed clear margins is the recommended primary treatment, followed by regular surveillance every 3-6 months for at least 5 years. 1

Initial Assessment and Risk Stratification

When evaluating multiple suspicious lesions with confirmed SCC, it's essential to determine risk factors for each lesion:

High-Risk Features:

• Tumor size >2 cm in diameter (doubles local recurrence risk, triples metastasis risk) 1
• Depth >4 mm or extending to subcutaneous tissue (Clark level V) 1
• Poor histological differentiation 1
• High-risk anatomic locations (lip, ear, face, genitalia, hands, feet) 1, 2
• Perineural involvement 1, 2
• Recurrent lesions 1
• Immunosuppression 1

Treatment Algorithm

1. Primary Treatment for Each Lesion:

• Standard-risk lesions (<2 cm, well-differentiated, no high-risk features):

  • Surgical excision with 4-6 mm margins 1
  • Alternative options for smaller lesions: electrodesiccation and curettage, or cryotherapy 1

• High-risk lesions (>2 cm or with high-risk features):

  • Mohs micrographic surgery or surgical excision with complete circumferential peripheral and deep margin assessment 1
  • Wider margins (6-10 mm) for larger tumors 1

• For patients who cannot undergo surgery:

  • Radiation therapy (though this is considered category 2B evidence) 1

2. Imaging and Staging:

• For lesions ≥5 cm or overlying difficult anatomical sites, imaging with MRI or CT is recommended to assess tumor extent 1
• Evaluate regional lymph nodes clinically; if lymphadenopathy is present, consider ultrasound-guided fine-needle aspiration 1
• For large tumors (≥5 cm) or symptoms suggesting metastatic spread, consider staging with CT or PET-CT 1

3. Adjuvant Treatment:

• If extensive perineural or large-nerve involvement is present, adjuvant radiation therapy is recommended 1
• For patients with multiple recurrent lesions, consider multidisciplinary tumor board consultation 1

Follow-up and Surveillance

• First 2 years: Every 3-6 months 1
• Years 3-5: Every 6-12 months 1
• Beyond 5 years: Annual examinations for life 1

Each follow-up should include complete skin examination and regional lymph node assessment 1. This is critical as 95% of local recurrences and metastases occur within 5 years 1.

Risk Reduction Strategies

• Counsel patient on sun protection (protective clothing, sunscreen) 1
• Teach skin self-examination techniques 1
• Avoid topical and oral retinoids as they are not recommended to reduce keratinocyte cancer incidence in immunocompetent individuals 1
• Selenium and β-carotene supplementation is not recommended 1

Pitfalls to Avoid

1. Underestimating risk: Multiple lesions increase the risk of future SCCs; 35% at 3 years and 50% at 5 years 3
2. Inadequate margins: Insufficient surgical margins are associated with higher recurrence rates
3. Inconsistent follow-up: Regular surveillance is critical for early detection of recurrences
4. Overlooking lymph node assessment: Regional metastasis significantly worsens prognosis
5. Neglecting patient education: Patients should understand the importance of sun protection and self-examination

Special Considerations

For patients with extensive disease or metastases, a multidisciplinary approach involving dermatology, surgical oncology, radiation oncology, and medical oncology is recommended 1. This is particularly important as metastatic SCC has a mortality rate exceeding 70% 2.

For this 58-year-old patient with multiple suspicious lesions, careful documentation of each lesion's characteristics, appropriate surgical management with histologically confirmed margins, and diligent long-term follow-up will provide the best chance for favorable outcomes.