From the Guidelines
The treatment of squamous cell carcinoma (SCC) on the legs typically involves surgical excision as the primary approach, with Mohs micrographic surgery often preferred for high-risk areas to preserve healthy tissue while ensuring complete tumor removal, as recommended by the guidelines of care for the management of cutaneous squamous cell carcinoma 1.
Treatment Options
The choice of treatment for SCC on the legs depends on several factors, including tumor size, location, depth, differentiation, patient age, and overall health status.
- For small, well-defined tumors, simple excision with appropriate margins (usually 4-6 mm) may be sufficient.
- Electrodesiccation and curettage can be used for superficial, low-risk lesions less than 2 cm in diameter.
- For patients who cannot undergo surgery, radiation therapy is an effective alternative, typically delivered in fractions over several weeks.
- Topical treatments like 5-fluorouracil or imiquimod may be considered for superficial lesions or as adjuvant therapy.
- For advanced or metastatic SCC, systemic therapy with immune checkpoint inhibitors such as cemiplimab (Libtayo) or pembrolizumab (Keytruda) may be necessary, as supported by recent studies 1.
Post-Treatment Follow-Up
Post-treatment follow-up is crucial, with skin examinations every 3-6 months for at least 2 years, as patients with one SCC have a higher risk of developing additional skin cancers 1.
Considerations
Early treatment is essential as SCC on the legs can be aggressive due to the thinner skin and poorer circulation in this area.
- The guidelines for the management of cutaneous squamous cell carcinoma provide evidence-based recommendations for clinical treatment, including staging, biopsy technique, prevention, and follow-up 1.
- The choice of wound closure may be guided by anatomical considerations and availability of suitable donor skin or alternatives, as discussed in the management of cutaneous squamous cell carcinoma in patients with epidermolysis bullosa 1.
From the Research
Treatment Options for Squamous Cell Carcinoma of the Legs
- Local destruction, excision, and topical therapy are effective treatments for squamous cell carcinoma in situ (SCCis) of the lower extremity, with no significant difference in patient-reported outcomes (PRO) regarding healing time, aesthetic appearance of scar, interference in activities of daily living (ADLs), or likelihood of choosing the same treatment 2.
- The recurrence rates associated with these therapies and anatomic site were also examined, and biopsy-proven and clinical recurrence rates were found to be low, at 4.0% and 1.3%, respectively 2.
- Histopathology and correct surgical excision remain the gold standard for the diagnosis and treatment of squamous cell carcinoma (SCC), but new diagnostic imaging techniques such as dermoscopy and reflectance confocal microscopy have increased the diagnostic accuracy 3.
Surgical Excision and Radiation Therapy
- The first line treatment of cutaneous SCC is complete surgical excision with histopathological control of excision margins, with a recommended standardised minimal margin of 5 mm even for low-risk tumours 4.
- Radiation therapy represents a fair alternative to surgery in the non-surgical treatment of small cSCCs in low risk areas, and can be used as adjuvant treatment for high-risk tumors 4, 5.
- A systematic review of primary, adjuvant, and salvage radiation therapy for cutaneous squamous cell carcinoma found that pooled local control and local recurrence rates were 87.3% and 8.6%, respectively 5.
Guidelines and Recommendations
- The American Society for Radiation Oncology recommends definitive RT as primary treatment for patients with BCC and cSCC who are not surgical candidates, and conditionally recommends RT with an emphasis on shared decision-making in those situations in which adequate resection can lead to a less than satisfactory cosmetic or functional outcome 6.
- The guideline also recommends against the use of carboplatin concurrently with adjuvant RT and conditionally recommends the use of systemic therapies for unresectable primaries where treatment may need escalation 6.