P6056Evaluation of the definitions of ‘‘high-risk’’ cutaneous squamous cellcarcinoma using the American Joint Committee on Cancer staging criteriaand National Comprehensive Cancer Network guidelines

Melinda B. Chu, MD, St. Louis, MO, United States; Eric S. Armbrecht, PhD, St.Louis, MO, United States; Jordan B. Slutsky, MD, St. Louis, MO, United States;Mark A. Varvares, MD, St. Louis, MO, United States; Maulik Dhandha, MS, St.Louis, MO, United States; Ronald J. Walker, MD, St. Louis, MO, United States;Scott W. Fosko, MD, St. Louis, MO, United States

Background: While most do not, some cutaneous squamous cell carcinoma (cSCC)lesions display aggressive behavior, leading to locoregional metastasis, and evendeath. Recently, new guidelines have been proposed to aid in this assessment andidentification of these tumors.

Objective: To evaluate the definitions of ‘‘high-risk’’ cSCC using the American JointCommission on Cancer (AJCC) staging criteria and National Comprehensive CancerNetwork (NCCN) guidelines and to assess the concordance between thesedefinitions.

Methods: A retrospective chart review included all cSCC on the head and neck seenby an academic dermatology department from July 2010 to November 2011.Complete clinical information was available for 269 cases of the 296 cases identified.AJCC staging criteria and the NCCN guidelines were applied to the cohort.

Results: In the AJCC analysis, 257 tumors were included. Eyelid carcinomas wereexcluded per the guidelines. The majority, 211 (82.1%) were stage 1 and 46 tumors(13.9%) were stage 2. Almost all (n ¼ 45) were stage 2 because of size ($ 2 cmalone); only 1 tumor was up-staged because of ‘‘high-risk features.’’ Two ‘‘high-riskfeatures’’ (Clark level and Breslow depth) were almost never recorded and otherswere rarely observed: perineural invasion (n¼ 12), hair-bearing lip (n¼ 12), and ear(n¼ 38). Using the NCCN classification system, 231 (87%) of tumors were classifiedas ‘‘high-risk.’’ While only 1 of 12 risk factors is needed for an SCC on the head andneck to be classified as ‘‘high-risk,’’ 43.2% of tumors had 2 or more NCCN risk factors.Size ($ 6 mm on ‘‘mask areas of the face’’ and $ 10 mm on forehead, scalp, cheeks,and neck) was the most common risk factor listed.

Conclusion: This analysis shows there is still some discordance in the definitions of‘‘high-risk’’ SCC. Few SCCs are stage 2 by AJCC staging criteria, while most SCCs are‘‘high-risk’’ by the NCCN guidelines. While progress has been made in classifying‘‘high-risk’’ SCC, further studies are needed to understand the importance of anyindividual risk factor and the impact of multiple risk factors to generate a unifieddefinition of ‘‘high-risk’’ SCC to optimize management.

APRIL 20

cial support: None identified.

Commer

P6706Free skin cancer screening provides access to care

Courtney McFaddin, MD, Scott and White Memorial Hospital/Texas A&M HealthScience Center, Temple, TX, United States; David Butler, MD, Scott and WhiteMemorial Hospital/Texas A&M Health Science Center, Temple, TX, United States;Katherine Fiala, MD, Scott and White Memorial Hospital/Texas A&M HealthScience Center, Temple, TX, United States; Scarlett Boulos, MD, Scott and WhiteMemorial Hospital/Texas A&M Health Science Center, Temple, TX, United States

Since the inception of the national melanoma/skin screening program in 1985, theAmerican Academy of Dermatology (AAD) and its members have provided morethan 2.1 million free skin cancer screenings and identified at least 206,500 lesions ofwhich were 23,500 suspected melanomas. While statistics on clinically suspiciouslesions identified during these screenings have been reported, the numbers ofresultant biopsies from individual screenings and the histologic findings of thosebiopsies have not been reported. Our institution held its annual free skin cancerscreening sponsored by the AAD on May 5, 2011. Two hundred five patients werescreened in total, and 103 (50%) were referred for further evaluation and treatment.Of those referred, biopsies were recommended in 48 (47%). Over the ensuingmonths, 47 biopsies were performed on 33 screened patients (69% of those referredfor biopsy and 16% of all patients screened). Malignancies were found in almost halfof the patients biopsied (15 of 33 [45%]), some of whom had multiple cancerouslesions. In all, 19 malignancies were detected including 15 basal cell carcinomas,1 squamous cell carcinoma, and 3 melanomas. Our data highlight the importance ofproviding free skin screenings as a mechanism by which patients can gain access todermatologic care.

cial support: None identified.

Commer

13

P6542Generalized trichilemmal cysts with an unfavorable outcome

Virginia Sanz-Motilva, MD, Department of Dermatology, Hospital Universitario 12de Octubre, Madrid, Spain; Antonio Martorell-Calatayud, Department ofPathology, Hospital de Manises, Valencia, Spain; Blanca Homet, Department ofOncology, Hospital Universitario 12 de Octubre, Madrid, Spain; FranciscoVanaclocha-Sebasti�an, Department of Dermatology, Hospital Universitario 12de Octubre, Madrid, Spain; Jos�e-Luis Rodr�ıguez-Peralto, MD, Department ofPathology, Hospital Universitario 12 de Octubre, Madrid, Spain

Background: Trichilemmal cysts (TCs) are common lesions, often located on thescalp, that arise from the external root sheath of hair follicles. They can be inheritedby an autosomal-dominant transmission. Proliferating trichilemmal cysts (PTCs)usually present as fast-growing neoplasms that should be differentiated from TCsand squamous cell carcinoma (SCC). A spectrum of cases has been observed rangingfrom a trichilemmal cyst with slight epithelial proliferation to a tumor with markedepithelial hyperplasia mostly solid resembling a SCC.

Case report: A 48-year-old Saharan woman presented with 2 large exophytic masseslocated in the right breast and the interscapular area. These tumors had beenpresent for aproximately 2 years. The patient also complained of multiple cysticnodules diffusely distributed. The first nodules appeared when she was a teenagerand 2 of her 7 children presented similar cystic lesions. Her medical history wasunremarkable. On examination, there were around 30 dome-shaped nodulesranging from 1 to 5 cm in diameter involving different areas of her body, includingscalp. In addition, she presented 2 tumors on her large breast (6 3 6 cm) andinterscapular area (8 3 4 cm) with a mamelonated and exudative surface. Someenlarged mobile bilateral axilar lymph nodes were noted. Under local anesthesia, 2biopsies of the large tumors were taken showing in both cases a squamous cellcarcinoma with trichilemmal differentiation. Some cystic nodules were also extir-pated resulting histologically in trichilemmal cysts and proliferating trichilemmalcysts. Image studieswere performed showing enlarged axilar lymph nodes that werebiopsied revealing only inflammatory findings. Because of the large size of thetumors, surgery was not considered and she was derived to oncology departmentwhere she underwent chemotherapy (6 cycles of taxol and carboplatin).Afterwards, the SCC on the back completely disappeared and the one on the rightbreast showed a necrotic appearance with a decrease of size and was excised withfree margins. She remains disease-free after 5 months of follow-up and some of thelargest lesions will be gradually extirpated.

Conclusion: We present a peculiar case of a patient with multiple trichilemmal cystsand proliferating trichilemmal cysts who developed 2 squamous cell carcinomasover previous adnexal tumors. In the situation of nonoperable squamous cellcarcinomas, chemotherapy could be considered.

cial support: None identified.

Commer

P6494Head and neck squamous cell cancer in parotid gland: Case report

Bruna Gouveia, MD, Dermatology Service of Federal University of Rio de Janeiro,Rio de Janeiro, Brazil; Leonardo Carneiro, MD, Service of patology of FederalUniversity of Rio de Janeiro, Rio de Janeiro, Brazil; Luzia El Hadj, MD, PhD,Service of otorhinolaryngology of Federal University of Rio de Janeiro, Rio deJaneiro, Brazil; Maria Helena Barbosa, MD, Service of otorhinolaryngology ofFederal University of Rio de Janeiro, Rio de Janeiro, Brazil; Nurimar Fernandes,MD, PhD, Service of Dermatology of Federal University of Rio de Janeiro, Rio deJaneiro, Brazil

Background: Squamous cell carcinoma (SCC) is the second most common cutane-ous malignancy, responsible for approximately 20% of cases, with 60% occurring inhead and neck. The rate of regional metastases from cutaneous squamous cellcarcinoma of the head and neck (SCCHN) is estimated to occur in\5% of patients.In those cases, parotid metastasis is around 3% and it indicates aggressive localdisease and more severe prognosis.

Objective: This case report aims at warning dermatologists about the risk of parotidinvolvement in SCCHN and discussing parotid mestastasis as an isolated prognosticfactor and as a therapy guide.

Case report: An 81-year-old woman had a tumor in the left zygomatic region with 3months of evolution. In physical examination, the tumor was 5 cm in diameter; itscenter was ulcerated with yellowish exudate and hematic crust. Its borders werewell-delimited and the lesion had a volcano-like bump. Head and neck computedtomography showed a lesion in skin that reached the parotid parenchyma. The firststep of the therapywas surgical excisionwith parotidectomy and lymphadenectomyof the upper jugular (level II) nodal basins. Frozen section procedure revealed SCCand the margins were tumor-free. After that, cervical nodes level II and intraparotidnodes were also studied and revealed squamous cell metastasis. Nerve injuriesoccurred in surgery because of the proximity of parotid and facial nerve. Therefore,the patient presents a peripheral facial palsy in her left side. Then, patient was keptin follow-up and did not present any metastatic involvement postsurgery.

Discussion: Because the parotid nodes receive lymphatic drainage from a large areaof the face and scalp, it is not surprising that metastatic parotid SCC is a commonmalignancy of parotid. Many studies show parotid involvement as an importantprognostic factor by itself. Thus, the new classification considers that the higher theparotid involvement the lower the survival index. There are some risk factors thatincrease significantly the risk for parotid nodal metastasis: the size of tumor, depth ofinvasion, proximity to the parotid gland and advanced age. When they are present,they forecast the necessity of parotidectomy. In this case report, the patient had allthese high-risk factors for the parotid involvement which guided the appliedtherapy.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB161