Management of the Neck in Nonmelanocytic Cutaneous Carcinomas

Cutaneous malignancies, exclusive of melanoma , are the most common cancers in the United States. The annual incidence is at least 600,000, with an annual mortality between 2500 and 5000. The exact numbers are difficult to ascertain given the many specialties involved (primary care physicians, dermatologists, otolaryngologists, and plastic and general surgeons) and that the treatment of many of the smaller and/or less aggressive lesions is not reported. It is believed that up to 90% occur within the head and neck region, most commonly the ears and upper face. 14 Multiple factors influence an individual's predilection, including fair complexion, sun exposure, altered immune status, hereditary factors, chemical exposure, and the presence of scar tissue . Many have pointed to a steady increase in the incidence of squamous and basal cell carcinomas , with most claiming a doubling or tripling in the last 30 years. Proposed etiologies for this trend include the general aging of our population, increased exposure to ultraviolet radiation by lifestyle choices, and possible environmental changes such as depletion of the ozone layer. Of specific concern to the head and neck surgeon is the presence of cervical metastatic disease , which occurs in 0.3% to 13.7% of cutaneous squamous cell carcinomas and 0.0028% to 0.4% of basal cell carcinomas. 14 , 29 Skin malignancies often are overlooked as possible sources of lymphadenopathy because of the relative infrequency of such sources compared to the more commonly metastasizing upper aerodigestive tumors, but they must be considered if present within 5 years of metastasis discovery. Distal tumor spread without persistent or recurrent locoregional disease is rare, but may cause a diagnostic dilemma when it occurs. The management of metastatic disease secondary to cutaneous malignancy requires the following: (1) understanding of the natural locoregional progression of disease; (2) awareness of prognostic factors for development of metastasis and identification of high risk lesions; (3) understanding of cervical lymphatic drainage patterns including the parotid and external jugular systems; and (4) emphasis on the importance of control of the primary lesion. These topics will be addressed and the author's approach to the management of the cervical nodal spread of nonmelanocytic cutaneous malignancies will be presented.