How would you approach a cutaneous squamous cell carcinoma with primary tumor completely excised, but multiple foci of LVI at the peripheral specimen margin and no other high-risk features?

In a prospective study that assessed clinical and pathological risk factors for primary tumor site recurrence after margin negative excision of cutaneous squamous cell carcinoma, the presence of desmoplasia was reported to be the primary variable associated with this event. The authors specified that the presence of perivascular invasion was always associated with desmoplasia, and is therefore a risk factor for primary tumor site recurrence (Brantsch et al., PMID 18617440).

With this in mind, I would discuss and consider adjuvant radiotherapy to the site of the primary tumor. I would use techniques described by a recently published consensus guideline (Porceddu et al., PMID 32289475).

We handle H&N skin cancers differently from limbs and trunk. For H&N, if there is extensive LVSI that’s already an indication to consider PORT with a generous margin in my mind, especially in an immunocompromised patient. A re-resection is not going to change that. Limbs and trunk are more forgiving if there is a recurrence and I would not offer RT. The issue comes down to the ability to salvage in the event of a relapse. Other factors are also to be considered e.g., size, depth of invasion, PNI, margin width, etc. Note that extensive LVSI is not a factor in the AJCC staging system. This is a relatively data-free zone and it’s hard to get a consensus.