Would you cover elective nodal regions in a patient with high-risk cutaneous SCC of the right medial forehead with clinically negative lymph nodes s/p WLE with graft?

This patient exhibits several adverse features that could warrant post-operative management. As a caveat, patient KPS and other factors may influence the decision point on if and what to treat. That said, the tumor size, thickness, and the presence of other high-risk features in aggregate (+PNI/LVSI, high-grade) with close deep margins place this patient at risk of occult nodal spread (Szewczyk et al., PMID 25217080 & Lubov et al., PMID 34493343). Primary tumor characteristics (e.g. size >2m, depth >4mm) can be used to predict the risk of nodal involvement as well as clinical outcomes (Grammatica et al., PMID 34170382). Furthermore, a recent JAMA Oncology meta-analysis article delineated factors impacting outcomes in patients with cutaneous...

Yes. Ipsilateral parotid nodes, plus 1b, 2, and 3.

Our single institution study (Clinical Skin Cancer) of high risk cutaneous SCCa showed only depth of invasion was predictive of regional nodal mets (10% rate in patients with depth of invasion of 4 mm or greater) based on a sentinel node mapping. Neither recurrence, tumor size, LVSI, PNI, nor grade 3 histology proved predictive.

Nodal basins associated with a forehead index lesion can be all over the place but it's probably reasonable to treat the tumor bed, pretragal nodes, parotid, and into the jugulodigastric and submandibular nodes on that side. It's been our experience that the most common site for forehead cutaneous SCCa is the parotid nodes.

Would also include course of V1 to Meckel's cave given PNI.