Squamous cell carcinoma without an epidermal attachment (SCC-WEA) is sometimes encountered on skin biopsy which can symbolize metastatic lesions from the skin or internal organs. Typically, cutaneous metastases emerge as multiple and often clustered nodules presenting concurrently. However, an isolated dermal SCC-WEA remains unclear in terms of workup and treatment.

A retrospective case series study identified the risk that such a lesion represents to metastasis and reviewed the usual management and outcomes among such patients. 

16 relevant cases with clinical documentation were marked. Biopsies of 6 of the 16 patients represented metastatic lesions, among which only 1 was from a noncutaneous source. 3 of these 6 patients presented with multiple nodules, including 1 case each of metastatic SCC from the esophagus, the penis, and the scalp that further metastasized widely, including to the pleura. 3 of the 6 cases of metastatic lesions were considered isolated in-transit metastases. The lesions in the next 10 patients represented local recurrence or a new primary cutaneous SCC.

8 patients among which underwent at least some form of imaging. All the patients with lesions representing in-transit metastases underwent imaging and received radiation as at least a component of their treatment. 

9 patients underwent Mohs excision or standard excision as monotherapy. The 3 patients who were treated with chemotherapy as a part of their regimen also had evidence of more than 1 metastatic lesion. The overall survival rate at 1 year was found to be 84.6%. The average follow-up was for 25.9 months. Death was reported in 2 patients as a direct result of their metastatic SCC.

Thus the authors of this paper recommended that a discussion be undertaken with patients regarding the consideration of imaging, which is particularly essential for higher-risk patients, including those with a history of organ transplant, noncutaneous SCC, more than 1 nodule on examination, or a suspected in-transit metastasis. 

The authors also recommended imaging of the tumor site, regional nodes, and contrast tomography of the chest, abdomen, and pelvis. 

Further, in the case of performing Mohs excision without imaging, the authors recommended submitting the tumor debulk specimen for evaluation of an epidermal connection and overall histology, which may assist in future decision making.

SOURCE- Rudningen KE, Hinshaw MA, Aylward JL, Gloria Xu YG. Characteristics, evaluation, and outcomes of patients with squamous cell carcinoma lacking histologic continuity to the epidermis. JAAD. 2022;86(3): P662-665. DOI:https://doi.org/10.1016/j.jaad.2021.02.039