Nonmelanoma skin cancers (squamous cell and basal cell
carcinomas) occur at an epidemic rate in many countries with the worldwide
incidence increasing. The sun-exposed head and neck are the most frequent
sites for these cancers to arise and in most patients diagnosed with
a cutaneous squamous cell carcinoma, local treatment is usually curative. However,
a subset is diagnosed with a high-risk cutaneous squamous cell carcinoma. High-risk
factors include size (> 2 cm), thickness/depth of invasion (> 4 mm), recurrent lesions, the presence of perineural
invasion, location near the parotid gland, and immunosuppression. These
patients have a higher risk (> 10–20%) of developing metastases to regional lymph
nodes (often parotid nodes), and in some cases also of experiencing
local morbidity (perineural invasion), based on unfavourable primary
lesion and patient factors. Despite treatment, many patients developing
metastatic cutaneous squamous cell carcinoma experience mortality and
morbidity usually as a consequence of uncontrolled metastatic nodal disease. It is
therefore important that clinicians treating nonmelanoma skin cancers have an
understanding and awareness of these high-risk patients. The aim of this article is to
discuss the factors that define a high-risk patient and to present some of the issues
pertinent to their management.