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Woods et al. J Cancer Metastasis Treat 2022;8:22 https://dx.doi.org/10.20517/2394-4722.2022.28 Page 7 of 14

Adnexal tumors
For cutaneous adnexal tumors, lymph node metastases identified after sentinel lymph node biopsy in early-
[38]
stage tumors are rare , so it may best be applied selectively, possibly only in patients with local
recurrence . One study suggested that apocrine carcinoma demonstrates high rates of lymphatic spread,
[39]
and so elective node dissection should be considered in this histology, although no cases in this study were
in the head and neck, in which regional spread may be less common [40,99] .

RECONSTRUCTION
Large defects in the parotid and neck region after clearance of nodal metastases may require a pedicled or
free flap , particularly in cases where adjuvant radiation is likely or good cosmesis is sought. However,
[100]
adjuvant radiation can result in significant free flap volume loss and so overcorrection is sometimes
required to ensure adequate function after radiation . In cases where the primary tumor involves the skull
[101]
[102]
base, closure is usually done in layers to prevent cerebrospinal fluid leak and close dead space .
For larger defects that include parotidectomy and neck dissection, an anterolateral thigh flap is typically
employed . Alternative local flaps to reconstruct the parotid region, for example, in cases where free tissue
[103]
transfer may be contraindicated, include the temporalis muscle flap, supraclavicular island flap, scalp flap,
preauricular flap, or temporoparietal fascia flap.

In cases with extensive perineural invasion, static facial reanimation can be used and this is sometimes
[102]
incorporated into the flap of choice . Dynamic reconstruction can be carried out using autologous nerve
grafts such as the greater auricular or sural nerves, the latter of which can be used for multiple anastomoses.
Nerve allografts can also be used for dynamic reconstruction, as well as masseteric or hypoglossal nerve
transfers, with oral commissure symmetry better in hypoglossal nerve use and time to the first movement
quicker in masseteric nerve use .
[104]

RADIATION
Radiation in regional lymph node metastases from NMSC is typically reserved for the adjuvant setting.
However, for cases undergoing parotidectomy for parotid nodal disease, elective neck radiation can be an
alternative to elective neck dissection with adjuvant radiation . Radiation or chemoradiation as primary
[105]
[106]
treatment can be considered in patients deemed unfit for surgical management .
For node-positive cases, adjuvant treatment is typically given to all patients with nodal disease greater than 3
cm with no extracapsular extension, those with extranodal extension, or those with incompletely excised
nodal disease. Some evidence suggests that it may also be considered with one positive lymph node ≤ 3 cm
with no extracapsular extension [107,108] . The recommended dose of adjuvant radiation is 60 Gy in 2.0 Gy
once-daily fraction, 5 days per week, or a biologically equivalent dose . Techniques such as Intensity-
[109]
modulated radiation treatment (IMRT), or volumetric modulated arc therapy are preferable. Non-IMRT
techniques, including 3-dimensional conformal radiation and electron or proton beam therapy, are
acceptable if adequate tumor coverage is achieved while constraints on organs at risk are met .
[109]
Brachytherapy use is limited to previously irradiated patients with incompletely resectable nodal disease.

The role of concurrent chemotherapy with radiation is controversial and is less certain than in cases of
mucosal SCC. Some research has suggested a lower chance of recurrence , but there has been no evidence
[110]
to suggest improvement in overall survival by the addition of chemotherapy , and it is possible that
[23]
outcomes could be worse with the use of concurrent chemotherapy . Concurrent chemotherapy is
[111]
typically used in cases of mucosal SCC demonstrating extranodal extension, and it has been associated with