A MULTICENTRE diagnostic study has demonstrated that ultrasonography and computed tomography (CT) significantly outperform physical examination in detecting nodal metastases in patients with high-risk cutaneous squamous cell carcinoma (cSCC), while also highlighting important limitations in immunosuppressed populations.
Early identification of nodal involvement is critical in high-risk cSCC, yet optimal staging strategies remain unclear. To address this, researchers conducted a prospective paired diagnostic study across 13 tertiary dermato-oncology centres in Spain, including 155 patients with histologically confirmed high-risk disease. Participants underwent baseline nodal assessment using physical examination, ultrasonography, and contrast-enhanced CT, with findings compared against histological results or short-term clinical follow-up.
Ultrasonography Shows Highest Sensitivity Among Modalities
Over a 3-month period following surgery, 7.7% of patients developed nodal metastases. Ultrasonography demonstrated the highest sensitivity for detecting metastases at baseline (63.6%), followed by CT (54.5%), while physical examination showed markedly poor sensitivity at just 8.3%. All three modalities showed high specificity, exceeding 95%, although physical examination reached the highest specificity (99.3%), reflecting its limited ability to detect early disease rather than true diagnostic strength.
Importantly, ultrasonography and CT showed strong agreement with each other, suggesting they may be used interchangeably depending on clinical context and resource availability. In contrast, concordance between imaging modalities and physical examination was poor, reinforcing the limitations of clinical examination alone for accurate staging.
Subgroup analysis revealed a striking divergence based on immune status. Among immunocompetent patients, both ultrasonography and CT achieved 100% sensitivity and excellent diagnostic accuracy, successfully identifying all metastatic cases at baseline. However, performance declined sharply in immunosuppressed individuals, where sensitivities dropped to 20.0% for ultrasonography and 16.7% for CT. In this group, nodal metastases frequently emerged rapidly during follow-up despite negative initial imaging.
Need for Tailored Guidelines in Immunosuppressed Patients
These findings underscore the need for tailored staging approaches in high-risk cSCC. While ultrasonography and CT represent clear improvements over physical examination for baseline nodal assessment, their limited sensitivity in immunosuppressed patients highlights the importance of vigilant follow-up and may warrant revised clinical guidelines.
Overall, the study supports the integration of imaging into routine staging of high-risk cSCC, while emphasising a more individualised approach based on patient immune status.
Reference
Ferrándiz-Pulido C et al. Diagnostic Modalities and Nodal Staging in High-Risk Cutaneous Squamous Cell Carcinoma. JAMA Dermatol. 2026;DOI: 10.1001/jamadermatol.2026.0803.
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