# Prognostic Factors of Locally Advanced Cutaneous Squamous Cell Carcinoma in Head and Neck Region in Transplanted Patients

## TL;DR

This study examines the factors affecting survival and outcomes in transplant patients with advanced skin cancer in the head and neck region.

## Contribution

The study identifies specific prognostic factors for locally advanced cutaneous squamous cell carcinoma in immunosuppressed transplant patients.

## Key findings

- Transplant patients with CSCC have significantly worse survival and higher recurrence rates.
- Neck metastasis with extranodal extension and compromised surgical margins are strong predictors of mortality.
- Immunosuppression and surgical procedures like temporalectomy are linked to higher recurrence risk.

## Abstract

Background: Cutaneous squamous cell carcinoma (CSCC) is the second most common neoplasm in humans and the most frequent in Brazil (80% in the head and neck region, 20% mortality). Brazil is a world leader in organ transplants (more than 30,000 transplants in 2019). The risk of transplant patients (Tx) developing CSCC is 65–250 times higher, with deeper infiltration, advanced stage, higher local recurrence, occult metastases, and worse survival. Objective: To investigate the prognostic factors of locally advanced cutaneous squamous cell carcinoma (LACSCC) of the head and neck region in transplant patients. Methods: 16-year retrospective, single-center series of patients with LACSCC in the head and neck region who underwent surgical treatment. Clinical and Tx data, clinical/pathological stage, surgical treatment, parotid/regional and distant metastases, recurrence, and survival were analyzed. Results: 156 patients were included: 69.2% women, 65.3 years; mean primary size: 4.24 cm, 66% T3/T4 tumors, 71% grade 2/3 differentiation, 20.5% transplant recipients, follow-up: 33.6 months. The most affected regions were malar/nasal (28.8%) and auricular (19.2%). Surgeries included wide resection with reconstruction (58.9%), exenteration (14.1%), and temporalectomy (11.5%). Univariate analysis: Recurrence: immunosuppressor drugs (p = 0.009), transplanted (p = 0.006), compromised margin (p = 0.049); Mortality: immunosuppression (p = 0.028), total resection and reconstruction (p = 0.013), stage (8ed) III-IV (p < 0.001), compromised margin (p < 0.001), neck metastasis with extranodal extension (p = 0.018). Multivariate analysis: Recurrence: transplanted HR: 3.69 (p < 0.001), neck metastasis extranodal extension HR: 5.41 (p < 0.001), evolution to distant metastasis HR: 5.27 (p < 0.001); Mortality: neck metastasis extranodal extension HR: 1.94, (p = 0.032), compromised margins HR: 1.87 (p = 0.001). Main surgical procedures: temporalectomy HR: 2.83 (p = 0.007), major rhinectomy HR: 2.47 (p = 0.005); Worst overall survival: Tx compared to NonTx (p = 0.069); Worst survival with recurrence: Tx compared to NonTx (p = 0.005). Conclusions: The LACSCC and transplanted (immunosuppressed) group present low survival, worse prognosis; The formulation of specific guidelines to standardize treatment and predict outcomes on this population are strictly necessary.