Background:  Primary cutaneous squamous cell carcinoma of the face and scalp (cSCC) is an endemic and typically indolent disease of elderly fair skinned individuals with a lifetime of sun exposure.  As a first echelon of lymphatic spread, the development of parotid nodal metastases subsequent to primary tumor removal (or at the time of diagnosis) signifies aggressive disease that warrants a multidisciplinary treatment team approach.  Our objective was to evaluate the presenting characteristics, treatment, and outcomes of patients who presented to our tertiary center with cSCC metastatic to the parotid nodal basin.

Methods:  Between 2007 and 2015, patients presenting to our tertiary head and neck oncology treatment center with cSCC metastatic to the parotid region were evaluated retrospectively.  Patient characteristics, treatment modalities utilized, as well as outcomes with respect to disease control, survival, and treatment related morbidities were studied.

Results:  Eighteen patients, 14 male, with a mean age of 74.3 years presented with metastatic cSCC to the parotid region lymph nodes during the study period.  All patients had fair skin and significant sun exposure history.  Thirteen patients presented with palpable parotid nodal disease with or without involvement of other ipsilateral neck nodal levels at a mean of 12.1 months subsequent to treatment of an ipsilateral facial or anterior scalp cSCC.  The majority of patients (11) had disease confined to the parotid nodal basin both clinically and pathologically.  Two patients presented with concurrent cSCC and metastatic parotid disease and 2 patients presented with what was ultimately felt to be metastatic cSCC to the parotid nodal basin from an occult cutaneous primary site.  The majority of patients (11) had evidence of skin involvement in association with their parotid region disease at the time of presentation.  No patient had facial palsy pre-treatment.  Patients underwent variations (depending on extent of disease and extranodal neck structure involvement) of parotidectomy with neck dissection and external jugular dissection, along with excision of overlying parotid region skin when it was involved.  Five patients required facial nerve sacrifice due to gross involvement and most patients who had skin excision had advancement  flap repair (7 patients) versus pectoralis flap repair (3 patients).  Nine patients received adjuvant radiation and 2 received adjuvant chemoradiation.  Six of the 7 patients who have died of disease thus far in this cohort had overlying parotid skin involvement at the time of presentation.

Conclusions:  cSCC metastatic to the parotid region is associated with significant disease related morbidity and mortality.  A coordinated multidisciplinary surgical and nonsurgical approach is required to care for these patients.  Since the vast majority of patients present at some time subsequent to management of a primary cSCC (13/18 in our cohort), there is a suggestion that more attention to the draining lymphatics (imaging, sentinel node evaluation) at the time of primary cSCC management should be undertaken for certain high risk lesions (large, ulcerated, recurrent).