Keratinocyte cancer can usually be diagnosed with a biopsy and most will not require further investigations. All patients should be clinically staged.

Staging should be clearly documented in the patient’s medical record.

In cases of SCC, the lymph nodes should be examined to see if the cancer has spread. Clinically suspected lymph node metastases should be confirmed by fine needle aspiration cytology if possible (under radiological or ultrasound guidance if required). Open surgical biopsy should be avoided (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).

Although cutaneous SCC is the usually suspected primary cancer for regional lymph node metastases, this is not always the case, especially for lymph nodes in the head and neck region, which is the most common site of regional metastases. Patients may have had several SCCs of the head and neck but may also be at increased risk for upper aerodigestive tract mucosal primary SCCs as the source of the SCC nodal metastasis. A thorough examination of the upper aerodigestive tract by an experienced clinician is necessary if there is any doubt as to the site of the primary tumour.

Sentinel lymph node biopsy (SLNB) may be offered to selected high-risk patients as prognostic information and to assess the presence of lymph node metastasis (Fahradyan et al. 2017; Matthey-Giè et al. 2013). If metastatic SCC is detected, a complete regional lymphadenectomy may be performed in a second procedure after SLNB.

All staging should be undertaken using the American Joint Committee on Cancer TNM guidelines.

Visit the Cancer Institute New South Wales website for information about understanding the stages of cancer.