Some patients will have metastatic disease on initial presentation. Others may present with symptoms of recurrent disease after a previous cancer diagnosis. Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic disease.

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Symptoms can often present as:

• new or changing skin lesions
• lumps or masses
• new/persistent symptoms.

These symptoms should be a trigger for further medical assessment.

The incidence of lymph node metastases from cutaneous SCC is low but may be considerably higher in the following scenarios:

• SCC occurring at sites of mucosal–squamous cell junctions, including the lip, anus and vulva
• immunosuppressed patients
• SCC occurring at sites of previous radiotherapy
• SCC arising in chronically inflamed/ulcerated areas.

Among patients who develop regional recurrence, specific tumour factors related to developing regional recurrence include the following:

• tumour size – SCCs larger than 20 mm are twice as likely to develop regional recurrence
• tumour site – SCCs located on the ear and lip have a higher rate of recurrence than SCCs in other sites
• tumour grade – poorly differentiated SCCs have double the recurrence rate of well-differentiated lesions
• tumour thickness – SCCs thicker than 4 mm recur three times more commonly than thinner lesions
• perineural invasion is the most serious predictor of regional recurrence, with up to 50 per cent developing regional recurrence (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).