Scientific Papers

Spectrum of malignant scalp tumours and its impact on management—a tertiary care cancer centre experience | World Journal of Surgical Oncology


There were 66 patients with histologically diagnosed malignant scalp tumours during the 10-year study period. Among these patients, 32 were men, and 34 were women. The mean age was 56 years. A total of 75% of the patients had an ulcerated lesion on the scalp and 25% with nodular lesions. The majority of the scalp lesions were located on the parietal (45%) and occipital regions (23%).

Out of 66 patients, 35 presented post-unplanned excision with margin involvement. Five patients with negative margins following excision at another centre had recurrence within 12 months. Re-excision showed residual disease in 28 of 35 patients (80%) post-margin-positive unplanned excision.

Squamous cell carcinoma (SCC) was the most common histology noted in 33 patients (50%). Other histology observed included sarcoma (21%) (Fig. 1), appendageal carcinoma (17%), basal cell carcinoma (BCC) (11%), and neuroendocrine carcinoma (NEC) (1%). In four patients with SCC, the tumour was poorly differentiated. Among patients with SCC and sarcoma, 37% had pathological T1, 47% had T2, 11% had T3, and 5% had T4 disease. Pathological N1 disease was noted in 12% of the patients.

Fig. 1
figure 1

Histological spectrum of sarcoma in the study group. MPNST, malignant peripheral nerve sheath tumour; DFSP, dermatofibrosarcoma protuberans

CT imaging revealed bone invasion in six patients. Among the 6 patients with bone invasion, all had squamous cell carcinoma. Final histopathology revealed bone involvement in only 3 out of 6 patients. Three of the six patients with suspected bone invasion in the preoperative imaging underwent outer table resection, while the others underwent craniectomy.

Ten patients had nodal involvement preoperatively based on the clinical and radiological evaluation. Seven patients had posterolateral neck dissections, 2 had parotidectomy for an intraparotid node, and 1 had parotidectomy with posterolateral neck dissection. According to the final histopathology report, 8 out of 10 patients had nodal involvement. There were nodal involvements in the following histology: SCC (3), angiosarcoma (3), appendageal carcinoma (1), and neuroendocrine carcinoma (1).

The mean defect size was 67.4 cm2, and rotation flaps (Fig. 2) were used most commonly (50%). In three patients with craniectomy defects, reconstruction was done with rotation flap (Fig. 3), trapezius flap, and titanium mesh reconstruction combined with rotation flap (Fig. 4). A regional flap reconstruction was performed on six patients: three with a trapezius flap (Fig. 5) and three with a temporal artery flap. Latissimus dorsi free flap reconstruction was performed in one patient with a large defect (Fig. 6).

Fig. 2
figure 2

Tumour at vertex, post wide excision defect closed with rotation flap and SSG at donor site

Fig. 3
figure 3

Wide excision with craniectomy without bone reconstruction. The defect covered with a rotation flap and SSG at the donor site

Fig. 4
figure 4

Frontal craniectomy defect reconstructed with titanium mesh and rotation flap

Fig. 5
figure 5

Post excision occipital craniectomy defect reconstructed with trapezius flap and SSG

Fig. 6
figure 6

Mean defect size after excision for different reconstruction techniques

In 12 patients, adjuvant radiation was used. Clinical follow-up was done every 3 months for the first 2 years, then every 6 months for the next 3 years, followed by an annual check-up. There were seventeen recurrences: 10 local recurrences, 3 nodal recurrences, and 4 systemic recurrences. Local and nodal recurrence was common in SCC, and systemic recurrence was common in sarcoma (Table 1). Univariate analysis suggested that variables such as age, gender, tumour site, size, histology, bone involvement, nodal involvement, unplanned margin positive excision, and residual disease in re-excision were not significantly associated with recurrence. Tumour size more than 6 cm, tumour histology (SCC & sarcoma), unplanned margin-positive excision, and residual disease in re-excision had higher recurrence, even though the p-value was not significant (Table 2).

Table 1 Clinical and treatment profile of various histological subtypes
Table 2 Binary logistic regression-risk factors for recurrence



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