Introduction: Malignant skin cancers of the scalp can present with calvarial invasion, dural extension, and rarely intraparenchymal involvement. Typically such lesions involve a multi-disciplinary approach involving head and neck surgery, neurosurgery and plastic surgery for optimal resection and reconstruction. We present a prospective analysis of patients with scalp malignancies who underwent resection and reconstruction.
Methods: Patients presenting with scalp malignancies (1993-2010, n=60) who required neurosurgical assistance for tumor resection were identified prospectively. We classified the extent of neurosurgical resection into four levels of involvement: scalp (level I), calvarial (level II), dural (level III), or intraparenchymal (level IV). Complications and evidence of local, locoregional, or regional recurrence were documented.
Results: Patients underwent resection to level I (n=60), level II (n=50), level III (n=9, all with duraplasty), and level IV (n=2). At a mean follow-up of 28 months, patients had local recurrence (29%), locoregional recurrence (12%), regional metastases (29%), and 58% required no further interventions. Scalp-based reconstruction involving plastic surgery was performed in 38 patients. All cases underwent craniectomy and 26% demonstrated dural invasion. The most commonly used free flap was latissimus dorsi. Complications occurred in 18% of all patients; the most common was wound dehiscence (n=5). Our analysis demonstrates that more aggressive resection (level III or IV) was associated with decreased incidence of local and regional recurrence (p <0.05) when compared to level I and II resections. Importantly, more extensive levels of resection were not associated with an increased incidence of complications.
Conclusions: Our study is the first attempt to classify the extent of neurosurgical resection for malignant scalp tumors and the largest series describing treatment of scalp malignancies with intracranial extension. Despite aggressive resection, the incidence of complications is low. This study demonstrates the efficacy of neurosurgical intervention, which should include the entire area of calvarial/dural involvement to prevent recurrence of these tumors.
Patient Care: This research analysis is, to our knowledge, the largest collection of patients presenting with scalp malignancies that require neurosurgical assistance. We have developed a neurosurgical grading system for extent of tumor invasion as well as neurosurgical resection. Our analysis supports an aggressive approach to prevent the recurrence of these invasive tumors. This understanding, validated by our classification of the extent of neurosurgical resection, will guide therapy for patients and will ultimately decrease the incidence of disease recurrence. Finally, this study supports an aggressive surgical resection that appears to be efficacious and without a significant increase in complications.
Learning Objectives: At the conclusion of this session, participants should be able to: 1) Describe the natural history of scalp malignancies, 2) Discuss the role of a neurosurgical grading system for level of tumor involvement and level of resection in management of scalp tumors, 3) Identify the role of aggressive resection to prevent local, locoregional, and regional recurrence of scalp tumors, 4) Appreciate the low risk of complications associated with extensive scalp tumor neurosurgical resections relative to less aggressive approaches.