Expert Consensus Establishes Imaging Recommendations for High-Risk Cutaneous Squamous Cell Carcinoma

Clinical Summary: 

• Design/Population: A multidisciplinary expert panel conducted a 3-round Delphi consensus to develop recommendations for staging and surveillance imaging in localized cutaneous squamous cell carcinoma. Of 54 invited experts, 45 completed all 3 rounds, representing dermatology, medical oncology, radiation oncology, radiology, surgery, and otolaryngology.
• Key Outcomes: The panel recommended staging and surveillance imaging for tumors with at least a 15% risk of metastasis and reached consensus or near consensus on several high-risk tumor features warranting imaging. CT was preferred for nodal staging and surveillance, with consensus supporting imaging for at least 2 years and nodal consensus supporting at least 3 years. 
• Clinical Relevance: These multidisciplinary recommendations provide a framework for identifying patients with localized cutaneous squamous cell carcinoma who warrant imaging and for standardizing modality selection and surveillance duration, potentially reducing variability in an area without established consensus. 

A multidisciplinary Delphi consensus established recommendations for staging and surveillance imaging in localized cutaneous squamous cell carcinoma (cSCC), supporting imaging for tumors associated with at least a 15% risk of metastasis and defining clinical features that may identify patients who warrant closer radiographic assessment. 

“There is no consensus on staging and surveillance imaging for cSCC,” stated Bina Kassamali, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and coauthors. “Although imaging has been shown to affect management, broad recommendations from the National Comprehensive Cancer Network have led to variability in clinical practice.” 

The consensus process included 3 iterative survey rounds conducted between January and June 2025, with data analyzed from February 2025 through January 2026. Experts were eligible based on recent cSCC publications, participation in relevant clinical trials, treatment volume, and/or at least 5 years of clinical practice.

Of 54 experts invited to participate, 45 (83%) completed all 3 survey rounds and were included in the final analysis. The panel included 15 dermatologists, 7 medical oncologists, 9 radiation oncologists, 9 radiologists, 3 surgeons, and 2 otolaryngology specialists. 

Structured surveys evaluated clinical scenarios, imaging modalities, and surveillance strategies. Consensus was defined as at least 80% agreement, while agreement between 70% and 79% was considered near consensus. 

The panel recommended staging and surveillance imaging for cSCC associated with at least a 15% risk of metastasis. Consensus or near consensus supported imaging for tumors with concern for metastasis, bone invasion, invasion beyond subcutaneous fat, large-caliber nerve invasion, or diameter of at least 4 cm.

Imaging was also supported for poorly differentiated tumors measuring at least 2 cm, as well as poorly differentiated tumors with lymphovascular invasion combined with either subcutaneous fat invasion or small caliber perineural invasion.

Computed tomography (CT) emerged as the preferred modality for both nodal staging and surveillance. For nodal staging, 84% of panelists preferred CT, meeting the threshold for consensus. CT was also preferred for surveillance by 78% participants, reaching near consensus. 

The panel also addressed the duration of imaging surveillance. Consensus was reached in favor of surveillance imaging for at least 2 years, while near consensus supported continuing imaging for at least 3 years.

The recommendations provide a risk-based approach to imaging localized cSCC, focusing surveillance resources on tumors with clinical and pathologic features associated with greater metastatic potential.

Source: 

Kassamali B, Schoenfeld JD, Sethi R, et al. Consensus guidelines for staging and surveillance imaging in cutaneous squamous cell carcinoma. JAMA Dermatol. Published online: July 8, 2026. doi: 10.1001/jamadermatol.2026.2163