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First page of Margin Control of Perineural Spread of Cutaneous Squamous Cell Carcinoma via Frontal Neurectomy: An Initial Report

Introduction: Complete surgical excision with clear margins is the standard treatment for cutaneous squamous cell carcinoma. Historically, orbital invasion required high dose radiation with or without chemotherapy or exenteration. However, if the orbital portion is confined to perineural spread within a nerve, and distal to the skull base foramen, a neurectomy offers a globe-sparing option that may more definitively prevent intracranial spread. This study is the first to report outcomes of globe-sparing neurectomy for isolated frontal nerve perineural spread in cutaneous squamous cell carcinoma. Case Presentations: Five consecutive patients underwent frontal nerve resection via an anterior orbitotomy. Treatment data were obtained from medical records, radiographic nerve involvement from MRI imaging, and pathology reports confirmed surgical margins and excised nerve lengths. Four patients with negative proximal margins received subsequent radiation and/or chemotherapy/immunotherapy and remained alive and disease-free intracranially at post-operative months18-54. One patient, despite an extended resection surpassing the radiographically measured nerve involvement, had a positive margin and subsequently underwent exenteration. Up to 80% of the frontal nerve length (maximum 44 mm) could be safely resected without vision, globe, or orbital injury. Conclusion: Frontal nerve excision via orbitotomy, in combination with radiation and/or chemotherapy/immunotherapy, prevented intracranial tumor extension in all cases with negative proximal margins and avoided orbital exenteration in 80% of patients. Given the risk of microscopic spread beyond visible radiographic margins, maximal excision should be considered. Globe-sparing neurectomy provides a viable, low-morbidity surgical option that can be integrated into multidisciplinary management strategies for appropriate patients to achieve local disease control.

S. Karger AG, Basel
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2025
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