Imaging with ultrasonography or computed tomography may detect more nodal metastases compared with physical examination in patients with high-risk cutaneous squamous cell carcinoma, according to a prospective study.
In a multicenter, paired-diagnostic study across 13 tertiary dermato-oncology centers in Spain, researchers evaluated 155 patients with high-risk cutaneous squamous cell carcinoma between 2022 and 2025. All of the patients underwent complete physical examination, high-resolution ultrasonography, and contrast-enhanced computed tomography (CT) at baseline, with results compared against histopathologic confirmation or short-term clinical follow-up. The primary outcome was sensitivity in detecting nodal metastases, with secondary outcomes including specificity, positive predictive value, and negative predictive value, and area under the receiver operating characteristic curve.
Ultrasonography showed the highest sensitivity at nearly 64%, followed by CT at 55%, compared with just over 8% for physical examination. Both imaging modalities demonstrated similar overall diagnostic accuracy and near perfect agreement with each other, while concordance with physical examination was low. Specificity was 95% and over for ultrasonography and CT and 99% for physical examination.
Differences emerged by immune status. Among patients without immunosuppression, ultrasonography and CT detected 100% of nodal metastases. In contrast, sensitivity declined to 20% for ultrasonography and about 17% for CT in patients who were immunosuppressed, with most metastases becoming clinically apparent within 3 months following negative baseline imaging.
The researchers also noted false-positive findings with imaging, often related to benign conditions, contributing to modest positive predictive values.
In an accompanying editorial, Selin Tokez, MD, PhD, and Marlies Wakkee, MD, PhD, wrote that ultrasonography and CT “outperform clinical examination, i.e, palpation of the draining lymph nodes in the detection of nodal metastases at baseline,” but noted that the reduced sensitivity observed in immunosuppressed patients may reflect rapid disease progression from micrometastases to clinically apparent nodal disease rather than limitations of imaging alone.
The researchers identified several limitations, including a small number of metastatic events, variability in timing between diagnostic tests, and potential intercenter and interobserver differences. Short follow-up may also have affected the detection of metastases that emerged after baseline staging.
The findings supported the use of imaging in baseline nodal staging among patients with high-risk cutaneous squamous cell carcinoma, while indicating that performance may differ by immune status.
“[S]trategies effective in immunocompetent individuals may be less reliable in those with immunosuppression,” wrote lead study author Carla Ferrándiz-Pulido, MD, PhD, of the Hospital Universitari Vall d’Hebron, and colleagues.
Full disclosures of the study authors can be found in the study.
Source: JAMA Dermatology, Editorial
