Primary tumour treatment

In the largest series of nasal vestibule SCCs published to this date, the 5-year DSS and OS was only 74% and 50%, reaffirming the need for an aggressive treatment strategy even for early-stage tumours (2). The authors of this series reported significantly higher 5-year locoregional control for Wang T1 tumours in case of surgery alone (94%) or surgery with adjuvant radiotherapy (87%) compared to radiotherapy alone (61%) (2). Indeed, many authors recommend upfront surgery regardless of the stage of the tumour (2,7–9), albeit the level of evidence remains limited.
Interstitial brachytherapy or even radiotherapy seem to be acceptable non-surgical alternatives for early-stage SCCs. In a systematic review by Tagliaferri et al. , the 5-year local control rate following brachytherapy ranged from 69 to 97%, with 79% of patients having good cosmetic outcomes despite the risk of soft tissue necrosis (10). The two largest series were published by the same team and concerned only Wang T1 and T2 tumours (22,23). Tumour size <1.5cm resulted in a significantly better local and regional control, whilst tumour volume ≥2.3cm3 was associated to a worse regional control (22,23). Radiotherapy alone or with a boost of brachytherapy seems to provide poorer local control rates, which remain acceptable for early-stage SCCs (2,11,24).
There is a clearer consensus regarding the management of locally-advanced nasal vestibule SCCs in the form of surgery alongside adjuvant radiotherapy (2,12,13). Several authors reported worse outcomes when treating Wang T2 and T3 tumours using radiotherapy alone compared to surgery with or without adjuvant radiotherapy (2,12).
Bouaoud et al. observed a significantly better DFS and OS in patients treated by adjuvant radiotherapy after TR for locally-advanced SCCs. They also proposed neo-adjuvant chemotherapy for fast-growing lesions, although there is no statistical evidence to support this claim (13).
Zaoui et al. recommended adjuvant radiotherapy only for advanced staged tumours. In their series of 26 vestibule SCCs treated by primary surgery, which included only 50% of patients having TR, only two patients received postoperative radiotherapy. Despite low rates of adjuvant radiotherapy the 5-year DFS was 86.7% (8). In a similar series of 30 vestibule SCCs, also including 50% of patients having TR, Koopmanet al. achieved a 5-year DFS of 91.7%. Only seven patients in this series received adjuvant radiotherapy in instances of cartilage invasion, invasion of the upper lip or resection margins of 1mm or less from the tumour. They observed that poor tumour differentiation was significantly associated with poorer OS, but had no significant impact on DFS (9).