Surgical De-escalation After Neoadjuvant Immunotherapy for Cutaneous Squamous Cell Carcinoma: Oncological Safety and Reconstructive Consequences

Neoadjuvant programmed cell death protein 1 (PD-1) blockade can produce substantial regression of resectable cutaneous squamous cell carcinoma (cSCC), creating opportunities to preserve threatened structures and reduce reconstructive morbidity.Whether these responses justify smaller operations or omission of local treatment remains a separate clinical question.This narrative review examines prospective trials and retrospective cohorts reporting pathological response, planned versus performed surgery, reconstruction, treatment omission, and oncological outcomes, with a targeted literature update to October 2026.Prospective and retrospective reports document selected reductions in resection and reconstructive requirements.DISCERN directly compared pretreatment operative intent with performed surgery, whereas De-Squamate evaluated protocol-defined omission of surgery and radiotherapy with continuing pembrolizumab.These findings support feasibility, but small cohorts, response-based selection, heterogeneous postoperative treatment, and limited follow-up restrict conclusions about comparative safety.Anatomical imaging can underestimate pathological regression, while negative biopsies cannot establish clearance throughout an unsampled tumour bed.Adjuvant C-POST results inform postoperative systemic treatment and should not be extrapolated to reduced surgical margins.NRG-HN014/C-PRE evaluates an integrated perioperative strategy rather than the isolated effect of reducing surgery.A practical approach should record pretreatment disease and operative intent, reassess each involved anatomical compartment, specify the proposed operative change, and document margins, subsequent treatment, surveillance, and salvage options.Future studies must measure durable cancer control alongside function, reconstructive morbidity, patient-reported outcomes, and total treatment burden.