Saturday, May 31, 2008

Know When to Cut, Know when to Punt

The patient is an 87 yo man with a mild dementia. He lives in an assisted care facility. Has an attentive and caring daughter. In October of 2007 he had a wide-local excision of s large SCC on the left forehead by a general surgeon. Path report showed "clear margins." When seen on May 30, 2008 a 4 x 3 cm recurrence was noted. The picture of the right TMJ area shows a scar from micrographic surgery from a similar lesion the patient had ~ 10 years ago. His daughter said it took 6 months to heal.

1. What contributes to the aggressive behavior of this small subset of SCCs?
2. Would you refer to Mohs, XRT, or just watch?
3. Are you comfortable playing God with patients like these?

Comment: There is a subset of SCCs that metastasize and kill patients. MA Weinstock and his collaborators have written on this subject.

Weinstock MA, et. al.
Nonmelanoma skin cancer mortality. A population-based study.
Arch Dermatol. 1991 Aug;127(8):1194-7.

Department of Medicine, Veterans Affairs Medical Center
Providence, RI 02908.

To estimate the magnitude of nonmelanoma skin cancer mortality
and describe itsparameters, we reviewed the medical records of
all deaths certified as due to this cause among Rhode Island
residents from 1979 through 1987. After excluding acquired
immunodeficiency syndrome-associated Kaposi's sarcoma, we
confirmed that nonmelanoma skin cancer was the cause of death
for 51 individuals, a quarter of the number of melanoma deaths
reported. The age-adjusted nonmelanoma skin cancer mortality rate
was 0.44/10(5) per year. Fifty-nine percent were due to squamous
cell carcinoma, and 20% were due to basal cell carcinoma. Most
appeared actinically induced. Among deaths from SCCs, the mean age
was 73 years. At least 80% of the squamous cell carcinomas metas-
tasized, and 47% arose on the ear. None appeared due to refusal of
treatment. Among deaths frombasal cell carcinoma, the mean age was
85 years, and refusal of surgical intervention was documented in
40%. Study of nonmelanoma skin cancer mortality provides for estimation
of the magnitude of this problem, complements otherstudies of
prognosis, and helps guide prevention, early detection, and treatment.


  1. Is the recurrence biopsy-confirmed? If not, have you considered erosive pustular dermatosis of the scalp?

  2. I would recommend radiotherapy in this situation. It is virtually always effective at least in the short term and if a suitable facility is nearby it should not be too inconvenient for the patient or too stressful.

  3. Wade GebaraJune 02, 2008

    This is a large lesion and even with a complete response will likely take several months to heal. Generally we see a flattening of the lesion during treatment followed by a slow shrinkage of diameter and the scab falls off very slowly over time. I would expect a complete response rate of about 80% with 20 fractions of treatment. If there is bone erosion ( we can do a CT as part of treatment planning) then the control rate would be closer to 70%. Would be happy to talk with him about this treatment option. W. Gebara, Radiotherapist

  4. This is a difficult case for several reasons. First, it has been my impression that these types of patients have some type of immunosuppression although not enough of them have been studied in this regard to pinpoint the exact nature of the immunosuppression. However, it is not uncommon to see lesions as this in organ transplant patients where immunosuppression clearly plays a role. The right cheek area actually looks like a large split-thickness skin graft rather than a scar. The daughter said that this site took 6 months to heal after Mohs surgery and presumably reconstructive surgery done 10 years ago. This again points to an underlying issue of immunosuppression. In fact, there may be a new carcinoma superior to the graft (the small crusted lesion).

    The forehead lesion depicted in the photographs appears much larger than dimensions given. I have concerns that the previous surgical excision truly had negative microscopic margins. Without knowing precisely how the surgical specimen was analyzed, I cannot give further commentary.

    The patient's daughter will need to have a comprehensive consultation with any specialist or group of specialists who will provide treatment for her father.

    In terms of treatment, we need to take into context the patient's medical and mental status. One would have to assume that the patient was relatively medically and mentally stable to undergo a wide excision in October of 2007. But, we don't know the size of the original lesion at that time and whether the surgery was done with general or local anesthesia. The details of his medical status are important in this regard. If he has hypertension or other cardiovascular issues, then local anesthesia with epinephrine might be contraindicated for Mohs micrographic surgery (MMS) as he would need a considerable amount of local anesthetic to treat the present lesion. I have done very large cases of MMS, but logistically this would be a difficult case for many reasons including the fact that the patient would have to be hospitalized, he would have to go through several staged procedures and it would take multiple hours to microscopically process all of the tissue involved. It could take 2 to 3 consecutive days to do these procedures and because the patient has dementia, it would be difficult for him to undergo several rigorous procedures. Subsequently, most likely under general anesthesia, a plastic or head and neck surgeon would have to do a very large split thickness graft to repair the surgical wound assuming the periosteum was free of disease. There is more discussion on this matter in the next paragraph.

    My recommendation would be to obtain a preoperative CT scan to determine if there is obvious bony involvement. If there were no findings of bony invasion, I would have a dermatologist or Mohs surgeon do multiple punch biopsies at least 1.5 cm beyond the obvious clinical lesion or areas of induration beyond the gross lesion. This would give some indication as to how far the lesion subliminally invaded or extended. Deep incisional biopsies are more preferable because I have seen cases of neoplasm tracking along the galea aponeurotica with no skin or subcutaneous disease seen in the same microscopic sections of tissue that included skin contiguous to periosteum of bone. If initial biopsies were positive, then additional biopsies could be taken further peripherally until negative margins were found. Obviously, this is a poor substitute for Mohs micrographic surgery, but it is one way to get some relative evaluation of the extent of deep and peripheral disease. Once that information was acquired, I would suggest that a very skilled head and neck surgeon excise the entire lesion based upon the perimeter biopsies. The depth of the lesion should be to periosteum unless the lesion is already fixed to underlying bone. If the periosteum was free of disease, a split graft could be applied to the wound. The pathologist would have a major task to properly step section a large surgical specimen but that is what would be required to carefully assess the neoplasm for differentiation, level of invasion, presence of neurotropism and margin analysis. If the neoplasm invaded bone, then removal of the outer table of bone should be done. The preop CT would generally give the surgeon the answer about bony invasion and he or she would be prepared this step in treatment. Generally, if the patient is medically well, irrespective of his age, I treat him with a team of specialists with the goal to cure him. Further adjunctive treatment as radiation therapy would be considered based upon the level of differentiation of the squamous cell CA and the potential findings of neurotropic disease.

    If surgery is beyond the scope of his care, then I would consider having an appropriate specialist do multiple peripheral skin biopsies to help determine margins for the radiation oncologist. Clearly, the peripheral margin will be the most difficult to determine. I have done this process with some of my patients who refused surgery or for other reasons could not have surgery. Also, it is crucial that this treatment be overseen by a specialist who has a significant experience in managing complex skin malignancies. Radiation therapy may not necessarily be curative and often only palliates for a time. These concepts have to be reviewed with the patient’s daughter.

    The above discussion is meant for patients who are medically and mentally well enough to undergo them. This particular case is vexing because there are other extenuating circumstances that will affect a plan of management. Is he living in an assisted care facility because his daughter can't take care of him at home? Is he debilitated in ways that have not been mentioned in the brief information that was provided? How does his “mild” dementia affect his daily living? Whatever method of treatment is chosen, wound care would be a challenge because this patient is living in an assisted living facility. These facilities range from quite good to terrible in terms of the quality of care provided for post-surgical or post-radiation patients. If his daughter could afford it, private duty surgical care nurses might have to be hired temporarily. However, historically, 10 years ago, it took 6 months for the Mohs site to heal on the right cheek. This could result in a significant expense in the event that medical insurance wouldn’t cover these costs.

    The second question posed was with regard to treatment or "just watch" this patient. I’ve discussed considerations for treatment. By “just watching”, this patient will die of his cutaneous neoplasm and it can be a horrific problem to manage in advanced stages especially with a patient who is already suffering some form of dementia. The first statement in this report was: “Know when to cut, know when to punt.” I understand the philosophic concept, but who is going to make the decision to punt and on what basis? I have seen these types of patients die from their advanced skin disease and it was always a horrendous dilemma including constant bleeding from the neoplasm, infections, pain, and consequences of metastasis.

    The issue of “mild” dementia in this case cannot be overlooked or necessarily minimized. His ability to remember information, recognize family and caretakers, and function in some type of productive way will impact upon how he not only recovers physically from treatment but also how he continues to manage his daily life including mental functioning. Will he be able to comprehend what he will endure with treatment or with out treatment? This issue transitions into the third question posed. “Are you comfortable playing God with patients like this?” A physician’s analysis of this case will be influenced by many factors including professional education, level of professional experience, religious and cultural beliefs, life experiences, his or her own emotional and physical level of wellness, and much more. Considering the magnitude of these factors and how they interplay with one another, I wonder if any meaningful consensus could be had regarding this question.

    The management of this gentleman will be very difficult. I don’t have any answers that are wiser than the next physician. However, based upon several decades of experience with these kinds of cases, treatment offers hope. No guarantees, but at the very least, hope.

    Please give us a follow-up.

    Sincerely yours,

    Michael J. Albom, M.D.
    Mohs Micrographic Surgeon
    New York, New York


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