A Case for Palliative Dermatology

The patient is an 87 yo woman who lives with her grandson in a small Kentucky hill town many miles from a medical center.  Two years ago, a squamous cell carcinoma was excised and grafted from her scalp.  It has recurred and is now a management problem.  The patient has a moderate dementia but is happy and comfortable at home with a large supportive family.  She has no life-threatening medical problems other than this lesion.

The tumor was debulked, cultured and a Xeroform dressing applied.  Her daughter-in-law was instructed how to change the dressings.

Post-op appearance:

Pathology showed a moderately differentiated squamous cell carcinoma extending to the base of the specimen.

Her family wants to do as little as possible with the goal of supporting her quality of life.

Palliative care in dermatology has only recently  been getting attention.  

Some options for this woman include
1. Intralesional 5 Fluorouracil or topical 5FU
2. Short Course Radiotherapy (1)
3. Palliative Mohs surgery (2)

Note: On 10.6.23 the patient had micrographic surgery.  This showed squamous cell carcinoma ectending to the calvarium and invading it.  In addition, there was infiltrating basal cell carcinoma at the periphery.  Chemotherapy with pembrolizumab may help some healthier patients, but is not practablew for this woman.  Palliative care is appropriate, but guidelines are limited.
Clinical photo 1 week afte4r Mohs micrographic surgery:

 Your thoughts will be helpful.

Post-Script:  The patient stayed home for two months after we saw her.  We arranged for a visiting nurse to come and do dressing changes.  She was comfortable and required no pain meds.  Then she had a seizure, was admitted to hospital and died two days later.  The tumor had eroded through her skull and she had a terminal event.  The palliative approach assured that she spent her last few months at home without being subjected to worthless and time-consuming procedures.

References:
1. Milena F et. al.  A Short course Accelerated RadiatiON therapy (SHARON) dose-escalation trial in older adults head and neck non-melanoma skin cancer. Br. J Radiol. 2022 Jun 1;95(1134):20211347.

2. Noriaki Nakai et al. Clinical usefulness of Mohs' chemosurgery for palliative purposes in patients with cutaneous squamous cell carcinoma with risk factors or without indication for surgery: three case report. J Dermatol. 2015 Apr;42(4):405-7.

3.  Leah L Thompson et. al. Palliative care in dermatology: A clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol. 2021 Sep;85(3):708-717. J Am Acad Dermatol. 2021 Sep;85(3):708-717.

4. Fidanzi C, Davini G, Dini V, et al. Palliative management of a recurrent destructive cutaneous squamous cell carcinoma of the scalp with brain exposure. Wounds. 2022;34(1):E7-E9. PMID 35119380
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