This 93 yo woman has a biopsy proven SCC of her scalp. She has congestive heart failure, anemia and has recently been hospitalized for pneumonia. She lives alone and mentally is sharp. She has had a number of other SCCs and BCCs in the past.
O/E: 4 x 3 cm erosive lesion on scalp. First picture is before debridement and second after.
Question: What is the best approach to maximize her quality of life?
Reference:
1. Oto Open. 2022 Feb 8;6(1):2473974X211073306.
O’Neill L. Malignant Fungating Wounds of the Head and Neck: Management and Antibiotic Stewardship. Full Free Text
Malignant fungating wounds (MFWs) are unfortunate and underreported manifestations of some advanced head and neck cancers. The management of MFWs is complex and challenging. MFWs are often mistaken for infectious processes/abscesses and treated indiscriminately with oral or intravenous antibiotics. Our aim is to promote awareness of MFWs and provide education on their management.
Fran Storrs: "Radiation"
ReplyDeleteDoug Johnson: "I would shave remove with a gillette blade. C&D then inject 1/2cc of flourouricil 50mg/cc into 5-6 sites at the base.
ReplyDeleteIf recurs then more 5fu or refer for excision."
Marius Rademaker: It depends a bit on the patient. Is she/he otherwise well, phycially and mentally? If so they may have 7+ years of life expectancy, so treatment would be appropriate.
ReplyDeleteAre they fed up of surgery or any medical procedure (in my experience patients can reach a threshold after which hey don’t want anything done to them.
This looks like an SCC, but it could be a merkels, BCC or even a melanotic melanoma. Mohs surgery would be the best surgical option, but they may not want this. Depending on histology, brachytherapy (if you have that available) might worth considering. We have a great radiotherapy team, so they are constantly coming up with alternatives to conventional radiotherapy. However, palliative external beam radiotherapy is possibly the most often used treatment in older patients who are fed up of treatment.
Good radiology to determine extent of bone involvement would be appropriate if more aggressive treatment is being considered.
I not sure about medical therapy with monoclonals such as the anti-PD1 or cetuximab in this age group.
Cryotherapy using a guard and thermal probes under sedation is a cheaper option, but always a risk of bone necrosis.