Presented by Dr. Antoine LeBlanc
Houlton, Maine
The patient is a 94 year old woman in good health. She has no significant underlying health conditions. For the past couple of years she has had a painless, slowly enlarging erosive squamous cell carcinoma of the scalp. It is 2.2 cm in diameter. The calvarium is exposed. Histopath shows focal perineural invasion.
What is the Goldilocks approach here?
Although her general health is good, she does not drive and trips to hospital are difficult to arrange. She is reluctant to pursue interventions, but the morbidity of her tumor is worrisome.
Dr. Patrick Kenny, Victoria, B.C.
ReplyDeleteWhat a challenge high risk tumour for recurrrence . Conventional wisdom suggests re excision and post op radiation therapy and MRI to delineate extent of tumour extension done first . Is she likely to accept this approach which she might consider excessively aggrsssive ? Is it possible for her to get a virtual consultation with Head and neck surgery so she knows her options as well,as with medical oncology .
Pembrolizumab , Cemiplimab or cosibelimab have been used to treat advanced SCC that cannot be cured with surgery or radiation . What might the funding for this like in Maine .
Megan Moore,M.D.
ReplyDeleteThese are so awful and scary (esp with her age, exposed bone, perineural invasion). Has she been scanned? Nodal involvement would change the approach from the start. Regardless looking at a major surgery, radiation. Maybe onc for chemo/immunotherapy? I do intralesional mtx or 5FU for palliative tx of large SCCs sometimes but I am very wary with the exposed bone and PNI.
Has she been getting routine care from her PCP, so we are sure of her comorbidities?
If she truly does not want treatment this could go quickly, and painfully. . . .
Riley McLean, Mohs surgeon, UMass, Worcester, MA
ReplyDeletethat's a really, really tough case. I would suspect that the bone is involved- hard to tell how healthy it l ooks from the photo. She's probably best off with immunotherapy if she wanted to do some treatment, but like we've talked about before, that's an expensive treatment for who knows how much gain. I think she's probably out of the scope of surgery- she's at least a T3 by BWH I believe (greater than 2 cm, PNI, and likely extension beyond the fat). I'm happy to run her by our tumor board if you think that would be helpful?
Warren Heymann, M.D. Head of Dermatology Cooper Medical School
ReplyDeleteTough case. I am usually in favor of active surveillance, but in an otherwise healthy 94 year old with a genuinely high risk leison, I would try to encourage her to get over her fear and have Mohs surgery. At least try to convince her to get XRT and maybe cemiplimab.
She needs to know that she can really have a miserable existence if this is untreated.
Douglas Johnson, M.D., Honolulu, Hawaii
ReplyDeleteI would try C&D with intralesional 5FU
Or just 5FU 50mg/ml .05cc every square cm total 0.5-1cc after lidocaine ring block.
Repeat every 1-2 weeks
I don’t think the Mohs, MRI etc are practical for this woman.