Squamous Cell Carcinoma of Scalp

The patient is a 96 yo man with a 6 month history of a tumor on the vertex of the scalp.  He has advanced dementia and is taken care of by his 93 yo wife with the help of his three children and some grandchildren.  He has insulin dependent diabetes and is on Coumadin and insulin.  His diabetes is under good control.  The scalp tumor bled a few days ago and his wife took him to the ER where a biopsy was done.

Exam: There is a 4.5 cm tumor on the vertex of the scalp.  Small areas of erosion, He has a 9 mm tumor on the right ala nasi.  (By history, he picks on the nasal lesion)

Clinical Photos:

 

Pathology from scalp lesion pending.

Diagnosis: Probable squamous cell carcinoma of the scalp.  Nonmelanoma skin cancer nose.

Plan:  In this 96 year old man, a palliative approach seems to be indicated.  His case will be discussed with a Mohs surgeon and a dermatologist who has a special interest in palliative dermatology.

Reference:

1. De Felice D. Definitive weekly hypofractionated radiotherapy in cutaneous squamous cell carcinoma: response rates and outcomes in elderly patients unfit for surgery. Int J Dermatol. 2021 Nov 24;61(8):911–915.   Free Full Text

Our series shows that vulnerable elderly patients with cSCC achieve an optimal response rate (95.7%) with a low toxicity profile after 7‐8 weekly fractions of 8 Gy per fraction with megavoltage electrons. All patients who had developed pain or bleeding before treatment had achieved symptom relief. Only a minority of patients (11.1%) had died of the disease. The efficacy of the hypofractionation RT is therefore of the utmost importance for tumor control and patient quality of life. 

Keratinocyte Skin Cancer in a Centenarian

The patient is a 100 year-old widow who lives independently in an apartment complex.  She’s been on supplemental oxygen for almost 20 years.  She has friends who visit regularly, but no close relatives nearby.  She enjoys life and is a great sports fan.

 

She has a biopsy proven nodular basal cell on the left second toe and a biopsy proven superficial squamous cell carcinoma involving most of the dorsum of left middle finger.  The closest Mohs surgeon is an hour away.

 

Clinical Photos

Discussion: Optimal treatment of these lesions would be micrographic surgery, but this may be too aggressive for this relatively frail woman and wound care at home would be difficult. Individuals of this age may not live long enough to benefit from “gold standard” therapy, however, unchecked tumor progression can worsen their quality of life if treatment is withheld.  Radiotherapy would also be difficult as many trips for fractionated care would be taxing for her.

 

There are few therapeutic guidelines for patients like this.  We would appreciate your suggestions as we plan to address the patient and her tumors.

 

References:

1. A J G Leus, et. al. Treatment of keratinocyte carcinoma in elderly patients - a review of the current literature. J Eur Acad Dermatol Venereol. 2020 Sep;34(9):1932-1943.  Free PMC article

 

2. Christopher McLaughlin, Mark A Russell. Single-fraction high-dose palliative radiotherapy for facial cutaneous squamous cell carcinoma: a case report. Ann Palliat Med. 2022 Oct;11(10):3337-3340.