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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Skin Cancer Observation from Baghdad

Case presentation by:
Professor Khalifa Sharquie,
Baghdad, Iraq

I have had the opportunity to see many cases of skin grafting on the face after excision of multiple skin solar keratosis and skin malignancy. Some of these have been in patients with xeroderma pigmentosa (XP). The grafts remained free of actinic disease and have stayed clear for many years, in some cases for more than 20 years. I have never observed them to develop solar damage, solar keratosis or malignancy.

Today, I am presenting one of these cases. A 65 yo man with history of marked sun damage since early life. During the course of his illness, he has developed frequent and multiple solar keratosis and squamous cell carcinoma. Positive family history was seen in his son. Excisions and graftings have been carried out for big cancers since 1982 but he has never developed any solar damage or skin malignancy in the grafts.





Questions:
1. Is it justifiable to excise the skin of such patients with multiple keratosis and malignancies, especially in patients with XP early in life as a part of preventive measures against skin malignancy especially malignant melanoma.
2. What is the mechanism behind this odd observation. Could fibroblasts of the graft share in prevention?
3. Is there any role in the use of imiquimod in these patients? (last question from DJ Elpern)