Clinical Case 2 Scenario

Drs In and Emerick analyze the data from our second clinical case scenario and tell us what they would do if it were their patient.

Glenn J. Hanna, MD: Let’s discuss the first- or second-case scenario, because it will illustrate some of the points around multidisciplinary management quite well. The question that comes up is when should multidisciplinary management or a team be involved in decision-making for these patients? I would argue that [it should] in most cases. There are many subtleties regarding skin cancers, and nonmelanoma skin cancers in particular: location of the disease, how infiltrative and deep it is, and the pathologic risk factors, but also the patients themselves are often quite delicate. They’re often a much older population with many more comorbidities.

Immunosuppression is almost the standard, whether it’s for a CLL [chronic lymphocytic leukemia] background or for people who have an autoimmune condition. There’s a fair amount of complexity to the comorbidities that the team often faces when making decisions. As we’ve had the evolution of newer systemic therapies, like checkpoint blockade, it becomes a matter of how to sequence things and what the right combination of approaches is or modalities are to treat these patients and individualize therapy.

With that, we have a 68-year-old woman who’s had prior sun exposure. She presents with a progressive lesion on the side of her face. We’ll keep it somewhat vague. Perhaps it’s over the zygomatic region and in the cheek area—preauricular if you will, or in front of the ear. It has poorly defined borders. She has a history of psoriasis and is on some topical immunomodulators but has not required any biologics for disease-modifying agents orally. She has high cholesterol and hypertension, has not smoked, and has a biopsy confirming that this lesion is a poorly differentiated cutaneous squamous cell carcinoma.

Dr In, when you see this description, what kinds of things are you thinking about in terms of risk stratification? Whom are you involving in the team in this scenario, and how do you approach the therapy?

Gino K. In, MD, MPH: At her age with a localized tumor, I’d review her case at our multidisciplinary tumor board and pose the question to our team but also to our head-and-neck surgeons: is this lesion resectable? I’d defer them regarding the surgical complexity, whether there’s facial nerve compromise, etc. If resection is an option, then perhaps that’s the way to go, at least initially. On the other hand, if the patient is unresectable, that’s where this discussion becomes a lot more interesting. If they’re also not eligible for radiation, could we consider something like systemic therapy? Perhaps PD-1. That therapy is well tolerated and efficacious, but I don’t know if I would necessarily go to that first. As you mentioned, Dr Hanna, these cases are almost always complex. It’s certainly worth reviewing as a team first.

Glenn J. Hanna, MD: Maybe with that, we’ll make the multidisciplinary discussion come to life. Dr Emerick, knowing what you’ve read about this patient—it’s somewhat unfair that you don’t get any imaging or a clinical photo—what would you be thinking about for a large squamous cell in this patient on the side of the face?

Kevin Emerick, MD: I’d like some imaging. In all seriousness, though, it’s part of our multicenter discussion. Imaging is important. Oftentimes you discover that there’s more extensive, deep involvement. It helps you prepare that person for surgery, for what to expect. It helps you as a surgeon realize you shouldn’t be operating on this person. Imaging is really important. Your clinical exam is important. You want to feel it. You want to move it. You want to get a sense if this is deeply stuck down. You want to do a good cranial nerve exam. Is there facial nerve involvement? Is there trigeminal nerve involvement? That’s going to dramatically change your management for this person.

My sense from that description is they probably have enough risk factors that they’re at risk for regional metastasis. If I’m thinking about doing a surgical resection for this patient and we decided that surgery is the right approach, I’d likely recommend excising this person with CCPDMA [complete circumferential peripheral and deep margin assessment] in a staged fashion and doing a sentinel node biopsy at the same time. This would follow surgically if we decided this was surgically resectable.

Glenn J. Hanna, MD: What kinds of reconstructive thoughts do you have on this? There are options like tissue transfer and skin graph coverage. What would you be thinking about in this scenario surgically?

Kevin Emerick, MD: I think about the entire spectrum of reconstruction. It depends on who this person is. [We can go] from a full-thickness skin graft to a local flap, a surgical facial advancement flap. When needed, there are large pedicle flaps or a free tissue transfer. If there’s nerve grafting involved, some of those are the things we think about from a reconstruction standpoint.

I also think about it in the context of whether you’re going to need postoperative radiation therapy, because you’re going to be much happier to see a well-healed local flap, a surgical facial advancement flap, or a slow-healing skin graft. We want to think about some of those things, which speaks to the importance of having a multidisciplinary approach and thoughtfulness to it.

This transcript has been edited for clarity.

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