SM14: Cases of Aggressive Skin Carcinoma Raise Treatment, Management Questions for Otolaryngologists

One challenge in aggressive skin cancer cases is getting enough information on the pathology to determine the best course of treatment.

A healthy, 47-year-old woman from a rural, isolated area presents to your center with a nose lesion that a previous biopsy says is basal cell carcinoma. What is the best way to treat and manage this patient?

A panel here at the Triological Society Combined Sections Meeting reviewed the case in a session on aggressive skin carcinomas. The panelists generally agreed that they would have the pathology reviewed at their own center before proceeding to surgery.

The moderator, Dale Brown, MD, professor of otolaryngology-head and neck surgery at the University of Toronto, then unveiled the post-surgery photo. To get clear margins, much of the woman’s tissue was lost, perhaps more than anticipated.

Much of the discussion on the case centered on how much reconstruction to do on the patient and how quickly, given the chance of recurrence:

• Keyvan Nouri, MD, chief of dermatology services at the Sylvester Comprehensive Cancer Center in Miami, said he’d be inclined to wait several years. “There is a risk that it may come back, so I would try to do some sort of construction that’s not going to mask the tumor so it would be easy to actually watch this area for some time,” he said. “I would say for five years maybe.” He might do more minor work right away and would consider a prosthesis but would wait longer for a fuller, “more elegant” procedure. The risk in major reconstruction right away is that the tumor might grow back beneath scar tissue, going unseen until it’s too late, he added.
• Patrick Gullane, MD, chair of otolaryngology-head and neck surgery at the University of Toronto, said he might wait six months before reconstruction. “You can sit with the patient and discuss the options with her and try to paint a picture that a prosthesis long term may be better actually and may look better than some free tissue transfer,” he said.
• Carol Bradford, MD, chair of otolaryngology-head and neck surgery at the University of Michigan in Ann Arbor, said some patients might be more demanding of reconstruction than others. “If it was one of us, it’s going to be a huge impact on that individual’s quality of life, so I think it centers on the goals of care, the risks of recurrence versus the suboptimal, potentially, result of not doing early reconstruction,” she said.

Cancer on the Ear Raises Questions of Occult Metastases

Another case involved an elderly man with significant but fairly typical co-morbidities who was found to have squamous cell carcinoma in the conchal bowl, with cartilage involved.

• Sandro Stoeckli, MD, chair of otorhinolaryngology at the University of Zurich, said he would initially have an ultrasound done, without ruling out a CT or an MRI, or both.
• Dr. Bradford said she would go straight for a CT with contrast. “These patients have an unusually high risk of occult nodal metastases,” she said. “Even if there is no clear sign of regional adenopathy, the patient is still at risk.”
• Dr. Nouri, who specializes in Mohs surgery, said this might not be the best choice for that approach. “The tumor has to grow in a continuous fashion,” he said. “If it doesn’t grow in a continuous fashion or if you think there is a role for micrometastases, it may not work, because you’re not going to be able to histologically accurately assess the Mohs section.”

• Brian Moore, MD, of the Gayle and Tom Benson Cancer Center in New Orleans, said one of the challenges in these cases is getting enough information on the pathology to determine the best course. “With head and neck cutaneous squamous cell cancer, we’re a little bit limited by our pathologists and our dermatopathology reports for the biopsy,” he said. “[When] we get a melanoma patient, we get a lot of information. And so then (in contrast), we know immediately that this is a patient who needs a sentinel lymph node biopsy…. The question really is, at your institutions, are you able to get your dermatopathologists to provide you that additional information so that, up front, we may target these patients with appropriate therapy?”

Dr. Bradford agreed that can be an issue but added, “This is a bulky tumor of the ear. Regardless of what our dermatopathologists say, we know that’s a highly aggressive tumor.” She cautioned, though, that a sentinel lymph node biopsy might not be as reliable when there’s “a lot of deep invasion.”