Skin Cancer - Episode 1

Case 1: 69-Year-Old Male With Locally Advanced cSCC

November 25, 2019

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ahmad Tarhini, MD, PhD:Thank you for joining us for thisTargeted Oncology™ Virtual Tumor Board®, which is focused on skin cancers. Today, my colleagues and I will review 4 clinical cases on both melanoma and nonmelanoma skin cancers. We will discuss an individualized approach to treatment for each patient, and we’ll review key trial data that impact our decisions.

I’m Dr Ahmad Tarhini, senior member and director of Cutaneous Clinical and Translational Research at Moffitt Comprehensive Cancer Center and Research Institute in Tampa, Florida.

Today I’m joined by Dr Meredith McKean, an investigator in the Melanoma and Skin Cancer Research Program of the Sarah Cannon Research Institute in Nashville, Tennessee; Dr Deborah Wong, assistant professor of medicine in the Division of Hematology/Oncology at UCLA Medical Center in Los Angeles, California; and Dr Kevin Emerick, co-director of the Multidisciplinary Cutaneous Oncology Center, assistant professor of otolaryngology, head and neck surgery, at Massachusetts Eye and Ear at Harvard Medical School in Boston, Massachusetts.

Kevin S. Emerick, MD:Our first case is an otherwise healthy 69-year-old male. He’s fair skinned and is a retired construction worker. He recently presented to his primary care physician with what he described as a wound behind his ear that wouldn’t heal. He’s noticed this for at least 4 months. He had also noticed some numbness in the area. He was referred to a dermatologist who specialized in skin cancers. He’s generally a healthy gentleman, with an ECOG [Eastern Cooperative Oncology Group] performance status of 1.

On exam, he has a 4.5-cm ulcerated lesion in the postauricular region that felt greater than 5 mm thick. He had no palpable lymphadenopathy. The dermatologist performed a biopsy that revealed poorly differentiated squamous cell carcinoma, 7 mm thick, and into the subcutaneous fat.

Ahmad Tarhini, MD, PhD:Thanks, Kevin. Interesting case. We’d like to start the discussion. What are some of the high-risk features of this patient’s cutaneous squamous cell carcinoma?

Kevin S. Emerick, MD:I think one of the obvious ones is this a large lesion. It’s 4.5 cm. We usually use 2 cm as an initial cutoff, and 4 cm as another cutoff. The thickness, I think, in this case is also important, and there are 2 features to thickness. One being greater than 6 mm. In this case, it’s at least 7 mm. And into the subcutaneous fat, I think, is an important depth feature as well.

Deborah J. Wong, MD, PhD:I think, also, the poorly differentiated nature, histologically, also probably contributes to him being higher risk.

Kevin S. Emerick, MD:We also don’t know, from this pathology report, whether there’s perineural spread, perineural invasion, lymphovascular invasion, which are additional high-risk features.

Ahmad Tarhini, MD, PhD:The NCCN [National Comprehensive Cancer Network] guidelines present a nice definition of high-risk and low-risk features, if you could discuss this, Kevin.

Kevin S. Emerick, MD:The NCCN guidelines break it down into 2 different categories. One being a little bit more clinical. So, size—greater than 2 cm. There is some nuance to that. Lesions in the M or H area distribution, if greater than a centimeter, are considered to be of high risk.

When you look at the lesion, if the borders are a bit irregular, it’s considered high risk. Tumors that come back, that are recurrent in nature are high risk. Our immunosuppressed population—that can be solid organ transplant, CLL [chronic lymphocytic leukemia] patients, patients who are on biologics for rheumatoid arthritis, for example, can contribute to immunosuppression.

One of these that occurs within a site of previous inflammation or radiation can elevate the risk in tumors that grow quickly, or have some neurological symptoms. These are also high-risk features.

The second part of the NCCN guidelines are the pathological features. This is a field that we’ve mentioned, poorly differentiated, greater than 6 mm or into the subcutaneous fat, as well as the perineural and lymphovascular involvement that we mentioned.

And the last one is some of the subtypes that we sometimes see in the pathology reports—with acantholytic, adenosquamous, different types of metaplastic subtypes that are sometimes described—that are also considered to be high risk.

Ahmad Tarhini, MD, PhD:Interesting. What additional testing would you order in the treatment planning of this patient?

Kevin S. Emerick, MD:For me, this is in a location, the exact depth of it; and is it invading into some of the nearby mastoid bone in the postauricular region? Is it sneaking down into the ear? These are really important things that would be hard to tell on examination. And so, I think a CT [computed tomography] scan with contrast of the head and neck region would be an important next piece of information in the work-up.

Transcript edited for clarity.