Deciding Between Surgery or Systemic Therapy

Gregory A. Daniels, MD:The question of when to refer to other providers is a difficult one. A dermatologist is usually presented with a lesion, and I think the thought process should be again along the lines of, is this a low-risk patient or a high-risk patient? For low risk, simple excision makes sense, and just confirming that one has negative borders, whether that’s with the Mohs technique, or some other margin assessment technique.

However, when you get to a lesion where it might need reconstruction and/or the chance that the recurrence is, as I mentioned earlier, more than 10%, that’s a time where referral should happen. That would be to ENT [ears, nose, and throat] surgery, for example, in the head and neck area. That’s what we commonly use, or plastic surgery. In those cases, once the referral is made, I think a team approach with a radiation therapist and even a medical oncologist comes in to play.

When there’s a question of resectability for a lesion, I think that’s a red flag for referral to consider all the alternatives. The options include resection. However, we need to balance the morbidities of that resection and patient preference, as well as what the patient can tolerate and what their goals are. One may also consider systemic therapies in the case of these questionably resectable lesions, or when they’re clearly not resectable. There are some newer agents that have activity in unresectable squamous cell cancer that means that we need to have this discussion anew.

Transcript edited for clarity.

Case: A 79-Year-Old Male With Metastatic CSCC

April 2016

• A 79-year-old male presented to dermatologist with a large ulcerative lesion on clavicle; he reported lesion first appeared 5 months ago while living in Florida for the winter
• Diagnosed with localized cutaneous squamous cell carcinoma
• Standard surgical excision performed with 4 mm clinical margins; postoperative margins negative

May 2018

• Patient returns to dermatologist for follow-up c/o multiple lesions on shoulder and neck around the site of prior excision
• PE:
  • Multiple visible, ulcerated lesions, approximately 2-3cm in diameter; suspected tumor depth >5mm
  • Multiple palpable nodes ~2cm
• Imaging confirmed 7 mm invasion into subcutaneous fat; parotid nodal involvement
• Biopsy confirmed cutaneous squamous cell carcinoma, poorly-differentiated
• Diagnosis: Metastatic cutaneous squamous cell carcinoma
• Stage IV: T3N2M0
• Patient started on cemiplimab