Imaging in the Diagnosis of an Ocular CSCC Case

Anna C. Pavlick, DO:This case essentially looks at a 64-year-old woman who develops a rapidly growing lesion on the lower part of her eyelid that develops numbness and tingling. She finally presents to her dermatologist for evaluation. This lesion is subsequently biopsied. It’s proven to be a poorly differentiated aggressive squamous cell carcinoma. The diameter of the lesion is about 8 mm, and is in an anatomically challenging area for management. The patient also has a history of hypertension, hyperlipidemia, and rheumatoid arthritis, which, again, would make some people question whether this is a candidate for systemic therapy with an immunotherapy, like cemiplimab.

Based on the clinical presentation, where this lady has numbness and tingling associated with the lesion, it makes you very concerned that she’s got perineural invasion. And so, you want to get a good imaging study. I would probably get an MRI [magnetic resonance imaging] of her head and neck, predominantly her head, to make sure that there is no perineural tracking where you actually see tumors thickening along the entire course of the nerve. Many of these lesions can grow very quickly and you can have extension of tumor even to the base of the scull or into the orbit. So you really want to have a good assessment of exactly how deep this lesion is.

On that imaging, if you realize that this is not a simple lesion located in a challenging area you would then go on to image the rest of this patient to make sure she doesn’t have any distant disease. You can do CAT [computed axial tomography] scans of the chest, abdomen, and pelvis. Sometimes we do PET [positron emission tomography] scans, but with the new economic sanctions that are in place it’s very challenging to get a PET scan approved.

If a patient has commercial insurance, it’s a little easier. But, again, most of these patients are older and have Medicare as their primary insurance. When getting a PET scan, you really have to think about whether you want it for the simple reason that Medicare patients are covered for 4 PET scans in the course of their lifetime. You’ve got to use them wisely because you only get 4. If you want more than 4, you really have to argue for it. There’s a chance that it will be denied and then the patient subsequently gets stuck with the bill.

Sometimes it’s more challenging to treat young patients because they’ve got 50,000 things they want to do. It’s a challenge to get them to actually make appointments and come in and make their health a priority. Young patients don’t think that they should be sick. Older patients have accepted the fact that things are starting to slow down. Most of these patients are retired and are more than happy to come and have their issues taken care of. I usually don’t have much of a compliance issue with my older patients.

Transcript edited for clarity.

A 64-Year-Old Woman With Very Large Ocular CSCC Tumor

• History
  • A 64-year-old woman was referred for a left lower eyelid lesion that was rapidly increasing in size. She complained of intermittent twitching and numbness in the area. She reported that the lesion started on the lower eyelid.
  • PMH: stent placed 10 years ago; hyperlipidemia, well controlled on simvastatin; hypertension, well controlled on metoprolol; rheumatoid arthritis
• PE
  • Ulcerated lesion, approximately 8-mm in diameter
  • ECOG PS 1
• Imaging confirmed perineural, vascular, and bone invasion
• Biopsy confirmed cutaneous squamous cell carcinoma, poorly-differentiated, Clark level V, perineural invasion, vascular invasion
• Stage: T3N0M0