Case Review: Recurrent Cutaneous Squamous Cell Carcinoma

Anna C. Pavlick, DO:This is a case of a 74-year-old gentleman who has a long-standing history of excessive sun exposure with multiple sites of cutaneous squamous cell carcinoma that have been removed in the past. He suddenly notices this large growing lesion on his arm and swelling that has developed in his axilla. As a consequence, he presents to his doctor a biopsy of the primary lesion as well as the lymph node that’s under his arm. He is diagnosed with squamous cell carcinoma of the skin that’s now metastasized to his axillary lymph nodes.

Because the lymph node mass is so large, it’s decided that the patient should receive neoadjuvant chemotherapy with cisplatin and 5-FU [5-fluorouracil]. The patient undergoes 3 cycles of therapy and then gets taken to the operating room. In the OR [operating room], the primary lesion is removed and the lymph nodes are resected because they’re no longer adherent to the chest wall.

It’s a very deep squamous cell carcinoma of the skin with perineural invasion, and the axillary contents demonstrate that 12 of 16 nodes are involved with metastatic squamous cell cancer of the skin.

The patient is then observed for the next year, and on routine imaging the patient is found to have multiple pulmonary nodules in May 2017. At that point, it is then decided that the patient should undergo chemotherapy. The patient is treated with a combination of paclitaxel and carboplatin, and after 3 cycles, the patient is reimaged. Again, there’s progression of disease with enlarging hilar nodes, mediastinal nodes, and pulmonary nodules, and now the patient also has bone metastases.

At this point, the patient is now treated with cemiplimab. The patient was treated for 3 cycles, which is given every 3 weeks. After 4 doses at 12 weeks later, the patient gets reimaged, and there’s a dramatic response with a decrease in the amount of pulmonary nodules and hilar nodes.

When the patient originally presented with a large lesion and a large axillary mass that was adherent to the chest wall, normal procedure would be to undergo imaging with CAT [computed tomography] scans—chest, abdomen, and pelvis. If the patient’s alkaline phosphatase level was elevated, with normal liver enzymes, there’s also a consideration doing a bone scan. Since squamous cell cancer frequently metastasizes to the bone, you’d want to make sure the patient doesn’t have bone metastasis right from the get-go.

The patient would then be either operated on or treated, and then the same imaging tests should be repeated prior to either the next therapy or whether the patient goes to the operating room.

Some of the high-risk features that we look for in squamous cell carcinoma are essentially how large the primary lesions are especially whether there’s perineural invasion, because squamous cell cancers love to grow right along the nerves that are in the area. Many times if that happens, it’s very difficult to obtain clear margins because the tumors just track along those nerves. This patient also had 12 of 16 positive lymph nodes, which is really negative prognostic indicator with respect to how well the patient is going to do.

Transcript edited for clarity.

Case: A 74-Year-Old Male With Recurrent Metastatic CSCC

November 2017

• A 74-year-old male from Florida, with history of multiple resections of CSCC on neck, back and shoulders presents with new deep lesion that exhibited perineural invasion and c/o palpable left axillary mass
• Imaging confirmed 6cm left axillary nodal conglomerate
• Patient treated with neoadjuvant cisplatin/5FU for 3 cycles
• Surgical resection of primary lesion; Lymphadenectomy revealed CSCC involvement in 12 out of 16 resected lymph nodes

May 2018

• Follow-up scans revealed early disease progression with multiple pulmonary nodules
• Patient started on carboplatin/paclitaxel for 3 cycles

November 2018

• Repeat imaging showed disease progression in pulmonary nodules and multiple lymphadenopathies; mediastinal, left and right axillary; bone metastases
• Patient started on cemiplimab for 3 cycles

February 2019

• Reimaging PET-CT revealed reduction in size and metabolic activity of right and left axillary, and mediastinal lymphadenopathies; pulmonary nodules had considerable reduction in size and were no longer substantial