Resectability and Risk Status in CSCC

Anna C. Pavlick, DO:Risk is really evaluated based on several factors. Where is the location of the tumor? Has this recurred in a previously resected or previously radiated area? Is there numbness or tingling, which are trademarks of perineural invasion? How deep is it? How big is it? Is it attached to skull? Is it attached to bone? Is it attached to muscle? We also consider its location. Is it on the eye? Is it on the lip? You’ve got to look at where it is with respect to functionality of organs. That’s how you determine the risk.

Most people think that head and neck squamous cell carcinoma and cutaneous squamous cell carcinoma are interchangeable. However, they’re very, very different. CSCC originates from the skin. It happens as a result of sun damage. It has a high mutational burden. Squamous cell cancer of the head and neck is usually a consequence of smoking. Again, it is a toxin-related injury. Most of these tumors are also associated with viruses and are managed very differently. They don’t have the same high mutational burden that cutaneous squamous cell cancer does, and they do respond differently when it comes to immunotherapy.

Looking at this case, it’s very complex. As I had said before, everything is potentially resectable, depending on the surgeon that you talk to. The question is, is it the right thing to do? You’ve got a lady who has a lesion on her lower eyelid with perineural invasion. When it comes to resectability, could it be resected? Sure, it could be resected. However, the surgery that would need to be done is pretty extensive and she would need a skin flap. You’d also want to make sure that the perineural extension doesn’t go all the way back into her skull, where you leave disease behind. So that has to play a role in how you decide whether this is a resectable lesion.

Regarding her comorbidities—the hypertension, the hyperlipidemia—99% of Americans have those. What 99% of Americans don’t have is rheumatoid arthritis. Is rheumatoid arthritis an exclusion criteria for immunotherapy with cemiplimab? The answer is, no. Do oncologists need to be astutely aware that these agents are going to exacerbate that underlying autoimmune disease? Absolutely.

Before I start any of my patients who have rheumatoid arthritis on immunotherapy, I touch base with their rheumatologist. It’s important to make a plan ahead of time. Be prepared that these agents, although they will provide control of a squamous cell cancer that has the potential to be disfiguring or life threatening, are really going to exacerbate their underlying joint pain or their rash, depending on what their autoimmune issue is. Just be prepared to be able to work with the rheumatologist to control the pain for those patients so that they can be comfortable and still receive the therapy that they need.

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