Surgery Versus Immunotherapy in CSCC

Anna C. Pavlick, DO:I think in the community, because there’s not a multidisciplinary tumor board in every hospital or because physicians don’t have time to go to multidisciplinary tumor boards, it really is the responsibility of the dermatologist to set up consults for these patients, especially if they have a recurrent lesion in a radiated area, or have a large lesion, or have the lesion in an area that’s going to require a very large disfiguring surgery. Again, we can operate, but what are we going to leave the patient looking like?

And so, yes, you can certainly recommend consults with a head and neck surgeon and medical oncologist. This way there is a unified plan moving forward. Some patients may have a partial response, where the tumor will shrink up. Then you need a surgeon. So it’s always good to get everybody onboard in the beginning and keep those lines of communication open so that you can easily move the patient from your medical therapy over to get a surgical procedure, if that’s the right thing to do.

I think patients need to be informed about the risks and benefits of each modality. So what are the risks of radiation, and what are the potential benefits? What are the risks of surgery? What am I going to look like when this is done? Am I well enough to undergo this degree of a procedure without having another complication, like a stroke or a heart attack, in the postoperative phase?

Can the patient receive systemic immunotherapy? The answer is not always universally yes. We run into a big issue with patients who have undergone an organ transplant. Organ transplant patients are notorious for having multiple invasive squamous cell cancers. However, we know that by giving these patients an anti—PD-1 [anti–programmed cell death-ligand 1] therapy, such as cemiplimab, they’re going to reject their organ. So if a patient gets sent to me and has a liver transplant or a kidney transplant and has locally advanced squamous cell disease, I’m not the right person for them. I’m either going to refer them back to the surgeon or to the radiation oncologist because I need to preserve the transplanted organ.

For this woman, I don’t think that surgery is the right option. She’s got such extensive perineural invasion. She’s got such a poorly differentiated squamous cell cancer in a very difficult area. Can it be done? Sure. Do I think it’s the right thing to do? Probably not. Radiation, on the other hand, is going to cause her to have potential visual issues, so I don’t think that’s really a feasible thing to do either.

Can she get immunotherapy with cemiplimab? My answer is, yes. Am I going to exacerbate her rheumatoid arthritis? You bet I am. And so, I’m going to need to really communicate with her rheumatologist beforehand to make sure that we work together to keep her comfortable and treat her cancer at the same time.

I would not be excited about giving her an older, conventional treatment such as an EGFR receptor inhibitor or chemotherapy. Again, it doesn’t provide her with durability, and we’re looking to really get rid of this for her because it’s a locally advanced tumor.

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