The Multidisciplinary Approach to Choosing a Treatment

Gregory A. Daniels, MD:I think it’s critical to consider multiple inputs into these cases. Again, most cutaneous squamous cell cancers are handled very well with the dermatologist, and/or a surgeon. Because they’re low risk, they’re going to be resected, and the chance of recurrence is less than 10%.

However, when you start to get into those patients where reconstruction is going to be considered, or the risk of recurrence can be expected to be higher than 10%, it really makes sense to get a multidisciplinary team involvement. You’re already thinking that there may be application of radiation in the adjuvant setting perhaps, or you want them to better plan out the surgery and have other surgeons involved in the discussion. I think these high-risk patients deserve at least a consultation, if not a tumor board type setting where they could be discussed.

Because these patients may require involvement of people such as a plastic surgeon, reconstruction experts, as well as radiation and medical oncology, it helps to have a team with experience in bringing together these kinds of care. Often this is done at a large academic referral center. However, there are community practices that are well set up for having a multidisciplinary team approach, and that should be encouraged.

The factors to determine resectability really depend on a patient where cure is going to be a reasonable goal for the intervention, whether it’s surgery or radiation. It also depends on whether the toxicities or morbidities of those modalities fit with that patient’s expectations and the willingness to undergo these things.

For example, sometimes lesions are involving the side of the face, as these are sun-related cancers. That may involve removal of parts of the ear or a reconstruction of the nose. For some patients that’s acceptable, but for other patients it’s not acceptable. So, there are many factors that go in to what is a resectable tumor.

The definition of locally advanced is anything that is in the dermas and spreading in the dermas, but hasn’t entered the lymph nodes or distant organs. Lymph node involvement for cutaneous squamous cell would be considered metastatic disease, unlike some other cancers. I consider locally advanced to be those tumors that are borderline resectable or where the treatment would not be expected to lead to a cure.

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