Extensive Axillary SCC

[Haybrant]

Interesting one - older woman was being treated for CLL with systemics, was developing increased left arm edema, imaging showed new metabolically active nodes throughout the axilla/supraclav. Biopsy was done thinking she may have transformed to high grade lymphoma. Excisional biopsy of the axilla shows poorly differentiated carcinoma favoring SCC, unknown primary. This is the PET/CT. What would you do, if this is all SCC this is a terrible situation. Picture attached

---

Members don't see this ad.

 

[nkmiami]

I would treat axilla 55-60GY. . Tumor should be sent out for next generational sequencing- likely to have high mutational burden..
Likely to be skin primary as CLL predisposes to very aggressive skin cancers ( up to 25% of pts)..(skin scc may actually have some of highest response rate to immunotherapy of all tumors)

 

[Haybrant]

I would treat axilla 55-60GY. . Tumor should be sent out for next generational sequencing- likely to have high mutational burden..
Likely to be skin primary as CLL predisposes to very aggressive skin cancers ( up to 25% of pts)..(skin scc actually have highest response rate to immunotherapy of all tumors)

interesting, is there a citation on the immunotherapy and skin response rates you mentioned. Thank you,

 

[nkmiami]

Sorry, should not have been so definitive- relating a speakers opinion at one of the meetings.
It was from a presentation at ASTRO or the AACR, maybe Ezra Cohen, a medical oncologist at UCSD?. Anyway, I have had 2 cases that had a complete response in the metastatic setting. both had very high mutational burdens, .but low PDL1 expression.

15. Borradori, L.; Sutton, B.; Shayesteh, P.; Daniels, G.A. Rescue therapy with anti-programmed cell death protein 1 inhibitors (PD-1) of advanced cutaneous squamous cell carcinoma and basosquamous carcinoma: Preliminary experience in 5 cases. Br. J. Dermatol. 2016, 175, 1382–1386. [CrossRef] [PubMed] 16. Chang, A.L.; Kim, J.; Luciano, R.; Sullivan-Chang, L.; Colevas, A.D. A case report of unresectable cutaneous squamous cell carcinoma responsive to pembrolizumab, a programmed cell death protein 1 inhibitor. JAMA Dermatol. 2016, 152, 106–108. [CrossRef] [PubMed] 17. Degache, E.; Crochet, J.; Simon, N.; Tardieu, M.; Trabelsi, S.; Moncourier, M.; Templier, I.; Foroni, L.; Lemoigne, A.; Pinel, N.; et al. Major response to pembrolizumab in two patients with locally advanced cutaneous squamous cell carcinoma. J. Eur. Acad. Dermatol. Venereol. 2017, in press. [CrossRef] [PubMed] J. Clin. Med. 2018, 7, 10 8 of 8 18. Ravulapati, S.; Leung, C.; Poddar, N.; Tu, Y. Immunotherapy in squamous cell skin carcinoma: A game changer? Am. J. Med. 2017, 130, e207–e208. [CrossRef] [PubMed] 19. Winkler, J.K.; Schneiderbauer, R.; Bender, C.; Sedlaczek, O.; Fröhling, S.; Penzel, R.; Enk, A.; Hassel, J.C. Anti-PD-1 therapy in nonmelanoma skin cancer. Br. J. Dermatol. 2017, 176, 498–502. [CrossRef] [PubMed] 20. Falchook, G.S.; Leidner, R.; Stankevich, E.; Piening, B.; Bifulco, C.; Lowy, I.; Fury, M.G. Responses of metastatic basal cell and cutaneous squamous cell carcinomas to anti-PD1 monoclonal antibody REGN2810. J. Immunother. Cancer 2016, 70. [CrossRef] [PubMed]

 

[evilbooyaa]

It's like metastatic from a skin primary but that looks like localized disease in a breast cancer lymph node distribution. Agree with radiation to 60-64Gy (limited by brachial plexus), and if there's ever a skin cancer case that should get concurrent cetux, this is it. Depends on the willingness of your med-onc.

What's all that uptake in liver/spleen? CLL? Is CLL pet-avid?

 

[Haybrant]

It's like metastatic from a skin primary but that looks like localized disease in a breast cancer lymph node distribution. Agree with radiation to 60-64Gy (limited by brachial plexus), and if there's ever a skin cancer case that should get concurrent cetux, this is it. Depends on the willingness of your med-onc.

What's all that uptake in liver/spleen? CLL? Is CLL pet-avid?

that's actually just the renal uptake

 

[evilbooyaa]

that's actually just the renal uptake

D'oh! Hard to tell on the 2D Pet only. never mind then.

 

[xrt123]

I would treat axilla 55-60GY. . Tumor should be sent out for next generational sequencing- likely to have high mutational burden..
Likely to be skin primary as CLL predisposes to very aggressive skin cancers ( up to 25% of pts)..(skin scc may actually have some of highest response rate to immunotherapy of all tumors)

Do you order the Next Gen or do your Medoncs? Even if they do and there is a high mutational burden is this covered for immunotherapy? Obviously MMR mutation gets things covered but I have never heard of this in the setting of skin. I can barely get IMRT covered in this setting.

 

[medgator]

Do you order the Next Gen or do your Medoncs? Even if they do and there is a high mutational burden is this covered for immunotherapy? Obviously MMR mutation gets things covered but I have never heard of this in the setting of skin. I can barely get IMRT covered in this setting.

I've had commercial payors refuse to cover PET or CT imaging for workup, IMRT etc. in pretty-advanced skin cancers. It's ridiculous. Can't imagine they will cover a 5-figure monthly immunotherapy either

 

[Haybrant]

Ya lot of push back when it comes to skin. Why do people act like skin Mets are somehow this different entity it’s so ridiculous

 

[Palex80]

It's palliative... i wouldn't push the dose that high and would rather hypofractionate.

 

[medgator]

It's palliative... i wouldn't push the dose that high and would rather hypofractionate.

Do you treat all of your unknown primary SCCs with palliative intent? This is looks like fairly confined disease. In an otherwise good PS patient, I would consider chemo-radiation, personally, although the OP mentions an "older woman"

 

[Haybrant]

Do you treat all of your unknown primary SCCs with palliative intent? This is looks like fairly confined disease. In an otherwise good PS patient, I would consider chemo-radiation, personally, although the OP mentions an "older woman"

not all, I had an inguinal Unknown primary that went to surgery and treated him adjuvantly with curative intent. Are you implying that this would be curative w chemoRT? I think there is essentially 0 chance of that if this is truly all carcinoma

 

[medgator]

not all, I had an inguinal Unknown primary that went to surgery and treated him adjuvantly with curative intent. Are you implying that this would be curative w chemoRT? I think there is essentially 0 chance of that if this is truly all carcinoma

In a good ps patient, it would probably buy more time and local control/relief of sx.

Iirc, the recent astro guidelines in palliative lung bless chemo rt in certain situations as well, do they not?

 

[Haybrant]

In a good ps patient, it would probably buy more time and local control/relief of sx.

Iirc, the recent astro guidelines in palliative lung bless chemo rt in certain situations as well, do they not?

That’s the point though, it’s certain situations. That’s why I asked about this situation. Not I treat all palliative or all w curative attempt as you were asking

 

[medgator]

That’s the point though, it’s certain situations. That’s why I asked about this situation. Not I treat all palliative or all w curative attempt as you were asking

I was asking/quoting palex actually

 

[nkmiami]

Do you treat all of your unknown primary SCCs with palliative intent? This is looks like fairly confined disease. In an otherwise good PS patient, I would consider chemo-radiation, personally, although the OP mentions an "older woman"

Ya lot of push back when it comes to skin. Why do people act like skin Mets are somehow this different entity it’s so ridiculous

I dont know, also find that as well. I would also favor erbitux or chemo xrt, but when it recurrs/mets out, a number of centers are using immunotherapy, In terms of coverage, we have found most companies are very willing to provide immunotherapy if insurance declines as long as there is some literature supporting its use. Lately, I have seen a number of small cell lung pts getting immunotherapy in 2nd line this way. Precisely because it so expensive, they want to "induce" its use. As far as being elderly- those are pretty much the only patients who get these cancers, and cll for that matter.

 

[Palex80]

Do you treat all of your unknown primary SCCs with palliative intent? This is looks like fairly confined disease. In an otherwise good PS patient, I would consider chemo-radiation, personally, although the OP mentions an "older woman"

No, I do not treat all my unknown primary SCC with palliative intent.

But do take a look at that PET image, please. You call that "fairly confined"? I count 20+ nodes/manifestations there, pretty much the entire axilla, possibly parts of the chest wall, the supraclavicular, infraclavicular fossa, the lower neck and who know's what else, since we only have this one 2D image. That is not "fairly confined" disease. Fairly confined disease would have a been a couple of nodes in the axilla...
Who said the patient has a "good PS"? Haybrant only stated "older woman", whatever that means. I presume she is in her late 70s or 80s. Chemoradiation for 75+ years of age is not exactly a walk in the park.

And I still stand by what I said. The chance of curing her with chemoradiation is below 5%. I wouldn't push it.

But this is of course based on the assumption that everything on that PET is SCC, which we apparently do not know. Uptake is however quite high (or at least it looks like that), CLL generally has lower uptake.

 

[mavrik13]

This is a situation where you let the patient guide you. If you have a motived, well patient who wants to do everything, chemoRT (our med oncs tend to use weekly cis) is not unreasonable, treating to 60Gy/30 (personally wouldn't go higher than that). I don't know data for cetux, would love to see it. I agree with Palex the chance of cure is low, but that wouldn't preclude me from being aggressive. It would also be reasonable to do an aggressive palliation of 50Gy/20, or standard palliation of 30Gy/10 if particularly frail.