Recurrent Skin SCC, Nerve involvement

[Haybrant]

Surgery sent a guy with recurrent SCC of the medial LUE above the elbow joint. Initial resection was in June and adjuvant RT was recommended but the patient refused (close margin, 4 cm in size). It regrew quite rapidly in the last 1.5 months and is 4.5 cm in size. Ive attached a picture. No sig clinical symptoms but MRI shows that it is wrapping around the ulnar nerve and in close approximation with brachial vein. Surgeon send to request input about definitive RT vs pre-op RT to reduce size of mass. Apparently he is concerned about proximity to vasculature that could lead to need for amputation (was surprised to hear that tbh)

So many issues to consider here, thoughts about this situation? Would you prefer surgery first even if there is gross dz/margin positive resection? Pt is a healthy 70

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[BobbyHeenan]

Wow, tough case.

I'm not sure what the best answer here is. Not sure that a "debulking" buys you anything if gross disease is left behind. Then you're going to full dose in an area that has seen surgery X2. If surgeon insists this guy needs another operation I'd go for pre op....

However, my gut tells me to just treat definitively and use surgery as salvage. I'd fear that a pre op dose is going to lead you with a positive margin then what do you do? I'd probably give him a definitive dose and re-image 6 weeks after treatment and if still residual disease then go to surgery. I know that higher XRT dose could complicate surgery and wound healing, but there's a chance long term cure could be obtained without surgery.

I'd be interested in other opinions as well, thanks for sharing the case.

 

[evilbooyaa]

Tell the surgeon that you respectfully disagree that this requires an operation. This isn't sarcoma that can't be cured with RT alone. I've never heard of pre-operative RT for SCC. That'd be like saying pre-operative RT for Cervix cancer (in this day and age). Why hamper your curative treatment (RT in this scenario) to allow for a surgery, especially one that's involving multiple critical structures?

I wouldn't recommend a debulking surgery, especially if there's gross disease. I wouldn't even be fan of a + margin resection if you can just do definitive RT instead.

 

[Haybrant]

Tell the surgeon that you respectfully disagree that this requires an operation. This isn't sarcoma that can't be cured with RT alone. I've never heard of pre-operative RT for SCC. That'd be like saying pre-operative RT for Cervix cancer (in this day and age). Why hamper your curative treatment (RT in this scenario) to allow for a surgery, especially one that's involving multiple critical structures?

I wouldn't recommend a debulking surgery, especially if there's gross disease. I wouldn't even be fan of a + margin resection if you can just do definitive RT instead.

Agree, never heard of neoadjuvant RT. Its not going to do anything useful and carries significant harm.

How would you guys treat this thing; there are a lot of clips from prior surgery and infiltrated tissues below surface. Wrap a bolus around his arm and photon him covering all the prior treatment clips? Also, would you consider chemo?

 

[nkmiami]

I would still be in favor of concurrent chemo with xrt to at least 60 GYy despite the lack of evidence for an aggressive skin cancer like this. There are also clinical trials of immunotherapy in skin if he relapses after chemo/xrt

 

[evilbooyaa]

I'd sim with bolus on and treat it like a sarcoma in terms of depth (although not length), being generous with my coverage given previously surgerized. AP/PA, Obliques, electrons w/ bolus, IMRT, whatever gives you the best coverage.. It'll be more toxic than standard skin cancer treatment, but I think this guy has bad acting disease, like one of those skin SCCs that mets out.

I don't know of any data for chemo but it's always a consideration.

Definitely haven't treated enough of these at my institution though to feel comfortable easily recommending anything, so would defer to others.

 

[OTN]

I would not treat preoperatively- cure rate is good with either surgery + adjuvant RT or definitive RT, so I wouldn't risk preop RT (wound complications, etc). It sounds to me like definitive RT makes the most sense. I prefer 70 Gy in 2 Gy fractions if the patient can travel, though you can hypofractionate if needed (50 Gy in 20 fx, for example). No concurrent chemo- no data. I've treated ENORMOUS skin cancers definitively this way, and they almost always respond very well.

It's too thick for HDR brachytherapy, but you may even be able to get away with electrons, depending on its depth. Use bolus, naturally.

 

[nkmiami]

There was a recent trial of carbo in australia that was negative (weekly carbo is also not effective in head and neck cancer) , but I would still be in favor of chemo/erbitux- as did the lecturer at ASTRO this year. No evidence- we probably will never have any, so got to extrapolate. Also would consider nodes? I would consider VMAT and treating the axilla to around 45 Gy.

 

[Haybrant]

There was a recent trial of carbo in australia that was negative (weekly carbo is also not effective in head and neck cancer) , but I would still be in favor of chemo/erbitux- as did the lecturer at ASTRO this year. No evidence- we probably will never have any, so got to extrapolate. Also would consider nodes? I would consider VMAT and treating the axilla to around 45 Gy.

Was not planning to treat nodes; would anyone else? Has a PET which is negative. Seems like too much extrapolating, first extrapolate chemo then extrapolate for nodes.

 

[medgator]

Was not planning to treat nodes; would anyone else? Has a PET which is negative. Seems like too much extrapolating, first extrapolate chemo then extrapolate for nodes.

Would not treat nodes or give chemo. I believe you're on solid footing to consider chemo in node+ cutaneous SCC but the data is sparse unfortunately. I don't use size as a consideration typically to given chemo in cutaneous SCC.

Agree with OTN, standard fx to 70 would be the ideal route given the lesion size and location. Pre-op XRT is nonsense... this is not a sarcoma, and should respond well to definitive XRT. It's just that some dermatologists like to cut more than they should.

It's good that you got a PET pre-treatment. You could probably estimate depth on the CT portion of that study to choose the appropriate electron energy and bolus, otherwise just do a CT SIM if you aren't sure instead of a clinical setup to make sure you're not missing anything with electrons. If too deep, could also bolus and treat with photons.

 

[seper]

I would not consider definitive XRT as good alternative to surgery here.

 

[medgator]

I would not consider definitive XRT as good alternative to surgery here.

There are really no good alternatives here IMO, but given the tumor involvement of ulnar nerve and vascular abutment/invasion, I'd opt for XRT over possible amputation and/or oncologically-inadequate surgery followed by post-op XRT, personally.

 

[BobbyHeenan]

I would not consider definitive XRT as good alternative to surgery here.

I think concurrent chemo (cis weekly) or erbitux is reasonable and I'd actually push for that if going for definitive treatment. I would not treat the nodes if PET was negative at the nodes.

If the surgeon thinks a negative margin limb sparing surgery is likely, then I agree with you, seper. I was thinking though from the original post that a sub-total resection or a margin + resection was likely...so in that case I don't think surgery right now is a good option if that is true.

 

[seper]

Referral to sarcoma surgeon --> surgery with flap -- > postop XRT

 

[evilbooyaa]

Referral to sarcoma surgeon --> surgery with flap -- > postop XRT

It involves the ulnar nerve entirely and is very close to the brachial vein on imaging, meaning resection margin will go right up to the brachial vein or sacrifice it with possible reconstruction (not sure if that's 100% necessary given collateral venous return, that'll be up to the surgeon). If you put this guy through a surgery, the ulnar nerve will be sacrificed. He may require vein reconstruction.

Why no belief in high-dose RT? It works for other invasive SCCs, what's the concern for this clinical scenario?

 

[seper]

You going to get a hole after XRT. Also, XRT may not get rid of tumor because it is in a hypoxic scar.

 

[Haybrant]

You going to get a hole after XRT. Also, XRT may not get rid of tumor because it is in a hypoxic scar.

What options are there for a hole after RT? Would you still request surgery if there is high risk of amputation at this point? I'd rather deal w a hole than no arm?

 

[nkmiami]

Agree about no amputation- I have seen some of these ulcerative skin cancer lesions actually granulate in and start to heal during the radiation.

 

[evilbooyaa]

You going to get a hole after XRT. Also, XRT may not get rid of tumor because it is in a hypoxic scar.

As stated otherwise, I think a hole is better than an amp. I'd say a hole is even better than zero function of the ulnar nerve due to it being sacrificed.

Hypoxic scar for SCC not responding to 70Gy? Given that we can 50Gy for normal, non-ugly, definitive settings and we're discussing being more aggressive with possible addition of Cetuximab or something, I disagree.

Yes his rates to control this aren't 100%, but if this were me I would like to try definitive RT +/- chemo and save surgery for salvage.

 

[mavrik13]

Seems reasonable to treat definitively - likely would do 60/30 but 70/35 or 50/20 also options (would favor higher dose options). I don't disagree with seper (surgery with adjuvant RT would be best) but if surgery would be morbid/unresectable, treat with definitive XRT with surgery for failure. I'd favor close follow-up with a low threshold for surgical excision - don't want to miss the chance for a limb sparing salvage. Wouldn't electively treat nodes.

It's interesting to think about - I've seen a few axilla nodal mets from skin cancer recently and we've treated neoadjuvantly when not surgically resectable, who then get 60Gy followed by surgery.

 

[nkmiami]

Seems reasonable to treat definitively - likely would do 60/30 but 70/35 or 50/20 also options (would favor higher dose options). I don't disagree with seper (surgery with adjuvant RT would be best) but if surgery would be morbid/unresectable, treat with definitive XRT with surgery for failure. I'd favor close follow-up with a low threshold for surgical excision - don't want to miss the chance for a limb sparing salvage. Wouldn't electively treat nodes.

It's interesting to think about - I've seen a few axilla nodal mets from skin cancer recently and we've treated neoadjuvantly when not surgically resectable, who then get 60Gy followed by surgery.

I am kind of alone here on nodal coverage, but a head and neck skin cancer that is a T4 SCC with major perineural invasion has quite a high rate of nodal involvement, even more so if there is poor differentiation.

 

[evilbooyaa]

I am kind of alone here on nodal coverage, but a head and neck skin cancer that is a T4 SCC with major perineural invasion has quite a high rate of nodal involvement, even more so if there is poor differentiation.

I don't think this is a T4 lesion. I haven't heard that it's frankly invading the bone, just nerve and vessel.
Despite how ugly it looks and feels by description, it's still a T2 by staging. Perineural invasion of the skull base makes you T4 per the 7th edition.

I don't have a lot of clinical experience with this, but, looking further into it, I no longer disagree with your final point about nodal RT.

Outcomes of primary cutaneous squamous cell carcinoma with perineural invasion: an 11-year cohort study. - PubMed - NCBI

Nerve Caliber stratified (>0.1mm as the cut-off) showed that large caliber involvement had a 17% vs 4% of nodal recurrence. Large nerve caliber involvement is associated with other risk factors (which this patient has as well). I think it's worthy of discussion with the patient.

 

[Brim]

So... do you chase the nerve to the skull base? That would be quite a field.

 

[Haybrant]

I hear you guys about the nodal issue but im not gonna treat his nodes. the local issue is such a big deal here and he'll be on pretty active surveillance initially as well.

 

[medgator]

Think of it like eni in nsclc... realistically this guy is either going to get cured with local rt or he will met out and it is unlikely to be an isolated regional nodal recurrence imo

 

[Palex80]

There is obviosuly no data on neoadjuvant RT.

Primary RT combined with chemo is indeed an option, the problem will be what might be left behind in terms of non-healing ulcus.
A big issue which needs to be adressed when discussing the option of surgery will be what kind of reconstruction / procedure is planned after removal of the tumor, since this will have implications in terms of possible adjuvant RT.