High-risk skin cancer needs multidisciplinary management

A 62-year-old cardiac transplant patient with a rapidly growing SCC that was larger and deeper than could be anticipated prior to biopsy.

High-risk non-melanoma skin cancers such as squamous cell carcinoma (SCC) have always been notoriously challenging to treat. This is especially true for immunosuppressed individuals such as organ transplant recipients (OTR). The aggressiveness of these high-risk tumors has made a multi-disciplinary approach increasingly crucial in the optimal treatment and management of this patient population.

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Fiona O’Reilly Zwald, M.D., M.R.C.P.I.“It is very practical and useful to have different physician specialists nearby when approaching complicated high-risk skin cancer patients because, more likely than not, such cases will require a multidisciplinary approach in order to help ensure that the patient receives the best possible medical care available,” says Fiona O’Reilly Zwald, M.D., M.R.C.P.I., Dermatology Consultants, PC, Piedmont Transplant Institute, Atlanta, Ga.

The criteria

Several parameters need to be met in order to classify non-melanoma skin cancer, such as SCC, as high-risk, including:

• Large tumor size (usually greater than 2 cm diameter)

• Increased tumor depth

• Recurrence

• Location of the tumor (usually in the head and neck region)

Although advanced basal cell carcinomas (BCC) can technically be considered high-risk due to their sheer size, these tumors rarely metastasize, casting the remaining focus on SCC and other potentially aggressive tumors.

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In addition to the aggressiveness of these tumors, Dr. Zwald says that high-risk SCCs are usually very large and often challenging to surgically remove. It is not uncommon to find inoperable tumors in elderly patients whose physical status does not allow for invasive surgery.

Moreover, high-risk tumors can be very tricky to manage Dr. Zwald says, because they often invade substantially into the subcutaneous tissue and can have perineural invasion of the tumor as well. “That’s a major concern because even if I perform a wider resection of a tumor using the Mohs surgery technique, I will always bring in other specialties and ask for adjuvant radiation therapy afterwards in order to help ensure that the tumor does not recur,” Dr. Zwald says.

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Immunosuppressed patients such as OTRs present a number of challenges and will often have multiple non-melanoma skin cancer tumors that tend to grow very quickly. In addition, Dr. Zwald says that there are a number of time-sensitive comorbidities, such as potential postoperative infections, that the dermatologic surgeon must be wary of and address in immunosuppressed patients.

NEXT: Coming to consensus

A 62-year-old cardiac transplant patient with a rapidly growing SCC that was larger and deeper than could be anticipated prior to biopsy.

Coming to consensus

“High-risk skin cancer patients can be very complex and the optimal treatment and management of these patients requires multi-disciplinary care. In my experience, most physicians who are likely to take care of these patients usually do not do so unless they have a multidisciplinary team around them. Depending on the individual case, this can include transplant colleagues, surgical oncologists, ENT physicians, infectious disease colleagues, radiation oncologists and plastic surgeon colleagues,” Dr. Zwald says.

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When addressing these difficult tumors, Dr. Zwald says that it is often best to first perform an excision to remove the bulk of the tumor volume, and then to follow up with radiation therapy.

Although relatively uncommon, sometimes there is disagreement among specialists regarding the optimal treatment of high-risk skin cancer patients. In such scenarios, Dr. Zwald advises that the dermatologic surgeon should try to communicate to the other specialists what his or her concerns are, and try to educate them as to the necessity of performing certain treatments for the patient from the perspective of a dermatologist. The intent, of course, is to find common ground for a proposed treatment plan in the individual patient.

Sumaira Z. Aasi, M.D., Ph.D.“When excising tumors, Mohs surgeons have a good sense of when the cancer is low-risk, and we have a good sense of when a tumor is going to behave badly. I think that one of the biggest challenges when managing high-risk skin cancer patients is that we really do not have enough information on these aggressive tumors prior to the surgery itself,” says Sumaira Z. Aasi, M.D., Ph.D., Clinical Professor in Dermatology, Clinical Professor in Surgery and Plastic & Reconstructive Surgery, Stanford School of Medicine, Stanford, Calif.

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Oftentimes, Dr. Aasi says that biopsies are done in such a way that they do not garner enough information for clinicians to recognize or at least be suspicious of the aggressiveness of a particular skin cancer. As such, it is not until these patients are being treated with an excision or with Mohs surgery that other critical telltale features of the tumor come to light and help confirm the true aggressiveness of the tumor. Accordingly, Dr. Aasi says there needs to be a bit of a philosophical shift in our specialty when approaching a lesion that could potentially be a high-risk SCC.

“We tend to lump all non-melanoma skin cancer or keratinocytic tumors together. When we see a suspicious lesion that looks like it could have an aggressive course, particularly in immunosuppressed and OTR patients, I believe that we should approach it differently with a biopsy from the get-go, so that our pathologist can examine the tissue and inform us about certain features present that might lead us to categorize the tumor as an aggressive one,” Dr. Aasi says.

The clinician should make an effort to perform a deeper and more complete biopsy so that features such as depth, degree of cellular differentiation, perineural invasion, and angiolymphatic invasion can be appreciated. The dermatopathologists should make every effort to comment systematically on all these risk markers. A biopsy confirming a superficial or nodular basal cell carcinoma should be different than a biopsy of a suspicious squamous cell carcinoma.

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“Clearly, a multi-disciplinary treatment and management of high-risk skin cancer patients is very important. I think we have to understand and appreciate the limitations we have as dermatologic surgeons and also the limitations of other specialties. At the same time, we and other specialists can bring complementary skills and tools to the table to optimally manage these patients,” Dr. Aasi says.

Melanoma has been one example of a skin cancer where systematic reporting of critical and prognostic histologic features and the multidisciplinary management of patients has been useful.

NEXT: Collaboration, cooperation

A 62-year-old cardiac transplant patient with a rapidly growing SCC that was larger and deeper than could be anticipated prior to biopsy.

Collaboration, cooperation

According to Dr. Aasi, collaboration and cooperation between head and neck surgeons, radiation oncologists, medical oncologists as well as radiologists will allow all of us to optimally manage and successfully treat patients with aggressive skin cancers. The perspective of a head and neck surgeon plays an important role here, Dr. Aasi says, as Mohs surgery can often treat local disease extremely well but these high-risk skin cancer lesions might not only be locally invasive in the skin but also spread regionally to the lymph nodes.

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“When approaching a high-risk skin cancer patient, we need to think of the entire individual as a host trying to fight off a cancer. If the cancer is infiltrating deeply, poorly differentiated, has perineural or angiolymphatic invasion, we need to be wary. We have to learn how to best anticipate these factors, do the proper biopsies that would demonstrate them, [and] encourage our dermatopathologists to look for and report them so we can manage these patients accordingly, perhaps with the help of imaging, involving other colleagues in a multidisciplinary setting, or even more frequent follow-up and surveillance,” Dr. Aasi says.

Drs. Aasi and Zwald have no relevant disclosures.