An 84-year-old man comes to the office with a slowly growing, reddish-brown lesion on his face. He has had no associated pain, itching, or discharge and no history of trauma to the area. The patient is a retired postal worker and spends most of his leisure time on a nearby beach. Medical history is notable for moderate dementia, coronary artery disease, and diet-controlled diabetes mellitus. Examination shows a 0.6-cm, irregular, reddish-brown lesion on the forehead. Palpation of the submandibular and cervical lymph nodes is normal, and no other suspicious lesions are noted on skin examination. Biopsy of the lesion reveals well-differentiated invasive squamous cell carcinoma with no perineural or vascular involvement. After discussion with his family, the patient declines surgical excision but says he is willing to consider nonsurgical alternate treatments. Which of the following is the most appropriate recommendation for this patient?

Question

An 84-year-old man comes to the office with a slowly growing, reddish-brown lesion on his face.  He has had no associated pain, itching, or discharge and no history of trauma to the area.  The patient is a retired postal worker and spends most of his leisure time on a nearby beach.  Medical history is notable for moderate dementia, coronary artery disease, and diet-controlled diabetes mellitus.  Examination shows a 0.6-cm, irregular, reddish-brown lesion on the forehead.  Palpation of the submandibular and cervical lymph nodes is normal, and no other suspicious lesions are noted on skin examination.  Biopsy of the lesion reveals well-differentiated invasive squamous cell carcinoma with no perineural or vascular involvement.  After discussion with his family, the patient declines surgical excision but says he is willing to consider nonsurgical alternate treatments.  Which of the following is the most appropriate recommendation for this patient?

Quizplus · Accepted Answer

Explanation: Squamous cell skin cancer (SCSC) is the second most common skin malignancy and carries a low but significant risk of metastasis if untreated. High-risk lesions (eg, large size, poorly differentiated histology, perineural invasion) warrant surgical excision. Most low-risk invasive SCSC lesions (as in this case) should also be excised in order to obtain histologic confirmation of tumor margins. However, additional options are available for patients who do not wish to have surgery or are poor surgical candidates. These include cryotherapy, electrosurgery, and radiation therapy. Cryosurgery and electrosurgery are well-tolerated office-based therapies that offer good results. SCSC is also amenable to radiation therapy, which can be tailored to spare surrounding tissue resulting in good cosmetic results. However, radiation therapy requires multiple visits and increases the risk of future malignancies; it is therefore typically used in older patients who refuse surgery. The choice of treatment depends on local expertise, cosmetic factors, and patient preference. (Choice A) BRAF gene mutations are seen in most cutaneous melanomas and lead to accelerated melanocyte growth and metastasis. BRAF kinase inhibitors (eg, vemurafenib) can increase survival in patients with melanoma but are not used in SCSC. (Choice B) Systemic chemotherapy is recommended for locally advanced, high-risk SCSC that cannot be adequately treated with surgical or radiation therapy, and for metastatic disease. It is not indicated for low-risk lesions. (Choice C) Radiation therapy in low-risk SCSC is administered with curative intent and has a low local recurrence rate. As this patient has minimal symptoms, palliative services are not indicated at this time. (Choice D) Photodynamic therapy and topical agents (eg, 5-fluorouracil) are used in treating actinic keratosis and Bowen disease (SCSC in situ), but they should not be used for invasive SCSC due to the risk of recurrence. Educational objective: Surgery is the preferred treatment for both low- and high-risk invasive squamous cell skin cancer (SCSC). Other approved options for low-risk SCSC include cryotherapy, electrosurgery, and radiation therapy. References: Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies. (http://www.ncbi.nlm.nih.gov/pubmed/24191270)

An 84-Year-Old Man Comes to the Office with a Slowly