58 yo man with large forehead squamous cell carcinoma

This 58 year old man is a former construction worker who was admitted to the psychiatric ward for depression, suicidal ideation, and homelessness.

He has not sought medical care in over fifteen years. He presented with this lesion on his forehead, which he reports has been there for 1.5 years. By history, the lesion began as a pigmented macule, then became more like a 'pimple' which persisted and slowly got larger. The patient at first put a band-aid over it and then later covered it with a baseball cap. He says that he did not have a mirror and so was not paying much attention to it, but it has been more painful in the past 2-3 months.

He recently has suspected that it is cancer, but has not been moved to find medical care because of greater feelings of hopelessness and defeat.

Laboratory Data

Nil

Squamous Cell Carcinoma of the Forehead

He has been offered radiation therapy. The patient is considering treatment but still expresses apathy and hopelessness. 

This case is illustrative how critical it is to treat the patient as well as the disease, what a significant comorbidity depression can be, and how denial and lack of access to medical care can greatly complicate treatment and prognosis.

How would you treat this man?  Do you feel XRT is superior to micrographic surgery or other modalities in this patient?

Squamous Cell Carcinoma, homelessness, mental illness

Carlos Garcia MD, Associate Professor, Department of Dermatology, Univeristy of Oklahoma, Oklahoma City, Oklahoma, USA on June 23, 2011

The author provided good data including pertinent negatives (LN, fixed, no labs, etc)

This patient has an aggressive SCC with high risk for recurrence and metastases. Work-up should include CT scan to rule out bony involvement. Therapy depends on the latter but will mainly be surgical. I do not think radiation therapy would offer a would alternative as a primary therapy but may have an adjuvant role.

David Elpern MD, Dermatologist, Williamstown, MA, USA on June 23, 2011

Ms. Ellis did a great job with this case. Thank you! The patient is homeless and has no support system. This is a large lesion and I wonder how much necrosis XRT will cause? We have some experts in XRT who will weigh in on this. Alternatively, Mohs might be the best approach for a tumor of this size. It might need to heal by secondary intention (which would take months) or grafted which will require attention to the site. At any rate, he'd require a long hospitalization for complete healing. The patient is isolated and has some kind of psychiatric illness -- possibly just depression. Whatever treatment, he can will not be able to live in a homeless shelter for quite a while after treatment. Someone will have to take an interest in him and forge a relationship, gain his trust and hold his hand (figuratively). It may have to be Ms. Ellis if her med school program will allow her to spend the time. Or a social worker. The treatment may be the easiest part.

Malcolm Lane-Brown FACD, Consultant Dermatologist, Sydney, NSW, Australia on June 23, 2011

Typical of the homeless in Australia. A valuable lesson because of the underlying psychiatric problem. Sxrt is the best treatment modality. The homeless are usually non-compliant. Cosmesis is not a concern. One dose only? Half-way house, AA, etc. should be considered.

Thamir Kubaisi MD, Assistant Professor, Department of Dermatology, Al-anbar, Iraq on June 23, 2011

The surgical removal is superior if he fit for it. Iin addition this patient might not continue the course of radiotherapy because he neglects himself.

Phung Huynh MD, Dermatologist, Milford, CT, USA on June 25, 2011

Bryan Chang (Radiation Oncologist at Yale) agrees radiation is a good choice, but would first do a CT of head & neck (looking for nodal involvement & r/o intracranial invasion) as well as a CXR prior to treatment to evaluate for metastasis. Treatment would be 60-70 Gray with daily treatments over 6-7 weeks.

Michael Albom MD, Clinical Professor, Dept Dermatology, New York University, New York City, NY, USA on June 25, 2011

I think that you and Ms. Ellis beautifully encapsulated the dilemma of this sad gentleman.  His psychiatric diagnosis is going to be critical to determine his ability to understand the basic concepts of his cutaneous neoplasm and available treatments.  It will also be very important in assessing his ability to comply with whatever treatments may be available for him.  If he doesn't have the capacity to understand these issues,   it would realistically be next to impossible to provide him with appropriate medical care.

Let's assume for the sake of argument that, with psychiatric intervention, he would be able to undergo treatment.  The next issue to resolve is arranging a place for him to live with responsible people monitoring him, hopefully through a social services agency.  Let's assume that can be done.

Then, evaluation for treatment is next.  He's got a very large squamous cell carcinoma that may well have invaded his skull.  Clearly, a CT scan can determine whether or not he has cortical invasion or deeper involvement of the bone.  If his has bony involvement, radiation therapy (XRT), in my experience, is very likely to fail.  For purposes of a baseline evaluation, it would be reasonable to obtain a CT of the remainder of his head and neck at the same time as that of the skull evaluation.  This is important because he is at higher risk for metastasis if his tumor is poorly differentiated histologically and/or is neurotropic, 

Based upon the constellation of findings in this case, I would recommend that a wide surgical excision with histological examination of the surgical specimen be done under general anesthesia in a hospital.  I have concern that the surgical specimen may only be sampled and an inadequate study of the margins could occur, but hopefully the hospital-base pathologist would do as much as possible in determining microscopic margin control   If bony involvement had been established by CT scan, a highly skilled plastic surgeon or head and neck surgeon would have to remove the involved segment of bone.  If the tumor has invaded both inner and outer tables of bone, a neurosurgeon may join the team.  The type of reconstruction would depend upon the depth of bony involvement and other findings at surgery.  The types of repairs could vary from a large split thickness skin graft and flaps to a microvascular free-flap.  He would have to be kept in the hospital for a long enough period of time to be sure he was healing well with no complications such as infection, bleeding or necrosis of tissues at the repair site.

Mohs surgery could be utilized but very few medical centers in the United States allow their Mohs surgeons to do the procedure under general anesthesia in a general operating room.  It would still take a team of surgeons to manage the entire case.

After discharge from the hospital, he will require frequent monitoring regarding post-operative care to ensure that he isn't negatively impacting the surgical site by pulling at his bandages or picking at the site of reconstruction.  Such intervention by the patient could cause bleeding, infection or failure of the surgical repair.  He will have to be living in quarters where his basic home-care needs are provided by appropriate aides.  Social workers will be needed to keep him motivated and meaningfully occupied within this setting.  Medical and surgical supervision will have to be undertaken by his physicians and nursing personnel.  Clearly, his management will be very labor intensive.

It will take a dedicated team headed by a very motivated person to take charge of all of the multitude of variables in his care.  He may not be a particularly compliant patient and that would add another set of dilemmas to his management.  His overall psychiatric status will have to be monitored closely in the event that he develops a serious depression or suicidal thoughts.  Frankly, a very sizable number of health care personnel will be required to oversee this gentleman's daily care.  Unfortunately, our health care system  is not always up to the task to provide the level of intensive management to such a patient when there are so many complexities involved.  Hopefully, he will obtain the care he desperately needs.

Doug Johnson MD, University of Hawaii, Honolulu, Hawaii on July 2011.

Large neglected tumor but good chance if it is localized. Palpate for nodes. Skull and CXR, CT if they will pay Mohs with skin graft or Debulk and superficial xray 4500 cGy over 2-3 weeks, 6-8 txs.