Know When to Cut, Know when to Punt

The patient is an 87 yo man with a mild dementia. He lives in an assisted care facility. Has an attentive and caring daughter. In October of 2007 he had a wide-local excision of s large SCC on the left forehead by a general surgeon. Path report showed "clear margins." When seen on May 30, 2008 a 4 x 3 cm recurrence was noted. The picture of the right TMJ area shows a scar from micrographic surgery from a similar lesion the patient had ~ 10 years ago. His daughter said it took 6 months to heal.





Questions:
1. What contributes to the aggressive behavior of this small subset of SCCs?
2. Would you refer to Mohs, XRT, or just watch?
3. Are you comfortable playing God with patients like these?

Comment: There is a subset of SCCs that metastasize and kill patients. MA Weinstock and his collaborators have written on this subject.

Weinstock MA, et. al.
Nonmelanoma skin cancer mortality. A population-based study.
Arch Dermatol. 1991 Aug;127(8):1194-7.

Department of Medicine, Veterans Affairs Medical Center
Providence, RI 02908.

To estimate the magnitude of nonmelanoma skin cancer mortality
and describe itsparameters, we reviewed the medical records of
all deaths certified as due to this cause among Rhode Island
residents from 1979 through 1987. After excluding acquired
immunodeficiency syndrome-associated Kaposi's sarcoma, we
confirmed that nonmelanoma skin cancer was the cause of death
for 51 individuals, a quarter of the number of melanoma deaths
reported. The age-adjusted nonmelanoma skin cancer mortality rate
was 0.44/10(5) per year. Fifty-nine percent were due to squamous
cell carcinoma, and 20% were due to basal cell carcinoma. Most
appeared actinically induced. Among deaths from SCCs, the mean age
was 73 years. At least 80% of the squamous cell carcinomas metas-
tasized, and 47% arose on the ear. None appeared due to refusal of
treatment. Among deaths frombasal cell carcinoma, the mean age was
85 years, and refusal of surgical  intervention was documented in
40%. Study of nonmelanoma skin cancer mortality provides for estimation
of the magnitude of this problem, complements otherstudies of
prognosis, and helps guide prevention, early detection, and treatment.