Skin Squam Possibly Short Time to Recurrence

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Haybrant

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Not sure why I cant get a straight forward case these days but heres another one. This is a 93 year old guy (pleasantly demented) that presented with at 2.5 cm cystic looking lesion and his PCP sent him to plastic surgery who decided to resect it and put a flap in afterwards. Deep margin is positive and all other margins are very close like 1mm. He delayed coming in for adjuvant RT for a while and now presents 1 month post surgery. His picture is below. I think there is recurrent tumor possible in 2 discontiguous spots, new areas his daughter who takes care of him did not see previously. What would you do now? Thought I should send him to derm to verify if there is recurrence. The primary was in the location of the medial arrow. If they are both tumor how would you proceed? Plastics got not imaging beforehand

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You could reach out to the dermatologist for his opinion. At his age I don't think it's going to change his dosing whether it's adjuvant versus recurrence. Did he have PNI at time of surgery? Even if not, I'd consider (mandatory IMO if he did have PNI) an MRI make sure he doesn't visible enhancement along nerves given the delay - I've seen too many cheek SCCs start tracking, especially when they're even somewhat deep.

Otherwise treat with whatever fractionation you'd use for a 93 year old with SCC of the cheek.
 
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Fortunately there was no pni. How would you set this up. Just track along that inferior/medial scar and add 2 cm margin where possible and electron him. Looks like the nasal labia and the lip commisire is gonna take on a good amount of dose. People put anything on the inside gums/mouth to protect at all? Wax?
 
I don't see a whole lot of white men with skin cancer, but this can surely be post-op change. Whatever you do, treat with wide margins.
 
If he fails again after radiation, I just saw a slide that these type of skin cancers apparently have the highest response of any tumor to checkpoint inhibitors.
 
assuming the two lesions I pointed out in arrows are tumor would this be a reasonable electron cutout? (no clue why all pictures are 90 degrees rotated,apologies)
 

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assuming the two lesions I pointed out in arrows are tumor would this be a reasonable electron cutout? (no clue why all pictures are 90 degrees rotated,apologies)

Seems reasonable. Maybe a little skimpy medially but I understand why. Wax mouthguard or something similar? Btw, kudos on the case presentations. Good discussion
 
Perhaps you can mold something to put inside his mouth to prevent excessive dose to the gingiva if you are going to treat this with electrons.
 
I treat a ton of skin cancer, and I often send these vaguely-defined sccs back to my derm colleagues for help delineating tumor extent. So far, they have been more than happy to accommodate and appreciate the collaboration.
 
I treat a ton of skin cancer, and I often send these vaguely-defined sccs back to my derm colleagues for help delineating tumor extent. So far, they have been more than happy to accommodate and appreciate the collaboration.

thanks reganite, since youre treating so many what do you think about the electron field above? What dose would you go to in this patient w positive deep margin assuming none of these repeat biopsies come back positive
 
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biopsies were negative. what dose would you guys go to for positive margin - someone suggested 55 in 20 above, 2.75's seem high to me
 
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