Skin Squamous with brain invasion

[busy body]

Got a guy with multiple recurrences of skin cancer of the scalp who now has brain and bone invasion locally just adjacent to the precentral gyrus. 78yo and a KPS of 70. Anyone think more resection is necessary since they will not resect the area well enough to get a GTR? Should I just do 60 Gy and 30fx and tell neurosurgery to hold off? Can't really find much literature on outcomes once the brain parenchyma is involved by skin cancer.

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[evilbooyaa]

Should've gotten radiation like 5 stops ago, but I'm sure he wasn't referred to you prior to this point. I'd do 60/30, consider a focal boost of 4/2 as possible. Agree no point of NSG to resect b/c he's going to need adjuvant RT anyways. Be wide in your margins.

 

[Palex80]

Indeed, irradiation now seems reasonable without further surgery. Check for nodes; when these tumors grow aggressively they tend to metastasize too...

 

[Neuronix]

I'd consider chemo (platinum or cetuximab) as well. No data--this person is just going to need all the help they can get.

I imagine that they've already had systemic staging.

 

[seper]

After managing a few of such cases, my strong bias is surgery first. XRT does not result in durable control. Disease often linger locally.
Of course not everyone is a candidate for craniotomy.

 

[evilbooyaa]

After managing a few of such cases, my strong bias is surgery first. XRT does not result in durable control. Disease often linger locally.
Of course not everyone is a candidate for craniotomy.

I'd argue that a 78yo w/ KPS of 70 (as long as the KPS is not due to his tumor, which I expect is the case) is not the greatest patient to take for a craniectomy.

Agree with the other two points about lymph node evaluation and consideration of concurrent chemo.

 

[busy body]

Thanks for the helpful insight.

 

[Reaganite]

After managing a few of such cases, my strong bias is surgery first. XRT does not result in durable control. Disease often linger locally.
Of course not everyone is a candidate for craniotomy.

Agree with this wholeheartedly if patient is a candidate. If someone isn't gonna go in and resect bone, this is short-term palliation. I have been sent a few myself and they all did poorly with XRT alone (i.e. tumor regrowth only a few months later). Gave 1 patient concurrent chemo and did nothing. These aggressive squams of the skin are bad news.