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    High-risk skin cancer needs multidisciplinary management

    A 62-year-old cardiac transplant patient with a rapidly growing SCC that was larger and deeper than could be anticipated prior to biopsy.

    High-risk non-melanoma skin cancers such as squamous cell carcinoma (SCC) have always been notoriously challenging to treat. This is especially true for immunosuppressed individuals such as organ transplant recipients (OTR). The aggressiveness of these high-risk tumors has made a multi-disciplinary approach increasingly crucial in the optimal treatment and management of this patient population.

    READ: SCC staging update defines high-risk tumors

    Fiona O’Reilly Zwald, M.D., M.R.C.P.I.“It is very practical and useful to have different physician specialists nearby when approaching complicated high-risk skin cancer patients because, more likely than not, such cases will require a multidisciplinary approach in order to help ensure that the patient receives the best possible medical care available,” says Fiona O’Reilly Zwald, M.D., M.R.C.P.I., Dermatology Consultants, PC, Piedmont Transplant Institute, Atlanta, Ga.

    The criteria

    Several parameters need to be met in order to classify non-melanoma skin cancer, such as SCC, as high-risk, including:

    • Large tumor size (usually greater than 2 cm diameter)
    • Increased tumor depth
    • Recurrence
    • Location of the tumor (usually in the head and neck region)

    Although advanced basal cell carcinomas (BCC) can technically be considered high-risk due to their sheer size, these tumors rarely metastasize, casting the remaining focus on SCC and other potentially aggressive tumors.

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    In addition to the aggressiveness of these tumors, Dr. Zwald says that high-risk SCCs are usually very large and often challenging to surgically remove. It is not uncommon to find inoperable tumors in elderly patients whose physical status does not allow for invasive surgery.

    Moreover, high-risk tumors can be very tricky to manage Dr. Zwald says, because they often invade substantially into the subcutaneous tissue and can have perineural invasion of the tumor as well. “That’s a major concern because even if I perform a wider resection of a tumor using the Mohs surgery technique, I will always bring in other specialties and ask for adjuvant radiation therapy afterwards in order to help ensure that the tumor does not recur,” Dr. Zwald says.

    READ: Moving toward personalized medicine for melanoma

    Immunosuppressed patients such as OTRs present a number of challenges and will often have multiple non-melanoma skin cancer tumors that tend to grow very quickly. In addition, Dr. Zwald says that there are a number of time-sensitive comorbidities, such as potential postoperative infections, that the dermatologic surgeon must be wary of and address in immunosuppressed patients.

    NEXT: Coming to consensus


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