Primary Cutaneous Squamous-Cell Carcinoma on the Face: Penetration to the Base of the Brain M IC H A E L J. ALBOM , M.D.
A recurrent squamous-cell carcinoma that was found clinically to have metastasized to regional lymph nodes was managed by a surgeon skilled in Mohs' techniques, a plastic surgeon, and a radiotherapist in a premeditated plan. The malignancy was further found to have ex tended to the base o f the brain. As much surgery as was deemed feasible, still short o f complete ablation o f the malignancy, was performed. Radiotherapy to the neck prior to radical lymphadenectomy and to the base o f the brain subsequently was administered. After one year o f follow-up, the patient is well, though prognosis is guarded.
A 56- y e a r - o l d w h i t e w o m a n was referred for treatment of a squamous-cell carcinoma on the right cheek. The pertinent history was that five years ago, a lesion described as a “ blind pimple” appeared on the right cheek. By squeezing it, the patient forced a slight discharge. Healing proceeded in the course of a few weeks and a simple “ scar” is said to have resulted. There was no appreciable change in the site until a year later, when a warty growth appeared upon it, and in the course of another year the growth enlarged to a mass that came to be almost 4 cm above the surface of the skin. The lesion was then biopsied and read to be a squamous-cell carcinoma. It was treated by curettage and electrodesiccation. Within three months swelling recurred at the site. By the time o f referral, the patient had an erythematous, firm, movable nodule, measuring 2 x 2.5 cm in diameters on the right cheek (Fig. 1). Physical examination of the head and neck for lymphadenopathy revealed a firm, movable lymph node, 2.5 cm in size, in the digastric triangle and a firm, freely movable, submandibular lymph node, 3 cm in size. The remainder of physical examination was negaDr. Albom is Assistant Professor o f D erm atology, D epartm ent of D erm atology, New York U niversity Medical C enter, N ew York, N ew York. A ddress reprint requests to Dr. Michael J. Albom, D epartm ent of D erm atology, 566 First Avenue, N ew York, N.Y. 10016.
318
J. Dermatol. Surg. Oncol. 5:4 April 1979
tive in findings for overt metastatic disease. L abora tory findings, particularly roentgenography o f the chest, were within normal limits. The plan o f management was to trace out and ablate the carcinoma on the face by M ohs’ microscopically controlled surgery, and then to irradiate the nodes in the neck prior to radical dissection. Five separate mi-
FIGURE 1. Clini cal appearance o f the recurrent squamous-cell carcinoma at the time o f presentation.
AL BOM
I,
i >.3 . > FIGURE 2. His tologic appear ance o f the recur rent squamous cell carcinoma showing malig nant cells in perineural tissue and between nerve bundles.
croscopically controlled layers were taken under local anesthesia (infraorbital nerve block technique) with 1% lidocaine and epinephrine. The malignancy was found to extend principally along perineural tissue and between nerve bundles. The histologic pattern is clearly seen in sections stained with hematoxylin and eosin (Fig. 2). Over 60 frozen sections o f tissue were examined as the malignancy was traced to the perios teum of the infraorbital foramen. The neoplasm did not appear to invade bone but to extend only along the perineural sheaths. The final size of the surgical wound at this time measured 5.5 x 5.0 cm and reached deep to the maxilla (Fig. 3). Since a disease-free plane had not yet been reached, within 48 hours a plastic surgeon proceeded to resect the right cheek and infraorbital skin, part o f the right maxilla, the infraorbital nerve to its foramen o f exit, and the floor o f the orbit. A frozen section o f the infraorbital nerve in entirety showed well-differentiated squamous-cell carcinoma in its perineural space and between bundles o f peripheral nerves. The posterior wall of the maxilla was then re moved completely to expose the pterygopalatine fossa. A piece of the maxillary branch of the trigeminal nerve was removed to the point where it disappeared into the body o f the pterygoid bone. This piece of nerve also proved to be positive for squamous-cell carcinoma. Since further surgery was not deemed feas ible because it appeared certain that the malignancy had reached to the base of the brain, a split-thickness skin graft was placed upon the surgical defect (Fig. 4) and radiotherapy was resorted to. Four days postoperatively, radiotherapy to the right
FIGURE 3. Clini cal appearance o f the defect at the time when M ohs’ surgery was dis continued. Planes free o f malignancy had been reached except in nervous tissue.
FIGURE 4. Clinical appearance o f the defect after resection o f parts o f the maxilla, the floor o f the orbit, the infraorbital nerve and the trigeminal nerve to the pterygoid bone. The nerves were still positive for malignancy.
side of the neck was begun. With a Cobalt 60 ap paratus, a total dose of 5,000 rads was administered in 25 fractions over a 36-day period. By the end of this course of radiotherapy, the jugular node in the digas tric triangle was no longer palpable and the subman dibular node was much reduced in size from what it was originally. Radiotherapy was then begun to the foramen rotundum with a 4 MeV apparatus and bolus of 2 cm in thickness. Before completion of this course of radiotherapy, radical dissection of the neck, parotidec tomy, and dissection of the facial nerve were per formed. The remainder o f the course of radiotherapy
J. Dermatol. Surg. Oncol. 5:4 April 1979
319
PRIMARY CUTANEOUS SQUAMOUS-CELL CARCINOMA ON THE FACE
was then completed. A total dose of 4,500 rads was administered in 22 fractions over a 35-day period. The final histologic examination of tissue obtained from the dissection of the neck revealed squamous-cell carcinoma in one parotid lymph node and in one of three submandibular lymph nodes. Thirty-three other regional lymph nodes were negative. One year postoperatively, the patient is alive and well with no evidence of further metastatic disease. Needless to say, the prognosis still remains guarded.
dissection reduced the chance of recurrence after surgery. A multidisciplinary team-approach by specialists in oncology proved to be invaluable in the management of this very diflicult case of squamous-cell carcinoma with ultimately inaccessible regional spread. This kind of cooperative effort makes for investigational and therapeutic programs that maximize curative or at least desirably palliative results.
COM M ENT
Dr. Phillip R. C asson, Associate Professor o f Surgery (Plastic), N .Y .U . M edical C enter, perform ed the m ajor surgery, and Dr. Anthony T. Farina, Associate Professor o f Clinical R adiology, Divi sion o f Radiation Oncology, N .Y .U . M edical C enter, adm inistered the radiotherapy.
ACKNOW LEDGM ENT
The Mohs technique of microscopically controlled surgical excision delimited precisely the cutaneous ex tent of the malignancy and revealed its propagation via nerve sheaths. The latter revelation was of assistance to the plastic surgeon because it enabled him to better plan surgical resection. In addition, the histologic find ings raised our suspicion that even normal-appearing neural tissue within the orbit might be invaded by the malignancy. This indeed proved to be the case. The radiotherapist was able to treat the base of the brain, which was surgically unapproachable. Pretreating the neck with ionizing radiation before the radical neck
320
J. Dermatol. Surg. Oncol. 5:4 April 1979
G E N E R A L B IB L IO G R A PH Y Jesse, R. H ., and L indberg, R. D. The efficacy of com bining radia tion therapy with a surgical procedure in patients with cervical m etastasis from squam ous cancer o f the oropharynx and hypopharynx. C ancer 35:1163—1166, 1975. Mohs, F. E. Chem osurgery: M icroscopically Controlled Surgery for Skin Cancer. Springfield, Illinois, C harles C Thom as, 1978. Strong, E. W. Preoperative radiation and radical neck dissection. Surg. Clin. N o rth Am. 49:271-276, 1969.
A recurrent squamous-cell carcinoma that was found clinically to have metastasized to regional lymph nodes was managed by a surgeon skilled in Mohs' techniques, a plastic surgeon, and a radiotherapist in a premeditated plan. The malignancy was further found to have ex tended to the base o f the brain. As much surgery as was deemed feasible, still short o f complete ablation o f the malignancy, was performed. Radiotherapy to the neck prior to radical lymphadenectomy and to the base o f the brain subsequently was administered. After one year o f follow-up, the patient is well, though prognosis is guarded.
A 56- y e a r - o l d w h i t e w o m a n was referred for treatment of a squamous-cell carcinoma on the right cheek. The pertinent history was that five years ago, a lesion described as a “ blind pimple” appeared on the right cheek. By squeezing it, the patient forced a slight discharge. Healing proceeded in the course of a few weeks and a simple “ scar” is said to have resulted. There was no appreciable change in the site until a year later, when a warty growth appeared upon it, and in the course of another year the growth enlarged to a mass that came to be almost 4 cm above the surface of the skin. The lesion was then biopsied and read to be a squamous-cell carcinoma. It was treated by curettage and electrodesiccation. Within three months swelling recurred at the site. By the time o f referral, the patient had an erythematous, firm, movable nodule, measuring 2 x 2.5 cm in diameters on the right cheek (Fig. 1). Physical examination of the head and neck for lymphadenopathy revealed a firm, movable lymph node, 2.5 cm in size, in the digastric triangle and a firm, freely movable, submandibular lymph node, 3 cm in size. The remainder of physical examination was negaDr. Albom is Assistant Professor o f D erm atology, D epartm ent of D erm atology, New York U niversity Medical C enter, N ew York, N ew York. A ddress reprint requests to Dr. Michael J. Albom, D epartm ent of D erm atology, 566 First Avenue, N ew York, N.Y. 10016.
318
J. Dermatol. Surg. Oncol. 5:4 April 1979
tive in findings for overt metastatic disease. L abora tory findings, particularly roentgenography o f the chest, were within normal limits. The plan o f management was to trace out and ablate the carcinoma on the face by M ohs’ microscopically controlled surgery, and then to irradiate the nodes in the neck prior to radical dissection. Five separate mi-
FIGURE 1. Clini cal appearance o f the recurrent squamous-cell carcinoma at the time o f presentation.
AL BOM
I,
i >.3 . > FIGURE 2. His tologic appear ance o f the recur rent squamous cell carcinoma showing malig nant cells in perineural tissue and between nerve bundles.
croscopically controlled layers were taken under local anesthesia (infraorbital nerve block technique) with 1% lidocaine and epinephrine. The malignancy was found to extend principally along perineural tissue and between nerve bundles. The histologic pattern is clearly seen in sections stained with hematoxylin and eosin (Fig. 2). Over 60 frozen sections o f tissue were examined as the malignancy was traced to the perios teum of the infraorbital foramen. The neoplasm did not appear to invade bone but to extend only along the perineural sheaths. The final size of the surgical wound at this time measured 5.5 x 5.0 cm and reached deep to the maxilla (Fig. 3). Since a disease-free plane had not yet been reached, within 48 hours a plastic surgeon proceeded to resect the right cheek and infraorbital skin, part o f the right maxilla, the infraorbital nerve to its foramen o f exit, and the floor o f the orbit. A frozen section o f the infraorbital nerve in entirety showed well-differentiated squamous-cell carcinoma in its perineural space and between bundles o f peripheral nerves. The posterior wall of the maxilla was then re moved completely to expose the pterygopalatine fossa. A piece of the maxillary branch of the trigeminal nerve was removed to the point where it disappeared into the body o f the pterygoid bone. This piece of nerve also proved to be positive for squamous-cell carcinoma. Since further surgery was not deemed feas ible because it appeared certain that the malignancy had reached to the base of the brain, a split-thickness skin graft was placed upon the surgical defect (Fig. 4) and radiotherapy was resorted to. Four days postoperatively, radiotherapy to the right
FIGURE 3. Clini cal appearance o f the defect at the time when M ohs’ surgery was dis continued. Planes free o f malignancy had been reached except in nervous tissue.
FIGURE 4. Clinical appearance o f the defect after resection o f parts o f the maxilla, the floor o f the orbit, the infraorbital nerve and the trigeminal nerve to the pterygoid bone. The nerves were still positive for malignancy.
side of the neck was begun. With a Cobalt 60 ap paratus, a total dose of 5,000 rads was administered in 25 fractions over a 36-day period. By the end of this course of radiotherapy, the jugular node in the digas tric triangle was no longer palpable and the subman dibular node was much reduced in size from what it was originally. Radiotherapy was then begun to the foramen rotundum with a 4 MeV apparatus and bolus of 2 cm in thickness. Before completion of this course of radiotherapy, radical dissection of the neck, parotidec tomy, and dissection of the facial nerve were per formed. The remainder o f the course of radiotherapy
J. Dermatol. Surg. Oncol. 5:4 April 1979
319
PRIMARY CUTANEOUS SQUAMOUS-CELL CARCINOMA ON THE FACE
was then completed. A total dose of 4,500 rads was administered in 22 fractions over a 35-day period. The final histologic examination of tissue obtained from the dissection of the neck revealed squamous-cell carcinoma in one parotid lymph node and in one of three submandibular lymph nodes. Thirty-three other regional lymph nodes were negative. One year postoperatively, the patient is alive and well with no evidence of further metastatic disease. Needless to say, the prognosis still remains guarded.
dissection reduced the chance of recurrence after surgery. A multidisciplinary team-approach by specialists in oncology proved to be invaluable in the management of this very diflicult case of squamous-cell carcinoma with ultimately inaccessible regional spread. This kind of cooperative effort makes for investigational and therapeutic programs that maximize curative or at least desirably palliative results.
COM M ENT
Dr. Phillip R. C asson, Associate Professor o f Surgery (Plastic), N .Y .U . M edical C enter, perform ed the m ajor surgery, and Dr. Anthony T. Farina, Associate Professor o f Clinical R adiology, Divi sion o f Radiation Oncology, N .Y .U . M edical C enter, adm inistered the radiotherapy.
ACKNOW LEDGM ENT
The Mohs technique of microscopically controlled surgical excision delimited precisely the cutaneous ex tent of the malignancy and revealed its propagation via nerve sheaths. The latter revelation was of assistance to the plastic surgeon because it enabled him to better plan surgical resection. In addition, the histologic find ings raised our suspicion that even normal-appearing neural tissue within the orbit might be invaded by the malignancy. This indeed proved to be the case. The radiotherapist was able to treat the base of the brain, which was surgically unapproachable. Pretreating the neck with ionizing radiation before the radical neck
320
J. Dermatol. Surg. Oncol. 5:4 April 1979
G E N E R A L B IB L IO G R A PH Y Jesse, R. H ., and L indberg, R. D. The efficacy of com bining radia tion therapy with a surgical procedure in patients with cervical m etastasis from squam ous cancer o f the oropharynx and hypopharynx. C ancer 35:1163—1166, 1975. Mohs, F. E. Chem osurgery: M icroscopically Controlled Surgery for Skin Cancer. Springfield, Illinois, C harles C Thom as, 1978. Strong, E. W. Preoperative radiation and radical neck dissection. Surg. Clin. N o rth Am. 49:271-276, 1969.
