A Neglected Facial Ulceration

in an Elderly Man

presented by

Henry Foong FRCP, Ipoh, Malaysia (1)

Andrew Carlson MD, FRCPC, Albany, NY, USA (2)

on September 17, 2004

(1) Consultant Dermatologist, Foong Skin Specialist Clinic, Ipoh, Malaysia

(2) Associate Professor, Divisions of Dermatopathology and Dermatology
Albany Medical College, Albany, NY, USA

Comments by

Michael Albom M.D, Clinical Professor of Dermatology, Ronald O. Perelman Department of Dermatology, New York University Medical Center, New York, NY, USA on Sept 18, 2004

This patient's massive cutaneous facial neoplasm presents a very serious dilemma in terms of management. I would suggest that additional information is needed to evaluate this case. An MRI or CT scan of the head and neck would help to assess the depth and spread of invasion of disease and what critical underlying anatomic structures are invaded by this neoplasm. A needle biopsy would determine if the cervical adenopathy was due to neoplastic or inflammatory cells. Immunochemical histologic stains would be useful if the routine basic histochemical stains showed equivocal histologic findings.

A single biopsy of the main tumor mass may not necessarily be histologically representative of the entire neoplasm which may actually consist of multiple histologic subtypes. In other words, I have seem massive cutaneous tumors, such as this one, that have demonstrated microscopic elements consistent with basal cell carcinoma, squamous cell carcinoma and eccrine carcinoma. In my experience, basal cell carcinomas with multiple types of differentiation are more biologically aggressive in their invasive capabilities as compared to ones that reveal only single histologic patterns of basal cell carcinoma. This is a general comment and not meant to be inclusive since infiltrative and/or morphealike basal cell carcinomas can be extremely biologically aggressive.

The histologic evaluation of this neoplasm has relevance because it is somewhat unusual for a primary (previously untreated) basal cell carcinoma to become so massive within 4 years (assuming the history is accurate and the patient is not immunosuppressed).

If surgery was to become part of a plan of treatment, immunochemical histologic stains could not only be helpful to truly identify the nature of this neoplasm but also could assist in obtaining accurate microscopic control of the final surgical margins.

Performing as complete a workup as possible would ultimately determine whether or not treatment would consist of surgery alone or be combined with radiation therapy (and/or additional adjuvant treatment). We don't know the patient's overall physical and mental status as well as his social and familial circumstances. All of these factors and many more would contribute to the determination of his therapeutic management.

As I often work with excellent radiation therapists, I have immense respect for these experts. However, I have found during my many years specializing in the management of advanced skin cancers that there are a limited number of experts who have the advanced radiation armamentarium, special technical expertise and experience to treat such massive tumors.

Even though this patient is presently undergoing radiation therapy, I have serious concerns about radiation therapy being used as his only treatment. These types of very large neoplasms have a tendency to spread well beyond their presumed clinical margins. Therefore, the treatment may be doomed to failure from the start if the chosen field of radiation was inadequate. Also, in my experience, when radiation therapy fails, these kinds of tumors become more biologically aggressive with further direct invasion of underlying structures. In addition, there becomes an increased risk for metastatic spread of disease. If there is invasion of disease into osseous structures, radiation therapy is less likely to succeed. Even if palliation is the intended goal of treatment, there is no way to realistically predict the period of time that will elapse before the neoplasm begins to further expand. I have seen cases where the neoplasm grew with a vengeance within a few months of the completion of radiation therapy. Realistically, there would be nothing more, in terms of treatment, to offer this patient if radiation therapy was not successful.

I would not discount the possibility of combined surgical and radiation treatment until of full workup was completed. I have worked with teams of highly skilled head and neck surgeons, radiation therapists and plastic surgeons who have been able to successfully treat patients with massive facial tumors. It would be important to emphasize that, even under the care of the best experts, there are treatment failures that also occur in trying to eradicate these massive cancers. I will shortly describe a personal experience about such cases even though they occurred decades ago.

Since these massive cutaneous tumors occur relatively infrequently, there is limited published information about these cases with regard to accurate histories, detailed physical findings, laboratory studies including significant hematologic parameters, clinical bood chemistries, radiologic scans, complete detailed histologic findings, how surgical margin analysis was accomplished when surgery was done, precise description of treatment, long-term followup as to the success of treatment and the physical and emotional functionality of the patient.

Some empathetic physicians are of the opinion that these types of patients have such advanced disease that any surgical or radiological intervention would be too stressful or rapidly lead to the patient's demise. I can readily appreciate the humane considerations behind this opinion. However, there are serious practical issues to consider as this neoplasm continues to expand and invade into this patient's head. In 1973, during my residency training in dermatology, I worked at a particular hospital that was devoted only to the care of patients with serious oncological conditions. I attended to 2 patients who were said to be inoperable with massive recurrent basal cell carcinomas of the face and scalp. The unsuccessful previous treatments had consisted of surgical intervention followed by radiation therapy. One of the patients had direct invasion of neoplasm into his brain. Controlling constant oozing and bleeding from these tumors was almost impossible and the pain they experienced was only partially relieved by narcotic analgesics. Both patients died soon after, one due to acute uncontrollable hemorrhage and the other from complications of infection. At the advanced stages of their diseases, there was literally no treatment to offer these patients 31 years ago.

Fortunately, our academic knowledge and technological advances have expanded since that time over 3 decades ago. For example, almost 2 years ago, I worked with a team of specialists consisting of a head and neck surgeon, 2 neurosurgeons, a plastic surgeon, and a radiation oncologist to treat a massive basal cell of the entire right face, neck and scalp with invasion into the dura of the brain. His most recent examination reveals a man with some loss of facial nerve function because of the deep depth of disease, but otherwise he is completely intact mentally and physically. Clearly, even though he seems to be free of disease at 2 postoperative years, much more time has to lapse with continued medical scrutiny before true success can be claimed. My point is that now there is technology in surgery and radiation therapy that was not available even 5 years ago.

With all of this said, we hope that this patient will have success in his present course of treatment. It would be helpful to have a followup as to his ultimate outcome.