tumor board management of complex skin …...©2011 mfmer | slide-1 tumor board management of...

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Tumor Board Management of Complex Skin Cancers

DFSP, EMPD, and Melanoma Jerry D. Brewer, MD, MS, FAAD brewer.jerry@mayo.edu Professor of Dermatology Division of Dermatologic Surgery Department of Dermatology Mayo Clinic / Mayo Clinic College of Medicine

AAD February 18, 2018

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Disclosures

• None

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Dermatofibrosarcoma Protuberans

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History • 39 yo female • DFSP in the right mons pubis • Very sensitive to surgery (can’t do it awake) • Sent for 2nd opinion of best way to treat

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Work up • Excisional biopsy

• Felt to have positive margins • MRI

• No definite residual tumor in the subcutaneous tissues or subjacent muscles

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Pre-op

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Course • Coordination with outpatient surgery unit • Mohs with conscious sedation • Tumor cleared with 2 stages

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Defect

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Closure

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6 month post-op

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Course • DFSP – couldn’t be better! • Family

• Increased stress • Mom with “cancer” • 2 Teenage sons

• Previous A / B student • Very good basketball player • School – Grades plumet • Drops out of basketball team • Drugs and alcohol

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Course • Took > 2 years • One son back on track fairly quick • Other more struggles

• Starting to get out of drugs and alcohol • Family doing well • Following January

• Invasive ductal carcinoma – right breast • Currently undergoing treatment • Family stable

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Lessons • Things might look fantastic from our standpoint • We may not really truly understand the stressors families

feel with what patients go through • We treat skin cancer every day

• Routine • For patients…it is not routine

• very much a stress for many • Good to keep perspective

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Case 2 - DFSP

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History • 51 year old female • Lump on left shoulder

• Noticed July 2017 • US guided biopsy

• Favor DFSP vs Cellular Fibrous Histiocytoma • MRI

• 8-mm enhancing soft tissue nodule • Abuts and likely invades the deltoid muscle

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Pre-op

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Course • Scheduled for Mohs Surgery • Consult with Orthopedics Oncology

• Possible collaboration in case deeper than anticipated

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Course • Patients apt for Mohs surgery canceled • Called patient

• Told by Orthopedic Oncologic Surgeon • You should not have Mohs

• “We would like more of a wider margin than a more close margin excision”

• Need deltoid removed all the way to acromion • Parascapular flap closure

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Course • Called Orthopedic Oncology colleague

• Discussed differences of opinion • Patient confused

• Requested another call from Orthopedic Oncology colleague

• Ultimately decided to go with Mohs surgery

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Debulking

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Final Defect – clear with 2 stages

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Closure

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Forest Plot – Recurrence MMS vs WLE

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• Heterogeneity • p value – 0.133

• Model • p value – 0.024

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Course • Patient recovered well • Minimal pain

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Lessons • Difficult tumors • Better when collaborating • Sometimes collaborating can bring an extra layer of

confusion • Good to have all collaborators on same page

• Decreases mixed messages sent to pt • Sometimes collaborating on difficult cases

• Good opportunity to cordially educate colleagues

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Extramammary Paget’s Disease

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History • 83 year old female • Rash in vulva for 2 years

• Very itchy, burns, and sometimes bleeds • Treated with topical clobetasol • Felt to be LS&A by IM

• Biopsied • EMPD

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Pre-op

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Course • Scouting biopsies

• Prior to surgery

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Scouting Biopsies

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Positive Scouting Biopsies • Right vulva A, J, K, L, M, R, Q, and P • Key here – right vulva S was negative!

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Course

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Course

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Closure post mohs

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Course

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Course

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Closure

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Course • Pt doing well • Recovery without complications

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Lessons • Scouting biopsies

• Very helpful! • Collaboration

• Gyn/Onc • Plastic Surgery

• Good communication • Scheduling • Expectations

• Challenging tumor can be satisfying

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Melanoma

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Kai AC, Richards T, Coleman A, Mallipeddi R, Barlow R, Craythorne EE. Five-year recurrence rate of lentigo maligna after treatment with imiquimod. Br J Dermatol. 2016 Jan;174(1):165-8.

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Imiquimod and Lentigo Maligna • Recurrence rate post MMS

• 0 to 6.25% • 40 patients • Imiquimod three times weekly x 6 weeks • 25 (62.5%) – experienced inflammation • 15 non-inflamed

• Continued 5 times weekly x 4 additional weeks • All eventually experienced inflammation

Kai AC, Richards T, Coleman A, Mallipeddi R, Barlow R, Craythorne EE. Five-year recurrence rate of lentigo maligna after treatment with imiquimod. Br J Dermatol. 2016 Jan;174(1):165-8.

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Imiquimod and Lentigo Maligna • 3 died • 11 (27.5%)

• Residual LM on histology • 18 (66.7%)

• Clear pathologically • 0% 5 year recurrence

Kai AC, Richards T, Coleman A, Mallipeddi R, Barlow R, Craythorne EE. Five-year recurrence rate of lentigo maligna after treatment with imiquimod. Br J Dermatol. 2016 Jan;174(1):165-8.

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History • 61 yo female • 1998 biopsy – supposed LM that was not read correctly

• Untreated for 5 years • Early 2000 – re-evaluated…LM

• 3 surgeries – plastic surgery • Flap closures • SLNB

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History • 2007 – Outside dermatologist

• Biopsies – atypical melanocytic hyperplasia • Imiquimod – pt stopped prematurely

• 2009 – two more biopsies • LM • 4 more months of Imiquimod • Pigmented areas resolved

• 2010 • Mayo Clinic • Do I need anything else done?

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61 yo female with recurrent LM

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October 2011

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Case • 63 yo PA • LMM of the scalp

• Breslow 1.2mm • Clark IV • 0 Mitosis /mm2

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Pre-op

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Positive 1st Layer

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Positive 1st Layer

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Lessons • Be careful deciding initial treatment approach • Surgery 1st line • Consider topical therapy carefully • Scouting biopsies • Mohs surgery • Mart-1 Immunostains helpful • Collaboration important • Close follow up

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Comments/Questions

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Thank You!