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

©2011 MFMER | slide-1

Tumor Board Management of Complex Skin Cancers

DFSP, EMPD, and Melanoma Jerry D. Brewer, MD, MS, FAAD [email protected] 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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©2011 MFMER |

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Disclosures

• None


Dermatofibrosarcoma Protuberans


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



Work up • Excisional biopsy

• Felt to have positive margins • MRI

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



Pre-op



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



Defect



Closure



6 month post-op



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



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



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

• What patients and families might be going through ©2011 MFMER | slide-14


Case 2 - DFSP


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

Presenter

Presentation Notes

09-405-023 - Seifert


Pre-op


Course • Scheduled for Mohs Surgery • Consult with Orthopedics Oncology

• Possible collaboration in case deeper than anticipated


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


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


Debulking


Final Defect – clear with 2 stages


Closure


Forest Plot – Recurrence MMS vs WLE


• Heterogeneity • p value – 0.133

• Model • p value – 0.024


Course • Patient recovered well • Minimal pain


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


Extramammary Paget’s Disease


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

Presenter

Presentation Notes

2 043 996 - Tomsche


Pre-op


Course • Scouting biopsies

• Prior to surgery


Scouting Biopsies


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


Course


Closure post mohs


Course


Closure


Course • Pt doing well • Recovery without complications


Lessons • Scouting biopsies

• Very helpful! • Collaboration

• Gyn/Onc • Plastic Surgery

• Good communication • Scheduling • Expectations

• Challenging tumor can be satisfying


Melanoma


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.


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



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

• Residual LM on histology • 18 (66.7%)

• Clear pathologically • 0% 5 year recurrence



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


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?


October 2011


Case • 63 yo PA • LMM of the scalp

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


Pre-op


Positive 1st Layer


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

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