Ophthalmic manifestations of perineural spread of facial skin malignancy

Radical Tumor Denervation Activates Potent Local and Global Cancer Treatment

This preliminary study seeks to determine the effect of R&P denervation on tumor growth and survival in immunocompetent rats bearing an aggressive and metastatic breast solid tumor. A novel microsurgical approach was applied "in situ", aiming to induce R&P denervation through the division of every single nerve fiber connecting the host with the primary tumor via its complete detachment and re-attachment, by resecting and reconnecting its supplying artery and vein (anastomosis). This preparation, known as microsurgical graft or flap, is radically denervated by definition, but also effectively delays or even impedes the return of innervation for a significant period of time, thus creating a critical and therapeutic time window. Mammary adenocarcinoma cells (HH-16.cl4) were injected into immunocompetent Sprague Dawley adult rats. When the tumors reached a certain volume, the subjects entered the study. The primary tumor, including a substantial amount of peritumoral tissue, was surgically isolated on a dominant artery and vein, which was resected and reconnected using a surgical microscope (orthotopic tumor auto-transplantation). Intending to simulate metastasis, two or three tumors were simultaneously implanted and only one was treated, using the surgical technique described herein. Primary tumor regression was observed in all of the microsurgically treated subjects, associated with a potent systemic anticancer effect and prolonged survival. In stark contrast, the subjects received a close to identical surgical operation; however, with the intact neurovascular connection, they did not achieve the therapeutic result. Animals bearing multiple tumors and receiving the same treatment in only one tumor exhibited regression in both the "primary" and remote- untreated tumors at a clinically significant percentage, with regression occurring in more than half of the treated subjects. A novel therapeutic approach is presented, which induces the permanent regression of primary and, notably, remote tumors, as well as, evidently, the naturally occurring metastatic lesions, at a high rate. This strategy is aligned with the impetus that comes from the current translational research data, focusing on the abrogation of the neuro-tumoral interaction as an alternative treatment strategy. More data regarding the clinical significance of this are expected to come up from a pilot clinical trial that is ongoing.

Metastatic Zosteriform Squamous Cell Carcinoma in an Immunocompetent Patient

Background:

Although described in several reports of internal malignancies metastasizing to the skin, zosteriform metastases have been reported in only two cases of cutaneous squamous cell carcinoma (SCC). In both of these reports, the patients were immunosuppressed related to renal transplantation.

Objective:

We present a case of an immunocompetent patient with zosteriform metastases originating from a recurrent cutaneous SCC. The lesions were present along the maxillary division of the trigeminal nerve.

Methods:

Biopsies from eight lesions were studied using hematoxylin and eosin (H&E) and with immunohistochemistry.

Results:

Neural involvement was detected in H&E preparations before and during excision of the metastatic nodules by Mohs micrographic surgery. The tumor cells reacted with antikeratin antibodies. The patient has had no evidence of recurrence or metastases 30 months following surgery.

Conclusion:

To our knowledge, this is the first case of cutaneous SCC with zosteriform metastases in a patient with an intact immune system. SCC should be included in the differential diagnosis of lesions presenting in a dermatomal distribution.

Intracranial Management of Perineural Spread in the Trigeminal Nerve

Since the mid-1960s surgeons have attempted to cure intracranial perineural spread (PNS) of cutaneous malignancies. Untreated patients with trigeminal PNS die from brainstem invasion and leptomeningeal disease. It was understood that resection with clear margins was potentially curative, but early surgical attempts were unsuccessful. The prevailing wisdom considered that this surgery failed to improve the results achieved with radiation therapy alone and was associated with high morbidity. However, with improved imaging, surgical equipment, and better understanding of cavernous sinus (CS) anatomy and access, contemporary surgeons can improve outcomes for this disease. The aim of this paper is to describe a technique to access the interdural compartment of the CS and treat PNS of cutaneous squamous cell carcinoma (cSCC) in the intracranial trigeminal nerve and ganglion. It is based on the experience of the Queensland Skull Base Unit, Australia in managing PNS of cutaneous squamous cell carcinoma of the head and neck (cSCCHN).

Treatment recommendations in patients diagnosed with high-risk cutaneous squamous cell carcinoma

Non-melanoma cutaneous cancers occur at an epidemic rate in Australia. With an ageing population, more Australians will develop these cancers and at an increasing rate. In the majority of cases local treatment is highly curative. However, a subset of the population will be diagnosed with a high-risk cutaneous squamous cell carcinoma. These can be defined as patients at risk of having subclinical metastases to regional lymph nodes based on unfavourable primary lesion features (including inadequately excised and recurrent lesions), patients with metastatic squamous cell carcinoma to regional lymph nodes, and squamous cell carcinoma in immunosuppressed patients. The mortality and morbidity associated with high-risk cutaneous squamous cell carcinoma is usually as a consequence of uncontrolled metastatic nodal disease and, to a lesser extent, distant metastases. Radiotherapy has an essential role in treating these patients and in many cases the addition of adjuvant radiotherapy may be life saving. It is therefore important that all clinicians treating skin cancers have an understanding and awareness of the optimal approach to these patients. The aim of this article is to present treatment recommendations based on an overview of the current published literature.

Metastatic Zosteriform Squamous Cell Carcinoma in an Immunocompetent Patient

BACKGROUND

Although described in several reports of internal malignancies metastasizing to the skin, zosteriform metastases have been reported in only two cases of cutaneous squamous cell carcinoma (SCC). In both of these reports, the patients were immunosuppressed related to renal transplantation.

OBJECTIVE

We present a case of an immunocompetent patient with zosteriform metastases originating from a recurrent cutaneous SCC. The lesions were present along the maxillary division of the trigeminal nerve.

METHODS

Biopsies from eight lesions were studied using hematoxylin and eosin (H&E) and with immunohistochemistry.

RESULTS

Neural involvement was detected in H&E preparations before and during excision of the metastatic nodules by Mohs micrographic surgery. The tumor cells reacted with antikeratin antibodies. The patient has had no evidence of recurrence or metastases 30 months following surgery.

CONCLUSION

To our knowledge, this is the first case of cutaneous SCC with zosteriform metastases in a patient with an intact immune system. SCC should be included in the differential diagnosis of lesions presenting in a dermatomal distribution.

The management of perineural spread of squamous cell carcinoma to the ocular adnexae

PURPOSE

To analyze a series of patients with periorbital perineural spread of squamous cell carcinoma and propose treatment guidelines.

METHODS

Retrospective, noncomparative, interventional case series of 17 patients with clinical, radiologic, or histologic evidence of distant perineural spread. Treatment, recurrence, progression, and mortality rates were recorded.

RESULTS

Numbness and pain were the most common symptoms, whereas ophthalmoplegia, ptosis, and facial palsy were the most frequent signs. All cases received wide-field radiotherapy to at least 50 Gy. Chemotherapy and surgery (biopsy, debulking, exenteration) were used in selected cases. Disease progression occurred in 6 patients, 4 of whom died. Median disease-free survival in the remainder was 37.5 months.

CONCLUSIONS

The diagnosis of perineural spread is largely clinical and may be confirmed with imaging findings in the majority of cases. The role of biopsy is usually complementary but may be essential in some cases. In patients with evidence of distant perineural spread, radiotherapy volumes inclusive of potential antegrade and retrograde spread are recommended. Three-dimensional conformal planning or intensity-modulated radiation therapy assists in minimizing damage to adjacent structures. Synchronous chemotherapy should be considered to potentiate the effectiveness of radiation. The place of surgery in the treatment of perineural spread is palliative.

Perineural invasion of cutaneous malignancies

BACKGROUND

Perineural invasion is an important mode of tumor spread and is associated with increased aggressiveness and a propensity for recurrence among cutaneous malignancies.

OBJECTIVE

To review the pathogenesis, diagnosis, and treatment of cutaneous tumors exhibiting perineural invasion.

METHODS

This article is based on a review of the medical literature concerning tumors with perineural involvement.

RESULTS

This article describes the clinical signs and histologic features of cutaneous malignancies exhibiting perineural involvement.

CONCLUSION

Appropriate patient care mandates consideration of perineural invasion in the evaluation of cutaneous tumors. As the majority of patients present without symptoms of neural involvement, physicians must be vigilant in the search for this type of tumor spread.

Really painful double vision

A 67-year-old woman with a history of chronic headache and recent removal of two squamous cell lesions from her forehead presented with left facial pain and diplopia. A diagnosis of Tolosa-Hunt syndrome was made based on clinical presentation and imaging studies. When the patient did not respond to steroids, further studies were done, including biopsy, which revealed perineural spread of squamous cell carcinoma.

Perineural spread leading to orbital invasion from skin cancer

Orbital and intracranial invasion from skin cancer is an uncommon but serious consequence of skin cancer located around the orbit, particularly the forehead. Perineural spread is an aggressive manifestation of skin cancer similar to lymph node metastases. Such spread can provide access to the orbit and squamous cell carcinoma is the most common histology reported. Treatment should be directed at preventing such orbital spread. Adjuvant radiotherapy is strongly recommended. Disease may present in an advanced state within the orbit or beyond the orbital apex and involve the cavernous sinus. Palliative radiotherapy should be considered in such advanced cases. Presented are the cases of four patients treated for advanced orbital and intracranial spread from periorbital skin cancer.

Perineural spread in head and neck skin cancer

Perineural spread (PNS) in the head and neck is an infrequent but aggressive manifestation of skin cancer. As such, it can provide access to the intracranial cavity. Squamous cell carcinoma is the most common histology with the facial and trigeminal nerves most often involved. Orbital invasion is an uncommon but devastating result of PNS located around the orbit, particularly the forehead. Diagnosis can be difficult and initial investigations are often unhelpful. Treatment should ideally be directed at preventing further spread before it develops. Adjuvant radiotherapy is often recommended. The disease may present at an advanced state within the orbit or parotid gland or even within the intracranial cavity. Clinicians need to be aware of the potential for PNS because a group of these patients will die from this potentially preventable and treatable form of metastatic skin cancer.

Squamous cell cancer: a practical approach

Cutaneous squamous cell carcinoma (SCC) is the second most common form of skin cancer and is treated frequently by dermatologists. For many years, the level of knowledge regarding treatment of SCC has taken a backseat to the treatment of basal cell carcinoma and malignant melanoma. As dermatologists become more surgically proficient and assume a leading role in the surgical care for cutaneous carcinoma, a thorough knowledge of the appropriate management of SCC is of paramount importance. In particular, it is essential to recognize that, unlike basal cell carcinoma, certain SCC have a significant metastatic potential and require more comprehensive care. This review targets the etiology, pathogenesis, clinical presentation, histopathology, and treatment of SCC. Particular attention is focused on providing appropriate care for SCC and recognizing and arranging appropriate management for high risk SCC.

Perineural spread of cutaneous squamous cell carcinoma via the orbit. Clinical features and outcome in 21 cases

OBJECTIVE

To describe the clinical features, treatment, and outcome of a series of patients with perineural spread (PNS) of cutaneous squamous cell carcinoma (SCC) via the orbit.

DESIGN

A cohort study.

PARTICIPANTS

Twenty-one patients identified with PNS of cutaneous SCC via the orbit.

INTERVENTION

Patients were treated with various combinations of conservative or radical surgery, external beam radiation therapy, and chemotherapy.

RESULTS

Of 21 cases, 17 (81%) were male. Age at presentation with PNS ranged from 38 to 82 years (median, 66 years). The forehead and eyebrow were the most common site of the primary lesion. All but one had altered or decreased sensation, but only nine presented with pain. Fourteen (67%) had ophthalmoplegia at presentation, and 14 (67%) had evidence of PNS involving branches of the facial nerve. Despite combinations of radical surgery, conservative surgery, and radiation therapy, no method of treatment appeared more effective, and 14 patients died from 9 months to 5 years after presentation with PNS (median, 3 years), usually from local and intracranial disease. Two survived to 14 and 18 years, one is alive at 3 years with recurrent local and distant disease, and four are alive without evidence of disease at 2, 3, 4 and 12 months after radiation therapy.

CONCLUSIONS

Perineural spread of cutaneous SCC via the orbit carries a poor prognosis. Early radiation therapy may offer the best form of palliation. The role of radical surgery probably is limited once orbital involvement is apparent, as the cavernous sinus and facial nerve branches usually are involved.

Perineural Spread of Facial Squamous Cell Carcinoma to the Vestibulocochlear Nerve

Perineural spread of facial squamous cell carcinoma (SCC) is a well-recognized cause of trigeminal and of facial nerve palsies. 1 Vestibulocochlear nerve involvement by perineural spread has not been convincingly demonstrated. Here we report a patient with perineural spread of facial SCC not only to the trigeminal and facial nerves but also to the ipsilateral vestibulocochlear nerve. The anatomic and pathophysiologic basis of this spread is discussed.

The many faces of squamous cell carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma is a disease that has a multitude of clinical, histologic, and etiologic subtypes, all of which are of significance to the clinician.

OBJECTIVE

Ten of the most common and clinically significant subtypes of squamous cell carcinoma are presented to emphasize the clinical importance of each and to emphasize and contrast their differences.

METHODS

The literature of each subtype of squamous cell carcinoma is reviewed and capsulized.

RESULTS

Appropriate diagnosis, therapy, and postoperative management of all subtypes of squamous cell carcinomas are dependent upon the understanding of their unique characteristics.

CONCLUSION

The 10 common variants of squamous cell carcinoma presented in this paper: neurotrophic squamous cell carcinoma, Bowen's disease, squamous cell carcinoma in transplant patients, keratoacanthoma-like squamous cell carcinoma, squamous cell carcinoma of the lip, adenoid squamous cell carcinoma, spindle cell squamous cell carcinoma, radiation-induced squamous cell carcinoma, verrucous carcinoma, and Marjolin's ulcer, have unique etiologic, histologic, and clinical features that significantly influence their diagnosis, treatment, and subsequent management. It is imperative that physicians responsible for the care of these patients understand the implication of these unique characteristics.