Chemotherapy Delayed for Several Months

    This case involves a fifty-seven-year-old female patient who developed a lump in the right upper margin of her neck at the angle of the jaw bone. The patient presented to an ENT physician who ordered a CT that showed an 18mm right buccal lesion with a solitary 17mm peri parotid metastatic node. The patient was sent for a fine needle biopsy that confirmed a well to moderately differentiated squamous cell carcinoma. Subsequently, the patient underwent a surgical resection of the buccal mucosa with a right neck dissection and a split thickness skin graft from the right thigh. The patient was staged by pathology as a T2N2B with extracapsular spread. The patient was discharged four days after surgery with no mention of external beam radiation follow-up or chemotherapy plans. Two months later, the patient was called in for follow-up scans that revealed a recurrence of cancer. At this point, it was determined that the patient had passed the window of opportunity to benefit from chemotherapy and she was now determined to be at stage four.

    Question(s) For Expert Witness

    • 1. What would be the prognosis if radiation or chemotherapy were started after surgery?

    Expert Witness Response E-000029

    Although patients infrequently die from cutaneous squamous cell carcinoma (SCC), these tumors can cause significant morbidity. Most cutaneous SCCs are located in the head and neck region, where surgery for advance stage disease can be disfiguring. Despite the inherent limitations of TNM staging, the outcomes of patients with head and neck cutaneous SCC follow a predictable pattern. In general, most patients with early-stage tumors fare well (overall five-year survival rate >90%) when the tumors are adequately treated. Most patients present with early-stage tumors, and the prognosis is reasonably good for completely excised lesions. Various mortality rates have been reported, with some rates as high as 4-8%. By adhering to a policy of complete excision of all lesions, the recurrence rate should be 10% or less. The outcome of patients with advanced-stage cutaneous SCC is considerably worse. For patients with lymph node metastases, the five-year survival is even lower, estimated at 25-45%. Most large series in the literature have reported the risk of nodal or distant metastasis for primary tumors to be 2-6%.

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