Case 1: Approaching a Borderline Resectable Advanced cSCC

This video series has been produced independently by Dermatology Times and supported through an educational grant by Sun Pharmaceuticals.

Dr. Patel presents the program's first case: a 78-year-old woman with an enlarging, ulcerated lesion on the right temple and preauricular area, measuring close to five centimeters. Her history includes hypertension, diabetes, coronary artery disease, and prior keratinocyte carcinomas. Examination and imaging reveal eyelid and forehead ptosis, invasion toward the parotid gland, and an intraparotid lymph node concerning for metastasis, though no distant spread. Biopsy shows a poorly differentiated tumor with deep dermal and subcutaneous invasion and confirmed perineural invasion, what Dr. Patel calls the "kitchen sink" of high-risk features.

Dr. Carr explains that a case like this would go immediately to a tumor board. Historically, before checkpoint inhibitors arrived around 2018, it would have meant large resection, partial parotidectomy, node dissection, and radiation, with substantial functional cost, including likely sacrifice of the temporal branch of the facial nerve. Because the tumor is borderline resectable, he argues it is exactly the scenario where neoadjuvant immunotherapy deserves consideration, provided the patient has no contraindications to checkpoint blockade. Dr. Patel pauses to define terms for the audience: neoadjuvant therapy precedes definitive treatment, perioperative spans before and after surgery, and adjuvant follows it.

Dr. Chandra approaches the case much the same way, beginning with disease burden and resectability. If a tumor is resectable or borderline resectable, she sees a strong role for neoadjuvant immunotherapy of limited duration; if unresectable, systemic therapy becomes the main line, shifting goals from curative toward palliative. Importantly, she reassures patients that starting systemic therapy does not close the door on later surgery or radiation should they respond well, a point she finds patients deeply appreciate.

In the next episode, "Coordinating Multidisciplinary Referrals in Advanced cSCC," Dr. Chandra and Dr. Carr tackle a practical question, when a multidisciplinary team isn't available, who should a community dermatologist call first, and why systemic therapy never takes surgery off the table.