Melanoma/Skin Cancer&nbsp;&nbsp;&nbsp;

Have you considered intralesional cempilumab for locally advanced NMSC/KCs prior to surgery?

Baeza-Hernández & Cañueto, PMID 38201585 Stratigos et al., PMID 37708630 Zargham & Strasswimmer, PMID 35872877

What approach, or dosing interval, do you find is most effective reducing side effects of Hedgehog Inhibitors (i.e., vismodegib) for patients with numerous BCC?

Pedersen et al., PMID 36430669 Farberg et al., PMID 38896403 Ip & McKerrow, PMID 34160825

How have you incorporated gene expression profiling tests for melanoma or SCC into your practice and has it changed your approach to treatment and/or monitoring?

Do you obtain MRI for cutaneous SCC with microscopic PNI to assess for gross perineural tumor spread?

Are there other settings where MRI is used for nerve assessment and radiation planning such as for certain definitive RT cases?

What’s your approach to treating multiple facial BCCs in gorlin syndrome?

Specifically when surgery is not practical and the patient cannot tolerate SHH inhibitors. If using SHH inhibitors, how long do you keep patients on t...

In what clinical scenarios do you consider pre- or post-treatment with Imiquimod for cutaneous melanoma?

Vaienti et al., PMID 37615838 Fan et al., PMID 26730231 Wolf et al., PMID 15837872

How would you manage a large area of multiple, recurrent cutaneous squamous cell carcinomas of the scalp with ulcerations and non-healing areas despite cryotherapy, multiple Mohs procedures, and 5-FU?

Would you hypofractionate or be more conservative at 2 Gy per fraction? Would your management be affected knowing the patient is on hydroxyurea?

8 Answers available

What are your favorite strategies in fixing post-surgical depressions from facial flaps?

What is the recommended approach for systemic therapy in a patient with metastatic cutaneous squamous cell carcinoma with active autoimmune disease (dermatomyositis)?

When would you recommend adjuvant radiation therapy for a patient with a completely resected (negative margins) dermatofibrosarcoma protuberans?

Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?

Do you recommend an additional procedure for melanomas if there is tumor within 1-2mm of the margin?

How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?

Would your management change given that this recurrent lesion is over 10 cm and the patient previously achieved complete response on immunotherapy 5 y...

In patients with multiple basal cell carcinoma lesions on vismodegib, would you hold vismodegib while delivering radiation therapy to one locally advanced BCC lesion that was not amenable to surgery?

In your experience, what has been the most effective form of field therapy for your patients with higher burdens of actinic keratoses?

And what factors push you towards the selection of a specific treatment modality?

What is your treatment algorithm for actinic cheilitis?

What topical therapies have you found most effective? Have you found laser therapy to be effective?

Is narrow-band ultraviolet B (nbUVB) phototherapy contraindicated or recommended with caution in patients with a personal history of melanoma?

How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?

Would you offer adjuvant immunotherapy in an elderly patient with stage IIB desmoplastic melanoma post resection with underlying autoimmune disease?

How do you determine which patients you prescribe 5-fluorouracil vs 5-fluorouracil with calcipotriene for actinic field disease?

Do you favor one treatment over the other? Do you find one treatment more effective than the other?

What goes into your decision making when deciding between superficial radiation and Mohs surgery for cutaneous squamous cell carcinoma of the head and neck?

Size: 3 cm, cN0

How do you approach patients with advanced resectable basal cell carcinoma for possible use of hedgehog inhibitors?

How would you approach the post-operative radiation treatment volumes for a Merkel cell carcinoma of the hand?

Would you treat the primary site alone, include the hand and arm lymphatics to the epitrochlear nodes (one continious treatment volume from hand to el...

What criteria do you use to determine the resectability of mucosal melanoma of the H&N region?

Is T4 disease a contraindication?

What systemic therapy would you offer a patient with metastatic melanoma who is BRAF WT and developed metastases while on adjuvant nivolumab?

Any role for adjuvant systemic therapy for resected sebaceous skin carcinoma?

How do you approach melanoma patients with a positive sentinel node with extra-nodal extension for definitive surgical management?

Is completing nodal dissection warranted for surgical management?

How would you approach patients receiving neoadjuvant pembrolizumab (SWOG 1801) for melanoma with no response to systemic treatment?

The SWOG 1801 trial showed improved event-free survival (EFS) in patients receiving neoadjuvant pembrolizumab followed by 15 cycles of adjuvant pembro...

How do you approach patients with very low risk stage IIIA cutaneous melanoma for adjuvant immunotherapy?

Very-low-risk stage IIIA disease includes non-ulcerated lesions, primary ≤2 mm thickness, SLN metastasis <1 mm. Per NCCN the toxicity of adjuvan...

How would you approach a recurrent, cutaneous SCC of the face with high-risk features s/p resection?

Definitive radiation therapy > 5 years ago. Positive margins, PNI of 0.1 mm. What volume would you cover? Dose/fractionation?

How would you manage a Merkel cell carcinoma that spontaneously regressed clinically in a patient medically high-risk for surgical resection/anesthesia?

How would you treat the primary tumor (located in the chest)? Would you treat the regional lymph nodes?

How would you treat a periungual squamous cell carcinoma of the thumb?

What surveillance plan would you recommend for stage IV melanoma patients who achieve a CR or stable PR response with immunotherapy?

How do you approach patients with metastatic uveal melanoma not a candidate for tebentafusp-tebn?

What histologic findings most commonly lead you to order additional staining for potential desmoplastic melanoma?

Especially in cases where the MIS portion is obvious but the dermal component may not be.

How do you approach patients with polypoid/nodular melanoma for adjuvant therapy when Breslow depth is not available on pathology?

In this scenario do we use the actual tumor size for "T staging".

How do you approach the management of basal cell carcinoma with single lymph node involvement?

In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...

Are you routinely using neoadjuvant cemiplimab for cutaneous squamous cell carcinoma of any site?

Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?

Would you continue cemiplimab or pembrolizumab adjuvantly, following resection of initially unresectable cutaneous squamous cell carcinoma?

Do you base your decision on extent of residual disease? Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...

Is the phase 2 data regarding neoadjuvant cemiplimab in cutaneous squamous cell carcinoma sufficient to adopt for all patients or will you await phase 3 data?

Is a placebo-controlled trial anticipated?

6 Answers available

Do you consider downstaging neoadjuvant cemiplimab for borderline resectable CSCC in order to facilitate surgical resection?

How do you approach patients with a new primary melanoma, not an in-transit metastasis, while on adjuvant immunotherapy/treatment for a previous melanoma lesion?

How do you approach patients with early stage resected melanoma (Stage IIA) for adjuvant treatment?

Do you always excise down to the fascia when treating invasive melanomas and does body site location influence the depth of excision?

What role, if any, do biomarkers play in selecting appropriate patients for neoadjuvant cemiplimab in cutaneous squamous cell carcinoma?

What oral therapies do you most commonly recommend for skin cancer prevention?

How would you approach a 2 cm malignant primary cutaneous adnexal adenocarcinoma of the axilla s/p resection with positive margin who is unable to undergo additional surgery?

If the patient had no nodal sampling, would this influence your decision?

Is close observation a reasonable option for elderly patients with a small basal cell carcinoma of the face?

How would you approach a patient with malignant spindle cell neoplasm of the scalp excised with a focally positive deep margin?

What dose and margins would you use? The patient is s/p a liver transplant on immunosuppression.

In what scenario would you add systemic therapy with adjuvant radiation therapy in resected, locally-advanced, cutaneous squamous cell carcinoma?

Reference: TROG 05.01 Trial

Do you get routine MRI brain for surveillance on patients with history of stage III melanoma?

Do you recommend a deep shave biopsy or punch biopsy for sampling concerning melanocytic lesions?

Is there benefit in switching between sonedegib to vismodegib or vice versa for patients with unresectable basal cell carcinoma of the face that progresses on first line hedgehog inhibitor?

Are there any situations in which you would treat a cutaneous in-situ squamous cell carcinoma of the head and neck with radiation?

How do you treat non-melanomatous skin cancers in poorly vascularized tissue?

This is an elderly patient with a BCC/SCC over the shin who is not eligible for Mohs due to concern for wound-healing issues. Orthovoltage/superficial...

What therapies do you most commonly utilize for patients with SCC in situ on the head and neck?

Do you favor topical treatments or surgical management?

What is your treatment approach to patients with confluent actinic keratoses on lower extremities?

Does topical 5FU cause eruptive keratoacanthomas or have any other concerning side effects?

What prescription or over-the-counter therapies do you recommend for patients with side effects from vismodegib?

Have you had success with therapies such as L- carnitine and other remedies?

When would you offer post-op radiation for the treatment of sebaceous carcinoma of the eyelid?

Would you irradiate elective lymph nodes for a T1 Merkel cell carcinoma of the head and neck with a negative sentinel lymph node?

Would a history of immunosuppression impact your decision?

What protocol do you follow when performing staged excision with paraffin sections for the treatment of cutaneous melanoma?

If you perform MART-1 staining, what protocol do you follow?

Do you utilize surgical and medical treatments when treating patients with erythroplasia of queyrat, bowenoid papulosis or giant condyloma acuminatum?

Do you routinely collect debulking specimens for paraffin-embedded or frozen section staining prior to taking a Mohs layer for all skin cancers?

If not, what tumor characteristics prompt you to collect debulking specimens for paraffin or frozen section staining?

What are your preferred IHC stain(s) for desmoplastic melanoma?

Would you offer adjuvant radiation therapy for a Merkel cell carcinoma limited to the epidermis with close margins?

What is the incidence of melanoma arising from vitiliginous patches, and do they develop from different mechanisms than melanomas arising from normal skin?

How would you approach treatment of an elderly patient with recurrent atypical fibroxanthoma (malignant spindle cell neoplasm) after Mohs surgery?

What is the role for surgery vs RT?

How would you manage eccrine porocarcinoma of the great toe with positive superficial groin and pelvic lymph nodes s/p toe amputation and pelvic lymph node dissection?

Would you offer systemic therapy and/or radiation therapy to groin/pelvis?

How would you manage a nodal recurrence of cutaneous SCC if the patient is unable to receive surgery for 6-8 weeks?

In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...

How do you approach breast conserving therapy in a woman who has formed bothersome keloids after prior surgeries?

Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...

How would you approach an early inguinal recurrence after surgical resection of Merkel Cell carcinoma in the popliteal region?

How would you manage a patient with cutaneous SCC of the lower extremity with isolated inguinal nodal involvement?

What is the role and sequence of surgery and/or RT? Which nodal levels would you include in your RT field(s)?

How would you treat a patient with an keratoacanthoma of the right nasal ala?

What approaches (surgical vs non-surgical) offer the best cosmesis for keratoacanthoma (low grade squamous cell carcinoma) ?

What type of surveillance would you recommend following resection of primary mucinous carcinoma of the skin?

How would you approach treatment of a patient with asymptomatic, oligometastatic basal cell carcinoma?

Is there a role for radiation? Does your approach differ depending on site(s) of disease, and/or if the patient has Basal-Cell Nevus (Gorlin) sy...

Would you offer definitive radiation therapy for a Merkel cell carcinoma in which surgical resection would be disfiguring or result in significant dysfunction?

In general, how would you approach such a case with regards to creation of your treatment volumes and dose-fractionation?

What is your preferred radiotherapy regimen for palliative treatment of cutaneous T cell lymphoma?

How would you manage a small recurrent melanoma of the lower eyelid in a patient deemed inoperable?

Would you recommend radiation therapy or immunotherapy? If proceeding with radiation therapy, what dose-fractionation and technique would you utilize?

Would you recommend post-op RT for an ulcerated Clark's level IV melanoma of the zygomatic/preauricular region following a WLE with diffuse melanoma in-situ at the margins?

What dose-fractionation schedule would you utilize?

What is your approach to elective radiation of the neck with primary cutaneous squamous cell carcinoma?

When do you electively treat the ipsilateral versus ipsi- and contralateral neck?

How would you approach the treatment of a low grade adnexal carcinoma of the scalp in a patient with prior history of WBRT as a child?

This particular case involves a patient with a frontal scalp low grade eccrine carcinoma status-post excision with positive margin complicated by...

Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?

What is your preferred setup/immobilization for patients with cutaneous malignancy of the toe involving the medial aspect of the digit?

Would you offer adjuvant RT for a small merkel cell carcinoma of the lateral canthus with a close margin?

Given the location but no other high risk features would you offer RT? If so, what dose and fields?

Would you recommend adjuvant radiation for an atypical fibroxanthoma of the scalp that is completed resected with +PNI and +LVI?

What pathologic features are most important when evaluating the possible need for adjuvant therapy?

How would you manage a high risk SCC of the scalp that has wound healing issues after Mohs surgery?

Would you offer RT? If so, shat dose fractionation do you recommend?

Would you offer adjuvant radiation to the surgical bed for a Merkel cell carcinoma of the upper extremity with low-risk features as per the NCCN Guidelines?

*Negative margins, <1cm in size, no LVI, negative SLNB, not immunocompromised, no prior surgery (as well as a negative PET/CT scan).

How do your adjuvant treatment recommendations change, if at all, for clinically node positive Stage III desmoplastic melanoma?

Are there guidlines for elective coverage of nodal basins in head and neck for skin cancer removed in the area?

Is there a role for treating actinic keratosis with superficial radiation therapy to widespread areas on scalp?

If so, what is your suggested dose/fractionation?

Would you recommend surgery +/- adjuvant XRT or definitive XRT in elderly patients with recurrent squamous cell carcinoma of the ear with direct invasion through the cartilage of the helix?

What are the indications for adjuvant radiotherapy for basal cell carcinoma of the skin of the head and neck?

NCCN lists only substantial perineural invasion. What about other high-risk adverse features such as histologic subtype, multiple recurrences, d...

What risk factors prompt you to treat an early-stage nasal squamous cell carcinoma of the skin with post-operative radiation to the primary and/or elective nodal radiation?

When elective nodal radiation is recommended, which nodes would you treat (i.e. facial, pre-auricular, peri-parotid, levels I-III, etc.)?

Would you offer adjuvant radiation for a <1 cm preauricular sebaceous carcinoma after wide local excision?

Patient underwent a shave biopsy of a 6x5x2mm preauricular lesion that showed moderatley differentiated sebaceous carcinoma with deep and lateral marg...

How would you manage treatment of keloid that is so large it requests a graft?

What dose/fractionation would yield the lowest risk of graft failure? Does your treatment management change based of location, ex the ear vs back?

Do you offer radiation in the setting of a resected desmoplastic melanoma with negative margins given that several retrospective studies show a local control benefit?

If so, how large of a margin would you place on the primary lesion and would you incorporate any adjacent lymph node levels?

When does perineural invasion for a squamous cell carcinoma of the skin of the head and neck merit adjuvant radiotherapy?

Following Mohs surgery and in the absence of other high risk features, do you offer RT for any PNI? A single nerve < 0.1 mm? A single ne...

What is the best management for recurrent basal cell carcinoma after prior radiation and vismodegib?

Would re-irradiation be an appropriate option? What dose/field would you incorporate? If treating with standard fractionation, would you take the enti...

Do you treat fully resected squamous cell carcinoma of the ear with cartilage invasion with adjuvant radiation?

If so, what is your treatment volume?

What is the value of resection in high risk (but small or early stage) skin cancers at the medial canthus?

Is modern surgical/reconstruction treatment superior to radiation therapy? If contact brachytherapy or superficial (orthovoltage) therapy isnt possib...