Clinical Case 3 Scenario

Glenn J. Hanna, MD: Our final case will illustrate the last point, about bringing immunotherapy agents into the up-front or early setting before surgery. In case 3 we have a 62-year-old female patient living in Southern California who presents with an ulcerative lesion in close proximity to the right eye. This area is not healing well. She has a good performance status, with no immunosuppression history or autoimmune concerns. There are no clinically palpable lymph nodes in the head or neck region. The biopsy confirms a high-risk localized cutaneous squamous cell, perhaps with some concerning features: ulceration, perineural invasion, etc. The tumor is approaching 2.5 cm, but it’s close to the right eye. The question becomes what we’re eluding on. What’s the appropriateness of up-front resection and the risk to the eye? We’ll highlight the emerging data on neoadjuvant I/O [immuno-oncology]. We’ll turn it back to Dr Emerick first. What would you be thinking about in terms of this kind of lesion and the location for a surgical strategy?

Kevin Emerick, MD: Thinking about this surgically, it’s important to do as best as you can determine what the function of the eye will be after surgery and can you get a clear margin. If you take someone with a normal-functioning eye, and you anticipate your surgery will require exenteration, that’s a good time to pause and think about nonsurgical treatments, whether we want to call it neoadjuvant or a definitive approach with anti–PD-1 therapy. We can get into that a little. That’s the key. What’s going to be the function of the eye? Obviously, part is exenteration, moving the eye. When you spend a lot of time working around the eye, you start to understand the functional impact of the eyelids. Maybe the eye is fine, but if you have to remove all of the lower eyelid and a significant portion of the upper eyelid, you’re not going to have a protective mechanism to make that globe continue to work. You’re going to have good vision. Those become some of the important things I think about surgically.

It comes back to the things I mentioned before. I’m going to touch this. I’m going to feel it, and I’m absolutely going to get imaging. Those are the key things to help figure out what’s the role of surgery. As we move into the discussion about neoadjuvant treatment and want to avoid issues with her eye and surgery, we also must look into a crystal ball: what happens if someone doesn’t respond? If we have a tumor that’s readily resectable with reasonable morbidity is a subjective term. The reasonable morbidity is also making sure we don’t miss our surgical window, which underscores the importance of doing this as a team and doing this with a group of people who understand this disease and these treatments. This must be a group of people who, especially in this situation, understand this disease and these treatments. It’s important.

This transcript has been edited for clarity.