Invasive metastatic skin cancer in the background of chronic lymphocytic leukemia.

A 76-year-old woman with chronic lymphocytic leukemia (CLL) presented with a 10-year history of recurrent left preauricular squamous cell carcinoma of the skin. She had been initially treated by a dermatologist, who had administered cryotherapy 3 times. After developing a recurrence, she underwent radiotherapy, which temporarily controlled the disease. When she developed another recurrence, she underwent several surgical resections, including Mohs' surgery, which again provided transient disease control.

Approximately 1 year prior to the patient's presentation to us, she began to notice left-sided facial numbness and left frontal-nerve paralysis associated with a left facial ulceration. At presentation, she had progressed to complete left facial nerve paralysis (figure 1, A). In addition, she exhibited a 2 x 2-cm area of nodular ulceration (figure 1, B). The ulceration was biopsy-proven to be an invasive squamous cell carcinoma. Palpation of the neck revealed diffuse adenopathy in levels IIb and V on the ipsilateral side. Findings on the remainder of the head and neck examination were within normal limits.

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Magnetic resonance imaging (MRI) of the brain showed no obvious intracranial disease or signs of retrograde nerve travel, and computed tomography (CT) of the temporal bones was negative. However, MRI of the face disclosed an ulcerative soft-tissue lesion that extended down to the level of the temporalis muscle, masseter muscle, and superficial parotid gland (figure 2). No signs of bone involvement were noted on CT of the face. The workup for distant metastasis was negative.

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The patient was taken to the operating room for a radical left parotidectomy, left neck dissection, zygomatic arch resection, and infratemporal resection (figure 3, A). The surgical margins were negative, including the proximal facial nerve margin (figure 3, B). Two of 47 lymph nodes were positive for metastatic squamous cell carcinoma, and all 47 lymph nodes were positive for CLL.

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The patient was reconstructed with a radial forearm free flap, left brow lift, static suspension, and gold-weight insertion into the left upper eyelid (figure 3, C). She received adjuvant radiotherapy. Six weeks postoperatively, her facial symmetry had improved (figure 4), and at 3 years, she had shown no signs of recurrent disease.

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Cutaneous malignancies in the general population are usually relatively easy to control, but squamous cell and basal cell skin carcinomas behave more aggressively in the background of CLL. The rate of metastasis is greater than 10% in patients with CLL, compared with only 5% among those without CLL. It is the relative state of immunosuppression created by CLL that is responsible for this predisposition. These patients must be watched very closely for the possible development of cutaneous malignancies. If a skin cancer develops in a patient with CLL, these tumors can be very aggressive and should be treated accordingly. These tumors warrant the same amount of concern as would a squamous cell carcinoma in any other area of the head and neck. The primary site and the regional nodal basins should be thoroughly evaluated.

Suggested reading

Hampton T. Skin cancer's ranks rise: Immunosuppression to blame. JAMA 2005;294:1476-80.

Kaplan AL, Cook JL. Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia. Skinmed 2005;4:300-4.

Mehrany K, Weenig RH, Lee KK, et al. Increased metastasis and mortality from cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia. J Am Acad Dermatol 2005;53:1067-71.

Sofia Avitia, MD; Jason S. Hamilton, MD; Ryan F. Osborne, MD, FACS 

From the Department of Otolaryngology--Head and Neck Surgery, Charles R. Drew University of Medicine and Science (Dr. Avitia); the Osborne Head and Neck Institute (Dr. Hamilton and Dr. Osborne); and the Head and Neck Cancer Center, Cedars-Sinai Medical Center (Dr. Osborne), Los Angeles.