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


A 76-year-old woman with chronic lymphocytic leukemia chronic lymphocytic leukemia
n. Abbr. CLL
Lymphocytic leukemia occurring mainly in older adults, characterized by slow onset and gradual progression of symptoms.
 (CLL) presented with a 10-year history of recurrent left preauricular squamous cell carcinoma squamous cell carcinoma
n.
A carcinoma that arises from squamous epithelium and is the most common form of skin cancer. Also called cancroid, epidermoid carcinoma.
 of the skin. She had been initially treated by a dermatologist, who had administered cryotherapy Cryotherapy Definition

Cryotherapy is a technique that uses an extremely cold liquid or instrument to freeze and destroy abnormal skin cells that require removal.
 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 palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis.  of the neck revealed diffuse adenopathy in levels IIb and V on the ipsilateral ipsilateral /ip·si·lat·er·al/ (ip?si-lat´er-al) situated on or affecting the same side.

ip·si·lat·er·al
adj.
Located on or affecting the same side of the body.
 side. Findings on the remainder of the head and neck examination were within normal limits.

[FIGURE 1 OMITTED]

Magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures.  (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 ulcerative /ul·cer·a·tive/ (ul´se-ra?tiv) (ul´ser-ah-tiv) pertaining to or characterized by ulceration.

ulcerative

pertaining to or characterized by ulceration.
 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.

[FIGURE 2 OMITTED]

The patient was taken to the operating room for a radical left parotidectomy Parotidectomy Definition

Parotidectomy is the removal of the parotid gland, a salivary gland near the ear.
Purpose

The main purpose of parotidectomy is to remove cancerous tumors in the parotid gland.
, 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.

[FIGURE 3 OMITTED]

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.

[FIGURE 4 OMITTED]

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 JAMA
abbr.
Journal of the American Medical Association
 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 FACS Fellow of the American College of Surgeons.

FACS
abbr.
Fellow of the American College of Surgeons



FACS

fluorescence-activated cell sorter.
 

From the Department of Otolaryngology--Head and Neck Surgery, Charles R. Drew University of Medicine and Science Drew is perhaps best known for its medical school designed to train physicians interested in working in urban environments, and founded in the response to the 1965 Watts riots to train minority doctors who would serve the poor of the South Los Angeles area.  (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.
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Title Annotation:HEAD AND NECK CLINIC
Author:Osborne, Ryan F.
Publication:Ear, Nose and Throat Journal
Date:Feb 1, 2007
Words:616
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