[Skip to Content]
[Skip to Content Landing]

Cutaneous Squamous Cell Carcinoma With Orbital Extension

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 72-year-old homeless man was referred for management of a recurrent cutaneous squamous cell carcinoma (SCC) of the right temple and brow. On review of history, maxillofacial magnetic resonance imaging (MRI) with and without contrast done 5 months prior to presentation showed a 5.9 × 5.3 × 3.7-cm mass centered at the right temple that tracked along the right lateral orbital wall as well as an enhancing right intraparotid lymph node. The patient was lost to follow-up and re-presented 5 months later with an enlarged crusting and ulcerating lesion of the right temple/brow (Figure 1A). On ocular examination, best-corrected visual acuity was 20/100 OD and 20/125 OS due to cataracts, pupils reacted normally without afferent pupillary defect, and ocular motility was full. He had mild proptosis in the right eye and right lower eyelid retraction. Orbicularis strength was intact and symmetric in both eyes. MRI of the orbits, face, and neck with and without contrast showed a 6.1 × 5.7 × 4.0-cm mass with erosion through the right sphenoid wing, involvement of the lacrimal gland, and abutment of the lateral rectus (Figure 1B). In discussing treatment strategies for the orbital component of the disease, the patient was strongly against an orbital exenteration.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Stage T3N1M0 recurrent cutaneous SCC of the face

B. Neoadjuvant cemiplimab immunotherapy (anti–PD-L1 antibody), globe sparing orbitotomy, and surgical excision of the mass

Advanced cutaneous SCC with orbital involvement has historically been difficult to treat with 10-year survival rates less than 20%.1 The standard treatment is exenteration, due to difficulty in obtaining clear margins in the orbit. Exenteration has been shown to provide better local control with clear margins obtained in 42.5% to 97% of cases and lower rates of local recurrence with overall survival of 83% and 65% at 1 and 5 years, respectively.2 However, recently, the overall survival benefit of exenteration vs conservative surgeries has been questioned.24 In addition, exenteration causes facial disfigurement, loss of vision, psychological distress, and some, like this patient, may decline this surgery.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Catherine Y. Liu, MD, PhD, Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Viterbi Family Department of Ophthalmology, 9415 Campus Point Dr, La Jolla, CA 92037 (yul107@health.ucsd.edu).

Published Online: October 6, 2022. doi:10.1001/jamaophthalmol.2022.3919

Conflict of Interest Disclosures: Dr Liu reported grant support from Horizon Therapeutics and royalties from Wolter Kluwers Health. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Kang  SY , Toland  AE .  High risk cutaneous squamous cell carcinoma of the head and neck.   World J Otorhinolaryngol Head Neck Surg. 2016;2(2):136-140. doi:10.1016/j.wjorl.2016.05.004 PubMedGoogle ScholarCrossref
2.
Martel  A , Hamedani  M , Lagier  J , Bertolotto  C , Gastaud  L , Poissonnet  G .  Does orbital exenteration still have a place in 2019?   J Fr Ophtalmol. 2020;43(2):152-174. In French. doi:10.1016/j.jfo.2019.04.021 PubMedGoogle Scholar
3.
Sullivan  CB , Andresen  NS , Kendell  N , Al-Qurayshi  Z , Pagedar  NA .  Survival outcomes for advanced cutaneous squamous cell carcinoma of the head and neck.   Ann Otol Rhinol Laryngol. 2019;128(10):949-955. doi:10.1177/0003489419848786 PubMedGoogle ScholarCrossref
4.
Goldfarb  JA , Ferrarotto  R , Gross  N ,  et al.  Immune checkpoint inhibitors for treatment of periorbital squamous cell carcinoma.   Br J Ophthalmol. 2021;bjophthalmol-2021-319417. doi:10.1136/bjophthalmol-2021-319417PubMedGoogle ScholarCrossref
5.
Gerring  RC , Ott  CT , Curry  JM , Sargi  ZB , Wester  ST .  Orbital exenteration for advanced periorbital non-melanoma skin cancer: prognostic factors and survival.   Eye (Lond). 2017;31(3):379-388. doi:10.1038/eye.2016.218 PubMedGoogle ScholarCrossref
6.
Migden  MR , Rischin  D , Schmults  CD ,  et al.  PD-1 blockade with cemiplimab in advanced cutaneous squamous-cell carcinoma.   N Engl J Med. 2018;379(4):341-351. doi:10.1056/NEJMoa1805131 PubMedGoogle ScholarCrossref
7.
Migden  MR , Khushalani  NI , Chang  ALS ,  et al.  Cemiplimab in locally advanced cutaneous squamous cell carcinoma: results from an open-label, phase 2, single-arm trial.   Lancet Oncol. 2020;21(2):294-305. doi:10.1016/S1470-2045(19)30728-4 PubMedGoogle ScholarCrossref
8.
Argenziano  G , Fargnoli  MC , Fantini  F ,  et al.  Identifying candidates for immunotherapy with cemiplimab to treat advanced cutaneous squamous cell carcinoma: an expert opinion.   Ther Adv Med Oncol. 2022;14:17588359211066272. doi:10.1177/17588359211066272 PubMedGoogle ScholarCrossref
9.
Gross  N , Ferrarotto  R , Nagarajan  P ,  et al.  LBA74—phase II study of neoadjuvant cemiplimab prior to surgery in patients with stage III/IV (M0) cutaneous squamous cell carcinoma of the head and neck (CSCC-HN).   Ann Oncol. 2019;30(5):v910. doi:10.1093/annonc/mdz394.071 Google ScholarCrossref
10.
Chik  JYK , Leung  CWL , Wong  KH .  Palliative radiation therapy for patients with orbital and ocular metastases.   Ann Palliat Med. 2020;9(6):4458-4466. doi:10.21037/apm.2019.12.02 PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close