Ricardo Vieira, André Pinho, Ana Brinca

Department of Dermatology, Coimbra University Hospital, Portugal

Case presentation

A 68-year-old woman, with a 6-year history of heart transplantation and chronic renal insufficiency (creatinine clearance: 27 ml/minute), presented with a large ulcerated tumor involving the left pre-auricular region and the anterior auricle (Figure 1). Several satellite and in-transit nodules were observed in the mastoid and submandibular regions. Three years prior to this presentation, the patient was diagnosed with a squamous cell carcinoma of the left temporal region which was removed by wide excision. At that time, the immunosuppressive drugs were changed (switch from mycophenolate and cyclosporine to everolimus and tacrolimus). A locoregional recurrence was observed 1 year ago and the patient was treated with parotidectomy, supraomohyoid neck dissection and adjuvant radiation therapy (60 Gy, 30 fractions).

Figure 1: 

Figure 1 - Viera

Work-up, treatment and follow-up

The biopsy revealed a poorly differentiated squamous cell carcinoma (Figure 2).
Figure 2: 

Figure 2 - Viera

No distant metastases were identified in imaging studies, but the CT scan showed invasion of the external auditory canal, tympanic cavity and mastoid bone (Figure 3).

Figure 3:

Figure 3 - Viera

The patient was not considered a candidate either to surgical excision or to additional radiation therapy, considering the high morbidity and the unlikeliness to obtain a complete remission. Due to the co-existing renal impairment, the decision was to perform monotherapy with cetuximab (induction with 400 mg/m2 and then 250 mg/m2 weekly). After an early clinical shrinkage of the tumor, cetuximab was discontinued at week 16 due to disease progression. A chemotherapy regimen was started (cisplatin 100 mg/m2 single dose, 5-fluorouracil 1000 mg/m2/day during 5 days, each 28 days, dose adjusted to renal function). After 6 cycles, a clinical and radiologic complete remission was obtained (Figure 4) and sustained after a 7-month follow-up.

Figure 4:

Figure 4: Viera

Key message

Chemotherapy remains vital in the era of targeted therapies and immunotherapies.


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