How do I determine if a patient with a large squamous cell carcinoma or basal cell carcinoma is a surgical candidate?

Determining Surgical Candidacy for Large SCC or BCC

For patients with large squamous cell carcinoma (SCC) or basal cell carcinoma (BCC), surgical candidacy is primarily determined by whether the patient can tolerate anesthesia and the surgical procedure itself, and whether complete tumor removal with adequate margins is technically feasible without unacceptable functional or cosmetic compromise. 1

Primary Assessment Framework

Patient-Related Factors

• General fitness and medical comorbidities are the first consideration—patients with serious coexisting medical conditions may not tolerate surgery safely 1
• Use of antiplatelet or anticoagulant medications must be evaluated, though these are typically manageable rather than absolute contraindications 1
• Age alone is not a contraindication—however, very elderly patients in poor general health may benefit more from palliative rather than curative treatment 1
• Patient preference plays a legitimate role when multiple treatment options exist 1

Tumor-Related Factors

• Anatomic location determines technical feasibility—tumors involving critical structures (eyes, major nerves, bone) may require multidisciplinary consultation 1
• Extent of disease must be assessed—imaging (particularly MRI) should be obtained if large nerve involvement or base of skull extension is suspected 1
• Resectability with acceptable margins is key—if negative margins are unachievable even with Mohs surgery or extensive procedures, the patient is not a surgical candidate 1

When Surgery is Contraindicated

Radiation therapy becomes the primary treatment option for non-surgical candidates, though it is generally reserved for patients over 60 years due to concerns about long-term sequelae 1

Specific Non-Surgical Scenarios

• Negative margins unachievable by Mohs surgery or more extensive surgical procedures 1
• Medical contraindications where anesthesia or surgery poses unacceptable risk 1
• Patient refusal of surgery when radiation can achieve comparable cure rates 1
• Genetic conditions predisposing to skin cancer (basal cell nevus syndrome, xeroderma pigmentosum) or connective tissue diseases where radiation is contraindicated 1

Alternative Treatment Pathways

For Non-Surgical Candidates with BCC

• Radiation therapy can achieve very good cure rates and excellent cosmesis when properly applied 1
• Hedgehog pathway inhibitors (vismodegib, sonidegib) should be considered via multidisciplinary tumor board consultation if both surgery and radiation are contraindicated 1
• Clinical trials should be explored for complex cases 1

For Non-Surgical Candidates with SCC

• Radiation therapy offers cure rates comparable to surgery, particularly for head and neck locations 1, 2
• Systemic therapy with cemiplimab is FDA-approved for metastatic or locally advanced SCC when patients are not candidates for curative surgery or curative radiation 3
• Clinical trials are strongly recommended for metastatic cutaneous SCC 1

Critical Decision Points

When to Pursue Multidisciplinary Consultation

• Complicated high-risk cases where standard approaches may be insufficient 1
• Extensive perineural or large-nerve involvement requiring adjuvant radiation planning 1
• Residual disease present when further surgery and radiation are contraindicated 1
• Regional or distant metastases requiring systemic therapy consideration 1

Common Pitfalls to Avoid

• Assuming elderly patients cannot tolerate surgery—age alone should not exclude surgical candidacy; functional status and comorbidities matter more 1
• Performing aggressive surgery on asymptomatic low-risk lesions in frail patients—conservative or palliative approaches may be more appropriate 1
• Failing to obtain adequate imaging for large tumors before declaring them unresectable 1
• Not considering radiation as a primary curative option—when properly applied, radiation achieves excellent outcomes and may be preferable for function and cosmesis 1, 2

Practical Algorithm

1. Assess patient's ability to tolerate anesthesia and surgery based on comorbidities and functional status 1
2. Evaluate tumor resectability through clinical examination and imaging if needed 1
3. If surgical candidate: Proceed with Mohs surgery or excision with complete margin assessment for high-risk/large tumors 1
4. If not a surgical candidate: Consider radiation therapy as primary treatment (preferred for patients >60 years) 1
5. If both surgery and radiation contraindicated: Multidisciplinary tumor board consultation for systemic therapy (hedgehog inhibitors for BCC, cemiplimab for SCC) or clinical trial enrollment 1, 3