Dialogue Volume 13 Issue 4 2017 - Page 60

PRACTICE PARTNER which was poorly tolerated. In June 2014, the patient developed metas- tases in the liver, bone and lung. There was no evidence of local recurrence in the head and neck. She declined palliative radiation to the spine because of her previous experience with radiation. The patient was started on palliative pamidronate for the bone metas- tases and started on an aromatase inhibitor (because the cancer was estrogen positive and there was a case report of a patient with the same type of cancer responding to ex- emestane). The patient was later switched to densoumab in lieu of the pamidronate. By August 2014, the patient’s condition had deteriorated rapidly. She was under palliative care until she died on September 11, 2014. Eccrine carcinomas are relatively rare (i.e., less than 5% of cancer cases) and given their scarcity, literature primarily consists of case series and case reports. There are no guide- lines with respect to treatment for eccrine carcinomas and treatment of the primary is limited to predominantly surgical. Due to the relative rare nature and the lack of information pertaining to this type of cancer, referral of the patient to a regional cancer centre, at least for an opinion, may have been beneficial. “There is no evidence to guide how patients with eccrine carcinomas should be followed up. Given the fact that they can behave very badly, it would have been reasonable to follow the patient every three to six months, for five years. Diagnostic tests could have been performed if new symptoms or signs developed,” stated the Commit- tee. There is no evidence, however, that this approach would have changed the outcome, the Committee acknowledged. The surgery performed on the patient was within acceptable standards. The fact that so many lymph nodes were involved indicated 60 DIALOGUE ISSUE 4, 2017 a very poor prognosis with respect to the de- velopment of metastatic disease. The use of combined radiation and chemotherapy was reasonable. The use of cis-platin has been used in squamous cell head and neck cancers and even those of the skin. The fact that this cancer does have similarities with breast cancer, and that breast cancer responds to cis-platinum, also makes this choice of agent reasonable. The severe mucositis, dehydra- tion that resulted in the patient admission to hospital is not uncommon in this setting; there is no known role for adjuvant systemic therapy in this type of cancer. The Committee stated that there is no evi- dence to suggest that use of more intensive imaging or laboratory investigations would have detected metastatic eccrine carcinoma early enough to make a difference; that the patient presented with such diffuse disease further confirms this fact. “With respect to the systemic treatment of this type of cancer, health-care practitioners currently use case reports as a guide,” stated the Committee’s report. “Doxorubicin and paclitaxel are two options, but response rates are poor; there is no chance of cure and there are significant risks of toxicity. It was noted that the patient had already been admitted for chemotherapy toxicity when receiving chemotherapy in the adjuvant setting.” The Committee stated that exemestane was a reasonable choice, given the fact that the cancer was estrogen positive and it has a good side effect profile. The management of the bone metastases with pamidronate and ultimately, denosumab, was also reasonable. The palliative care provided to the patient was well-documented and detailed and in- cluded notations on symptoms and rationale for options chosen. The medications and their dosages/frequency were within thera- peutic standards. MD