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