 So this is my presentation from the oculoplastics one and from the oculoplastics conference. And this is something that Dr. Patel helped me put together. And I'm really hoping for a good discussion on this patient. I'm going to talk a little bit about the medical side of it, but Dr. Patel suggested and I think it's a great idea to focus a little bit more on the ethical and on the ethical side of this case. So I'm hoping to have a good discussion as that comes up. So this was a patient that was initially a telephone consult. So Dr. Patel was contacted regarding a patient who's an 86-year-old lady. And he was contacted because he'd seen her before and helped out with this. So she had an advanced left forehead squamous cell that was resected in 2013. And a pretty significant reconstruction done at that point. It was treated with radiation. And she had shown up at the ENT clinic who had also participated in her care, presenting with new masses in the left lacrimal gland and left parotid gland. And so the consult, so she had shown up at the ENT clinic. And the phone call was basically, we'd like you to biopsy the left lacrimal gland because if it is squamous cell, which they really suspected it was, she will need an exenteration, hemifacial resection, which is an invasive surgery. So she came to our clinic for evaluation. So over the past few months, she had noticed this new bump over her left eyelid. And then another bump, she'd also actually noticed these at her left jaw line. And so she had a little bit of blurry vision in her left eye. And no pain, no paristhegias. So her medical history, I'd mentioned this before. So in 2015, so this was just a month before we saw her, she'd had a squamous cell on the nose that was removed with Mohs surgery. In 2013, she'd had this wide resection of squamous cell in the left forehead. And still had positive margins, was treated with radiation. And then she'd had several other different places on her skin, resections of basal cell and squamous cell. Also arthritis, GERD, depression. And then in the past, she'd had non-Hodgkin lymphoma that was treated outside of the university, so I don't have a lot of details on this. But she was not receiving any treatment at that time. So this is a picture. So you can see a lot of this is just post-surgical changes from the previous surgery. But what she had noticed, and what we noticed on exam, was this new swelling here laterally in the area of the lacrimal gland. So the ENT service had already ordered the imaging. And this was what they had noticed, a 2 by 1 centimeter mass at the left lacrimal gland. And then they'd also noticed a second mass at the parotid gland. So sorry, I picked on Chris at a bad time last time. Are you OK now, Chris? Any thoughts on a differential diagnosis here? Right. Nice, yeah. Perfect, kind of right where we were. I just include a little bit more of a differential. We've got O-caps coming up. And I feel like sometimes these lacrimal and orbital tumors are some of the toughest ones. So squamous cell definitely bolded here, given her history really concerning for that. The pleomorphic adenomas, pleomorphic adenocarcinoma, adenoicistic carbosinoma, with her history maybe less concerning. Lymphoma, she does have a history of lymphoma. And then just a benign reactive lymphoid hyperplasia, as you mentioned. So I want to go back to the initial consult that we were called about. So we would like you to biopsy the left lacrimal gland, because if it is squamous cell, she'll need an exeneration and hemifacial resection. And so that is kind of the ethical discussion that I want to focus on, just kind of directed towards that treatment plan. So if it is squamous cell, so these are some of the questions we're going to discuss. I'm going to do a little bit more background, but I just want to introduce these so everyone could be thinking about them. So if it is squamous cell, should she have an exeneration hemifacial resection? How should we make that decision? Should cure be the goal? Does the way we present information influence the decision that the patients ultimately make? And as consultants, because Dr. Patel was a consulting physician in this situation, what is our role? And so I'm going to do a brief review of squamous cell and exeneration just to kind of aid with this discussion. So squamous cell is the second most common malignancy of the face, and it's the most common secondary epithelial neoplasm in the orbit. And the way it frequently gets to the orbit is perineural spread. And so this perineural spread, which is what we were concerned about in this situation, was first described in 1842. And so about 5%, when they cut out squamous cell, you can see evidence of perineural spread pathologically. But if it is recurrent, then the percentage is much higher if it's recurrent cancer. The symptoms, so formication. Let's see, Rhys, do you know what formication means? Because I didn't either. I had to look it up. So it's not formication. Formication means the feeling of ants crawling on your skin. So formication, I thought that was a good word that I learned. This athesia, peristhesia, numbness, so a lot of, as you'd imagine, symptoms associated with the nerves. And something that's important to keep in mind is that the perineural spread can take a long time to show up. It can be small amounts of cancer along the nerves, but then eventually that gets to the point where it's symptomatic. So it can present years down the road. And poor prognosis for squamous cell spread to the orbit. Five-year survival ranges between 20% and 30%. And this was just a nice case series, because it is fairly rare, so most of these are case series. 21 patients treated, 14 died with a median time to death of three years. And there's not, there aren't really good studies or good guidelines in terms of treatment. Most people recommend excentration plus or minus radiation, and definitely a multidisciplinary team. So because orbital excentration is the treatment that's frequently recommended, I just want to do a quick review on that. So first described in 1500s and again in the 1700s, the aim of excentration is to control the disease locally, so just get rid of the disease that's there that you can find. And 40% to 50% of exenerations are required basically for this for skin cancers. So tumors that originate in the eyelid or periocular skin. It is, there are a lot of complications with it. So fistula formation, tissue necrosis, chronic drainage, chronic pain. So it's certainly not a benign procedure. And I found one quality of life study that showed as you'd expect that there's significant reduction in quality of life. A lot of the exeneration studies are on what they call younger patients, so patients in their 50s or 60s. One did it in older patients, and the oldest they had was 85. And their patients did OK, but they were very carefully selected to be patients that were otherwise completely healthy and didn't have other health issues. Interestingly, so there was one comparative study that looked at exeneration versus conservative management. And they had 66 patients, which is, and it was sinus cancer, so not completely related to ours. They had similar survival, but the biggest problem with that is that it wasn't randomized. And so you can't really make conclusions on that, because patients who got the exeneration perhaps had had worse cancer in the first place. So there are some pretty amazing prosthetics that I learned about that look really good, but it turns out that most patients actually end up, in the states they've been done, prefer just not to use their prosthetic, because it's awkward. It still looks different enough that people still ask questions. And so I was surprised, the two studies I found said that most people just wear a patch instead. And then, so survival rate, so all comers, a few studies said 80% to 90%, five year around 60%. But again, if it was because of the perineural spread from squamous cell that they had the exeneration, the survival was much lower. So now we'll kind of get to what I'm hoping to spend most of my time on is this ethical discussion around the issues. I thought it would just be helpful to give a little bit of background information that we just did. And I also wanted to review the ethical values in medicine. I think sometimes we forget that we have these values that kind of give us a framework to look at a tough situation. And I feel like when we step back and look at what our community of physicians, what we recognize as important values, I feel like stepping back and looking at those values can kind of help us look at a tough situation in an objective way and really make a better decision. So these are the ethical values that are kind of accepted. So one is respect for autonomy. So not just deciding and determining everything for the patient, allowing them their autonomy. Beneficence, so that means what we do should be good. So we should look to do good things to help the patient. Nomileficence, so that's the famous one that we all, I think the one that pops into everyone's head which is first, do no harm. Justice, so fair treatment. Respect for person, so recognizing that they are a person, they're a person, not a patient. We're all human beings. And then honesty and being true in the way we present patients. So I just thought reviewing that might give us a little bit of background. And then just work our way into our ethical discussion questions. So any thoughts on this? So this first one, if it is squamous cell, should she have an exenteration hemifacial resection? And then just kind of how would you approach that? So any comments from the audience? 86. So that's a good question. And so she is a really sweet lady but that's what kind of gets to what I'm saying down below is the way you presented it to her totally influenced how she was doing it. But I think you're thinking along exactly the right lines. Make sure that it's her decision to see what she thinks or what she wants. Dr. Harry. Especially all of her pretty big decisions. Yeah, I like that thought a lot. You still have to be careful to respect the patient's autonomy but family help with it can make such, can be really helpful. And that actually brings up something that Dr. Patel always brings up that I think is a really good way for us to think about it. He always says if it were your, and I won't do the accent, but if it were your mother what would you want done? How would you take care of this patient if it were your mother? So I mean that's another way to look at this discussion. I'd be interested in this patient aside but just your own thoughts on that. If it were your mother or if it were yourself in this situation what would you, how would you approach that? Particularly if the cure rates are, at her age if the cure rates, we don't really expect necessarily cure to be a goal for her. And I think that her quality of life may be as good for the remaining time that she has depending on her health otherwise but it may be much higher if she doesn't have a really extensive ex-generation of facial resection. Yeah, I'm glad you mentioned that. I forgot to kind of reiterate that that they would also do a hemifacial resection. So I mean even more morbidity in this figure than just an ex-generation. Dr. Joe. Is there any other options presented to her for how that would be in the year? Yeah, so at this point, no. Yeah, at this point that discussion hadn't come up, so. I agree with that. I think, I mean especially when you look at the studies that are mostly done in younger patients, cure for this disease probably isn't, you know, the five year survival is 30%, you know. So cure might not be the best goal, but you know, local control. So yeah, I think that was a really good thought. Great, yeah, that's a good thought. Yeah. What's the natural course? How would she look if she did nothing? I mean, she looked like a man of stage which is very farming. Or would she look fairly, I mean, she might be worried about that. She wouldn't mind to not going out anywhere. Right. Yeah, very good thought. Thanks. Two things that I think may really direct the role of the physician and then also lead into what is our role as consultants and how comfortable we are with our arguments. It's really what is her, I guess, level of comprehension of her options. Mm-hmm. And then with that, assuming that that's, you know, an adequate level of comprehension, understanding options, then there's just personal preference among patients. We have some patients who really enjoy the more paternalistic relationship where it's asked the physician to make the decision based on their best judgments. Whereas others really want that ability to, on their own, autonomously make that decision. And then, you know, assuming that she comprehends, assuming she doesn't really comprehend or she just wants us to make the decision, then you're in question about what is our role as consultants? I think that would be... Right. Exactly. And that, I think, was kind of one of the big, just one of the big things for me is, you know, the question of your role as a consultant because we do the biopsy, the biopsy comes back positive. Probably see her in follow-up, but she'd be seeing the ENT service and if you disagree with what they decide to do, you know, how to handle that. And I think that was something that Dr. Patel also thought was interesting is just what, how, you know, so any thoughts on that? What's our role as a consultant? If, say, the information we don't really like the way that it's presented to the patient that she feels like she has to do the exeneration or she's giving up, she feels some sort of pressure into it. And that's what ends up happening. What's our role as a consultant? What could we do about that? Dr. Crum. I think having two surgical services come in, but it's very tough when you have a primary team as a surgery service and then also being a consultant as a surgery service because you can't do those nice, tolerant, but you can't have conversations. So I agree, that's very difficult. Right. Yeah, but you make such a good point about face-to-face conversations that I think sometimes in the world of electronic medical records don't happen as communication between knows. But I think that's a really good point about sitting down and talking. Dr. Zog. So the key is, the thing is step back and say, okay, what would I do again in this situation trying not to money happens a lot just in regular consults, you know, have a patient with monocular pneumonia. If you go in thinking that they have monocular pneumonia as a diagnosis, it muddies your assessment of the patient. So you have to kind of step back and ask the questions yourself, the history, you know, take somebody else's report. It's the trying not to be too fast and coming to the same conclusion that you're trying to hopefully come up with a different, a lot more confident in things, it's not just in these big cases. Right. Not just go along with the department. Yeah, I like that. I think reminding ourselves that we're not just a diagnostic test, like you said, you don't order an ophthalmology consult the same way you order an MRI, but we're physicians and should use our skills and think about it for the patient. That's really good. Let me frame this, that looks like you're saying, procedural services, when you're a consultant, you have to provide a service. The whole history pointed to metastatic breast cancer, serious changes, and I always feel chronic development and so on, plus the textbook case. To relapse into a reticence was a very scarce place that I scarce, and about a month later, I went to follow up with a patient and she had had a hepatectomy, a small normal section, and we all know that survival would happen. And so, I do go on there with a whole book on just this one case called Being Orphan. I and my fellows read about five books that I keep on my life in the U.S. government. Good that in this 21st century, we have philosopher surgeons, people who actually stand back, look at the history of medicine and think about who we are and why we're here today. And he made the point that we were, we asked the first question we asked this lady was, so she's been booked for a surgery. You and I all have patients who tell us, Dr. Katz, you're the doctor, do whatever you want, I just want to get better. We see these patients all the time, and this is that lady, she's a charming lady, but she just wants to be. At your mercy, you do whatever you want to do, so she's got a surgery date. Those of you who haven't seen the hemifacial perception, you basically have a phantom of the opera, you have nothing from the forehead down, you have a free flap that comes out from your back, and it looks like a slab of meat, doesn't matter how good surgeons we are, that's the way it works. So, the first question was, has your team discussed with you the option of not having surgery? And that daughter in the room says, you know what I'm not really told, this is the best way to treat it. Probably because the patient said, I'm at your mercy, you do whatever you think is best. And that little girl out there, spends a whole world of 360 pages, saying this one thing, tell your patients they have a choice of not having treatment, and then you make this a very good case, price of, what will you look like? Will radiation allow you to have a reasonable three years, five years of life, and not looking for a test, like it went from last year. That's the way it works. So that one statement was never used, and the question arises, what is our role as consultants? Do we pick the phone up and say, this will matter with you, perhaps why don't you tell him that you can't have surgery? Or do we say, don't operate on this patient and take a bowels up, and a liver up, because metastatic cancer in the oar, which is a sign that you basically are scared of spread of cancer and you're going to die. Just because you have no quality of service does not mean you do this, just because the family, many of the people I see, they haven't seen their loved ones for five years. They show up in my waiting room and say, do whatever you can to save this person's life. Do we really do that, and how do we present the patients? So these are philosophical questions. If you haven't read Atul Gawande's book, I strongly urge you, it's called Being Morphled. And then just a few months ago, an old professor of mine, you know, a surgeon called Henry Marsh came out of the book called Do No Heart. And if you haven't read that, I would strongly urge you to read this. And he tells you a neurosurgeon's perspective about tubers that grow in the brain, and the decisions that he makes about life and death and how aggressive to be. And then how do you handle the complications that we as orbital and facial surgeons put on our faces all the time when you get a result of just suboptimal? All the time. Fortunately, it's rare enough that we remember a few places. How do you handle that? Do you really go chasing a tuba that might be like right now, the one I'm asking the tuba and the apex of the orbit? It's not going to kill the patient. It's not going to blind the patient. Doctor, I can't just bear having this thing in my head. I'm walking out. Well, there are times when you say you're an idiot. You can't do that. Well, we mustn't be afraid of the past self-gaming that the patient will say, oh, you're so rude. It's your job to be rude at times. And say, don't be such a moron to be blind at the end of the story. So this breast cancer of a patient was after, I told you to put this case together, and that was even more jarring to me because now the patient has had $200,000 worth of surgery. And we have to bring our dollars in the sense here. I'm sorry, but hospitals, whether you like it or not, will push you to do more surgery, or virtually or covertly. This is the problem I see in all the hospitals I go to. They're very happy to put cases on. Nobody comes to me and says, oh, there's this patient I really need this doing. It's not that I expect them to say it every time, but it is good. We say, what are you doing and why? Why aren't you stepping back and allowing things to take the natural course and then deciding whether you're being treated? So this second case for frames, the dilemma we were faced with this patient, surgery's booked for so-and-so days. Would you call up the doctor and say, cancel the surgery, we all need to have a talk with the patient and the family, but I'm not the primary surgeon. I'm not the primary physician. I'm simply the mechanic who's going to diagnose to make a decision about what this particular tumor is. So short pants, how many of you would pick the phone up and say, please talk to the family and tell them there is an option of not having surgery? And I understand that there is this concern about, oh, the doctor will get mad at me. They'll refer patients to me. They might think I'm intrusive. Most of us, I think, would work on a phone call like that and I'm proud to say that people I work with around, I frequently get those calls. Do you think, what do you think, can we, shall we, should we leave it alone, et cetera? These are conversations I think we should all encourage to have. Again, although Henry Marsh's book is very revealing, and it's almost like a wonderful story, I took a honest book, I'll be mortal, I think we'll change you if you read that. I don't agree with everything he says, but that's the whole point about the loss of the surgeons is you don't have to leave everything someone says. Some degree of distinction. Thank you, Dr. Patel. So I wanna make sure that Russell can graduate from residency and give his neuro-ophthalmology presentation. But just real quick, I wanted to let everyone know what happened, so we did the biopsy, which was definitely indicated, and a good thing we did, because it actually came back as low grade follicular lymphoma. Remember, she had that history of lymphoma, so we'd actually, Dr. Patel and I had discussed this, discussed all the options and planned on presenting it before the biopsy came back. So it was interesting, it didn't come back as squamous cells, so fortunately, she didn't need that. Unfortunately, it's still cancer. And so she ended up seeing her oncologist in January, who's outside of the university system to discuss further treatment and complete staging, so I don't have any of those results. But it shows the point of do the biopsy, find the diagnosis, and then also, I thought the really big learning points were just to think about quality of life for the patients, remember the way that we offer something to patients can really influence what they decide to do, and then also consider our role as consultants and always try to do what's best for the patient. So thank you, Dr. Patel, for your help with that, and a lot of small references there. And then, Russell.