Skin Cancer

Treatment of Skin Cancer

The three important types of skin cancer (carcinoma) are:

• Basal cell carcinoma
• Squamous cell carcinoma
• Malignant melanoma

All are related to long-term sun exposure and repeated sunbathing. People with fair complexions are particularly prone to develop them because they lack the protective effects of skin pigment.

Basal cell carcinomas (BCCs) are the commonest and occur most frequently in the head and neck and other sun-exposed areas. One in four people in North America will get a BCC. Although malignant, locally destructive and capable of continued growth, they do not spread to other parts of the body (i.e. they don’t ‘metastasize’). However, they frequently recur if incompletely excised. A BCC usually appears as a raised red papule with small veins running over its surface. The papule may ulcerate leaving a small ulcer with a rolled edge, again showing the small veins. Complete excision is the treatment; and, as a Plastic Surgeon, I always plan the excision to place the scar in the most inconspicuous position. This would be along the natural grain of the skin, or, if possible, in a natural skin fold. Defects that cannot be closed by these means may require a local tissue rearrangement such as a ‘flap,’ or possibly a skin graft. Again, I would plan these procedures to minimize scarring. Pathological examination of all excised specimens is mandatory – either during the excisional process (by ‘frozen section’) or afterward – to ensure complete excision and confirm the diagnosis.

Neglected lesions might attain sufficient size to cause destruction of major facial structures such as the nose, eyelid or lip. In such cases an extensive preoperative work up is required including CT scans of the head and neck. Furthermore, complex reconstructive techniques are often necessary once the excision has taken place. As a Plastic Surgeon trained in major reconstructive techniques including microvascular surgery and practicing for over 30 years both in the University and in the private setting, I have the expertise to reconstruct the facial features to maximize function, minimize scarring and re-establish a normal appearance.

Squamous cell carcinoma (SCC) also occurs in sun-exposed areas including the face forearms and hands. It is not quite as common as BCC. An early and relatively benign form of SCC manifests itself as a keratosis. This is a small rough yellowish-brown warty growth frequently found on the forearms and the backs of the hands in individuals who have spent much of their lives outdoors. They also occur on the face in those chronically exposed to the sun. ‘Solar keratoses,’ as they are known, are premalignant with the capacity of changing into invasive SCCs. The latter are not only invasive, like BCCs, but unlike BCCs are able to metastasize (spread) via the lymphatics to other parts of the body and ultimately cause the demise of the patient. They tend to metastasize only after they have attained a certain size (2cm+). SCCs should be removed on sight. Total excision is mandatory and the reconstructive principles outlined above apply here too.

Malignant melanoma (MM) is a truly lethal tumor. Fortunately, it occurs much less frequently than either a BCC or SCC. It too is usually found on sun-exposed areas, but not always. It can even appear on the sole of the foot or under a nail. It looks like a mole but is characterized by its jet-black color, irregularity of pigment and, occasionally, a history of bleeding. Normal moles don’t bleed! MMs rapidly spread via the lymphatics and the bloodstream to local lymph nodes and internal organs such as the liver lungs bone and brain. The risk of spread is determined by the thickness of the lesion (the word lesion simply means a pathological entity, here the melanoma itself), measured microscopically in millimeters, rather than its overall size. Lesions less than one millimeter thick have a 95% five-year survival, whereas lesions greater than four millimeters thick have only a 50% five-year survival.

It is vital that you see a Plastic Surgeon or a Surgical Oncologist if you notice a preexisting mole turn black or bleed. Similarly, if a black mole suddenly appears out of the blue, you should seek medical help as soon as possible. MMs can be cured if treated early, yet may well prove fatal if neglected. Due to their aggressive behavior, MMs are excised with a larger cuff of normal tissue around them (‘wider margins’) than BCCs or SCCs. I use a special technique (‘sentinel node biopsy’) to see if the MM has spread to the local lymph nodes. If it has, I perform a complete excision of that nodal group. CT scans are used to determine whether the disease has spread to the internal organs. If it has, the outlook for the patient is extremely poor. Although there are various experimental drug trials under way, MMs have not proven particularly sensitive to chemotherapy or radiotherapy. Since MMs are either excised early or metastasize early, major reconstructive surgery is seldom needed. However, the same principles apply as for the other tumors.