Skin Cancer

Skin cancer is the most common cancer and is divided into melanotic cancers that involve pigment and Non-Melanoma skin cancers ( NMSC). NMSCs, mostly squamous cell carcinomas (SCC) and basal cell carcinomas (BCCs), generally occur in the elderly population over 50 years of age, and the incidence is increasing.

1. Research estimates that nonmelanoma skin cancer, including basal cell carcinoma and squamous cell carcinoma, affects more than 3 million Americans a year.
2. Research also shows that the overall occurrence of BCC increased by 145 percent between 1976-1984 and 2000-2010, and the overall incidence of SCC increased 263 percent over that same period

Patients often present with NMSC affecting predominantly sun-exposed areas such as the face, neck, and hands. The occurrence of tumors in these sites reflects the fact that exposure to UV radiation from the sun remains the most crucial risk factor for the development of BCC, this compounded with a fair skin increases the overall risk of both NMSC and MSC.

Fast growth, loss of sensation and open lesions are all indicators of an aggressive tumor with risk of metastases. Often a biopsy is needed where a small sample of tissue is sent to the laboratory to confirm the diagnosis before treatment. Medical aids often need this to exclude the excision of benign lesions in an expensive theatre expedition. The patient also needs to be examined for other suspicious lesions.

BCC grows slowly but can be locally destructive at times and have an extremely low risk of metastasis (<0.1%). That is the reason they are known as rodent ulcers. A well-defined and rolled border is usually present, with possible central ulceration or crusting. BCC can also be pigmented or appear as raised erythematous patches or plaques.

SCC is more aggressive than BCC and has a higher incidence of metastasis, although still relatively uncommon (2% to 6%). They may present as pink-colored, crusted, hyperkeratotic papules or plaques that can be eroded or ulcerated. SCC’s can spread to the nearest set of lymph nodes.

There are many treatments available depending on the size, location and type and how aggressive the tumor is:

1. Surgical excision remains the most effective modality with the lowest rate of treatment failures. Standard wide local excision is the most common treatment of choice for cutaneous BCCs and SCCs given the high cure rate (>90%) for most low-risk tumors and its cost-effectiveness. Frozen section is performed intraoperatively – this means that a pathologist is present in theatre to examine the specimen to see if it is taken out with a wide enough margin. If there is still a tumor at the edge, then a wider margin of excision is required.
2. Doctors use Radiotherapy as the initial therapy for patients who are not good surgical candidates or do not wish to have surgery or in those patients with advanced or incurable disease. It is avoided in the young patient, is less effective against aggressive or recurrent tumors and is more expensive and time-consuming.
3. Cautery (burning) and curettage (scraping) is highly operator dependent, cannot indicate if the tumor has been completely excised and should be limited to superficial lesions located in low-risk areas.
4. Cryosurgery (Freezing with Liquid Nitrogen) is not selective toward the tumor cells and does not allow for margin analysis. Cryosurgery is simple to perform and can be useful in the treatment of carefully chosen cases such as superficial or in situ BCCs and SCCs, with a cure rate greater than 90%.
5. Topical treatments including 5-fluorouracil (5-FU) and imiquimod (Aldara) can be used to treat selected superficial and in situ BCCs and SCCs. Imiquimod is a topical immunomodulator and is approved by the US Food and Drug Administration for the treatment of actinic keratosis and superficial BCCs.

As Plastic Surgeons the nitty gritty of NMSC treatment is surgical.

A detailed understanding of skin physiology and anatomy, careful wound analysis, and meticulous operative techniques are critical to a successful reconstruction.

The fundamental principles in reconstructive surgery are function before form and form before cosmesis. Preservation of function is of the highest importance. Regardless of how beautiful a scar is, it is worthless if a patient’s ability to breathe or vision is affected.

Plastic surgeons with their Knowledge of anatomy and surgical skill have a variety of options to reconstruct complicated defects using either primary closure, local flaps, skin grafts or free flaps to close the defect depending on the specific situation.

Generally, the safest, simplest, most straightforward technique with the least risk and the best outcome is selected to reconstruct the defect.

After surgery, various treatments such as Laser and scar management programs using silicon gel, or micropore tape and scar creams containing Alpha Centella and Onion extract can be used to improve cosmesis.

Postoperative follow up is needed to assess wound healing and to detect recurrence of tumor or new NMSC in patients at risk.