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Skin Cancer
P1
P2 P3
Previous Typically ED&C x 3 has a 75-80% rate of successfully eliminating the BCC. Given the slow growth rate and the tendency for BCCs to remain localized, ED&C x 3 is an excellent option under the proper conditions.
Mohs Micrographic Surgery
Named for namesake and creator Dr. Frederick Mohs, this form of excision combines surgical excision with immediate surgical confirmation that the tumor has been fully removed. Under local anesthetic, the visible cancer is removed, processed for surgical path and microscopically accessed, all at the same time in the specialist’s office. Should any remnant skin cancer remain, the edges are gradually removed, evaluated, etc. These steps are repeated as necessary to assure complete removal of the skin cancer and to preserve healthy uninvolved tissue. Mohs surgeons are typically dermatologists who have undergone an additional 1-2 years of training in this area. Mohs is particularly ideal for skin cancer involving the central face where protecting cosmetically important areas such as the nose is vital and is now the standard of care.
Imiquimod
The generic name for Aldara, this topical immune response modifier is known for its use to treat genital warts. The drug’s ability to provoke a local tissue production of tumor fighting interferons and tumor necrosis factor-alpha has taken this medication to the forefront of basal cell carcinoma treatment. While not yet FDA approved for skin cancer treatment, (although submitted to the FDA for consideration to become an approved treatment), multiple studies have shown the ability of topical Imiquimod to resolve early SBCCs as well as some popular basal cell carcinomas. Patients unable to undergo surgery and having very small BCCs may be potential candidates for supervised use of this “off label” therapy.
Less commonly used treatment options include laser destruction, cryosurgery, radiation therapy, topical chemotherapy with 5-fluouracil, and photodynamic therapy (Levulan Kerastick for early BCCs). Clinical trials involving biologic agents or a combination of biologic agents and retinoids are also ongoing.
Patients who have had a basal cell carcinoma should undergo a follow-up skin exam at least every 6 months for the first 5 years out from the time of treatment. I often revisit every 3 months for a few visits to keep my eye on ED& C sites to monitor for recurrence. It is during this time frame that the BCC would be most likely to recur. But it’s important to realize that skin in the same region is more at risk for developing an entirely new skin cancer. A complete skin examination is recommended, not just a spot check of the surgery site.
Squamous Cell Carcinoma
Affecting about 200,000 in the U.S. per year, squamous cell carcinoma (SCC) is a more dangerous form of skin cancer as it’s associated with a small risk (less than 1%) of spreading to other areas of the body. This results annually in approximately 2000 deaths. Squamous cell carcinoma arises on sun-exposed, sun damaged skin. The more sun exposure, even cumulative sun acquired from routine “tanning” is associated with a higher risk of developing SCC. Squamous cell carcinoma may also form on areas exposed to chemicals, thermal burns, radiation, and occasionally within vaccination scars. Arsenic exposure is an uncommon though important risk factor. Arsenic was found in “old fashioned” cough and cold treatments predominantly in the Southeastern U.S. More recently, arsenic exposure is typically associated with pesticide use.
Typically looking like a hard, sometimes scaly or crusty red bump or nodule, squamous cell carcinoma continues to grow in height and diameter until removed. Ulceration, itching and bleeding may develop. Squamous cell carcinomas may arise from precancerous skin changes known as actinic keratoses that resemble chronic reddish brown scaly patches on sun-exposed skin.
Due to the somewhat higher risk of squamous cell carcinoma of the skin to metastasize (spread to other areas of the body), the best option for treatment is one that guarantees complete removal. Straightforward excision or Mohs micrographic surgery would both be appropriate options. Here again, in patients who may be unable for some reason to undergo a full excision, other options may be appropriate in certain cases. These include laser destruction, ED&C x 3, radiation therapy, cryosurgery and treatment with 5-fluoruracil. Clinical trials are ongoing with the use of biologic therapies alone and with retinoids as well.
Follow-up again mirrors that of basal cell carcinoma patients. Because of the low potential for metastasis, quarterly skin checks are best. It’s important to remember that if one form of skin cancer develops, the level of sun damage has been reached that patients are at higher risk to develop any or all of them. Vigilance is the best bet for early detection and intervention.
Melanoma
By far the most lethal of these 3 skin cancers, melanoma is responsible for 7400 deaths a year in the U.S. Arising from pigment producing cells known as melanocytes, melanoma is associated with moles (medically termed nevi). The vast majority of moles are visible on the skin, and brown in color. Rarely, moles may be pink or red, (amelanotic) and there are even moles which can be hidden internally, such as at the back of the eye.
Fortunately, moles don’t change into Melanoma overnight. Gradually moles will go through a series of changes (some faster than others) known as dysplasia. The greater the degree of dysplasia,
the more likely the mole may turn into melanoma.
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Thank you for taking the time to read through this important information. I hope you have found this article informative.
Audrey Kunin, M.D.
(Any topic discussed in the this newsletter is not intended as medical advice. If you have a medical concern, please check with your doctor.)
Article updated July 16, 2002.
http://www.dermadoctor.com
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Bio
Dr. Kunin is a board certified dermatologist in Kansas City, Missouri. She
received her dermatology training at the Medical College of Virginia. She has
been featured on several local television and radio news and talk shows for her
expertise in her field. She also holds a position as Associate Clinical
Instructor at the University of Kansas Medical School Department of Dermatology.
In addition to general dermatology, her interests in cosmetic dermatology
include non-surgical approaches to skin rejuvenation, including chemical peels,
Botox, Isolagen, skin care products and sclerotherapy.
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