What Is Skin Cancer
The skin is the largest organ in the body, and skin cancers account for more new cancers than any other cancer type. Because the skin is a protective layer, it absorbs the damage of external influences such as solar radiation, chemicals, and environmental toxins.
Because the skin is composed of cells that are already fairly resistant to injury, when aggressive cancers develop, they may be more challenging to treat than tumors in other organ systems.
Happily, most skin cancers are lower risk malignancies that may be locally invasive, but rarely spread (metastasize) to other parts of the body. But even these tumors, if ignored, can become unsightly and dangerous.
Some skin cancers may look innocent, appearing only as a small pink bump, hiding their true nature. These lesions may represent a rapidly growing early metastasizing process for which aggressive treatment is indicated.
A respected dermatologist is the best option for individuals with new skin changes or lesions. Such a professional can assess personal risk and design follow-up programs to document change and respond with early intervention.
Once diagnosed with skin cancer, it is important to talk openly with your physicians. You need to understand the different treatments, how, and when they are given for your particular disease. You may also want to know about your future risk for recurrence and the development of new disease.
For patients referred for management of more worrisome disease, Dr Hyams and his staff will make sure that you get all the information you need to make informed decisions about your care.
Understanding Melanoma
Melanomas are cancers derived from the pigmented cells of the skin. They are associated with sunburns, but they may arise anywhere on the body, including sites where the sun doesn’t shine. Although representing a small percentage of skin cancers, melanoma is a potentially aggressive disease with a significant mortality.
Melanoma risk is traditionally assessed by thickness of the initial melanoma, and by the presence of lymph node involvement. However, new gene expression tools allow a much more precise assessment of risk, leading to better treatment choices.
Most melanomas require wide resection and some oncoplastic reconstruction of the defect. Many require an assessment of regional lymph nodes.
However, there are now very effective therapies for high-risk melanoma that can lead to cure, even in patients with distant recurrence of disease. But treatment success is best when the volume of disease is small, making individual followup very important for patients at elevated risk.
Optimal melanoma management requires attention to surgical detail, as well as a broad understanding of the disease and its biology.
Understanding Squamous Cell cancer of the skin
Squamous cell cancer (SCC) of the skin is a common tumor, representing approximately 20% of all skin cancers. This tumor is also associated with cumulative sun exposure.
When confined to the outer skin, this is called in situ SCC, or Bowen’s Disease. Bowen’s Disease itself poses no immediate threat, but may evolve to invasive disease.
Invasive squamous cancer of the skin is generally a slow to moderate growing local process that often appears as a raised firm bump, sometimes with a small central depression or scab. This gives it a characteristic “volcano” appearance.
Although most invasive SCC do not spread, the initial treatment of SCC is primarily surgical. With most disease localized, cure can be assured if margins of resection are suitably clear.
However, a small proportion of SCC are biologically aggressive, can locally infiltrate nerves and muscles. These tumors can spread to regional lymph nodes and to other body sites. These may be difficult to control. High-risk SCC may require more aggressive surgical management including lymph node biopsy followed by radiation therapy. High-risk SCC of skin may even require aggressive systemic drug therapy for curative management.
New developments in gene expression profiling may help us identify particularly high-risk SCC that requires more aggressive treatment and life-saving interventions.
Understanding other high-risk cancers
Other concerning skin cancers range from lower-grade sarcomas, to high grade skin sarcomas, to Merkel Cell Carcinoma.
Most skin sarcomas are more aggressive locally, and rarely spread to lymph nodes or beyond. Nonetheless a careful assessment is important. Careful surgery is even more important to prevent recurrence.
Merkel cell carcinoma is a special case of a rare, but very virulent neuroendocrine cancer, often much more aggressive than melanoma. Treatment is similar to that of melanoma, but outcomes are often much worse, especially in older patients.
Aggressive therapy with surgery, lymph node evaluation/removal, and radiation therapy, is often used in this difficult disease.
In cases of high risk or distant spread, drug therapy may be an important part of treatment.
As these tumors are quite uncommon, a surgical oncologist with experience in these diseases, is ideal for optimal management.
Understanding Basal Cell skin cancer
Basal cell cancers (BCC) are the most common cancer worldwide. These tumors are associated with cumulative exposure to sunlight.
BCC often appear as pearly red relatively flat lesions, and tend to be slow growing and only very rarely spread outside the site of origin. But if ignored, these tumors may become locally invasive and create significant harm.
Most small superficial BCC can be managed without surgery. However, as these tumors become larger, surgical intervention becomes the treatment of choice.
Most patients will have their BCC treated in the dermatology setting. But when tumors are large, invasive, or involving critical locations, surgical oncology management may be indicated.
The goal of surgical treatment is the efficient removal of the primary malignant tumor with a suitable margin of normal tissue. The resultant defect can be closed primarily, or with local tissue flaps that maintain contour and skin thickness, often with the scars hidden in natural skin folds.
These oncoplastic approaches to skin cancer are designed to maximally control disease, while minimally impacting cosmetic and functional outcome.
Oncoplastic Surgery for Skin Cancer
Skin tumor removal may lead to significant defects, particularly for larger lesions in awkward locations. Tumors on the scalp can result in long lasting open defects with exposed bone. Resection of skin cancers of the face can lead to significant visible deformity. Ill conceived operations, even with Moh’s surgery, can lead affected individuals to feel shunned and insecure.
Oncoplastic surgery utilizes plastic surgical techniques to perform better skin cancer surgery. Through careful design of incisions, defects can be filled, while contour and functionality are maintained. Scarring may be minimized.
Oncoplastic surgery for skin cancer employs a variety of techniques designed to develop a suitable soft tissue bed, facilitate grafting or transposition of replacement tissue, and stimulate healing. By placing incisions along lines of tension and natural creasing, appearance can be maximally maintained.
However, all of the cosmetic advantages are only useful if combined with appropriate disease management that reflects a deep understanding of the biology of each cancer.
Sentinel Lymph Node Biopsy for Skin Cancer
Lymphatics are vessels that return tissue fluid to the circulation. Lymph nodes are filtering stations along the lymphatics that trap bacteria, foreign debris, and cancer cells.
The presence of cancer cells in a lymph node increases the stage and risk of a cancer, and may lead to more aggressive postoperative treatment.
A protein-based dye, either colored or radioactive, make it possible to identify a specific lymph node draining a specific body area where a skin cancer arose.
By identifying the “most likely lymph node”, we can remove it and subject it to very detailed pathology analysis without having to remove large numbers of nodes. However, some parts of the body drain to more than one lymph node bed. Even when more than one lymph node bed must be sampled, the sentinel node technique, helps patients avoid more extensive lymph node removal.
If the so-called “sentinel lymph nodes” are negative, studies have shown that 94% of the time, remaining lymph nodes in that area would be free of disease as well.
When positive, other lymph nodes may be positive and may be treated with either removal, radiation therapy, or drug therapy.
The side effects of sentinel lymph node biopsy are few, making it the current standard of care in the management of many melanomas and high-risk skin cancers.
Managing Skin Cancer Risk
Skin cancer development is a product of genetic risk, chronic injury, and sporadic “errors” in cellular regulation. Modern genetic tools may identify gene mutations that predispose some individuals to unique cancer risks. Other individuals may be aware of an increased risk from long years of unprotected sun exposure in their youth. Others may have no unique predisposing features when they develop their first skin cancer.
Risk assessment and management is an important part of skin cancer control. A respected dermatologist is the key partner in this process. Dermatologists, working with surgical oncologists, can process the risk information and develop follow-up tools such as total body lesion mapping. They can establish appropriate follow-up regimens, and they can discuss evolving prevention strategies.
Surgical oncologists and dermatologists work closely together to manage risk, identify early cancers, and intervene appropriately. In the skin, the development of one basal cell cancer, squamous cell cancer, or melanoma, suggests that others will develop in future years. Joint follow-up and risk management are thus essential components of care.
Understanding Melanoma
Melanomas are cancers derived from the pigmented cells of the skin. They are associated with sunburns, but they may arise anywhere on the body, including sites where the sun doesn’t shine. Although representing a small percentage of skin cancers, melanoma is a potentially aggressive disease with a significant mortality.
Melanoma risk is traditionally assessed by thickness of the initial melanoma, and by the presence of lymph node involvement. However, new gene expression tools allow a much more precise assessment of risk, leading to better treatment choices.
Most melanomas require wide resection and some oncoplastic reconstruction of the defect. Many require an assessment of regional lymph nodes.
However, there are now very effective therapies for high-risk melanoma that can lead to cure, even in patients with distant recurrence of disease. But treatment success is best when the volume of disease is small, making individual followup very important for patients at elevated risk.
Optimal melanoma management requires attention to surgical detail, as well as a broad understanding of the disease and its biology.
Understanding Squamous Cell cancer of the skin
Squamous cell cancer (SCC) of the skin is a common tumor, representing approximately 20% of all skin cancers. This tumor is also associated with cumulative sun exposure.
When confined to the outer skin, this is called in situ SCC, or Bowen’s Disease. Bowen’s Disease itself poses no immediate threat, but may evolve to invasive disease.
Invasive squamous cancer of the skin is generally a slow to moderate growing local process that often appears as a raised firm bump, sometimes with a small central depression or scab. This gives it a characteristic “volcano” appearance.
Although most invasive SCC do not spread, the initial treatment of SCC is primarily surgical. With most disease localized, cure can be assured if margins of resection are suitably clear.
However, a small proportion of SCC are biologically aggressive, can locally infiltrate nerves and muscles. These tumors can spread to regional lymph nodes and to other body sites. These may be difficult to control. High-risk SCC may require more aggressive surgical management including lymph node biopsy followed by radiation therapy. High-risk SCC of skin may even require aggressive systemic drug therapy for curative management.
New developments in gene expression profiling may help us identify particularly high-risk SCC that requires more aggressive treatment and life-saving interventions.
Understanding other high-risk cancers
Other concerning skin cancers range from lower-grade sarcomas, to high grade skin sarcomas, to Merkel Cell Carcinoma.
Most skin sarcomas are more aggressive locally, and rarely spread to lymph nodes or beyond. Nonetheless a careful assessment is important. Careful surgery is even more important to prevent recurrence.
Merkel cell carcinoma is a special case of a rare, but very virulent neuroendocrine cancer, often much more aggressive than melanoma. Treatment is similar to that of melanoma, but outcomes are often much worse, especially in older patients.
Aggressive therapy with surgery, lymph node evaluation/removal, and radiation therapy, is often used in this difficult disease.
In cases of high risk or distant spread, drug therapy may be an important part of treatment.
As these tumors are quite uncommon, a surgical oncologist with experience in these diseases, is ideal for optimal management.
Understanding Basal Cell skin cancer
Basal cell cancers (BCC) are the most common cancer worldwide. These tumors are associated with cumulative exposure to sunlight.
BCC often appear as pearly red relatively flat lesions, and tend to be slow growing and only very rarely spread outside the site of origin. But if ignored, these tumors may become locally invasive and create significant harm.
Most small superficial BCC can be managed without surgery. However, as these tumors become larger, surgical intervention becomes the treatment of choice.
Most patients will have their BCC treated in the dermatology setting. But when tumors are large, invasive, or involving critical locations, surgical oncology management may be indicated.
The goal of surgical treatment is the efficient removal of the primary malignant tumor with a suitable margin of normal tissue. The resultant defect can be closed primarily, or with local tissue flaps that maintain contour and skin thickness, often with the scars hidden in natural skin folds.
These oncoplastic approaches to skin cancer are designed to maximally control disease, while minimally impacting cosmetic and functional outcome.
Oncoplastic Surgery for Skin Cancer
Skin tumor removal may lead to significant defects, particularly for larger lesions in awkward locations. Tumors on the scalp can result in long lasting open defects with exposed bone. Resection of skin cancers of the face can lead to significant visible deformity. Ill conceived operations, even with Moh’s surgery, can lead affected individuals to feel shunned and insecure.
Oncoplastic surgery utilizes plastic surgical techniques to perform better skin cancer surgery. Through careful design of incisions, defects can be filled, while contour and functionality are maintained. Scarring may be minimized.
Oncoplastic surgery for skin cancer employs a variety of techniques designed to develop a suitable soft tissue bed, facilitate grafting or transposition of replacement tissue, and stimulate healing. By placing incisions along lines of tension and natural creasing, appearance can be maximally maintained.
However, all of the cosmetic advantages are only useful if combined with appropriate disease management that reflects a deep understanding of the biology of each cancer.
Sentinel Lymph Node Biopsy for Skin Cancer
Lymphatics are vessels that return tissue fluid to the circulation. Lymph nodes are filtering stations along the lymphatics that trap bacteria, foreign debris, and cancer cells.
The presence of cancer cells in a lymph node increases the stage and risk of a cancer, and may lead to more aggressive postoperative treatment.
A protein-based dye, either colored or radioactive, make it possible to identify a specific lymph node draining a specific body area where a skin cancer arose.
By identifying the “most likely lymph node”, we can remove it and subject it to very detailed pathology analysis without having to remove large numbers of nodes. However, some parts of the body drain to more than one lymph node bed. Even when more than one lymph node bed must be sampled, the sentinel node technique, helps patients avoid more extensive lymph node removal.
If the so-called “sentinel lymph nodes” are negative, studies have shown that 94% of the time, remaining lymph nodes in that area would be free of disease as well.
When positive, other lymph nodes may be positive and may be treated with either removal, radiation therapy, or drug therapy.
The side effects of sentinel lymph node biopsy are few, making it the current standard of care in the management of many melanomas and high-risk skin cancers.
Managing Skin Cancer Risk
Skin cancer development is a product of genetic risk, chronic injury, and sporadic “errors” in cellular regulation. Modern genetic tools may identify gene mutations that predispose some individuals to unique cancer risks. Other individuals may be aware of an increased risk from long years of unprotected sun exposure in their youth. Others may have no unique predisposing features when they develop their first skin cancer.
Risk assessment and management is an important part of skin cancer control. A respected dermatologist is the key partner in this process. Dermatologists, working with surgical oncologists, can process the risk information and develop follow-up tools such as total body lesion mapping. They can establish appropriate follow-up regimens, and they can discuss evolving prevention strategies.
Surgical oncologists and dermatologists work closely together to manage risk, identify early cancers, and intervene appropriately. In the skin, the development of one basal cell cancer, squamous cell cancer, or melanoma, suggests that others will develop in future years. Joint follow-up and risk management are thus essential components of care.
