Did you know that the skin is the largest “organ” in the body? If you did, it might not be surprising to learn that skin cancers have the highest incidence of any cancers in the United States. According to the American Cancer Society, it is estimated that over 5.5 million new skin cancers will be diagnosed in about 3 million individuals this year.

The vast majority of these tumors are represented by low-risk basal and squamous cancer. These cancers occur with increasing frequency based on skin type, sun exposure, and age. Because of our aging population, and an emphasis on outdoor activities, these types of skin cancers are particularly common in the Coachella Valley.

Fortunately, basal and squamous skin tumors are local problems that rarely spread to lymph nodes or other organ body sites by metastasis. However, they can become bothersome, threatening, local processes that can lead to painful, unsightly, open wounds that become increasingly difficult to treat and may impact local function. For example, ignored squamous cancers of the scalp can erode bone and even grow into the brain, making cure difficult or impossible.

Squamous skin cancer, in particular, may present as a more aggressive biology, leading to widespread metastasis and death. In fact, some estimate a higher mortality from squamous cancer of the skin, than that of melanoma. Although such aggressive squamous skin cancer variants are rare, the huge total volume of this disease makes such events significant.

Fortunately, there are also new tools, incorporating gene expression profiling, that may identify particularly high-risk squamous cancers, allowing better staging, closer monitoring, and earlier intervention with appropriate drug therapy.

Melanoma, on the other hand, is the most common high-risk skin cancer. It accounts for over 100,000 new cases in the US. Despite resulting in 8,000 deaths per year, this disease often presents as an innocuous dark or blotchy colored pink spot on the skin. Early recognition of a melanoma by primary care providers, dermatologists, and patients, is important if we are to find melanomas at the earliest most curable stage. Thus everyone should become familiar with the ABCDE rule for assessing skin lesions as potential melanomas. These letters stand for: Asymmetry, Border irregularity, Color that is not uniform, Diameter greater than 6 mm, and Evolving size, shape or color.

However, once a melanoma is identified, it is important to have a care team with specific expertise in this very unique tumor. Appropriate resection must include suitable margins if recurrence is to be avoided. Decision-making regarding lymph node biopsy is increasingly complex, depending not only on tumor size, but also on other pathologic features and an assessment of intrinsic tumor biology. This means that a melanoma specialty surgeon may help you avoid unnecessary surgery to remove lymph nodes when it is unlikely to be helpful. In other situations, more extensive removal of tumor-containing lymph nodes may be indicated, and may have a major impact on local/regional disease control. These procedures should not be performed by the inexperienced, as the outcomes and complications are directly proportional to surgical expertise.

For selected patients, even with earlier stage disease, new non-chemotherapy biologically active drug treatments may be considered . But these must be customized to a patient’s underlying tumor biology. Even when not given initially, such therapies, can lead to effective cure, even in the setting of distant disease. But benefit seems to correlate with disease burden, making an appropriate followup regimen equally important. As a result, melanoma mortality has dropped dramatically over the last few years.

Beyond these more common diseases are a variety of unusual skin cancers, each presenting a particular and unique risk. These include forms of skin sarcoma, sweat gland tumors of the skin, and a special class of uniquely aggressive tumor called Merkel Cell Carcinoma. Management of all of these depends on a deep appreciation for their unique tumor biology, and a collection of effective surgical and adjunctive treatment tools designed to maximize outcome.

In the treatment of any of these skin cancers discussed above, oncoplastic surgery is an important part of our management strategy. This use of plastic surgical technique allows generous resections of tumor with widely clear margins, minimizing recurrence and maximizing maintenance of contour and cosmetic appearance.

Dr. Hyams optimizes high-risk skin cancer surgical care with effective local reconstruction. HIs understanding of the biology of these different tumors provides a strategy for your path back to better.