Many thanks to Dr. Navid Pourtaheri, new-to-our-community plastic surgeon, on Skin Cancer and Skin Cancer Reconstruction. This is a great summary of skin cancer findings and some specific indications and recommendations of when to involve plastic surgery.
A recording is available HERE
Skin cancer types: basal cell (BCC) squamous cell (SCC) keratoacanthoma, melanoma
Basal cell cancer (~4 million cases/year in US)
- variable in appearance, "can look like anything"-- don't know what it is until you remove it
- always slow growing (even high risk ones)
- primarily occur on sun-exposed areas (hand, ears, face)
- do sometimes spontaneous bleed or ulcerate
- can be locally invasive
- very rarely metastasize
Squamous cell cancer (SCC), 1.5 million cases/year in US
- variable appearance, but more commonly dry and scaly, also can be rough/thickened, wart-like, can ulcerate and form open sores
- more accelerated growth with local invasion than BCC (tend to progress more quickly)
- lower lips more common with SCC
- can be locally invasive, can metastasize
- curable if treated early
- actinic keratoses (AK) is pre-squamous cell lesion
Keratoacanthoma, 275K cases/year in US
- once considered subset of SCC
- dome-shaped lesion with central keratin plug
- almost always in sun exposed areas (face, ears, nose, hands)
- quite rapidly growing (faster than SCC), can be locally destructive
- unpredictable, can spontaneously regress
- less likely to metastasize
Melanoma, 197K cases/year in US
- most costly type of skin cancer
- 25% found in existing moles, 75% spontaneously occur on normal looking skin
- 50% are melanoma in situ>> high cure rate (90-100%)
- can be found ANYWHERE
- most common form is superficial spreading
- when goes deeper, called lentigo maligna
- 10-15% of cases are nodular melanoma, most aggressive, tends to be found invading
- remember ABCDE (see below) with special attention to "E" (evolving-- that is a changing mole)
- Breslow thickness correlates with 5-year survival
Treatment options for skin cancer
- Moh's surgery
- most commonly used in BCC and SCC (often contraindicated for melanoma)
- high risk areas (H zone)
- cosmetically sensitive areas, over joint surfaces
- decreases amount of tissue excised, maintaining the same cure rate
- Excision with margins and simple closure also acceptable
- Curettage (EDC)
- scrape the abnormal tissue, then burn it
- Cryotherapy more common in older patients, people who don't want a procedure, on blood thinners, large number (e.g. on face)
- Melanoma best excised w/margins, possible lymph node biopsy (plastic surgery, general surgery)
- sentinel node biopsy not indicated for melanoma in situ
When to refer to plastic surgeon?
- skin cancer not indicated for Mohs
- post dermatology resection, cannot close
- melanoma
Biopsy options
- shave: get full epidermis but only part of dermis (this is good because it won't form scar)
- always inappropriate for c/f melanoma because need full thickness
- punch: takes full thickness of skin
- incisional biopsy: get piece of abnormal with normal adjacent, done with scalpel
- excision: preferred for lesion is <1cm (cut the whole thing out with margin, 1mm of normal tissue is acceptable margin
- FNA not used for skin, but for clinically positive nodes
- Sentinel lymph node biopsy (SLNB) after melanoma diagnosis, after lymphoscintigraphy (radioactive dye that drains to the lymph node)
Imaging
- Always needed in >Stage 3 melanoma, definitely NOT indicated in stage 1 (stage 2, use your judgement, may be indicated)
- Most common: PET CT for assessing for metastases
- Chest CT also good modality b/c melanoma so often goes to lungs (chest xray not sufficient)
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