Treatment of Non-Melanoma Skin Cancers (NMSC)

• The treatment of NMSC requires careful evaluation of:
  • Tumor size
  • Pathologic characteristics
  • Anatomical location
  • Age
  • Overall health of the patient
  • Cost to the patient
  • Cosmesis
• Treatment modalities can be divided into:
  • Surgical and nonsurgical therapies:
    • Although surgical intervention is often the mainstay of treatment
• Surgical Techniques:
  • Primary surgical excision with a margin of clinically normal tissue:
    • Allows subsequent evaluation of the entire specimen for clear margins
    • Complete excision with a margin of clinically normal tissue:
      • Is associated with 5-year disease-free rates of:
        • Over 98% for BCC
        • Over 92% for SCC
  • Predetermined margins of 4 to 10 mm should be performed along Langer lines to achieve the best cosmetic result

• For well-defined, low-risk lesions less than 2 cm:
  • Excision with a 4-mm margin around the tumor border:
    • Is expected to definitively treat the tumor in 95% of cases
• For high-risk tumors:
  • A larger margin of at least 6 mm is indicated,
  • European guidelines suggest at least 10-mm margin should be used
• Recurrent BCC:
  • Is associated with a poor cure rate
  • A 10-mm excision margin is recommended
• For incompletely excised lesions:
  • Re excision is recommended if possible
• Mohs micrographic surgery:
  • Involves removal of the clinical margins of the tumor under local anesthesia with immediate evaluation of the margins with frozen sections
  • Small incremental sections are removed until the margins are clear
  • This technique allows for the best cosmetic results by preserving normal tissue, while ensuring that larger lesions with subclinical extension are entirely removed
  • Mohs micrographic surgery of primary and recurrent NMSC of the head and neck:
    • Has a cure rate (negative histologic margin):
      • Of 97%
  • The reconstructive choices after Mohs surgery:
    • Are similar to those available after traditional excision
  • Although Mohs micrographic surgery is time consuming and requires skilled practitioners, the benefits of superior cosmesis and excellent cure rates make it the treatment of choice for many patients
  • Indications for Mohs procedure are:
    • Centrofacially located tumors
    • Large tumors
    • Poorly defined tumor margins
    • Recurrent lesions
    • Lesions with perineural or perivascular involvement
    • Tumors at a site of prior radiation therapy
    • Tumors in the setting of immunosuppression
    • Patients with high-risk histologic subtypes of BCC
• There has been considerable interest in performing sentinel lymph node (SLN) biopsy:
  • In selected patients with high-risk SCC:
    • In hopes that detection and treatment of subclinical nodal metastases:
      • Will lead to improved outcomes for these patients
  • In a pooled evaluation of 83 high-risk SCC patients:
    • All patients with a positive SLN had lesions > 2 cm in diameter
    • Among patients with tumors < 2 cm, 2.1 to 3 cm, and > 3 cm in diameter:
      • The proportions of patients with a positive SLN were:
        • 0%, 15.8%, and 30.4%, respectively
    • While the available data suggest SLN biopsy can accurately identify micrometastatic nodal disease in patients with SCC:
      • Studies to date are limited by small sample size, limited follow-up, and lack of uniform criteria
    • Additional studies will be needed before definitive guidelines can be established with respect to SLN biopsy
• Destructive Techniques:
  • Destructive techniques for superficial BCC and SCC include:
    • Curettage
    • Cryotherapy
    • Laser ablation
  • Curettage involves debulking the tumor under local anesthesia with a sharp curette until firm underlying dermis is reached
  • The base is hyfrecated, and the process is repeated two or three times
  • This technique is reserved for:
    • Small (less than 1 cm), primary, low risk, or superficial tumors in non–hair-bearing areas:
      • As such is not suitable for recurrent or ill-defined tumors
  • The technique is based on the ability of the sharp curette to differentiate friable tumor tissue from normal dermis
  • If subcutaneous fat is reached during this technique:
    • It is necessary to convert to surgical excision:
      • As the curette will no longer be able to distinguish soft fat tissue from tumor
• Cryotherapy:
  • Is a destructive method primarily reserved for the treatment of precancerous lesions such as:
    • Actinic keratosis (AKs)
    • Occasionally for small, superficial, low-risk, primary BCCs or SCCs
  • Liquid nitrogen:
    • Is either sprayed with a cryogen or is directly applied to the lesion with cotton-tipped applicators for a period of time such that the visible thawing of the lesions takes at least 15 seconds (30 seconds for superficial SCC or BCC)
• Ablation with a carbon dioxide laser:
  • May be considered for precancerous lesions or low-risk BCC:
    • However, follicular involvement may be difficult to treat and lead to recurrence

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