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

#Arrangoiz #CancerSurgeon #Miami #SurgicalOncology #HeadandNeckSurgeon #CASO #CenterforAdvancedSurgicalOncology #BCC #SCC #NonMelonomaSkinCancer

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