Skin Cancers
Skin cancer is the most common form of cancer in humans, affecting more than 1 million Americans each year. One in five Americans will develop skin cancer at some point in their lives. Skin cancers are generally treatable and usually curable if caught early. However, people who have had one skin cancer are at a much higher risk of developing more skin cancers, which is why regular self-examinations and visits to a skin care specialists are strongly recommended.
The vast majority of skin cancers are composed of three types: basal cell carcinoma, squamous cell carcinoma and melanoma.
Basal Cell Carcinoma (BCC)
Over 800,000 basal cell carcinomas are diagnosed in the U.S. each year. This is the most common form of skin cancer that develops from the basal (or bottom) layer of the epidermis. BCC is the result of inherited susceptibility, sun exposure and time. These tend to be slow-growing tumors and rarely metastasize (spread beyond the skin). However, if left untreated, they can cause ulcerations that bleed, nerve damage and general destruction of surrounding tissue. BCC can present in a number of different ways:
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Raised pink or pearly bump with a central depression and small tiny blood vessels
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Pigmented bumps with a pearly quality
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An ulcer or erosion (open wound) that continuously scabs over and re-opens
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Flat scar-like growth with a waxy or whitish/shiny appearance and blurred edge
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Pink or reddish scaly area of skin that occasionally bleeds
Despite the different appearances of BCC, they all tend to exhibit one or more of the following: 1) growth 2) bleeding 3) flaky or scaly surface 4) color change. Eighty-five percent of BCC occur on the face and neck since these are areas that are most exposed to the sun.
Risk factors for BCC include having fair skin, sun exposure, age (most skin cancers occur after age 50), exposure to ultraviolet radiation (sun or tanning beds) and therapeutic radiation given to treat an unrelated health issue.
Squamous Cell Carcinoma
Squamous cell carcinoma comes from any layer of the epidermis. SCC often presents as a crusted or scaly patch of skin with an inflamed, red base. Over time, they can develop into pin or red bumps or ulcerated, bleeding nodules with a scab in the center. They can be tender to the touch. It is estimated that 250,000 new cases of squamous cell carcinoma are diagnosed annually, and that 2,500 of them result in death. They have a small risk of spreading to the lymph nodes which makes them more serious than BCC. Larger tumors and those on the scalp, ears, lips and genitalia are at higher risk. Patients are immunosuppressive medications and especially those who have had solid organ transplant are at much higher risk for SCC and for metastasis.
SCC most frequently appears on the scalp, face, ears and back of hands--where most sun-exposure occurs, but can occur in the mouth, in the nostrils and on the genitals. SCC tends to develop in fair-skinned, middle-aged and elderly people who have a history of chronic sun exposure. In some cases, SCC evolves from actinic keratoses (AK), which are precancerous leions that present as dry scaly lesions that can be pink, reddish-brown or brown with a white scale and appear most commonly on sun-damaged skin.
Diagnosing BCC or SCC requires a biopsy — either incisional (shave or punch technique) where only a part of the tumor is removed or excisional, where the entire tumor is removed along with some of the surrounding tissue.
Treatments for basal cell and squamous cell carcinoma include:
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Cryosurgery — Some basal cell carcinomas, especially superficial (shallow) tumor respond to cryosurgery, where liquid nitrogen is used to freeze tumor to cause cell death. The freezing causes a blister which heals on its own.
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Curettage and Desiccation — This treatment involves using a small metal instrument (called a curette) to remove tumor along with an application of an electric current (dessication) to the tissue to destroy any remaining cancer cells. The wound is left to heal on its own.
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Surgical Excision — In this treatment, the tumor and a safety margin is surgically removed with a blade and the wound is sutured.
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Mohs Micrographic Surgery — The preferred method for many facial tumors, aggressive tumors, large tumors, recurrent tumors and where preserving small amounts of tissue is critical (eyelid, ear, lips), Mohs Micrographic Surgery combines removal of cancerous tissue and immediate microscopic review while the patient waits. By mapping the tumor during removal, less healthy skin is removed and a higher cure rate can be achieved. The wounds are typical repaired with sutures.
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Topical Prescription Medications — These medications (there are several) can be applied at home and the treatment length ranges from days to months. Some agents are chemotherapy that directly kill the tumor while others stimulate the body's natural immune system to attack the tumor. This treatment is best for superficial tumors on the body.
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Radiation Therapy — Radiation therapy is utilizing powerful x-rays, gamma rays or charged particles to destroy tumor cells. It is used for very aggressive tumors, tumors where surgery cannot remove all of the tumor, or for non-surgical candidates. Occasionally it is used after surgery to reduce the chance of tumor recurrence and/or spread. Treatment is provided by a Radiation Oncologist over the course of weeks.
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Surgical Oncology Referral -- In cases of aggressive or potentially metastatic tumors, a surgical oncologist (either a hand surgeon, general surgeon, head and neck surgeon, ob/gyn surgeon or urologist) must remove the tumor under general anesthetic. This is especially important for tumors that have invaded deeply into the nose or ear or involve the deeper tissues of the hand or foot or genital region.
Patient characteristics such as age and health status along with tumor features including size, location, aggressiveness, and distinct or indistinct margins are important in determining which method is best for treating your BCC. Your health care professional can help you determine which whether is appropriate for your tumor.
Melanoma
Melanoma is much less common than BCC or SCC, but it is general more serious. Over 120,000 cases of melanoma are diagnosed per year with 1/2 of these being invasive, and thus having a risk of metastasis or spreading. It is the most common form of cancer among young adults age 25 to 29. Melanoma is responsible for nearly 9000 deaths per year in the U.S. Melanoma is a cancer of melanocytes, pigment containing cells found in the bottom layer of the epidermis. These cells produce melanin, the substance responsible for skin color, which explains why most melanomas present as dark brown or black lesions. Some aggressive melanomas spread to the lymph system and to internal organs, and thus, can be deadly. Early detection is important for treating this potentially serious skin malignancy.
Most melanomas grow from "normal" skin as a new dark spot. A smaller percentage of melanomas arise from preexisting moles. Therefore, it is for people to conduct regular self-examinations of their skin in order to detect any new or changing spots.
Family history is important for melanoma. Having a 1st degree relative (parent, sibling or child) puts one at higher risk themselves. Fair skin, blistering sun burns, tanning bed use, and having multiple moles and/or freckles are all risk factors.
Melanoma is diagnosed via a biopsy. If possible, an excisional biopsy (the entire lesion is removed) is preferred, but for large lesions, an incisional (partial biopsy) may be performed. Treatments include surgical removal, radiation therapy or chemotherapy.
Treatments for melanoma include:
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Wide Local Surgical Excision — In this treatment, the tumor and a relatively large safety margin is surgically removed with a blade and the wound is sutured. The amount of safety margin is determined by the depth and stage of the melanoma. For facial lesions, and especially irregular lesions, the surgeon will remove the visible tumor and patch the wound while waiting a week for the pathology results. This is a "slow version of Mohs miccrographic surgery."
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Mohs Micrographic Surgery — As for BCC and SCC, Mohs surgery is used for certain melanomas, especially lower risk tumors that are wide brown patches of skin with irregular edges on the head and neck. The tissue may be evaulated during the surgical visit or delayed. Treating melanoma with Mohs Surgery is not as widely performed as it is for BCC and SCC and it is more difficult.
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Sentinal Lymph Node Biopsy-- For more serious melanomas sampling of the lymph nodes near the tumor is suggested to detect whether or not the cancer has spread. This is performed by a surgical oncologist (general or head and neck surgeon) under general anesthetic. Often the melanoma is removed during the same operation. A dermatologist will refer such patients for this staging process and then follow them into the future for skin changes.
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Chemotherapy — For more serious tumors and especially for ones that have spread to lymph nodes and/or other organs, chemotherapy is used to attempt to destroy the metastatic tumor. Although, historically, treatments were not terribly effective for metastatic melanoma, newer, more promising drugs are available and are being studied.
How to Detect a Potential BCC or SCC
What to look for:
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A new pink, red or purple growth.
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A spot that develops a scab or never truly heals.
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Red, scaly lesions, especially on sun-exposed skin.
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A lesion that bleeds.
How to Detect a Potential Melanoma
What to look for:
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Large brown spots with irregular colors located anywhere on the body.
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New moles
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Existing moles that begin to grow, itch or bleed.
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Dark lesions on the palms of the hands and soles of the feet, fingertips toes, mouth, nose or genitalia.
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Brown or black streaks under the nails.
The American Academy of Dermatology has developed the following ABCDE guide for assessing whether a mole or dark spot may be dangerous
Asymmetry: One half the mole does not match the other half in size, shape or color.
Border: The edges of moles are irregular, scalloped, or poorly defined.
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