Melanoma and Basal Cell Cancer and Squamous Cell Cancer
Ralph A. Massey, MD — Santa Monica & Encino, CA
The most appropriate treatment for any particular patient with melanoma depends upon the “stage” of the melanoma.
The factors that determine the stage of a melanoma include; the thickness of the tumor within the skin and whether or not it has spread beyond the skin.
In the very earliest stages of melanoma, “melanoma-in-situ”, the disease is limited to the epidermis and has not yet started to invaded into the dermis below. At this stage surgical removal with a 0.5 cm. margin of normal appearing skin is the standard. However in cases involving the face or hands there is good evidence showing that Mohs Micrographic surgery may be advantageous. Furthermore, a few small studies have demonstrated a potential benefit from topical imiquimod (Aldra), although this approach is not the standard of care and is still experimental at this stage.
For early thin melanomas that are unlikely to have gone beyond the skin, surgical excision of the tumor with a 1 cm. wide safety margin is all that is required.
For thicker tumors that may have spread to local lymph nodes a “sentinel node biopsy” should be considered. This is a method of sampling the group of local lymph nodes to asses if the melanoma has spread or not.
For very thick tumors and those that have spread to local nodes then, in addition to the surgical removal of the primary melanoma itself, several other steps should be considered:
- CT and PET scans that help evaluate internal organs for possible spread of the melanoma.
- Surgical removal of the whole group of nodes where the sentinel node biopsy found tumor.
- Systemic treatments such as BRAF inhibitors, MEK inhibitors and or immunotherapy should be considered.
- Entry into an experimental protocol for newer, as yet unproven treatments such as vaccine therapy.
As director of The Skin Cancer Group, Dr Massey is able to make all of these options available for patient. Of cause for each individual patient a detailed discussion of the pros and cons of these choices will help guide the patient towards the most appropriate treatment course for him or her.
Basal Cell Cancer and Squamous Cell Cancer (None Melanoma Skin Cancer (NMSC)
There are many different options for the treatment of Basal Cell and Squamous Cell Cancers (NMSC). Which approach is most appropriate for any individual patient will depend on the type of cancer, its location, whether any previous treatments have been tried and of cause the patients general health and desires.
- Local destruction: Small, superficial skin cancers, especially those on the trunk can be treated by local destruction. Curettage and electrodessication (“scrape and burning”) cryotherapy (freezing) and CO2 laser vaporization are all examples of this. However these forms of treatment do not allow for pathological confirmation that the cancer has been completely removed and is not usually used cases such as: large skin cancers, aggressive subtypes, cancers in high-risk areas such as the face, ears or scalp and cancers in areas where cosmetically unacceptable scars may result.
- Surgical Excision: This is the most common treatment for low-risk skin cancers. It allows some sampling of the margins to asses if it is likely that the cancer has been removed. However, because complete margin control is not possible, the cure rate is not as high as with Mohs micrographic surgery and a relatively wide margin needs to be excised increasing the amount of skin that is removed.
- Topical creams: Both topical chemotherapy with 5-flurouracil and topical imiquimod have shown some success in treating superficial skin cancers. However the cure rates are generally lower than with other treatments and intense inflammation and swelling over a period of several weeks can make these difficult to tolerate. None the less in selected cases use of the topical agents alone or in combination with surgical therapy may be the best choice.
- Radiation Therapy: Radiation may be an appropriate treatment for NMSC in patients who are poor surgical candidates. Also radiation is sometimes useful as an adjunct used in combination with surgical treatment of aggressive tumors. However radiation treatment usually requires several treatments per week for several weeks, and can result in painful inflammation, skin breakdown and unsightly scars. Radiation can sometimes leave patients feeling tired and exhausted during the treatment period. Ironically radiation itself can be the cause of skin cancers years later. Still, in selected patients this may be the most appropriate option.
- Mohs Micrographic Surgery: This is the gold standard of skin cancer treatment. It offers the highest cure rate possible and removes the least amount of tissue possible. However it is not needed for many small, simple skin cancers on low risk areas, and it may require more time and expertise than some of the simpler treatments. (see Mohs surgery).
Through the Skin Cancer Group Dr. Massey is able to offer patients all of the above treatment options.
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