Skin Cancer Treatment

Skin cancer is the most common form of cancer worldwide. It is a skin tumor with a chance for growth, local tissue destruction and the potential to spread to other parts of the body.

There are three main types of skin cancers:

• Basal cell carcinoma (BCCA)
• Squamous cell carcinoma (SCCA)
• Melanoma skin cancers of different varieties

Basal cell carcinoma and squamous cell carcinoma are the most common types of skin cancer.

A parent or legal guardian is required for the first visit (please bring guardianship papers if you are not the parent), but a letter of permission can be written to let someone else accompany the patient to any follow-up appointments.

There are multiple types of basal cell skin cancers, but most types are very slow growing. The most aggressive type is morpheoform BCCA.

Basal cell carcinoma might appear as a pearly or waxy bump on the skin or a flat, pink/red- or brown-colored lesion. Basal cell carcinoma can sometimes bleed. It typically grows very slowly.

Squamous cell carcinoma (SCCA) is the second most common skin cancer. It comes from the outer layer of the skin, the epidermis. Usually, SCCA is found on the parts of the skin that are most often exposed to the sun. This includes the hands, face, arms, legs, ears and on the top of the head. However, it can occur in any part of the body. SCCA can also form in areas such as the mouth and on the genitals due to viral infections.

Squamous cell carcinoma can appear as a firm, red nodule or a rough, scaly, flat lesion that might itch, bleed and become crusty. SCCA often arises from precancerous skin lesions called actinic keratosis (AK). It is important to know the difference because an AK can sometimes be treated without surgery.

Over 1 million people are diagnosed with SCCA in the US each year. There are more than 15,000 deaths each year in the U.S. from SCCA, although most deaths are related to SCCA in the mouth or nose. SCCA on the skin results in about 3,000 U.S. deaths per year.

SCCA is more common in men and patients over the age of 50 but can be seen in younger patients with lots of sun exposure.

Repeated exposure to ultraviolet light, either from the sun or from tanning beds, is the leading cause of SCCA. Indoor tanning is linked to about 168,000 cases of SCCA in the U.S. each year.

People with light skin, light hair (blond or red) and light eyes (blue, green or gray) have a higher risk of skin cancer in general, as well as SCCA. However, darker skin patients such as African Americans are still at risk for SCCA.

Other risk factors include:

• Decreased immunity from things like:
  • Cancer of other organs
  • Chronic infections like AIDS
  • Taking immunosuppressive medications, including chemotherapy or some biologic medications
• Having an organ transplant
• Having skin injuries such as burns, scars, ulcers and skin areas that were previously exposed to chemicals
• Radiation injury to the skin
• Genetic skin disease called xeroderma pigmentosum
• Having long-lasting and repeated infections and inflammation of the skin or genital warts

Some common signs and symptoms of SCCA include:

• A rough-feeling bump, which will crust over and bleed, that is higher than the skin around it but has a depression in the middle
• A sore that will not heal or a sore that heals and comes back repeatedly
• Skin that is flat, scaly and red
• Actinic keratosis
• Actinic cheilitis, which develops mainly on the lower lip; causes tissue to become pale, dry and cracked
• A precancerous condition called leukoplakia, in which white spots develop in the mouth or on the tongue or gums

Sun exposure, having fair skin, light eyes and light hair are the most common risk factors. People with darker skin are still able to get skin cancer, but the risk is substantially lower. People outside frequently in sunny climates are also at high risk due to repeated sun exposure. Anyone with a lowered immune system is also at risk.

Risk factors unique to melanoma include a history of severe sunburns and the presence of large and irregular moles. Patients with atypical moles that are left untreated are also at risk. Congenital nevi from birth also present a higher risk of melanoma than other moles or freckles.

The leading cause of skin cancer is overexposure to sunlight, especially when it results in sunburn. The UV light damages DNA in the skin and causes it to become cancerous over time. Exposure to certain chemicals such as tar and coal can cause skin cancer for those with jobs that require frequent contact with these chemicals.

The most common warning sign of skin cancer is a change on the skin, typically a new growth or a change in an existing growth or mole. Another sign of skin cancer is skin areas that do not heal.

Treatment depends on the stage of the cancer. Some types of treatment include:

• Mohs type surgical resection uses a scalpel to remove the tumor and thin layer of surrounding tissue. It is well established that surgeons using Mohs type frozen section techniques provide the best chance to control skin cancers. This method allows for confident reading of 99.9% of the tissue edges surrounding the tumor to ensure full removal of cancerous cells. However, at most hospitals, coordination of this technical tissue read with large cancer removal and reconstruction under anesthesia is not logistically possible. As a result, many larger cancers receive less reliable oncologic management. The Virgin Islands Skin Cancer Center has developed a coordinated approach that combines expert plastic and reconstructive surgeons with on-site pathologists at SRMC. This allows for the best tumor removal and simultaneous reconstruction under one anesthesia.
• Excisional surgery involves a surgeon removing the tumor and an extra margin of normal skin to ensure all cancer has been removed.
• Electrosurgery uses electricity to destroy the tumor and some surrounding areas.
• Topical chemotherapy with 5-FU can be used to treat certain precancerous lesions.
• Radiation therapy is used for advanced diseases and patients with health problems that prevent them from having surgery or treating some cancers in sensitive areas. An outside radiation oncologist would provide this type of care.
• If the cancer spreads beyond the skin to other organs or surrounding tissue, chemotherapy, targeted drug therapy or immune therapy is often used. This would be coordinated with an outside medical oncologist.
• Large and/or recurrent skin cancers of the face and head present multiple challenges for patients and surgeons. First, removing the cancer with the best chance of permanent cure requires full surgical margin clearance and coordination of additional care (e.g., radiation therapy) as needed. Additionally, large skin and soft tissue defects created by removing the tumor require complex and often multi-stage reconstruction to achieve an acceptable appearance.
• Immediate reconstruction is performed the same day by our board-certified plastic surgeon. The choice of reconstruction will vary based on various factors, including location and size of the tumor; involvement of complex structures such as eyelids, lip, nose, ear, etc.; patient health; tumor type and other factors. Reconstructive options can vary from simple direct closure to skin grafting, local flaps or even free tissue flaps in advanced cases.

We can admit patients to Schneider Regional Medical Center or transport patients to hospitals staffed by our doctors in Florida on an as-needed basis if care is required that is not offered on the island.

Melanoma is not as common as basal cell or squamous cell carcinomas but is the most dangerous form of skin cancer. If left untreated or caught in a late stage, melanoma is more likely to spread to organs beyond the skin, making it difficult to treat and increasing the chances of death from skin cancer.

Melanoma means "black tumor.” The cells of the tumor produce melanin, the dark pigment that gives skin its color. Most melanomas are black or brown, but some are pink, red, purple or skin colored.

Any area of the body can be affected by melanoma. Men are more prone to develop melanoma on the trunk. Women are more likely to have melanoma on the arms and legs. About 30% of melanomas begin in existing moles, but the rest arise in normal skin.

Melanoma accounts for only about 1% of all skin cancers but causes the great majority of skin cancer-related deaths. It is one of the most common cancers in young people under 30, especially in young women. The incidence of melanoma has been dramatically increasing over the past 30 years.

Knowing how to spot melanoma is important because early detection allows for early treatment. Melanoma can appear as moles, scaly patches, open sores or raised bumps.

Use the American Academy of Dermatology's "ABCDE" memory device to learn the warning signs that a spot on your skin may be melanoma:

• Asymmetry: One half does not match the other half.
• Border: The edges are not smooth.
• Color: The color is mottled and uneven, with shades of brown, black, gray, red or white.
• Diameter: The spot is greater than the tip of a pencil eraser (6.0 mm).
• Evolving: The spot is new or changing in size, shape or color.

Some melanomas do not fit the ABCDE rule, so tell your doctor about any sores that won't go away, unusual bumps or rashes or changes in your skin or any existing moles.

Most experts agree that a major risk factor for melanoma is overexposure to sunlight, especially sunburns in youth. Ultraviolet (UV) radiation from tanning beds also increases the risk of melanoma and has been designated a carcinogen (cancer-causing) by the World Health Organization.

Although anyone can develop melanoma, an increased risk for developing the disease is seen in people with:

• A personal history of melanoma
• A family history of melanoma
• Fair skin, freckles, blond or red hair, and blue eyes
• A history of prolonged or excessive sun exposure, including blistering sunburns
• A history of tanning bed use
• Many moles, especially “atypical” moles
• A weakened immune system

Melanoma is more common in Caucasians but can occur in people of all skin types. Non-white individuals most often get melanoma on the palms, soles and nails.

If you have a mole or other spot that looks suspicious, your doctor may remove it and look at it under a microscope to see if it contains cancer cells. This is called a biopsy.

Once diagnosed, melanoma will be categorized based on several factors, such as how deeply it has spread and the appearance under a microscope. Tumor thickness is the most important characteristic in predicting outcomes.

Melanomas are grouped into the following stages:

• Stage 0 (Melanoma in situ): The melanoma is only in the top layer of skin (the epidermis).
• Stage I: Low-risk primary melanoma with no evidence of spread. This stage is generally curable with surgery.
• Stage II: There are features indicating a higher risk of recurrence, but there is no evidence of spread.
• Stage III: The melanoma has spread to nearby lymph nodes or nearby skin.
• Stage IV: The melanoma has spread to more distant lymph nodes or skin or has spread to internal organs.

Some patients may need a biopsy of nearby lymph nodes to determine if the melanoma has spread. This is called sentinel lymph node biopsy. Other necessary tests may include a chest X-ray, a computed tomography (CT) scan, a magnetic resonance imaging (MRI) scan, a positron emission tomography (PET) scan and blood work.

Treatment depends on the stage of the melanoma and health of the patient.

Surgery is generally the main treatment for melanoma. The procedure involves cutting out the cancer and some of the normal skin surrounding it. The amount of healthy skin removed will depend on the size and location of the skin cancer. Typically, surgical excision of melanoma can be performed under local anesthesia in the dermatologist's office.

In the early stages of melanoma, surgery has a high probability of being curative. More advanced cases may require other types of treatment in addition to or instead of surgery. Other treatment options may include lymphadenectomy (removal of surrounding lymph nodes), radiation therapy, immunotherapy (using the patient's immune system to attack the cancer cells) and chemotherapy.

Benign skin growths are non-cancerous bumps, spots and lumps on the skin that come in various shapes and sizes. Children may have freckles and moles that multiply or darken over time. As a person grows older and spends more time in the sun, their skin can change.

Dermatofibromas:

• Small, firm red or brown bumps caused by an accumulation of soft tissue cells under the skin, called fibroblasts. They often occur on the legs and may itch.
• Dermatofibromas can be surgically removed if they become painful or itchy.

Dermoid cyst:

• A benign tumor made up of hairs, sweat glands and sebaceous glands, which are located in the middle layer of the skin. Some internal dermoid tumors may even contain cartilage, bone fragments and even teeth.
• Dermoid cysts may be surgically removed for cosmetic reasons.

Freckles:

• Darkened, flat spots that typically appear only on sun-exposed areas of the skin. Freckles are common in people with blond or red hair. 
• No treatment is necessary for freckles.

Keloids:

• Smooth, firm, raised fibrous growths on the skin that form in wound sites. Keloids are more common in African Americans.
• Keloids respond poorly to most treatment approaches. Injections of corticosteroid drugs may help to flatten the keloids. Other treatment options include surgery or silicone patches to flatten the keloids further.

Lipomas:

• Round or oval lumps under the skin caused by fatty deposits. Lipomas are more common in women and tend to appear on the forearms, torso and back of the neck.
• Lipomas are generally harmless, but if the lipoma changes shape, your physician may perform a biopsy. Treatment may include removal by surgery if the lipoma bothers your child.

Moles (nevi):

• Small skin marks caused by pigment-producing cells in the skin. Moles can be flat or raised, smooth or rough, and some contain hair. Most moles are dark brown or black, but some are skin-colored or yellowish. Moles can change over time and often respond to hormonal changes.
• Most moles are benign, and no treatment is necessary. Some benign moles may develop into skin cancer (melanoma).