Skin cancer is currently the most commonly diagnosed cancer in the world. Unlike many other cancers, skin cancer often spreads very slowly. Only a small minority of those afflicted actually dies of the disease. Skin cancer is a malignant growth of the skin which can have a variety of different appearances. Skin cancers generally develop in the outermost layer of the skin, called the epidermis, so they are usually clearly visible. This makes most skin cancers detectable in the early stages. Most skin cancers are named after the type of skin cell from which they arise. The most common skin cancers are basal cell cancer, squamous cell cancer, and melanoma. Melanoma is less common than basal cell carcinoma and squamous cell carcinoma, but it is the most serious and is the most common cancer in the young population (ages 20-39).
The most significant risk factor for developing skin cancer is a chronic inflammation of the skin. This can result from:
1) Ultraviolet (UV) radiation types A and B, which can cause skin DNA damage resulting in cancer. Both natural (sun) and artificial UV exposure (tanning salons) are associated with increased skin cancer risk. Tanning beds cause free radical DNA damage and are associated with the deadliest form of skin cancer, malignant melanoma.
2) Chronic non-healing wounds, especially burns. The most common skin cancers arising in this situation are squamous cell cancers and are called Marjolin’s ulcers.
3) Genetic predisposition, or family history, including “congenital melanocytic nevus syndrome.”
4) Human papilloma virus (HPV), which is often associated with squamous cell carcinoma of the genitals, anus, oropharynx, and fingers. It is believed that the HPV vaccine might help prevent these cancers.
5) Ultraviolet germicidal irradiation used in air, food, and water purification plants.
Skin cancer generally has a 20- to 30-year latency period after the initial skin damage occurs. Skin cancer in older individuals today can be traced to their attitudes towards sun exposure in the 1970s and early 1980s when deep tans were considered attractive and “healthy.”
The most common types of skin cancers are:
1) Basal cell carcinoma (BCC) is the most common. These present on sun-exposed areas of the skin, especially the face. They are very slow-growing, rarely metastasize, and rarely cause death. They are easily treated with surgery or sometimes radiation.
2) Squamous cell carcinoma (SCC) is much less common than basal cell cancer. These metastasize more frequently than BCCs. Even then, the metastasis rate is quite low, with the exception of SCCs of the lip, ear, and in immunosuppressed patients.
3) Malignant Melanoma (MM) is the least frequent but most invasive of the three common skin cancers. They frequently metastasize to the lymph nodes or other organs.
Less common skin cancers include dermatofibrosarcoma protuberans, Merkel cell carcinoma, Kaposi’s sarcoma, keratoacanthoma, spindle cell tumors, sebaceous carcinomas, microcystic adnexal carcinoma, Paget’s disease of the breast, atypical fibroxanthoma and angiosarcoma.
There are a variety of different skin cancer symptoms and signs depending on the type and location. These can include pain, itchiness, bleeding, a non-healing skin lesion, skin ulceration or discoloration, and changes in existing moles, such as enlargement or change in shape. Basal cell carcinoma usually looks like a raised, smooth, pearly bump on the sun-exposed skin of the head, neck, or shoulders. Sometimes small blood vessels can be seen within the tumor. Squamous cell carcinoma is commonly a red, scaling, thickened patch on sun-exposed skin. Ulceration and bleeding may occur. Most melanomas are brown or black-pigmented lesions that arise within a previous mole. Signs that might indicate a malignant melanoma include a change in size, shape, color, or elevation of a mole. Other signs are the appearance of a new mole during adulthood or new pain, itching, ulceration, or bleeding.
Clinical diagnosis is usually made with a visual appearance by the patient or a physician but can only be confirmed with a skin biopsy. Skin biopsies are done under local anesthesia, usually in an office setting. The different types of biopsy are shave biopsy (good for diagnosing BCC and some SCC), punch biopsy (preferred for SCC and MM), and excisional biopsy (where the entire lesion is removed) which is the best method for diagnosing and staging melanomas. The most appropriate biopsy technique is determined by the physician based on the suspected type of skin cancer and the lesion’s size and location.
There are a variety of different options for the treatment of skin cancer. The most appropriate treatment method depends on the type of skin cancer, the location of the cancer, the size and depth of the cancer, the stage of the cancer (amount of spread), whether the cancer is a primary or recurrence and patient factors, including age and other medical conditions.
1) Radiation therapy, topical chemotherapy (5-fluorouracil or Efudex) or cryotherapy (freezing the cancer off) can sometimes provide adequate control of the disease, but usually have lower cure rates and higher incidence of cancer recurrence than surgical excision.
2) Other treatments include photodynamic therapy and electrodessication and curettage.
3) Immune therapy is currently experimental and is being tested as a possible method of treating skin cancer by stimulating the patient’s own immune cells to attack and kill skin cancer cells.
4) Currently, the most common form of treatment for all skin cancers is surgical excision. This method removes the entire lesion and a surrounding margin of normal non-cancerous tissue to hopefully remove any remaining microscopic skin cancer cells. The width of the surrounding margin depends on the type and thickness of skin cancer and can range from 2 mm to 5 cm. Pathology laboratory testing of the surgical margin is then performed to ensure that the entire cancer is removed. If a margin tests positive for cancer cells, then repeat surgery is usually necessary to remove the remaining cancer cells to decrease risk of recurrence. This testing can sometimes take up to two weeks depending on the type of cancer.
5) Mohs micrographic surgery is a relatively new technique used to remove the skin cancer with the least amount of surrounding normal tissue and therefore provides a better cosmetic result. The resection margins are checked immediately and more tissue is removed if tumor cells are found. Therefore, there is no two-week waiting period for pathology results. Most importantly, cure rates are equivalent to standard wide excision. Mohs surgery is performed by a specially trained dermatologist.
6) In the case of some metastatic skin cancer (disease that has spread), other treatments such as lymph node dissection and chemotherapy may be required.
Surgical excision of skin cancer often results in large disfiguring wounds. This is especially significant in the case of skin cancers of the head and neck, where surgical treatment can significantly alter the cosmetic appearance of the face. These wounds require reconstructive surgery to restore the normal appearance and function of the area. Dr. Gupta is well trained and highly experienced in such reconstructive challenges. If he performs the skin cancer excision, then he will plan to perform the reconstruction at the same time, or in some cases he may recommend delaying reconstruction until after the final pathology results reveal clear cancer-free margins. Dr. Gupta also works closely with many Mohs-trained surgeons in San Diego County to plan reconstruction of complex defects resulting from their skin cancer removal procedures. The best method of reconstruction depends on the size and location of the defect, and on the individual structures involved. Usually, Dr. Gupta will plan reconstruction in such a way that the resulting scars will hide in the natural skin folds or wrinkle lines of the area. Dr. Gupta is highly skilled in multiple reconstructive procedures, including complex repair, skin grafts, composite tissue grafts, skin flaps, deep tissue flaps, pedicled tissue flaps and complex microvascular free tissue flaps. Please feel free to browse the Photo Gallery to see examples of all of these procedures.
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