Treatment of Melanoma

Malignant Melanoma is also epidemic worldwide and is the third most common form of skin cancer. There is a great deal of information already published about malignant melanoma on the internet. We will limit our discussion primarily to the treatment of primary melanoma which is done in the dermatologist’s office. Early detection of melanoma is critical and saves people’s lives because the prognosis or risk of spreading varies directly with its depth of invasion. Most melanomas start out early and are not very deep; if they are caught at that stage and removed completely they are not likely to spread.

The lowest risk form of melanoma is called in situ (MIS) which is on the surface of the skin similar to squamous cell carcinoma in situ. Those cancers should not spread at all although our statistics tell us that actual cure rates for MIS are not 100% as one might think. That is probably because some patients who have been diagnosed with MIS might have had areas of invasion that were missed under the microscope, since standard pathology misses a great deal of what is actually cut out by the dermatologic surgeon due to how the tissue is processed. This is not wrong; it is just how things are done in standard pathology which when compared to MOhs micrographic surgical pathology is much less thorough. The pathology partly dictates our treatment and the margin of normal skin around the melanoma. If the melanoma is in situ the standard recommendation is 5 mm margins, although research shows that that may not be adequate in many cases. Frequently melanomas are very ill-defined. We use a special light, a Wood’s light, to help delineate the size of a melanoma. This is a black light or UV light which illuminates brown spots and helps us determine the size of the melanoma which sometimes can be quite subtle and difficult to see with the naked eye. In situ melanoma on the central face in critical areas such as the eyelids, nose, ears, and lips can be treated with Mohs micrographic surgery, but the pathology is difficult requiring a special stain called an immunoperoxidase stain which labels melanoma cells to increase our sensitivity and our success rates. Despite that, this form of melanoma has a higher recurrence or persistence rate after Mohs or any form of treatment. When we do Mohs micrographic surgery on this type of melanoma on the face, we often have patients use Aldara or imiquimod cream to help clean up single cells that we may have left behind. Aldara or imiquimod cream has been use for in situ or superficial melanoma, although the research is quite limited and failure raters are substantia; thus we rarely if ever recommend it as what is called primary treatment. We sometimes do recommend it as mentioned above for what is called adjuvant treatment after surgery to possibly help improve our cure rates.

Free Screenings in May

May is Melanoma & Skin Cancer Detection and Prevention Month. Solano Dermatology will be providing free skin cancer screening throughout the month. Follow the link for dates and contact information.

Learn More

http://www.solanodermatology.com/1408/

Patients’ Choice Award

Dr. Geisse was awarded the Patients’ Choice Award!

The Patients’ Choice award is bestowed upon physicians based on your patients’ appreciation and praise for the quality of care and service you provide.

Every month, more than 200,000 patients across the U.S. provide online feedback about their doctor experiences. They rate various components of the care they receive, such as bedside manner, doctor-patient face time, follow-up care, ease of appointment setting and courtesy of office staff. They also share their overall opinions.

Over the course of 2013, hundreds of thousands of patient reviews were written and shared. While physicians generally receive positive feedback from their patients, only physicians like you – with near perfect scores – have been voted by their patients for this honor.

In fact, of the nation’s 870,000 active physicians, only 5 percent were accorded this honor by their patients in 2013.

Congratulations Dr. Geisse!

PatientsChoice

Treatment of Basal Cell Carcinoma

Basal cell carcinoma is the most common skin cancer. There are millions of these every year in this country alone, much less worldwide. They are usually not very dangerous although they can be quite invasive, destructive and disfiguring. Most of these occur on the face but they can occur anywhere, even in areas where the sun does not shine. Most patients who get basal cell carcinoma have had sunburns, but they also have a genetic predisposition. There may be other co-factors that are not well understood at this time that are contributing to the epidemic of skin cancer.

The treatment of basal cell carcinoma partly hinges upon the pathology. Basal cell carcinoma has different pathologic subtypes grouped into non-aggressive and aggressive forms.

Non-aggressive or circumscribed basal cell carcinoma includes the nodular and superficial types. These can occur anywhere but they are common on the trunk.

The most common treatment for these low-risk, less aggressive basal cell carcinomas is an ablative procedure call curettage and electrodessication. Non-aggressive basal cell cancers are soft and mushy compared to normal skin. An experienced clinician can use a semi-sharp circular spoon-like tool called a curette to scoop out the obvious cancer, leaving behind normal skin. This is often, but not always, followed by a burning procedure called electrodessication to obtain an extra margin of safety. For the worst types of non-aggressive basal cell carcinomas the curettage followed by electrodesiccation is done three times. For the least aggressive types, such as superficial basal cell carcinoma on the trunk, sometimes curettage alone is adequate without using the burning which allows these to heal with better scars. These can also be removed with excisional surgery where the affected areas are cut out and then sewn in a layered fashion with absorbable sutures underneath the skin and some sort of stitching in the skin.

There are some non-surgical treatments for these non-aggressive basal cell carcinomas, primarily Aldara or imiquimod cream. Dr. Geisse authored the two major papers that led to the approval of Aldara or imiquimod cream to treat basal cell carcinomas in the United States. He was the principal investigator for 3M Pharmaceuticals who at that time owned the drug and sponsored the large double blind placebo controlled studies to get it approved. Drs. Beutner and Geisse did the very first study proving that this cream would work for basal cell carcinoma, which led to the larger studies, mentioned above. Despite Solano Dermatology Associates’ long history with Aldara or imiquimod, it is in fact rarely used for basal cell carcinoma. It is costly and creates a significant rash and has to be used for six weeks and only yields an 80% cure rate for small superficial basal cell carcinomas of the trunk. That compares to 90% cure rates for curettage and electrodesiccation or excision and thus, unless there is an extremely apprehensive patient who does not want surgery or the cancer is in an area where any scar would be emotionally devastating (such as on the central chest in a young woman), Aldara is not often used to treat basal cell carcinoma.

Mohs micrographic surgery is the treatment of choice for central facial tumors including so-called non-aggressive or circumscribed tumors. Mohs micrographic surgery, explained elsewhere, provides 98-99% certainly of removal; thus if the cancers are located on the nose, ears, lips or close to the eyes using lesser forms of surgery would not be in the patient’s best interest. The worst cases the Mohs surgeon sees are often the ones that have been previously incompletely removed by lesser forms of treatment. Sometimes many years can go by before incompletely treated basal cell carcinomas show up around or underneath the scar. By that time patients can lose their entire noses, eyelids and ears to this sometimes-destructive cancer.

Aggressive or non-circumscribed forms of basal cell carcinoma include infiltrative, micronodular and sclerosing or morpheaform basal cell carcinomas.

These variants of basal cell carcinoma are usually on the central face and can be much larger than they appear from the surface. They often have what is called “subclinical extension”. What that means is that the cancer has branches and roots that go out well beyond the small area that may be visible on the surface. These cancers are often incompletely removed by regular forms of surgery, thus Mohs micrographic surgery is the treatment of choice for these more aggressive cancers, particularly on that face. Wide and aggressive excision can be done on the trunk for aggressive basal cell carcinoma without doing Mohs since the scar is not as noticeable or as concerning to the patient and there is usually enough extra skin to close even large wounds.

Radiation therapy is rarely used for the treatment of basal cell carcinoma. It is expensive, requires multiple trips to the radiation oncologist and has some significant short term and more importantly long term side effects. The side effects include short term redness, swelling and sometimes bleeding and open areas of skin in the area that has been treated with radiation. Long term scarring and dilated blood vessels can occur and rarely second malignancies can occur in irradiated skin many years later. Around the eyes, nose or the glands of the face radiation can cause quite severe side effects such as dryness of the nose, bloody noses, dry eyes, loss of vision and loss of saliva formation from the parotid gland, which is the major gland in the cheek that forms saliva.

Solano Dermatology Associates rarely recommends radiation therapy and usually only for terrible cases where the surgery would be disfiguring in an elderly patient as a form of palliation, which means we shrink the tumor and keep it from bleeding or leaking on their beds, but do not necessarily cure it since these are slow growing cancers as a rule. Rarely, when basal cell cancers are deeply invasive or involve nerves, we use radiation after Mohs surgery to help ensure it does not return. If these cancers are large and deep on the face and involve the nerves of the face and if they are not completely removed they can lead to invasion of the brain through the cranial nerves. Radiation therapy as primary treatment of basal cell carcinoma providers somewhat over 90% cure rates, based upon fairly limited studies when compared to Mohs micrographic surgery which has a great deal of data to support its use and confirm its much higher cure rate.

Skin cancer is highly curable when caught early. Do you know how to SPOT skin cancer?

As a way to raise awareness of melanoma and other types of skin cancer, and to encourage early detection through self-exams, the American Academy of Dermatology designates the first Monday in May as Melanoma Monday®.

The American Academy of Dermatology is coordinating this national effort to raise awareness of skin cancer.

  • Skin cancer is the most common cancer in the United States.
  • Current estimates are that one in five Americans will be diagnosed with skin cancer in their lifetime.
  • Melanoma, the deadliest form of skin cancer, is the most common cancer for 25- to 29-year-olds.

Join Solano Dermatology Associates in the American Academy of Dermatology’s fight against skin cancer by participating in SPOT Orange on Melanoma Monday. Wear orange Monday, May 6, 2013 to show your support!


MelanomaMonday

Going on Spring Break this month? Think sunscreen, not sun tan!

Have you ever heard the myth that getting a base tan before spring break will help protect your skin? Don’t believe it!

A tan is a sign of damage to your skin. Try sunscreen instead! See what else the AAD has to say here: http://ow.ly/hTKnR

Dr. Geisse Honors Dozens of Dermatologists and Primary Care Physicians

December 2013
Dr. Geisse honors dozens of dermatologists and primary care physicians by donating in their behalf to the American Academy of Dermatology (AAD) Sustaining Fund.

With more than 90% of all the individual donors to the Sustaining Fund coming from Dr. Geisse’s contribution, you can see how truly generous Solano Dermatology Associates and Dr. Geisse are.

The donations were made in support of AAD programs.

To donate to the AAD Sustaning Fund and see a current list of donors:
See the full list of Tribute Honorees.

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Sun Protection Is Important All Year Long!

It’s that time of year! The weathers getting colder and the resorts in Lake Tahoe are opening. Solano Dermatology would like to remind all of our patients that sun protection is a year round concern!

Here’s a brief video of Olympic Gold-medalist Julia Mancuso and the importance of sun protection in the Winter months:

For more information, and to learn just how passionate Julia is about raising awareness to prevent skin cancer visit: The American Academy of Dermatology Website

Face Washing 101

How you wash your face can make a difference in your appearance. Follow these tips from dermatologists to help you keep your face looking healthy.

Skin Self-exam

Here’s a brief instructional video on how to perform a skin self-exam for possible skin cancers. When was your last skin check?