Treatment of Squamous Cell Carcinoma

Squamous cell carcinoma is the second most common skin cancer and is increasing at an alarming rate, particularly in the elderly. Squamous cell carcinoma without question is related directly to sun exposure and also to age. The more sun and sunburns you have had and the longer you live the higher your risk of developing squamous cell carcinoma. They often come from precancerous lesions called actinic or solar keratoses which fair-haired, fair-eyed patients suffer from who have had sunburns as a child and have had chronic sun exposure. These red, raw, itchy, sometimes tender scaly spots on the scalp, face, ears, back of the hands and arms can convert to squamous cell carcinoma. Squamous cell carcinoma can also develop on its own and grow rapidly often fooling patients thinking they are bug bites, boils or infected hairs. These types of squamous cell carcinomas can be dangerous; they present as a nodule that hurts, grow rapidly and have between a 5%-25% risk of spreading or becoming metastatic depending on their depth of invasion and location.

Metastatic squamous cell carcinoma can be lethal and requires aggressive surgery by our head and neck surgical colleagues. This most often happens when squamous cell carcinoma occurs on the scalp, ears, or lips. Squamous cell carcinoma in these areas would usually spread first to the lymph nodes of the neck or in front of or behind the ear. The goal in treating all skin cancers is to treat them early before they become dangerous and that is particularly true of squamous cell carcinoma because if they are not very deeply invasive the risk of them spreading is probably close to zero.

There are superficial forms of squamous cell carcinoma which are called in situ or Bowen’s disease (SCC in situ). There is a specialized form of squamous cell carcinoma in situ that can occur on the genitalia called Bowenoid papulosis which is induced by the wart virus, not by sun exposure. Just as in superficial forms of basal cell carcinoma, superficial squamous cell carcinoma can be treated with the scraping and burning procedure (curettage and electrodesiccation), excision or sometimes Aldara or imiquimod. Aldara or imiquimod has not been studied nearly as thoroughly for superficial squamous cell carcinoma as it has for basal cell carcinoma. Aldara’s cure rates for SCC in situ are supposed to be 80% based upon less reliable studies. We have seen a number of cases of squamous cell carcinoma in situ that have failed rather spectacularly from superficial treatment with Aldara or Efudex, which is called 5-fluorouracil. Solano Dermatology Associates does not recommend Efudex or 5-fluorouracil for cancers, only for the precancerous lesions called actinic keratoses despite its use by other practices for cancer. We do not recommend Efudex because its use is actually quite weak when compared to even the limited research done using Aldara for skin cancer. Aldara for squamous cell carcinoma in situ causes a severe reaction and it needs to be continued for ten weeks thus it is, just as is with basal cell carcinoma, infrequently used. For very large areas that have been resistant to superficial forms of treatment we will perform wide excision or Mohs micrographic surgery. This superficial form of squamous cell carcinoma is becoming alarmingly common and is actually difficult to treat adequately without significant surgery, particularly in hair bearing skin. It is always problematic to recommend aggressive surgery for a non-invasive, not very dangerous cancer but these can become very large and eventually invasive and need to be treated properly to avoid a much worse procedure down the road when it can become many times the size it was early on.

Invasive squamous cell carcinoma can be quite dangerous particularly if it is over 2 mm in depth or involves the muscle, the lip, the cartilage of the ear, or down to the bone of the scalp. Patients who have suppressed immune systems, such as transplant patients on drugs to keep their transplant healthy, patients with leukemias and lymphomas, and HIV infected patients who are immunosuppressed can get virulent forms of squamous cell carcinoma that can become metastatic and are often difficult to manage. These patients who have problems with their immune systems need to have their squamous cell carcinomas managed promptly and completely.

For squamous cell carcinomas of the face, full-thickness excision down to the fat and a layered closure is the treatment of choice. Mohs micrographic surgery can be used for squamous cell carcinomas of the central face, scalp or on the shins where they are increasingly common. Mohs is quite useful on areas like the shins and scalp because we can keep the wound smaller and allow a direct or primary closure as opposed to taking skin in from somewhere else as a skin graft, which is frequently needed for regular surgery in these areas because regular surgery takes larger margins. We try to avoid skin grafts which create a second wound and take a long time to heal particularly when over bone of the skull or over the tight, often swollen skin of the shins.

There is some evidence that Vitamin D3 deficiency might accelerate the growth of squamous cell carcinoma which might explain partly why elderly patients, even those in nursing homes who are getting no sun exposure, are developing these cancers at an alarming rate and are sometimes not being managed until they are quite aggressive. Any patient who has skin cancer, who then stays out of the direct sunlight as much as possible with hats, clothing and sunscreen should be taking Vitamin D3. We recommend 4,000-5,000 unites per day. If you have Vitamin D deficiency and are followed by your regular doctor then he or she should manage your Vitamin D dosage.

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.

What is Psoriasis?

Psoriasis is one of the most common skin problems (1 to 3 percent of people), and often appears as pink to red inflamed areas of overgrown skin, topped with white scale. These areas classically include knees and elbows but also often affect the hands, feet, scalp, underarms, groin or any other part of the body. Sometimes it may present as isolated severe dandruff. Psoriasis is an ongoing problem which may have periods of spontaneous remissions and recurrence. Many people notice their skin has seasonal flares. Although many patients report that another family member has psoriasis, most patients do not have anyone in the family with psoriasis. Psoriasis can affect the joints, known as psoriatic arthritis. This may present as pain, swelling and joint stiffness. Untreated psoriatic arthritis can lead to irreversible destruction of the joints.

All of our providers are knowledgeable and experienced in the treating psoriasis. We provide a range of therapeutic options from the gold standard treatments such as topical corticosteroids and light therapy to the newer treatments that may include excimer laser therapy or biologic therapy (injectable medications) for psoriasis. Some psoriasis responds readily to therapy, other patients may have to try many treatments before finding one that provides them optimal skin clearance. Rest assured: there are many treatment options out there and even more being developed. We will find one that works for you!

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Mohs Micrographic Surgery

How successful is the treatment of skin cancer?
What is Mohs Micrographic Surgery?
How do I prepare for the day of surgery?
What happens the day of surgery?
What can I expect after the surgery is completed?
Will I develop more skin cancers?
Mohs Surgery Photographs

How successful is the treatment of skin cancer?

Initial treatment of skin cancers has a success rate of 90%. Methods commonly employed to treat skin cancer include: excision (surgical removal and stitching), curettage and electrodesiccation (scraping and burning with an electric needle), cryosurgery (freezing), and radiation therapy (“deep” X-ray). Patients may have had one or more of these methods of treatment before coming for Mohs Micrographic Surgery.

The success rate in treating a recurrent skin cancer (ie. one that persists after conventional treatment) can be as low as 50%. The cure rate for Mohs Micrographic Surgery, even in treating recurrent lesions, is about 98%.

Mohs Micrographic Surgery (discussed in detail below) is very time consuming, requires a highly-trained team of medical personnel, and is available at relatively few locations in the country. Mohs Micrographic Surgery is reserved for recurrent skin cancers or for primary skin cancers that are difficult to treat usually including the central face.
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What is Mohs Micrographic Surgery?

In the early 1940′s, Dr. Frederick Mohs, Professor of Surgery at the University of Wisconsin, developed a form of treatment for skin cancers he called chemosurgery. The word “chemosurgery” is derived from the words “chemical” and “surgery.”

The procedure has been refined and improved upon so that most cases are done using fresh tissue omitting the chemical paste Dr. Mohs used. The procedure is now called Mohs Micrographic Surgery, “micro” because the procedure utilizes microscopes and “graphic” because the surgeon makes a map of the surgical site and the microscopic findings.

Our Mohs surgeons have sub-specialty surgical training in the technique and are Fellows of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Our team will help answer your questions, respond to your anxieties, assist in surgery, and instruct you in dressings and wound care after the surgery is performed. A technician, whom you may not even meet, performs the essential task of preparing the tissue slides which are examined under a microscope by the physician.

The surgery is performed as follows: the skin is treated with a local anesthetic so there is no pain; the tumor is scraped using a semi-sharp instrument called a curette; a thin piece of tissue is then removed surgically around the scraped skin and divided into pieces that will fit on a microscope slide; the edges are marked with colored dyes; a map or diagram of the tissue removed is made; and the tissue is frozen by the technician. A pressure dressing is then applied and the patient is asked to wait while the slides are being processed. The Mohs surgeon will then examine the slides under the microscope and be able to tell if any tumor is still present. If cancer cells remain, the Mohs surgeon is able to precisely locate them based upon his map. Another layer of tissue is then removed and the procedure is repeated until the Mohs surgeon is satisfied that the entire base and sides of the wound have no cancer cells remaining. This process ensures the complete removal of the cancer while preserving as much normal surrounding skin as possible. The removal, processing and interpretation of each layer of tissue takes approximately 1 hour. Only 15-30 minutes is spent in the actual surgical procedure, the remaining time being required for slide preparation and interpretation. It usually takes removal of 1-3 layers of tissue (stages) to complete the surgery. Mohs micrographic surgery is generally finished in one day. Sometimes a tumor may rarely be extensive enough to necessitate continuing surgery a second day.

At the end of Mohs Micrographic Surgery, you will be left with a surgical wound. This wound will be dealt with in one of several ways. The possibilities explained below include:

1. healing by spontaneous granulation
2. closing the wound or part of the wound with stitches
3. using a skin graft
4. using a skin flap

Healing by spontaneous granulation involves letting the wound heal by itself. This offers a good chance to observe the wound as it heals after removal of a difficult tumor. Experience has taught us that there are certain areas of the body where nature will heal a wound as nicely as any further surgical procedure. There are also times when a wound will be left to heal knowing that if the resultant scar is unacceptable and some form of reconstruction can be performed at a later date. In this way a less complex reconstruction may be possible as any new scar shrinks up to 50% in a year.

Closing the wound with stitches is often performed. This involves some adjustment of the wound and sewing the skin edges together. This procedure speeds healing and can offer excellent cosmetic results. For example, the scar can be nearly hidden in a wrinkle line.

Skin flaps involve movement of adjacent, healthy tissue to cover a Mohs defect. They are often chosen for complex cases because of the excellent cosmetic match of nearby skin.

Skin grafts involve covering a surgery site with skin from another area of the body. There are two types of skin grafts. The first is called a “split thickness graft.” This is a thin shave of skin, usually taken from the thigh or scalp, which is used to cover a very large surgical wound. This can either be a permanent coverage or temporary coverage before another cosmetic procedure is done at a later date. The second graft type is the “full thickness graft.” This graft provides a thicker layer of skin to achieve better cosmetic results. In this instance, skin is usually removed from behind or in front of the ear (the donor site) and stitched to cover the wound. The donor site is then sutured together to provide a good cosmetic result.

If your Mohs Micrographic Surgery is extensive or a functional impairment results, we may recommend you visit one of several consultant physicians. If you have been sent to us by another physician skilled in skin closures (for example, a plastic surgeon), he/she will take care of you after your cancer has been removed.

In summary, by microscopically pinpointing areas involved with cancer and selectively removing these tissues, the Mohs surgeon can successfully remove your skin cancer with the best cure rate and the least loss of normal tissue. A smaller wound also offers you the likelihood of a better final cosmetic result. Although every effort will be made to minimize the scar, you will be left with a scar of some kind. Mohs micrographic surgery is one of the few “no brainers” in medicine.
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How do I prepare for the day of surgery?

The best preparation for Mohs Micrographic Surgery is a good night’s rest followed by breakfast. In most cases, the surgery will be completed on an outpatient basis. Because you can expect to be here for most of the day, it is wise to bring a book or magazine to read. Also, because the day may prove to be quite tiring, it is advisable to have someone accompany you on the day of surgery to provide companionship and transportation home.

You or your referring physician may request a pre-operative visit to evaluate the need for Mohs Micrographic Surgery and meet your surgeon. At this visit, the technique will be discussed in detail and your questions answered. If you are coming a great distance and/or are being referred by a physician familiar with this technique, you may be referred directly for Mohs Micrographic Surgery without a pre-operative visit. If this is the case and you have never been a patient in our office before, you should plan to arrive 10-15 minutes before your scheduled appointment in order to complete some initial patient forms.

The cost of Mohs Micrographic Surgery is borne by most insurance carriers. Please be prepared to give insurance information to our billing personnel and bring with you any forms which may need processing. We can counsel you concerning your insurance coverage at the time of surgery. Some insurance companies require authorization prior to surgery.
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What happens the day of surgery?

Upon your arrival, you should check in at the registration window. When the surgical suite becomes available, you will be escorted by our surgical nurse to the Mohs surgical suites. If you have not had a consultation visit, our staff or the doctor will go through the procedure with you and answer any questions you may have. After this, the Mohs stages will be taken.

After the first stage, a pressure dressing will be placed over your surgical wound and you will be free to leave the surgical suite. It takes some time for the slides to be prepared and studied. During this time, you may wait in the waiting room, read a book or magazine, or take a short walk.

Most Mohs surgery cases are completed in 1-3 stages. Each stage involves the removal and microscopic examination of your skin for cancer. Therefore, the majority of cases are finished during one day. Once we are sure that we have totally removed your skin cancer, we will discuss our recommendations for dealing with your surgical wound with you.
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What can I expect after the surgery is completed?

    Pain

Most people are concerned about pain. We make every effort to minimize any pain associated with the procedure. You may experience remarkably little discomfort after your surgery. You will be provided with Vicodin or Darvocet, codeine-like compounds with acetaminophen for the first few days upon request. If you do not want narcotics, combining acetaminophen and ibuprofen often works well.

    Bleeding

A small number of patients will experience some bleeding post-operatively. This bleeding can usually be controlled by the use of pressure. You should take a gauze pad and/or ice pack and apply constant pressure over the bleeding point for 15 minutes; do not lift up or relieve the pressure at all during that period of time. If bleeding persists after continued pressure for 15 minutes, repeat the pressure for another 15 minutes. If this fails, call the doctor or visit a local Emergency Room.

    Complications

Some minor complications may occur after Mohs surgery. Swelling and bruising are very common following Mohs surgery, particularly when it is performed around or above the eyes. This usually subsides within 4-5 days after surgery and may be decreased by the user of an ice pack and elevation in the first 48 hours. A small red area may develop surrounding your wound. This is normal and does not necessarily indicate infection. However, if this redness does not subside in days or the wound begins to drain pus, or becomes painful you should notify us immediately. Itching and redness around the wound, especially in areas where adhesive tape has been applied, are not uncommon. When this occurs, ask your druggist for a non-allergenic tape and use petroleum ointment only. At times, the area surrounding your operative site will be numb to the touch. This area of anesthesia (numbness) may persist for several months or longer. In some instances, it may be permanent. If this occurs, please discuss it with your doctor at your follow-up visit.

Although every effort will be made to offer the best possible cosmetic result, you will be left with a scar. The scar can be minimized by the proper care of your wound. Some scars and flap surgery often require a second minor procedure in 6-8 weeks for optimal results. We will discuss wound care in detail with you and give you a Wound Care Informational Sheet which will outline how to take care of whatever type of wound you have.
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Will I develop more skin cancers?

After having one skin cancer, statistics say that you have a 50% chance of developing a second. There are precautions that can be taken to prevent further skin cancers. You should use a sunscreen (suntan lotion), applying it at least 30 minutes before exposure to sunlight. We would recommend that you use a SPF #30 or higher sunscreen. Despite manufacturer’s claims, we recommend that you re-apply sunscreen after swimming. A wide-brimmed hat, long-sleeved shirt, and other protective clothing are also appropriate and more effective than sunscreen alone. Avoidance of excessive sunshine is always recommended.

You should have your skin checked very closely by your referring dermatologist or dermatology PA at 6-month intervals. This is not only to check the surgical site as it is healing, but to check for the development of additional skin cancers. Some patients who come great distances will be followed post operatively by their referring physician. We recommend 6-month follow-up visits for 2 years, then yearly by your referring doctor. Of course, any areas of your skin that change, fail to heal, or just concern you should be brought to the attention of your referring physician or PA immediately.


John Geisse, MD
Serena Mraz, MD
Karl Beutner, MD PhD
Jennifer Fu, MD
Erica Aronson, MD
John Alexander, PA-C
Kyle Goleno, PA-C
Margaret Nonato, PA-C
Debra Stock, PA-C
Meghan Kennedy, PA-C

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