Definition
In this discussion we are talking about a lesion with
some substance that may be ulcerated or have a palpable component.
We are specifically excluding keratoses and other small surface rough
patches that may be the precursors of skin cancer.
Diagnosis
This is mostly clinical, by observation of the appearance and
features of the lesion. Seeing a lot of these and submitting all
lesions for histology will increase the accuracy of diagnosis. There
are no tests that can compete with experience. Use of magnifying aid
is recommended.
Biopsy is only used in the difficult cases where
the result may alter the treatment. There is little point in doing a
biopsy and then submitting the lesion for an excision. The only
biopsy that is worth doing is an excisional biopsy but this must be
done in such a way that the lesion is adequately treated no matter
what is the histological diagnosis. There is no place for biopsy of a
lesion suspected of being a malignant melanoma. The false negative
biopsy is the main danger as it may lead to incorrect advice or
treatment.
Treatment
Cautery and cryotherapy are fine for keratoses but have no place
in the established lesion. The biopsy combined with this technique
will confirm the diagnosis but there will be no specimen for the
pathologist who will not be able to tell the operator whether he has
completely excised the lesion. Another consideration is the cosmetic
result, which is usually a ghastly white patch that after repeated
treatment becomes resented by patients. If we are going to have
patients present willingly with early lesions than we must also pay
attention to the appearance of our work.
Surgical excision with a scalpel will give a better looking result
in the vast majority of locations. It also guarantees a specimen for
the pathologist to comment on. Occasionally there will be an
inadequate excision but this is preferable to not even knowing if the
cautery was inadequate. Any one operator's rate of inadequate
excisions should decrease with experience and plastic surgeons tend
to be more generous with their excision as they have the confidence
of knowing techniques of repair to fit any case.
Recurrence
There are published papers comparing the results of the various
treatment modalities, surgery has by far the lowest rate of all. This
is an area where quality assurance has a place, A surgeon should look
at his own rate and review the cases that were inadequately excised.
With experience and knowledge of the disease this can be lowered to
almost zero. There will always be the multifocal BCC which is
difficult to judge in width.
Results
Can be looked at in several ways. A low recurrence rate is one of
the most important goals but we must also remember the appearance of
the patient. As most of these lesions are on the face or some exposed
part of the body it is imperative that we pay attention and explain
to the patient what kind of scars they are likely to get. Too
many patients are disfigured by repeated cryotherapy. This is not
to say that the treatment should be compromised to make it look good.
A neat surgical scar, particularly in the elderly, blends in very well
with their wrinkles and is the preferred treatment.
The neglected lesions
We all see the occasional case where the patient has ignored an
obviously enlarging lesion but for whatever reason has not sought
treatment. The most worrying case is where they had a biopsy and were told
it was nothing. The only treatment for these is surgical excision and
histologic examination to judge the clearance. Attention to
appearance and public education are the keys to earlier detection.
Radiotherapy
There are some situations where this is the preferred form of
treatment. An elderly and frail person will do better with
radiotherapy than if they have extensive surgery. Do not forget that
radiotherapy usually means several visits and this in itself may be a
problem. It is also a costly form of treatment. There are areas, such
as eyelids, nose, ear and lower leg, which are not suitable for
radiotherapy.
Moh's technique
This is an attempt to prevent recurrences by having histological
control during the treatment process. In theory it is very inviting
but is extremely time consuming and expensive. It has a place for
some difficult lesions on the face but not as a routine method.
Frozen sections during an operation are little different from this
technique and are widely used by surgeons. The key is to
recognise the difficult lesion, this takes experience.
Cost of treatment
In this era of everything being dominated by budgets and economic
constraints, surgery is still cost effective. A surgeon's fee is no
larger than a dermatologist's when you compare the cost of two visits
vs many. The cost of hospitals can be significant but dermatologists
do not provide their equipment for nothing either. Pathology costs
should be similar.
The ideal setup
In a public hospital it should be a combined clinic where a
dermatologist and a surgeon see patients together or at least discuss
most cases. In private practice this is difficult to organise, a good
working relationship with a dermatologist is desirable. This leads to
a flow of cases both ways and benefits the patients.
Summary
It is important to provide good treatment for a large population
with skin cancers. Surgery is the preferred form of treatment in most
cases.
See the SurgeryAu Skin
Lesion registry for examples of skin cancers.
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