Skin Cancer Management (eBook)

Deborah MacFarlane is an Associate Professor in the Dermatology and Plastic Surgery Departments at the University of Texas MD Anderson Cancer Center.

Foreword 6
Preface 8
Acknowledgements 9
Contents 10
Contributors 12
Biopsy Techniques and Interpretation 15
Biopsy Technique 15
Pre-Op 15
Site Preparation and Anesthesia 15
Hemostasis 15
Shave Biopsy 16
Equipment 16
Technique 16
Complications 16
Saucerization 16
Equipment 16
Technique 17
Punch Biopsy 17
Equipment 17
Technique 17
Biopsy Care 17
Incisional Biopsy 18
Equipment 18
Technique 18
Complications 18
Wedge Biopsy 18
Complications 18
Excisional Biopsy 18
Technique 18
Complications 19
Biopsy Log 19
Interpretation of Results 19
Tissue Orientation and Margin Evaluation 20
Reporting of Surgical Margins 20
Fundamental Slide Interpretation 20
Low Power 20
Develop a Method for Examining Skin Specimens 20
Knowing the Clinician 20
Too Small a Sample 21
Too Aggressive a Sample 21
Two-Step Management 21
Too Little or Too Much Information 21
Know Your Laboratory 21
One Diagnosis Only 21
Too Many Diagnoses 21
Summary 21
References 22
Topical Therapies for Nonmelanoma Skin Cancers 23
Introduction and Background 23
Imiquimod 23
Mechanism of Action 23
Side Effect Profile 23
5-Fluorouracil 24
Mechanism of Action 24
Side Effect Profile 25
Diclofenac 25
Mechanism of Action 25
Side Effect Profile 25
Topical Therapy for Actinic Keratoses-The Loma Linda Experience 25
Monotherapy for Actinic Keratoses 25
Imiquimod vs. 5-Fluorouracil for AKs 27
Imiquimod and 5-FU Combination Therapy 27
Combination Therapy with Cryotherapy 28
Cost and Treatment Choice for AKs 28
Topical Therapy and Nonmelanoma Skin Cancer-The Loma Linda Experience 28
BCC Monotherapy 28
Imiquimod 28
5-Fluorouracil 30
SCC Monotherapy 30
Imiquimod 31
5-Fluorouracil 31
Combination Topical Therapy 31
Topical Therapy as a Surgical Adjunct to NMSC 31
Preoperative Topical Therapy 31
Intraoperative Topical Therapy 32
Postoperative Topical Therapy 33
Unusual Situations/Complications/Variations 33
Problematic Areas 33
Lips 33
Eyelids 34
Penis 35
Basal Cell Nevus Syndrome 35
Transplant Patients 35
Delayed Mohs Micrographic Surgery 36
The Skip Area Controversy 36
Summary 36
References 36
Chemical Peels for Precancerous Skin Lesions 41
Classification 42
Indications 43
Contraindications 44
Advantages 45
Current Products Available 46
Patient Selection 46
Informed Consent 47
Setup 47
Patient Preparation 47
Analgesia and Sedation 48
Application Technique 49
Post-procedure 52
Complications 52
Summary 53
References 53
Photodynamic Therapy 54
Photodynamic Therapy for Actinic Keratoses and Actinic Cheilitis 54
Patient Selection 54
Patient Education and Consent 56
ALA Photodynamic Therapy 56
Technique of Application 56
Illustrative Case 4.1 61
Techniques with Off-Label Light Sources 62
Illustrative Case 4.2 63
MAL Photodynamic Therapy 64
Technique of Application 64
Techniques with Off-Label Light Sources 64
Photodynamic Therapy for Squamous Cell Carcinoma In Situ, Superficial Basal Cell Carcinoma, and Nodular Basal Cell Carcinoma 64
Patient Selection 64
Illustrative Case 4.3 65
Patient Education and Consent 65
ALA Photodynamic Therapy 65
Technique of Application at the Roswell Park Cancer Institute 65
MAL Photodynamic Therapy 67
Technique of Application 67
Summary 69
References 69
Intralesional and Perilesional Treatment of Skin Cancers 70
I. METHOTREXATE 70
Indications and Contraindications 71
Pre-treatment Considerations 71
Preparing MTX for Injection 72
Description of Technique 72
Treatment Pearls 73
Post-injection Care 73
Expected Course of Treatment and Follow-Up 73
Illustrative Case 5.1 74
Illustrative Case 5.2 75
Illustrative Case 5.3 76
II. INTERFERON 77
Indications and Contraindications 78
Pre-treatment Considerations: Basal Cell Cancers 78
Pre-treatment Considerations: Squamous Cell Cancers and Malignant Melanomas 79
Obtaining Interferon alpha2b 80
Description of Technique (BCC, SCC, MM) 80
Administering Interferon alpha2b 80
Treatment Pearls 82
Post-injection Care 82
Expected Course of Treatment and Follow-Up (BCC, SCC, MM) 82
III. 5-FLUOROURACIL 84
Keratoacanthomas 84
Squamous Cell Carcinomas 85
Basal Cell Carcinomas 85
Indications 86
Contraindications 86
Pre-treatment Considerations 86
Obtaining and Preparing 86
Description of Technique 86
Note on Technique 86
Post-injection Care 86
Expected Course and Follow-Up 86
Adverse Effects 86
IV. BLEOMYCIN 86
Squamous Cell Carcinoma/Keratoacanthoma 87
Basal Cell Carcinoma 87
Metastatic Cutaneous Malignant Melanoma 87
Indications 87
Contraindications 87
Pre-treatment Considerations 87
Obtaining and Preparing 87
Description of Technique 87
Post-injection Care 87
Expected Course and Follow-Up 87
Adverse Effects 88
References 88
Electrodesiccation and Curettage 91
Indications/Contraindications 91
Preoperative Considerations 91
Description of Technique 92
Postoperative Care 92
Use of Curettage Alone 94
Complications 94
Summary 94
References 94
Cryosurgery 95
Basic Cryobiology 95
Indications 96
Contraindications 96
Preoperative Considerations 96
Equipment 97
Technique 97
Monitoring of Freeze Depth 98
Basal Cell and Squamous Cell Carcinomas Cure Rates 98
Illustrative Case 7.1 98
Illustrative Case 7.2 99
Illustrative Case 7.3 100
Illustrative Case 7.4 100
Leukoplakia and Actinic Cheilitis 101
Keratoacanthoma 101
Postoperative Care 101
Summary 102
References 102
Optimizing Surgical Outcomes 103
Preoperative Considerations 104
Bleeding Tendency 105
Wound Healing 107
History of Hypertrophic Scar or Keloid Formation 108
Prophylactic Antibiotics and Antiviral Medication 108
Allergies 110
Implantable Cardiac Devices 111
Patient Expectations 111
Intraoperative Considerations 111
Operating Suite 111
Surgical Site Preparation 112
Skin Marking 112
Choice of Antiseptic Solution 113
Anesthesia 114
Staff Preparation 115
Hand Washing/Surgical Scrubbing 115
Surgical Site Draping 115
Intraoperative Monitoring 115
Tissue Manipulation 115
Hemostasis 116
Designing the Closure 117
Suturing the Wound 118
Postoperative Considerations 118
Pain Control 118
Antibiotics 119
Timing of Suture Removal 121
Summary 122
References 122
Anesthesia 125
Indications and Contraindications 125
Preoperative Considerations 126
Topical Anesthesia 128
Complications 128
Infiltrative Anesthesia 129
Field Blocks 129
Tumescent Anesthesia 129
Regional Nerve Blocks 130
Facial Nerve Blocks 130
Digital Nerve Block 131
Hand Nerve Blocks 131
Foot Nerve Blocks 132
Penile Nerve Block 133
Postoperative Analgesia 133
Unusual Situations and Complications 133
Summary 135
References 135
Excision Techniques, Staples, and Sutures 137
Patient Preparation 137
Antibiotic Prophylaxis 138
Site Preparation and Anesthesia 138
Preoperative Antisepsis 138
Anesthesia 139
Excision Margins 139
Specimen Handling 140
Hemostasis 140
Suture Materials 141
Staples 141
Skin Adhesive 141
Skin Tape 142
Closure Techniques 143
Second Intention 143
Layered Closures 143
Description of Procedure 145
Elliptical Excision 145
Purse-String Repair 147
Standing Cones (Dog Ears) 150
Postprocedure Care 150
Complications 152
Summary 153
References 153
Mohs Surgery 155
Indications for Mohs Surgery 155
Cure Rates Following Mohs Surgery 156
Basal Cell Carcinoma 157
Squamous Cell Carcinoma 157
Preoperative Considerations 157
Guide to the Mohs Surgery Procedure 159
Slide Preparation 159
Variations on the Mohs Surgery Technique 161
Complications and Follow-Up 162
References 163
Cutaneous Flaps 165
Indications and Contraindications to Flap Closure 167
Preoperative Considerations 167
Flap Design 167
Random Pattern Flaps 169
Advancement Flaps 169
Rotation Flaps 173
Transposition Flaps 175
Island Pedicle Flap 178
Axial Flaps 180
Technical Pearls for Cutaneous Flap Surgery 182
Postoperative Dressings and Wound Care 183
Complications in Cutaneous Flap Reconstruction 184
Acute Complications 184
Contact Dermatitis 184
Infection 184
Bleeding Complications 185
Flap Ischemia 185
Management of the Ischemic Flap 187
Delayed Complications 187
Summary 189
References 189
Techniques in Skin Grafting 191
General Principles 191
Full-Thickness Skin Grafts 191
Technique 191
Preoperative Planning 191
Donor Site Considerations 192
Procedure 194
Immobilization 195
Post-Operative Care 196
Special Situations 196
Complications 196
Split-Thickness Skin Grafts 197
Equipment 197
Technique 197
Dressing 198
Donor Site Care 198
Postoperative Complications 198
Vacuum-Assisted Closure (VAC) 199
Free Cartilage Grafts 199
Technique 199
Dressing 199
Complications 200
Composite Grafts 200
Technique 201
Dressing 201
Donor Sites 201
Postoperative Care 201
Complications 201
Summary 201
References 201
Nail Surgery and Malignant Tumors of the Nail Unit 203
Anatomy 203
Preoperative Considerations 204
Instruments 204
Tourniquet 205
Radiographs 205
Anesthesia 205
Distal Wing Block 206
Technique 206
Nail Avulsion 206
Technique 207
Punch Biopsy of the Nail Bed 207
Technique 207
Nail Matrix Biopsy 208
Punch Biopsy of the Nail Matrix 208
Indications 208
Technique 208
Lateral Longitudinal Excision 209
Indication 209
Technique 209
Repair 209
Complications 209
Shave Biopsy of the Nail Matrix (Tangential Matrix Excision) 209
Indications 209
Contraindications 209
Technique 209
En Bloc Nail Unit Biopsy 210
Technique 210
Dressings 210
Complications 210
Malignant Tumors of the Nail Unit 210
Verrucae 211
Bowen’s Disease 211
Treatment 211
Squamous Cell Cancer 211
Treatment 212
Verrucous Carcinoma 212
Treatment 212
Basal Cell Carcinoma 212
Treatment 212
Metastatic Tumors 212
Treatment 213
Melanoma 213
Treatment 213
Summary 213
References 213
Practical Management of Melanoma 215
Medical History 215
Physical Examination 215
Imaging and Laboratory Tests 215
In Vivo Imaging 215
Radiologic Imaging 215
Laboratory Investigations 216
Staging of Melanoma 216
Management of Melanoma In Situ (Stage 0) 217
Excision of Melanoma In Situ 217
Mohs Surgery and Serial Excision of Melanoma In Situ 218
Medical Treatment of Melanoma In Situ (Stage 0) 218
Challenges of Melanoma In Situ Management 218
Management of Primary Melanoma (Stages I and II) 219
Surgical Management: Excisional Biopsy 219
Surgicial Management: Incisional Biopsy 219
Definitive Excision of Primary Melanoma 219
Surgical Management of Regional Melanoma (Stage III) 220
Elective Lymph Node Dissection 220
Sentinel Node Biopsy 220
Adjuvant Therapy for Intermediate Prognosis Melanoma (Stages IIB-III) 222
Melanoma Follow-Up 223
Regional Recurrences 223
Surgical Management of Metastatic Melanoma (Stage IV) 223
Evaluation of Patients with Suspected Metastatic Melanoma 223
Metastasectomy 223
Radiation Therapy for Advanced Melanoma (Stages II-IV) 224
Palliative Radiotherapy 224
Curative Radiotherapy 224
Chemotherapy of Advanced Melanoma (Surgically Unresectable Stages III, IV) 224
Immunotherapy of Advanced Melanoma (Surgically Unresectable Stages III, IV) 224
References 225
Skin Cancer in Skin of Color 229
Unique Features of Skin of Color 229
Role of the Ozone Layer 229
Basal Cell Carcinoma 230
Squamous Cell Carcinoma 231
Malignant Melanoma 232
Hypopigmented Mycosis Fungoides 233
Treatment Options and Operative Considerations 234
Summary 234
References 234
Management of Skin Cancers in Solid Organ Transplant Recipients 236
Epidemiology 236
Squamous Cell Carcinoma Following Organ Transplantation 236
Basal Cell Carcinoma Following Organ Transplantation 236
Melanoma Following Organ Transplantation 237
Skin Cancer Following Kidney Transplantation 237
Skin Cancer Following Heart Transplantion 237
Skin Cancer Following Liver Transplantation 237
Skin Cancer Following Stem Cell Transplantion 238
Pathogenesis 238
Immunosuppression and Skin Cancer 238
Azathioprine 239
Cyclosporine 239
Sirolimus 239
Presentation 239
Primary SCC in Transplant Patients 239
Extensive Field Disease 240
In-Transit Metastasis 241
Nodal Metastasis 241
Distant Metastasis 241
Basal Cell Carcinoma 242
Melanoma 242
Management 242
Primary Cutaneous SCC 242
Relapse 243
Management of Extensive Field Disease 244
Topical 5-Fluorouracil (5-FU) 244
Imiquimod 244
Diclofenac 244
Photodynamic Therapy (PDT) 245
Oral Retinoids 245
Reduction of Immunosuppression 245
Capecitabine 246
Management of Basal Cell Cancer in Transplant Recipients 246
Management of Melanoma in Transplant Recipients 246
Dermatologic Follow-Up and Screening in Transplant Recipients 246
Summary 247
References 247
Imaging of Head and Neck Skin Cancer 250
Anatomic Planes 250
Imaging Techniques 250
Computerized Tomography 250
Contraindications 251
Strengths and Limitations 252
Magnetic Resonance Imaging 252
Contraindications 253
Strengths and Limitations 254
Ultrasound 254
Strengths and Limitations 256
Positron-Emission Tomography 256
Lymphoscintigraphy 258
Strengths and Limitations 258
Imaging Pathology 259
Basal Cell Carcinoma 259
Illustrative Case 18.1 260
Cutaneous Squamous Cell Carcinoma 260
Illustrative Case 18.2 261
Illustrative Case 18.3 262
Illustrative Case 18.4 262
Melanoma 263
Illustrative Case 18.5 265
Dermatofibrosarcoma Protuberans 265
Illustrative Case 18.6 266
Merkel Cell Carcinoma 266
Illustrative Case 18.7 267
Sebaceous Carcinoma 267
Angiosarcoma 267
Illustrative Case 18.8 267
Summary 268
References 268
Radiation Oncology in Skin Cancer Treatment 270
Indications for Radiation 270
Radiation Modalities Used to Treat Skin Tumors 271
Radiation in the Treatment of Specific Skin Malignancies 273
Basal and Squamous Cell Carcinomas 273
Melanoma 275
Merkel Cell Carcinoma 276
Adnexal Carcinoma 277
Mycosis Fungoides 277
Radiation for Advanced Disease and for Palliation 278
Complications from Radiation 279
Summary 280
References 281
When to Refer Out 283
Reasons to Refer Out 283
The Lesion 283
The Patient 283
Psychological Referrals 284
The Doctor 285
The Doctor’s Colleagues 285
Specialists to Whom You May Need to Refer 286
Medical Oncology 286
Geneticists 286
Surgical Oncology 286
Radiation Oncology 286
Prosthetics 287
References 288
Chemoprevention of Skin Cancer 289
Systemic Retinoid Therapy 289
Indications 290
Contraindications 290
Dosing Recommendations 291
Adverse Effects 292
Routine Monitoring and Management of Adverse Effects 292
Mucocutaneous Side Effects 292
Laboratory Monitoring 293
Pregnancy Testing 294
Calcification 294
Use in Organ Transplant Recipients 294
Wound Healing 294
Chemoprevention of Nonmelanoma Skin Cancer: Other Agents 294
Topical Retinoid Therapy 295
Topical Tretinoin 295
Adapalene 295
Tazarotene 295
Application of Topical Retinoids 295
Nonsteroidal Anti-inflammatory Drugs 296
Diclofenac 296
Polyphenolic Antioxidants: Green Tea 297
Other Promising Chemopreventive Agents 297
Summary 298
References 298
Index 301