Treatment of Skin Cancers
Skin cancers are worldwide the most common human malignancies. In Europe, around one of 10 individuals develops a skin cancer by the age of 75 years. The risk increases with advancing years. The main factor behind the dramatic increase in skin cancers is the change in recreational activities coupled with a dramatic increase in exposure to the ultraviolet (UV) rays of sunlight.
The best-known and most-feared skin cancer among the public is melanoma, known colloquially as „black skin cancer“. Basal cell carcinoma and squamous cell carcinoma are more common but less well-known. Together they are referred to as non-melanocytic skin cancers, or „white skin cancers“. They are closely related to total UV exposure and the risk of developing such a tumor increases with age. Advice on how to avoid having trouble with a skin cancer is discussed under Skin Cancer Screening.
Superficial tumors that only involve the epidermis, the outer layer of the skin, and have not broken through the basal membrane at the base of the epidermis, are designated „in situ“ carcinomas or melanomas. Over time these tumors can invade deeper layers of the skin and even in rare cases cause metastases, spreading to local lymph nodes. Thus it is absolutely essential to treat skin cancers in their earliest stage. The early diagnosis and treatment of skin cancers leads to an almost 100% cure rate.
Melanoma is the most dangerous skin tumor because it frequently causes metastases. In Germany with 80 million inhabitants, there are around 25,000 new melanomas diagnosed annually and around 2000 deaths. In Switzerland with 8 millions inhabitants there are 2,000 new cases annually and 280 deaths. The most affected age group is 40-50 years. The number of patients with melanoma has roughly doubled every ten years.
The greatest risk factor for the development of a melanoma is the number of melanocytic nevi which are acquired after birth. An individual with more than 40 nevi has a 7-15 fold increased risk of developing a melanoma. Sunburns during childhood or adolescence also increase the risk of skin cancer by 2-3 fold. Individuals with pale skin (skin types 1 and 2), red or blond hair, freckles, frequent sunburns or a family history of melanoma have up to a 120 fold increased risk of melanoma.
Melanomas can easily be confused with harmless melanocytic nevi (moles). Around 80% are found on body sites that are normally covered. Tumors may occur on the scalp, under the nails or even on the sole. Each patient deserves a total body examination with each pigmented lesion according to the A-B-C-D rule. The goal of skin cancer screening is to decide which of the pigmented lesions are potentially malignant and thus identify melanomas at the earliest possible stage. Dermatoscopy has become an indispensable tool in this search. Examining lesions with 10x magnification makes possible a much more accurate evaluation. Most dermatoscopes today are connected to a computer; using a video documentation system, lesions can be photographed, analyzed with computer programs and later multiple images of the same lesion over time can be compared. If a lesion clearly shows change, it must be surgically removed.
If a melanoma is suspected, the pigmented lesion is immediately surgically excised with a small safety margin. The tissue is examined under the microscope by a dermatopathologist (physician specialized in the microscopic study of skin tumors and diseases). If the microscopic examination confirms the presence of a melanoma, then the further treatment is based on the tumor thickness measured under the microscope.
Basal cell carcinoma
Basal cell carcinoma is the most common malignant skin tumor. In Germany around 120,000 new cases are identified yearly in a population of 80 million, while in Switzerland with 8 million inhabitants, there are an estimated 25,000 new cases. This number seems to be doubling every 10-15 years. The main cause in almost every case is long-term and intensive sun exposure. At greatest risk are those who have worked for many years in outdoor jobs or spent extensive recreational time in the sun. The tumors are most often diagnosed in those who are 60-70 years of age. Other risk factors include pale skin (Skin types I and II), blond or red hair, and blue, green or gray eyes.
Basal cell carcinomas arise in the bottom of the basal layer of the epidermis, the skin's outermost component. They are appearing anywhere on the body but favor those areas most intensively exposed to sun, such as the nose, ears and lower lip. Basal cell carcinomas do not develop metastases. Typically they show a slowly invasive growth pattern, extending both laterally and deeper. They can damage underlying structures such as the eyelid, ear or nose cartilage, or extreme cases destroy muscles or bone. Thus it is crucial to identify them early before they have damaged adjacent tissues. This also insures the highest possible cure rate, which in expert hands is well over 95%.
Basal cell carcinomas typically present as a small glassy nodule which contains numerous tiny blood vessels. More advanced tumors show a central depression surrounded by slightly elevated border, made up of many small nodules. Later the tumor may become ulcerated with drainage. Other tumors may resemble a scar or a persistent patch of eczema, as the clinical appearance is highly variable!
If a basal cell carcinoma is suspected, the tumor is immediately surgically excised with a small safety margin. The tissue is examined under the microscope by a dermatopathologist. If the microscopic examination confirms the presence of a basal cell carcinoma, then all the lateral and deep borders of the excision are carefully examined (micrographic surgery) to insure the tumor has been completely removed. If tumor cells are found extending to a margin of the excision, a re-excision in this area is performed. Once the dermatopathologist has confirmed that the entire tumor has been removed, then the defect can be closed used a variety of plastic surgery approaches.
Through skin cancer screening, basal cell carcinomas can be discovered at an early stage, when only a small excision is required to assure complete cure. The smaller the tumor, the smaller the operation, and the less apparent the scar. Conversely, the larger the tumor, the more complicated the operation. After one or more procedures to remove the entire tumor, the defect is larger and more difficult to close with good cosmetic results.
In special situations, especially in elderly patients with multiple health problems and medications who have relatively superficial tumors, alternative therapeutic approaches can be considered. Two good options are photodynamic therapy (PDT) - using a light-sensitizing cream and phototherapy to destroy the tumor - or an immune-stimulating cream (imiquimod) which helps the body's natural mechanisms to destroy the tumor.
Squamous cell carcinoma
Squamous cell carcinoma is the second most common malignant skin tumor. In Germany around 54,000 new patients are identified yearly in a population of 80 million, while in Switzerland there are around 5,000 new cases among 8 million inhabitants. Once again, the incidence is increasing. The main cause in almost every case is long-term and intensive sun exposure. At greatest risk are those who have worked for many years in outdoor jobs or spent extensive recreational time in the sun. The tumors are most often diagnosed in those who are over 70 years of age. Other risk factors include pale skin (Skin types I and II), blond or red hair, and blue, green or gray eyes.
Most squamous cell carcinomas develop from actinic keratoses. These common lesions are typical rough or crusted, slightly red and minimally raised spots. They occur in sun-exposed skin; thus typical sites are the nose, forehead, cheeks, bald scalp, temples, ears, lower lip and backs of the hands. Actinic keratoses are very early precursors of squamous cell carcinoma and can be easily treated. If there is any question about the diagnosis, a small biopsy can be taken to confirm the clinical suspicion. The standard therapeutic approach is cryotherapy, spraying the lesions with liquid nitrogen to destroy them. There are many other effective approaches. Two good options are photodynamic therapy (PDT) - using a light-sensitizing cream and phototherapy to destroy the tumor - or an immune-stimulating or cytostatic cream (imiquimod / 5-fluoruracil), which helps the body's natural mechanisms destroy the tumor. Actinic keratoses can also be removed with curettage (scraping them off with a sharp spoon-like instrument) or a superficial tangential (shave) excision; the latter approaches provide tissue for dermatopathologic examination.
If actinic keratoses are not treated, a small percentage will develop into squamous cell carcinomas. Squamous cell carcinomas greater than 1cm in diameter have the potential to cause metastases. Skin cancer screening makes it possible to recognize and treat actinic keratoses easily before they can evolve into a squamous cell carcinoma!
Let me advise and help you! I look forward to performing a skin cancer screening on you and then in a personalized consultation discussing with you how you can best avoid the risk of skin cancers, or if needed, making recommendations for the treatment of any problem we identify.