EDUCATION CENTER

What Is Skin Cancer?

Skin cancer, like cancer in other organs of the body, is the result of the uncontrolled, abnormal growth of cells. Cells are the tiny, individual units of all organs in our body, and they are responsible for the normal activity that keeps us healthy. When the cells in the skin begin to grow in an uncontrolled, abnormal fashion, a tumor will result. This tumor may be benign or malignant.  

A malignant tumor is considered a cancer and should be removed to prevent the possibility of invasion and destruction of surrounding normal tissue, or the spread of the cancer to other organs in the body. This is known as a metastasis. Fortunately, metastasis of skin cancer is not common. Skin cancers, however, frequently invade surrounding normal tissue causing extensive destruction of skin and body structures. Benign tumors do not metastasize and, in general, do not cause harm to a patient if they are not removed.

Diagnosis

You’ve Been Diagnosed With Skin Cancer. What Do You Do Now?

Skin cancer may be more than meets the eye. Not all treatments for skin cancer are equal. Options range from common treatments preferred by many physicians such as scraping and burning (electrodesiccation and curettage), freezing (cryotherapy), radiation, and surgical excision, to Mohs micrographic surgery. Mohs micrographic surgery is an advanced surgical technique performed by a highly trained specialist. You should be aware of the benefits and drawbacks of each option and choose a treatment that will remove all the cancer, minimize the risk of recurrence, and leave as little scarring as possible.

When considering options, or to understand why previous treatments may have failed, it is important to recognize that the tumor, which is visible to you or your physician, may be just the “tip of the iceberg.” Cancer cells can not be seen with the naked eye. Many “invisible” cells may form roots or “fingers” of diseased tissue that extend beyond the boundaries of the visible cancer. Using a microscope to track down the roots of the skin cancer is an important step in treatment. If these cancer cells are not completely removed, they can lead to re-growth and recurrence of the tumor.

Types of cancer most likely to form these complicated root systems are those that:

  • are located in cosmetically sensitive or functionally critical areas around the ears, eyes, nose, lips and scalp
  • are located in areas where tissue is limited such as the eyes, ears, nose, lips, hands, fingers, and genitals
  • grow rapidly and/or uncontrollably
  • recurrent skin cancer or treatment failures

For these cancers, common treatment methods are often not successful, because they do not rely on a microscopic examination to determine the extent of the cancer. These common but less precise treatment methods can remove too little cancer or too much healthy tissue. This can then lead to a high rate of recurrence of the skin cancer necessitating additional surgery or cause unnecessary scarring.

If a cancer has been treated by one of these common methods and it recurs, the chances of it being cured when treated again by the same method becomes even less likely. The scar tissue surrounding a recurrent cancer makes it extremely challenging to separate healthy skin and cancerous tissue. Also there is a tendency to remove too much tissue when recurrent skin cancers are treated again with common methods.

 

Types of Skin Cancer

Basal Cell Carcinoma (BCC) is the most common type of skin cancer in the United States. About 80 percent of all skin cancer cases are BCC, the slowest growing and least dangerous of the three common types of skin cancer. It rarely metastasizes (spreads) to distant sites in the body. BCC develops from the cells in the epidermis (surface layer of the skin) known as the basal cell layer. This type of skin cancer occurs predominately in sun-exposed areas, such as the head, neck, hands, and forearms.

Basal cell carcinoma may have many different appearances. It most commonly appears as a small, pearly or skin-colored bump or nodule. Basal cell carcinoma can also appear as a flat growth, a scar, or a scaling area. Untreated, basal cell carcinomas may begin to bleed, crust (scab) over, and spread into surrounding tissue, leading to more extensive surgery and scarring.

Squamous Cell Carcinoma (SCC) is the second most common type of skin cancer in the United States. This cancer develops from cells in the epidermis known as squamous cells. Squamous cell carcinomas are more dangerous than BCC because they have a greater tendency to recur after surgery and to metastasize (spread) to other organs in the body.  The cure rate for SCC is about 95 percent when properly treated.

SCC, like BCC, occurs predominately in sun-exposed areas and is responsible for 15 percent of all skin cancer cases in the United States. It may appear as a red nodule or a rough scaling patch. Bowen’s disease (SCC in situ) is a form of SCC that has not yet invaded the second layer of the skin (dermis). Without invasion of the cells the risk of spread is minimal.

Malignant Melanoma (MM) is a life-threatening skin cancer that develops from the pigment-forming cells in the skin [melanocytes – “meh-LAN-oh-sites”]; hence, it tends to be a black or brown skin cancer. MM is the least common of these three types of skin cancer, but it is the most dangerous because it has a strong tendency to metastasize to distant organs. One in 50 men and women will be diagnosed with melanoma of the skin during their lifetime. In 2014, it is estimated that 9,710 deaths will be attributed to melanoma. Melanoma represents 2 percent of all cancers and 1 percent of all cancer deaths in the United States. Fortunately, early detection and surgical excision (see below) of MM can result in a high cure rate.

Treatment Options

Surgical Procedures

Mohs Micrographic Surgery This is a specialized treatment for certain skin cancers that require a specialist for their treatment. This is the most precise surgical method for skin cancer removal, with the highest cure rates for skin cancer. With this method, the surgeon excises the skin cancer and checks the tissue with a microscope while you wait. Further surgery can be performed immediately, and repair of the surgical wound is usually completed the same day.

Surgical Excision Surgical Excision is a common treatment method for skin cancer. This is performed using a scalpel, usually an outpatient procedure. Excision of skin cancers allows the surgical margins to be checked to confirm that the skin cancer  has been completely removed. After the tissue sample is removed, it is sent out to a pathology lab to check for complete removal of the tumor. This step usually requires several days. Excision allows many skin cancers to be treated in the office as an outpatient procedure by your dermatologist or physician. At this time, surgical excision is the preferred method of treatment for malignant melanoma.

Electrodesiccation & Curettage This method removes skin cancer by using a curette (a circular scalpel-like instrument) and electric needle. The curette scrapes  away tumor, since tumor cells are less cohesive than normal cells. The area is then treated with an electric needle to further destroy  remaining tumor cells. This method is commonly used and successful in many instances. The electrodesiccation and curettage method allows quick and simple treatment, often on the same day as a skin biopsy, when the diagnosis is almost certain.

Non-Surgical Methods Include:

Radiation Therapy X-rays are used to kill the cancer cells. This method also requires an estimate of the extent and size of the tumor.

Photodynamic Therapy An investigational technique where light and chemicals are combined to kill cancer cells.

Topical Therapy Topical treatments should be reserved for nonaggressive, superficial, small  skin cancers. Topical medications: Aldara (Imiquimod), 5-Fluorouracil (Efudex), or Carac Cream.

 

Skin Cancer Prevention

Steps for Skin Cancer Prevention

The following steps have been recommended by the American Academy of Dermatology to help reduce the risk of sunburn and skin cancer:

  • Apply sunscreen. When you are going to be outside, even on cloudy days, apply sunscreen to all skin that will not be covered by clothing. Reapply approximately every two hours, or after swimming or sweating. Use a broad-spectrum, water-resistant sunscreen that protects the skin against both UVA and UVB rays and that has an SPF of at least 30.
  • Use one ounce of sunscreen, an amount that is about equal to the size of your palm. Thoroughly rub the product into the skin. Don’t forget the top of your feet, your neck, ears, and the top of your head.
  • Seek shade. Remember that the sun’s rays are strongest between 10 a.m. and 3 p.m. If your shadow is shorter than you are, seek shade.
  • Protect your skin with clothing. When going outside wear a long-sleeved shirt, pants, a wide-brimmed hat and sunglasses.
  • Use extra caution near water, sand or snow as they reflect and intensify the damaging rays of the sun, which can increase your chances of sunburn.
  • Get vitamin D safely. Eat a healthy diet that includes foods naturally rich in vitamin D, or take vitamin D supplements. Do not seek the sun.
  • Don’t use tanning beds. Just like the sun, UV light from tanning beds can cause wrinkling and age spots and can lead to skin cancer.
  • Check your skin for signs of skin cancer. Your birthday is a great time to check your birthday suit. Checking your skin and knowing your moles are key to detecting skin cancer in its earliest, most treatable stages.
  • PROTECT CHILDREN: Remember 80% of your lifetime sun exposure occurs before the age of 18. Regular use of sunscreens in children can significantly reduce their chance of developing skin cancer later in life. Do not use sunscreen on children under 6 months of age. Limit their sun exposure.

 

Periodic Self-Examination

Prevention of skin cancer by proper sun protection is most important. Early detection, however, is essential since most skin cancers are easily cured if caught in the early stages. To aid in early recognition of any new or developing lesion, self-examinations are helpful. To perform your self-examination you will need a full-length mirror, a hand mirror, and a brightly lit room. Family members can also assist in regular self-examinations, especially for the back.exposed areas of the body.

Sun Screens

A sunscreen protects your skin from the suns Ultraviolet (UV) radiation by either absorbing or reflecting the UV rays. SPF stands for Sun Protection Factor and is a measurement of the protection level. This number, however, is based mainly on protection from UVB and not UVA rays. UVA rays are also important for skin cancer and skin aging. Titanium dioxide and Parsol® 1789 are 2 newer compounds in sunscreens, which provide broad coverage for both UVA & UVB.  

  • Choose sunscreen that has an SPF of 30 or higher, is water resistant, and provides broad-spectrum coverage, which means it protects you from UVA and UVB rays.
  • Apply sunscreen generously before going outdoors. It takes approximately 15 minutes for your skin to absorb the sunscreen and protect you. If you wait until you are in the sun to apply sunscreen, your skin is unprotected and can burn.
  • Use enough sunscreen. Most adults need at least one ounce of sunscreen, about the amount you can hold in your palm, to fully cover all exposed areas of your body. Rub the sunscreen thoroughly into your skin.
  • Apply sunscreen to all bare skin. Remember your neck, face, ears, tops of your feet and legs. For hard-to-reach areas like your back, ask someone to help you or use a spray sunscreen. If you have thinning hair, either apply sunscreen to your scalp or wear a wide-brimmed hat. To protect your lips, apply a lip balm with a SPF of at least 15. 
  • Reapply sunscreen at least every two hours to remain protected, or immediately after swimming or excessively sweating.
  • Your skin is exposed to the sun’s harmful UV rays every time you go outside, even on cloudy days and in the winter. So whether you are on vacation or taking a brisk fall walk in your neighborhood, remember to use sunscreen.

 

MOHS SURGERY

Advanced, Precise, Effective.

This is a specialized treatment for certain skin cancers that require a specialist for their treatment. This is the most precise surgical  method for skin cancer removal, with the highest cure rates for skin cancer. With this method, the surgeon excises the skin cancer and checks the tissue with a microscope while you wait. Further surgery can be peformed immediately, and repair of the surgical wound is usually completed the same day. 

Mohs Micrographic Surgery

Mohs micrographic surgery was developed by Frederic E. Mohs, MD over 50 years ago,  and it continues to be the most advanced and effective treatment procedure available for skin cancer. The goal of the procedure is to remove the skin cancer completely while minimizing the removal of uninvolved healthy tissue. It is performed under local anesthesia on an out-patient basis.

For decades, Mohs micrographic surgery has proven effective in removing skin cancer by combining the surgical removal of cancer with the immediate microscopic examination of the tumor and underlying diseased tissue. This process allows the surgeon to see beyond the visible disease and precisely identify and remove the entire tumor. Mohs surgery traces the path of the tumor cells using two key tools: a precise map of the surgical site and a microscope.

Mohs surgery is performed by a specially trained dermatologist (who serves as surgeon, pathologist and reconstructive surgeon) and who has completed a one to two year certified surgical fellowship.

Dr. Clark and Dr. Flynn completed rigorous Mohs Micrographic and Dermatologic Surgery fellowships  and are Fellows of the American College of Mohs Surgery (ACMS).

Which Skin Cancers Need Mohs Surgery?

Mohs micrographic surgery is effective for most types of skin cancer. 
It is most commonly used to treat basal cell and squamous cell carcinomas, but usually not malignant melanomas.
Mohs surgery is the 
treatment of choice when:

  • The cancer is large
  • The edges of the cancer cannot be clearly defined
  • The cancer is in an area of the body where it is important to preserve healthy tissue for the maximum functional and cosmetic result, or is likely to recur if treated by common methods:central face, eyelids, nose, ears, lips, and cheek
  • Skin cancer that has recurred, or for which prior treatment has failed
  • The cancer is especially aggressive
  • The patient has a deficient immune system, such as kidney or heart transplant patients
How Does Mohs Surgery Work?

After the local anesthesia has taken effect, the Mohs surgeon removes the visible portion of the tumor with a scalpel and the following activities take place.

  • A thin “pancake-like” layer of tissue is removed from the tumor site
  • A map or drawing is made of the removed tissue to be used as a guide to the precise location of any remaining cancer cells
  • The removed tissue is sectioned (thinly sliced), then mounted on microscope slides and stained for examination
  • The entire bottom surface and outside edges of the tissue section are thoroughly examined under the microscope to check for evidence of remaining cancer cells
  • If more cancer cells are seen under the microscope, their location is traced on the map so that only areas with remaining skin cancer undergo further surgery

If any of the sections contain cancer cells, the Mohs surgeon:

  • Uses the map to return to the specific area where cancer cells are still present
  • Removes another thin layer of tissue only from the specific area within each section where cancer cells were detected
  • Microscopically examines the newly removed tissue for additional cancer cells

If microscopic analysis still shows evidence of disease, the process continues layer by layer until the cancer is completely removed. When the removed tissue shows no sign of disease, the removal process stops – preserving or “saving” healthy, normal tissue. This technique ensures that the diseased tissue is removed, thereby minimizing the size of the surgical wound and the cosmetic impact. Only by this careful, systematic microscopic examination of the removed skin can the doctor be as certain as possible that no cancer remains, and that the cancer-containing tissue is removed. The importance of leaving as much normal, uninvolved skin as possible is readily appreciated when the skin cancer involves the eyelid, lip, nose, ear, or face.

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Advantages of Mohs Micrographic Surgery for Selected Skin Cancers
  • Offers the highest cure rate (up to 99 percent) 
  • Has the lowest chance of cancer re-growth
  • Spares the most normal skin in the tissue removal process 
  • Minimizes the potential for scarring or disfigurement 
  • Is the most exact and precise means of skin cancer removal 
  • Is cost-effective, outpatient surgery utilizing safe local anesthesia
About Our Mohs Micrographic Surgery Unit

The Mohs Micrographic Surgery Unit at Cary Skin Center is a state-of-the art outpatient surgical center. Dr. Clark and Dr. Flynn have completed certified surgical training fellowships of the American College of Mohs Surgery. Dr. Clark was the Director of the Mohs surgery unit at Duke University Medical Center from 1990 to 1998. Dr. Flynn served as Director of the Mohs surgery unit at Tulane University in New Orleans from 1993 to 2001. Mark Buchanan HT, ASCP, is director of the Mohs laboratory. He has specialized training in histotechnology, which is the preparation of tissue for microscopic examination.

MOHS Instructional Video

Reconstructive Surgery

Reconstructive Surgery

Following the removal of your skin cancer we will discuss with you the options for repairing the surgical wound. The surgical wound will be repaired by stitching the edges together or by using a skin graft or skin flap. These repairs are usually, but not always, performed on the day of your surgery. Occasionally, we must delay the repair until the next day. 

Dr. Clark and Dr. Flynn are extensively trained in surgical reconstruction. This includes basic closures, and more complicated skin flaps and skin grafts. They perform hundreds of these procedures each year. Our goal is to provide you the best possible cosmetic result after the removal of your skin cancer.

The size and depth of the surgical wound after removal of your skin cancer can not be predicted in advance. The method of reconstruction can not be predetermined either. After tumor removal is complete the options for reconstruction will be reviewed with you. In some instances, we may recommend you see a plastic or head & neck surgeon (ENT) for your repair.

At the completion of your surgery and repair, we will give you printed instructions on how to care for your wound.

Options for Management of Surgical Wounds:

Direct Closure: This is the most common method of repair. The wound edges are brought together to form a linear closure. Most surgical wounds following removal of the skin cancer are circular. When these wounds are closed by direct closure some puckering is produced at both ends. These puckers must be removed to produce a straight line, which is longer than the original diameter of the wound. Our goal is to hide this scar line in a pre-existing crease when possible.

Skin Flaps: Some surgical wounds are best repaired using a flap. A skin flap is when nearby tissue is recruited to cover the surgical wound. Many types and designs of skin flaps are used in order to restore function and produce the best possible cosmetic result. Smoking has been shown to decrease skin flap survival. We recommend stopping all smoking for a period 2 weeks before and 2 weeks after your surgery. 

Skin Grafts: When surgical wounds cannot be easily repaired by direct closure or a flap we will often use a skin graft. A skin graft is a procedure in which a piece of skin is removed from one part of the body and then transferred to another. Donor skin for skin grafts is usually taken from in front or behind the ear. The scar from the skin graft can usually be hidden around the ear in natural skin lines. Smoking has been shown to decrease skin graft survival. We recommend stopping all smoking for a period 2 weeks before and 2 weeks after your surgery.

Second Intention: This method allows the wound to heal on its own without any further surgery. A bandage is worn for 8-12 weeks while the area heals. As a rule, wounds left to heal by second intention do not produce as good a cosmetic result as sutured wounds. The patient must also wear a bandage for a prolonged period, which varies depending upon the size of the wound.

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