Management of Nonmelanoma Skin Cancer in 2007
As the incidence of nonmelanoma skin cancer (NMSC) increases, so does the number of modalities used to treat this condition. Surgery is the most frequent approach used to treat NMSC, and clinicians usually perform Mohs micrographic surgery, conventional excision, electrodesiccation and curettage or cryosurgery. The 'gold standard' for treatment continues to be Mohs micrographic surgery, but owing to the time and expense involved with this procedure, it is indicated only in patients with aggressive tumors or those where disfigurement or functional impairment is a risk. Although radiation therapy is effective, its use is limited because of the side effects induced; radiation therapy can be used in certain patients who are not surgical candidates. Newer noninvasive options for NMSC include topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy, which can be used particularly in patients with superficial tumors. Treatments should be tailored to tumor type, location, size, and histological pattern, and although surgical methods remain the most frequently used, newer noninvasive treatments can be used in select tumors and may reduce morbidity.
Nonmelanoma skin cancer (NMSC) is the most common human malignancy and it is estimated that over 1.3 million such cancers are diagnosed each year in the US. The incidence of NMSC is difficult to determine, however, as many cases are not reported because the cancer is not typically followed in tumor registries. Although the mortality caused by NMSC is low, 20% of Americans will develop this type of cancer during their lifetime, resulting in an annual cost to Medicare alone of $426 million. The vast majority of NMSC is basal-cell carcinoma (BCC; Figure 1), which comprises 75% of all NMSC cases. Squamous-cell carcinoma (SCC; Figure 2) accounts for 20% of NMSC cases. Treatment options for NMSC include both surgical and nonsurgical modalities. Regardless of the approach used, the goal is to remove the tumor, achieve a high cure rate, preserve the maximal amount of normal surrounding tissue, and provide an optimum cosmetic outcome. The choice of treatment approach depends on the location of the cancer, age and health status of the patient, and risk factors for tumor recurrence.
(Enlarge Image)
Figure 1.
Example of a basal-cell carcinoma in a patient with nonmelanoma skin cancer. (A) Nodular basal-cell carcinoma demonstrating typical pearly surface with telangiectasias. (B) Histopathology of a basal-cell carcinoma demonstrating basaloid islands with peripheral palisading and clefting.
(Enlarge Image)
Figure 2.
Example of a squamous-cell carcinoma in a patient with nonmelanoma skin cancer. (A) Keratoacanthoma, a type of squamous-cell carcinoma, on the temple. (B) Histopathology of a squamous-cell carcinoma demonstrating atypical keratinocytes extending into the dermis with inflammation.
As clinical diagnosis is not always reliable, a biopsy is usually performed on suspicious lesions, although some clinicians prefer to excise the entire lesion rather than perform an initial biopsy. Lesions that are raised can often be biopsied using a shave technique. If the area is flat or depressed, as with morpheaform BCC, a punch biopsy can be used, as a shave biopsy is unlikely to sample sufficient tumor cells. Sampling to the base of the lesion is especially important with SCC, where the architecture and depth are important diagnostic and treatment parameters.
The most frequently used method for the treatment of NMSC is surgical excision of the tumor. Surgical approaches include conventional excision, Mohs micrographic surgery (MMS), electrodesiccation and curettage and cryosurgery (Figure 3). MMS remains the 'gold standard' for the treatment of a range of NMSCs because this method provides the most complete histologic analysis of tumor margins, the highest cure rate, and preservation of the maximal amount of normal tissue by removing the tumor with the smallest margin necessary. Various nonsurgical methods for treatment may be suitable in certain patients, because of the potential for disfigurement and functional impairment and the inherent risks associated with any surgical procedure. Radiation therapy has also been used in specific circumstances, and a variety of other relatively new noninvasive options such as topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy are now available.
(Enlarge Image)
Figure 3.
Schematic diagram of the management of nonmelanoma skin cancer. Abbreviations: BCC = basal-cell carcinoma; C and E = curettage and electrodesiccation; MMS = Mohs micrographic surgery; SCC = squamous-cell carcinoma; RT = radiation therapy.
Summary and Introduction
Summary
As the incidence of nonmelanoma skin cancer (NMSC) increases, so does the number of modalities used to treat this condition. Surgery is the most frequent approach used to treat NMSC, and clinicians usually perform Mohs micrographic surgery, conventional excision, electrodesiccation and curettage or cryosurgery. The 'gold standard' for treatment continues to be Mohs micrographic surgery, but owing to the time and expense involved with this procedure, it is indicated only in patients with aggressive tumors or those where disfigurement or functional impairment is a risk. Although radiation therapy is effective, its use is limited because of the side effects induced; radiation therapy can be used in certain patients who are not surgical candidates. Newer noninvasive options for NMSC include topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy, which can be used particularly in patients with superficial tumors. Treatments should be tailored to tumor type, location, size, and histological pattern, and although surgical methods remain the most frequently used, newer noninvasive treatments can be used in select tumors and may reduce morbidity.
Introduction
Nonmelanoma skin cancer (NMSC) is the most common human malignancy and it is estimated that over 1.3 million such cancers are diagnosed each year in the US. The incidence of NMSC is difficult to determine, however, as many cases are not reported because the cancer is not typically followed in tumor registries. Although the mortality caused by NMSC is low, 20% of Americans will develop this type of cancer during their lifetime, resulting in an annual cost to Medicare alone of $426 million. The vast majority of NMSC is basal-cell carcinoma (BCC; Figure 1), which comprises 75% of all NMSC cases. Squamous-cell carcinoma (SCC; Figure 2) accounts for 20% of NMSC cases. Treatment options for NMSC include both surgical and nonsurgical modalities. Regardless of the approach used, the goal is to remove the tumor, achieve a high cure rate, preserve the maximal amount of normal surrounding tissue, and provide an optimum cosmetic outcome. The choice of treatment approach depends on the location of the cancer, age and health status of the patient, and risk factors for tumor recurrence.
(Enlarge Image)
Figure 1.
Example of a basal-cell carcinoma in a patient with nonmelanoma skin cancer. (A) Nodular basal-cell carcinoma demonstrating typical pearly surface with telangiectasias. (B) Histopathology of a basal-cell carcinoma demonstrating basaloid islands with peripheral palisading and clefting.
(Enlarge Image)
Figure 2.
Example of a squamous-cell carcinoma in a patient with nonmelanoma skin cancer. (A) Keratoacanthoma, a type of squamous-cell carcinoma, on the temple. (B) Histopathology of a squamous-cell carcinoma demonstrating atypical keratinocytes extending into the dermis with inflammation.
As clinical diagnosis is not always reliable, a biopsy is usually performed on suspicious lesions, although some clinicians prefer to excise the entire lesion rather than perform an initial biopsy. Lesions that are raised can often be biopsied using a shave technique. If the area is flat or depressed, as with morpheaform BCC, a punch biopsy can be used, as a shave biopsy is unlikely to sample sufficient tumor cells. Sampling to the base of the lesion is especially important with SCC, where the architecture and depth are important diagnostic and treatment parameters.
The most frequently used method for the treatment of NMSC is surgical excision of the tumor. Surgical approaches include conventional excision, Mohs micrographic surgery (MMS), electrodesiccation and curettage and cryosurgery (Figure 3). MMS remains the 'gold standard' for the treatment of a range of NMSCs because this method provides the most complete histologic analysis of tumor margins, the highest cure rate, and preservation of the maximal amount of normal tissue by removing the tumor with the smallest margin necessary. Various nonsurgical methods for treatment may be suitable in certain patients, because of the potential for disfigurement and functional impairment and the inherent risks associated with any surgical procedure. Radiation therapy has also been used in specific circumstances, and a variety of other relatively new noninvasive options such as topical chemotherapeutics, biological-immune-response modifiers, retinoids, and photodynamic therapy are now available.
(Enlarge Image)
Figure 3.
Schematic diagram of the management of nonmelanoma skin cancer. Abbreviations: BCC = basal-cell carcinoma; C and E = curettage and electrodesiccation; MMS = Mohs micrographic surgery; SCC = squamous-cell carcinoma; RT = radiation therapy.
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