reconstructive Surgery | Dr. Enrique Etxeberria, Plastic Surgery in Bilbao

Skin Cancer

Reconstructive Surgery - Skin Cancer - Skin Cancer

Skin Cancer

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In our consulting rooms we have set up a specialist unit for the treatment of skin cancer.
It is a multidisciplinary unit in which we join forces with specialist Dermatologists of renowned national prestige in the treatment of skin cancer using Mohs surgical techniques, and applying the expertise of reconstructive surgery to skin defects. Similarly, in cases that require it, we work with specialist oncologists with complementary support therapies.

This combination of specialties seeks three objectives:
•    To cure the disease within adequate margins.  The best moment to do so is the first time it is treated.
•    To leave the least sequelae possible so that the patient may continue living a normal life after the treatment, be it medical, surgical or radiotherapeutic.
•    In the case of the more aggressive tumours, to be able to rely on latest generation treatments with a multidisciplinary approach from all the different specialities.

WHAT IS IT?

Skin cancer is a disease caused by cancerous cells in any of the layers of the skin.
Two types can be distinguished:  non-melanoma and melanoma.
Non-melanoma skin cancer is the most common and is called non-melanoma because it is formed from skin cells other than the ones that accumulate pigment (melanocytes). Within this type are all skin cancers apart from malign melanoma which is less common and explained a little further on.
Skin cancer occurs more commonly in people with white skin who have spent a lot of time exposed to the sun, above all when the solar exposure took place during childhood and sunburn was experienced on a number of occasions.  Although it can appear on any part of the skin, it more commonly presents on the face, neck, hands and arms.
This skin cancer is one of the most common of all types of cancer, and it is calculated that some two million new cases are diagnosed each year around the world.
In recent years, the incidence of malign melanoma has increased spectacularly, it has multiplied by 3,3 in men and 2,5 in women. Despite this, it represents less than 3% of all tumours and early diagnosis campaigns have enabled the mortality rates to come down from by some 30% since the seventies.
Skin cancer can be recognised by a change in the appearance of the skin, such as a wound that does not heal or a small protuberance.  A small red stain may also appear, rough and scaly, with a tendency to grow.
In the event of any change or abnormality of the skin, you must seek medical advice.  The doctor may extract a sample and analyse it (biopsy) to verify whether it is a malign tumour or not.

RISK FACTORS

What causes this type of cancer is not fully known, although certain factors which influence its appearance have been studied.
•    Environmental factors
Excessive exposure to the sun influences the production of these cancers.  People who work outside, such as farmers and sailors, present a higher incidence.  They tend to appear on exposed skin, frequently on the head and neck.
Although sunlight helps to synthesize vitamins A and D, excessive exposure, whether it causes sunburn or not, increases the risk of developing skin cancer, including malign melanoma.
There is a correlation between the risk of melanoma and latitude.  The period of time during which a person has lived in equatorial latitudes also bears an influence, which means excessive exposure to sunlight throughout a period of one’s life.
Not only does prolonged exposure bear an influence but intense occasional exposure to sunlight can also do so, during vacations for example, representing a risk factor for both basocellular carcinoma and melanoma.
Melanomas differ from malign tumours of the non-melanoma type in relation to gender, age and location on the body.  The majority of malign skin melanomas do not occur in places which receive the greatest accumulation of ultraviolet exposure.
Although it is not known exactly what the most dangerous form of exposure to the sun is, some studies support the hypothesis that intense and intermittent exposure to ultraviolet radiation on skin which is normally protected is responsible for the formation of the melanoma.  Age also appears to have an influence and sunburn experienced prior to the age of 15 doubles the risk of melanoma.
•    Physical characteristics
People of white race of Scottish, English or Irish origin, with red or reddish hair, light coloured eyes and lots of freckles are particularly susceptible.
Melanoma is very rare in the black or oriental population, when it does occur it happens in areas with little pigmentation such as the palms of the hands and soles of the feet and their prognosis is worse.
The sensitivity of the skin to the sun and difficulty in tanning increase the risk of melanoma.
Skin reaction to sunlight is related to factors such as skin pigmentation, the number of freckles in childhood or adult age and the number of nevi (formations similar to moles and which are benign melanocytic tumours), all of them constituting risk factors for malign cutaneous melanoma.
The greater incidence of nevi in white individuals leads to the idea that ultraviolet radiation plays an important role in the development of nevi. It has been demonstrated that there is a greater incidence of nevi in areas of the skin exposed to sunlight as opposed to protected areas, with this increase being linked to a greater propensity to getting sunburn rather than getting tanned, the tendency to have freckles and a lifestyle linked to greater exposure to the sun.  A person with skin that is sensitive to the sun, more than 150 melanocytic nevi and the odd dysplastic nevus (with microscopic appearance similar to malign melanoma cells), could present 50 times more risk of melanoma than another person without these characteristics.
•    Genetic factors
Nevoid basal cell carcinoma syndrome is a hereditary disorder in which patients develop a large number of basocellular carcinomas from the second decade of life and which, ultimately, affect any area of the skin.
Xeroderma pigmentosum is a hereditary condition which is caused by DNA repair disorder, also linked to the appearance of multiple skin carcinomas.
Malign skin melanoma has a familiar predisposition.  The estimated risk of suffering from it is 70% in patients with neurocutaneous melanosis and different types of xeroderma pigmentosum, 1% in children of patients with non-familiar solitary melanoma and 6% in families with dysplastic nevus syndrome and the history of two or more malign melanomas.
•    Immunosuppression
People who have been treated with medicines which depress their immunological system, have a greater predisposition to developing melanoma.
•    Over-exposure to tanning lights and cabins
Tanning lights and cabins are a source of ultraviolet radiation.  Excessive exposure increases the risk of developing skin cancer.
•    Age
Approximately half of all cases of melanoma occur in people over the age of 50.
•    Other factors
Exposure to carcinogens, trauma or scars, lesions from chronic radiation and viral infections are some of the factors which predispose the appearance of skin cancer.

DIAGNOSIS

The doctor will base his diagnosis on the symptoms presented by the patient’s skin and his or her medical history.
When the existence of an anomaly is suspected, a biopsy will be performed.  With a biopsy the tissue is analysed under a microscope in order to examine the type of cells present.
Depending on the location of the skin alteration and the type, one type of biopsy or another will be employed.
Biopsy by scraping: The area of the skin to be biopsied is desensitized with local anaesthetic and the top layers of the skin are scraped with the blade of a scalpel.
Incisional and excisional biopsies: a wedge of skin is removed.  This is performed for deeper tumours.  With an incisional biopsy only a part of the tumour is extracted for analysis.  With an excisional biopsy, the entire tumour is removed.  If the extension of skin affected is large, an incisional biopsy will be performed, in the first instance, in order to not detract too much from the person’s appearance.
Biopsy by aspiration with a fine needle: a syringe with a fine needle is used to extract small particles of the tumour.  It is not used for the diagnosis of a suspicious mole but is used for the biopsy of lymphatic ganglia close to a melanoma.
When it is suspected the stage of the cancer is high, other tests will be performed for diagnosis of the spread such as scans, analysis of nuclear medicinal tests...

TYPES OF TREATMENT

After the medical examination, the diagnosis of skin cancer is confirmed with a biopsy. In this procedure the skin is first numbed with local anaesthetic.  Then, a piece of the tissue is removed and examined in the laboratory with a microscope to arrive at a definitive diagnosis.  If tumoural cells are found, treatment is required.  Luckily, there are different effective methods for eradicating basocellular carcinoma. The choice of treatment depends on the type of tumour, its size, location and depth of penetration, as well as the age of the patient, his or her general state of health and the likely cosmetic effect of the treatment.
For the most part, the treatment can be effected without hospital admission, in the doctor’s consulting rooms or in a clinic.  Generally, local anaesthetic is used for the surgical procedures.  These treatments cause minimal pain or discomfort, and rarely is there any discomfort after the treatment.
*MOHS MICROGRAPHIC SURGERY
Using local anaesthetic, the doctor removes the tumour together with a very thin layer of surrounding tissue.  The layer of skin is checked immediately and meticulously under the microscope.  If there is remaining tumour in the depths or peripheries of this surrounding tissue, the procedure is repeated until the last layer examined under microscope is tumour-free. This technique safeguards the greatest quantity of healthy tissue and has the highest cure rate, generally around 98 per cent or better. It is commonly used for tumoural recurrence, poorly delimited tumours or in critical areas around the eyes, nose, lips and ears.  After the excision of the skin cancer, the wound can be allowed to heal naturally or can be reconstructed using plastic surgery methods.
*SURGICAL EXCISION
After numbing the area with local anaesthetic, the doctor uses a scalpel to extract the entire tumour together with an additional border around it, as a margin of safety.  Then, the area is closed with stitches and the excised tissue sent to the laboratory for its microscopic examination for the purposes of verifying that all the malign cells have been removed.
*CURETTAGE AND ELECTRODESICCATION
Using local anaesthetic, the cancerous lump is scraped with a curette (sharp ring-shaped instrument). The heat produced by an electrocautery needle destroys the residual tumour and controls bleeding.  This technique can be repeated two or more times to thereby ensure the extirpation of all the cancerous cells.
*RADIATION
X-rays are applied to the tumour without requiring any surgery or any anaesthetic.  Total destruction generally requires various applications a week, for a few weeks. Radiation can be used for tumours which are difficult to treat surgically and for patients of advanced age and others with delicate health.
*CRYOSURGERY
Tumoural tissue is destroyed by freezing with liquid nitrogen, without requiring surgery or anaesthetic.  The procedure can be repeated during the same session to guarantee the total destruction of the malign cells.  The tumour is destroyed and a scab forms which falls off after a few days.  Cryosurgery is effective for the most common tumours and is the treatment of choice for patients with haemorrhages or intolerance to anaesthetic.
*PHOTODYNAMIC THERAPY (PDT)
PDT can be particularly useful when patients have multiple basocellular carcinomas (BCC).  In his consulting rooms, the doctor applies topical 5-aminolevulinic acid (5-ALA) on the lesions.  It is taken in by the abnormal cells.  The next day, the patient returns for the treated areas to be exposed to an intense light which activates the 5-ALA. This treatment selectively destroys the basocellular carcinomas and causes minimal damage to the normal skin around the lesion.
*LASER SURGERY
To remove superficial layers and a variable quantity of deeper layers of the affected skin, the carbon dioxide laser or Erbium-YAG laser is used. This treatment permits good control over the depth of the tissue extracted, and is used in certain cases as a secondary therapy when other techniques have failed.
*TOPICAL MEDICATION
Imiquimod is approved by the FDA exclusively for superficial basocellular carcinomas, with cure rates generally between 80 and 90 per cent. The cream at 5% is gently rubbed on the tumour five times a week for a period of up to six weeks or more.  It is the first in a new class of medications which work via the stimulation of the immune system.
5-Fluorouracil (5-FU) has also been approved by the FDA for superficial basocellular carcinomas, with similar cure rates. The liquid or lotion at 5% is gently rubbed on the tumour twice a day for three to six weeks.
There are current studies using imiquimod and 5-FU for more invasive basocellular carcinomas.  The side effects are variable, and some patients experience no discomfort whatsoever, but one may anticipate reddening, irritation and inflammation.

ADVICE ON HOW TO PROTECT ONESELF AGAINST SKIN CANCER

With early detection and adequate treatment, skin cancer can be cured in almost all cases.  But the first and greatest line of defence against this and other types of skin cancer is prevention.  From now on, incorporate the following safety measures vis-à-vis the sun into your daily routine:
•    Seek the shade, especially between 10:00 am and 4:00 pm.
•    Avoid sunburn.
•    Avoid tanning, and don’t use artificial tanning equipment.
•    If you are exposed to the sun, dress with clothing that protects you, even hats with wide brim and sunglasses with UV protection.
•    Every day, use a wide spectrum sun protection cream with factor 15 or above protection factor (SPF).
•    Apply an ounce – 30 grams (two spoonfuls) – of sun protection on all of the exposed parts of your body 30 minutes prior to each exposure.  Reapply every 2 hours or after swimming or perspiring a lot.
•    Keep newborn children away from the sun.
•    Examine your skin from head to toes at least once a month.
•    Visit your doctor every six months for a complete examination of your skin.