Treatment decisions should be made in conjunction with an experienced collaborative team of dermatologists, medical oncologists and surgeons.
For Basal and Squamous Cell Carcinomas
- Surgery is potentially curative. This includes excisional approaches including Mohs surgery by a dermatologist specially trained in this procedure.
- Radiation can be considered in people who cannot undergo surgery.
- Curettage and electrodessication for low risk tumors.
- Superficial therapies in people who cannot undergo surgery or radiation. This includes the topical chemotherapy 5-fluorouracil and the immunotherapy imiquimod in addition to cryotherapy and photodynamic therapy. Cure rates may be lower than that obtained with surgery or radiation therapy.
- If regional lymph nodes are involved, treatment includes a regional lymph node dissection. Postoperative chemotherapy and radiation therapy administered concurrently or sequentially needs to be considered in consultation with a medical oncologist experienced in the management of advanced skin cancers.
- If the cancer has spread distantly, treatment options include chemotherapy, surgery and radiation therapy, clinical trials, or close observation. The best treatment plan should be developed under the guidance of an experienced medical oncologist.
Wide local excision: for a localized cutaneous melanoma it is important to obtain wide margins.
Depth of the melanoma: Margin size desired
Melanoma in situ: 5 mm
Less than 1 mm: 10 mm
Over 1 mm: 20 mm (may necessitate skin grafting)
Sentinel Lymph Node Biopsy
A dye and/or a small amount of radioactive material is injected into the site on the skin where the melanoma developed. An experienced surgeon uses this to isolate the initial draining lymph node. The lymph node is removed and evaluated by pathologists to determine if the melanoma has spread to it. It is important that this procedure be performed prior to the wide excision. Following a wide excision, the accuracy of the sentinel lymph node procedure decreases. Sentinel lymph node procedures should be considered for melanomas that are over 1 mm in depth and for thinner melanomas with concerning features such as ulceration, mitoses, or regression.
- Regional lymph node dissection if the sentinel lymph node is involved.
- Radiation therapy can be considered postoperatively especially if the regional lymph nodes were involved with extension into the extranodal tissue (extracapsular extention).
- Inferferon alfa is an immune therapy approved by the Food and Drug Administration. This is administered by injection after recovery from surgery. It should be considered in consultation with an experienced medical oncologist in people whose melanoma has spread to regional lymph nodes or whose melanoma invaded deeply into the skin (4 mm or greater invasion).
- Systemic therapy for patients with stage IV melanoma (distant spread). There are three Food and Drug Administration (FDA)approved therapies:
1. Dacarbazine - a chemotherapy approved by the FDA for the management of stage IV melanoma (distant spread)
2. High dose Interleukin 2 (IL-2) - an immunotherapy approved by the FDA for the management of stage IV melanoma (distant spread)
3. Ipilumimab - an immunotherapy recently approved by the FDA for the management of stage IV melanoma (distant spread)
MOHS Micrographic Surgery
Mohs surgery is a highly precise technique for the treatment of skin cancer in which microscopic examination made during the procedure guides the removal of the lesion. The technique is named for Dr. Fredrich Mohs, who originated the procedure. When confronted with a skin cancer, the surgeon sees a lesion on the skin. The tumor could be limited to that visible portion on the skin, or the visible portion could only be the tip of the iceberg sticking up above the surface. There is no way to be certain by visual inspection. X-rays, CAT scans, and the like cannot ascertain the extent of the tumor. If the entire tumor is not removed, it will certainly re-grow and possibly spread.
Traditionally, the surgeon would essentially guess by taking margins of normal-appearing skin in all directions to try and be certain all the cancer was removed. This procedure may or may not have worked. If the skin cancer were actually small, normal skin was removed, creating an unnecessarily large wound and scar. If the cancer was actually big, cancer may have been left behind. Treatment with Mohs surgery removes the guesswork.
A small layer is removed representing the visible growth. No normal skin is removed. Microscope slides are made of this specimen while the patient waits. The Mohs surgeon personally looks at these slides, checking 100 percent of the edges and 100 percent of the bottom. If a small root of cancer is seen extending at one spot, the Mohs surgeon will go back to that one small spot and remove another layer of tissue. This second layer is again examined under the microscope. This process continues until all the cancer is gone. The entire procedure is done in the Mohs surgeon's office in a single day.
For basal cell carcinoma, this technique produces approximately a 99 percent cure rate. Furthermore, since no normal skin is removed, this high cure rate is achieved with the smallest wound possible. A small wound makes any repair work less conspicuous, particularly in critical areas such as the nose or near
Following cure with the Mohs technique, the resultant wound can be allowed to heal naturally, can be stitched by the Mohs surgeon, or the services of a plastic surgeon can be utilized. At Mount Sinai, we have a full array of reconstructive surgeons literally "down the hall" if needed or desired.
Skin Cancer Medical Oncology Program
Mount Sinai Medical Center
One Gustave L. Levy Place
New York, NY 10029-6574
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