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Skin Cancer and Skin Lesions

Otolaryngologist (Ear, Nose & Throat Specialist)

We often see patients with skin lesions that concern them due to a change in appearance, size or that may be causing discomfort. These lesions can be benign, pre-cancerous or skin cancer. Skin cancer is the most frequent form of all human cancers. There are roughly one million new cases of skin cancer each year in the USA. By the time we reach age 65, one-half of Americans will have developed at least one skin cancer. Skin cancer becomes noticeable due to changes in the appearance of the skin.

Common changes in appearance are lesions that do not heal and that are hard, scaly and painful.

There are three primary types of skin cancer. These three main types are classified depending on which layer of the skin they involve:

1. Basal cell carcinoma or basal cell epithelioma (BCC or BCE) is the least malignant as it tends to grow over months to years. It is rare for a basal cell carcinoma to spread to other parts of the body. BCC’s can begin as a small bump that develops a small central ulcer or pit. The involved tissue can become shiny or scaly. The raised border is a frequent indication that this lesion is a BCC. It is believed that BCC is most likely the result of intermittent sun exposure early in life. Therefore, BCC’s are much more common in the southern, sunny parts of the US rather than the northern parts. This is related to the amount of UV exposure in early /young life.

BCC’s have a very high cure rate if they are removed surgically.

The most common treatment for BCC is surgical excision. In smaller lesions, the tumor is removed and the skin is closed together with sutures. For these smaller lesions, an excision can be done in the office and the lesion will be sent to pathology. In large lesions, it may not be possible to close the skin directly, so skin is moved from surrounding tissue to repair the defect from the excision of the BCC. Occasionally it is necessary to do a free skin graft to repair the defect from the excision of the BCC. It is sometimes necessary to do these excisions as an outpatient surgery with local anesthesia or sedation and with a pathologist present. The pathologist ensures that the cancerous lesion has been fully excised. For a few BCC’s around the eyes and nose, the use of radiation therapy or Moh’s surgical excision technique may be required.

Extremely superficial lesions may be treated successfully with peeling by a strong acid. This technique is good as it leaves little to no scarring. This could mean applying the acid to one or more areas and can be done in the office. A full facial chemical peel is another option for someone who has extensive sun damage to their face. Depending on how strong the peel is, it can either be done in the office or for comfort done under sedation in an outpatient surgical setting. Some cases of BCC can be treated medically using creams such as 5FU (Efudex) or Fluoroplex. These agents destroy the BCC. Imiquimod (Aldara) destroys the BCC by stimulating the immune system. The disadvantage to creams is that the cure rates are lower and cause considerable irritation to the skin with peeling, redness and pain.

2. Squamous cell carcinoma (SCC) is a malignant tumor that begins in the upper part of the skin layers and is felt to be due to long-term, accumulated sun exposure. SCC’s are found in the tissues that line the surface of the skin and the hollow organs of the body, including the lining of the respiratory and digestive tracts. It is estimated that SCC occurs only 25% as often as BCC. The fairer the skin type and the lighter the eye color is, the more likely the skin cancer will be SCC. The earliest form of pre-SCC is called actinic keratosis (AK). This is Greek for “thickening of the skin from sun radiation”. These AK’s precede the change to SCC and appear as scaly, red, rough lesions on the head, face, ears, arms and hands. These can become tender. Over 10 years it is estimated that 15% of AK’s will become SCC’s.

SCC can metastasize to other parts of the body if left untreated. If SCC is treated in the early stages, there is a high cure rate.

Treatment for SCC has similar options to those for BCC. It is important to note that during the biopsy and surgery phase, the tissue is evaluated by the pathologist microscopically to determine that all the margins around the tumor are clear.

3. Melanoma is by far the most dangerous of the three skin cancers as it can metastasize quickly to other parts of the body. Melanoma comes from the pigment cells in the skin that make melanin (color). Therefore, these lesions are often brown or black in appearance. Early warning signs for melanoma are described by the letters “A,B,C and D.”

  • ‘A’ stands for Asymmetry, meaning one side is different from the other side.

  • ‘B’ stands for Border Irregularity.

  • ‘C’ stands for Color, which is usually brown to black or a mixture of the two. Rarely a melanoma can be clear in color.

  • ‘D’ stands for Diameter, that is expanding.

Recently Doctors Scope and Marghoob felt that a better detection system for melanoma would be to include the “ugly duckling” description. This means that at any given moment, this “ugly duckling” lesion looks and feels different than all the other moles and lesions. It also changes differently than all the other lesions. The melanoma simply does not look like all the other skin lesions or changes on the rest of the body.

Melanoma has a high cure rate if treated in the very early stages before metastases occurs. The risk for a melanoma is determined by the thickness of the lesion when the biopsy is examined microscopically by a pathologist.

Treatment for melanoma is primarily surgical. Radiation and chemotherapy are not particularly effective. In addition, lymph nodes around the area of the melanoma frequently need to be evaluated at the time of excision to evaluate for metastases. If positive nodes are found, these will require surgical treatment as well.

If you are concerned about a lesion or would like to have your skin checked please discuss this with Dr. LeSueur during your appointment.

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