Skin Cancer Management
Foreword
Preface
Acknowledgements
Contents
Contributors
Biopsy Techniques and Interpretation
Biopsy Technique
Pre-Op
Site Preparation and Anesthesia
Hemostasis
Shave Biopsy
Equipment
Technique
Complications
Saucerization
Equipment
Technique
Punch Biopsy
Equipment
Technique
Biopsy Care
Incisional Biopsy
Equipment
Technique
Complications
Wedge Biopsy
Complications
Excisional Biopsy
Technique
Complications
Biopsy Log
Interpretation of Results
Tissue Orientation and Margin Evaluation
Reporting of Surgical Margins
Fundamental Slide Interpretation
Low Power
Develop a Method for Examining Skin Specimens
Knowing the Clinician
Too Small a Sample
Too Aggressive a Sample
Two-Step Management
Too Little or Too Much Information
Know Your Laboratory
One Diagnosis Only
Too Many Diagnoses
Summary
References
Topical Therapies for Nonmelanoma Skin Cancers
Introduction and Background
Imiquimod
Mechanism of Action
Side Effect Profile
5-Fluorouracil
Mechanism of Action
Side Effect Profile
Diclofenac
Mechanism of Action
Side Effect Profile
Topical Therapy for Actinic Keratoses-The Loma Linda Experience
Monotherapy for Actinic Keratoses
Imiquimod vs. 5-Fluorouracil for AKs
Imiquimod and 5-FU Combination Therapy
Combination Therapy with Cryotherapy
Cost and Treatment Choice for AKs
Topical Therapy and Nonmelanoma Skin Cancer-The Loma Linda Experience
BCC Monotherapy
Imiquimod
5-Fluorouracil
SCC Monotherapy
Imiquimod
5-Fluorouracil
Combination Topical Therapy
Topical Therapy as a Surgical Adjunct to NMSC
Preoperative Topical Therapy
Intraoperative Topical Therapy
Postoperative Topical Therapy
Unusual Situations/Complications/Variations
Problematic Areas
Lips
Eyelids
Penis
Basal Cell Nevus Syndrome
Transplant Patients
Delayed Mohs Micrographic Surgery
The Skip Area Controversy
Summary
References
Chemical Peels for Precancerous Skin Lesions
Classification
Indications
Contraindications
Advantages
Current Products Available
Patient Selection
Informed Consent
Setup
Patient Preparation
Analgesia and Sedation
Application Technique
Post-procedure
Complications
Summary
References
Photodynamic Therapy
Photodynamic Therapy for Actinic Keratoses and Actinic Cheilitis
Patient Selection
Patient Education and Consent
ALA Photodynamic Therapy
Technique of Application
Illustrative Case 4.1
Techniques with Off-Label Light Sources
Illustrative Case 4.2
MAL Photodynamic Therapy
Technique of Application
Techniques with Off-Label Light Sources
Photodynamic Therapy for Squamous Cell Carcinoma In Situ, Superficial Basal Cell Carcinoma, and Nodular Basal Cell Carcinoma
Patient Selection
Illustrative Case 4.3
Patient Education and Consent
ALA Photodynamic Therapy
Technique of Application at the Roswell Park Cancer Institute
MAL Photodynamic Therapy
Technique of Application
Summary
References
Intralesional and Perilesional Treatment of Skin Cancers
I. METHOTREXATE
Indications and Contraindications
Pre-treatment Considerations
Preparing MTX for Injection
Description of Technique
Treatment Pearls
Post-injection Care
Expected Course of Treatment and Follow-Up
Illustrative Case 5.1
Illustrative Case 5.2
Illustrative Case 5.3
II. INTERFERON
Indications and Contraindications
Pre-treatment Considerations: Basal Cell Cancers
Pre-treatment Considerations: Squamous Cell Cancers and Malignant Melanomas
Obtaining Interferon alpha2b
Description of Technique (BCC, SCC, MM)
Administering Interferon alpha2b
Treatment Pearls
Post-injection Care
Expected Course of Treatment and Follow-Up (BCC, SCC, MM)
III. 5-FLUOROURACIL
Keratoacanthomas
Squamous Cell Carcinomas
Basal Cell Carcinomas
Indications
Contraindications
Pre-treatment Considerations
Obtaining and Preparing
Description of Technique
Note on Technique
Post-injection Care
Expected Course and Follow-Up
Adverse Effects
IV. BLEOMYCIN
Squamous Cell Carcinoma/Keratoacanthoma
Basal Cell Carcinoma
Metastatic Cutaneous Malignant Melanoma
Indications
Contraindications
Pre-treatment Considerations
Obtaining and Preparing
Description of Technique
Post-injection Care
Expected Course and Follow-Up
Adverse Effects
References
Electrodesiccation and Curettage
Indications/Contraindications
Preoperative Considerations
Description of Technique
Postoperative Care
Use of Curettage Alone
Complications
Summary
References
Cryosurgery
Basic Cryobiology
Indications
Contraindications
Preoperative Considerations
Equipment
Technique
Monitoring of Freeze Depth
Basal Cell and Squamous Cell Carcinomas Cure Rates
Illustrative Case 7.1
Illustrative Case 7.2
Illustrative Case 7.3
Illustrative Case 7.4
Leukoplakia and Actinic Cheilitis
Keratoacanthoma
Postoperative Care
Summary
References
Optimizing Surgical Outcomes
Preoperative Considerations
Bleeding Tendency
Wound Healing
History of Hypertrophic Scar or Keloid Formation
Prophylactic Antibiotics and Antiviral Medication
Allergies
Implantable Cardiac Devices
Patient Expectations
Intraoperative Considerations
Operating Suite
Surgical Site Preparation
Skin Marking
Choice of Antiseptic Solution
Anesthesia
Staff Preparation
Hand Washing/Surgical Scrubbing
Surgical Site Draping
Intraoperative Monitoring
Tissue Manipulation
Hemostasis
Designing the Closure
Suturing the Wound
Postoperative Considerations
Pain Control
Antibiotics
Timing of Suture Removal
Summary
References
Anesthesia
Indications and Contraindications
Preoperative Considerations
Topical Anesthesia
Complications
Infiltrative Anesthesia
Field Blocks
Tumescent Anesthesia
Regional Nerve Blocks
Facial Nerve Blocks
Digital Nerve Block
Hand Nerve Blocks
Foot Nerve Blocks
Penile Nerve Block
Postoperative Analgesia
Unusual Situations and Complications
Summary
References
Excision Techniques, Staples, and Sutures
Patient Preparation
Antibiotic Prophylaxis
Site Preparation and Anesthesia
Preoperative Antisepsis
Anesthesia
Excision Margins
Specimen Handling
Hemostasis
Suture Materials
Staples
Skin Adhesive
Skin Tape
Closure Techniques
Second Intention
Layered Closures
Description of Procedure
Elliptical Excision
Purse-String Repair
Standing Cones (Dog Ears)
Postprocedure Care
Complications
Summary
References
Mohs Surgery
Indications for Mohs Surgery
Cure Rates Following Mohs Surgery
Basal Cell Carcinoma
Squamous Cell Carcinoma
Preoperative Considerations
Guide to the Mohs Surgery Procedure
Slide Preparation
Variations on the Mohs Surgery Technique
Complications and Follow-Up
References
Cutaneous Flaps
Indications and Contraindications to Flap Closure
Preoperative Considerations
Flap Design
Random Pattern Flaps
Advancement Flaps
Rotation Flaps
Transposition Flaps
Island Pedicle Flap
Axial Flaps
Technical Pearls for Cutaneous Flap Surgery
Postoperative Dressings and Wound Care
Complications in Cutaneous Flap Reconstruction
Acute Complications
Contact Dermatitis
Infection
Bleeding Complications
Flap Ischemia
Management of the Ischemic Flap
Delayed Complications
Summary
References
Techniques in Skin Grafting
General Principles
Full-Thickness Skin Grafts
Technique
Preoperative Planning
Donor Site Considerations
Procedure
Immobilization
Post-Operative Care
Special Situations
Complications
Split-Thickness Skin Grafts
Equipment
Technique
Dressing
Donor Site Care
Postoperative Complications
Vacuum-Assisted Closure (VAC)
Free Cartilage Grafts
Technique
Dressing
Complications
Composite Grafts
Technique
Dressing
Donor Sites
Postoperative Care
Complications
Summary
References
Nail Surgery and Malignant Tumors of the Nail Unit
Anatomy
Preoperative Considerations
Instruments
Tourniquet
Radiographs
Anesthesia
Distal Wing Block
Technique
Nail Avulsion
Technique
Punch Biopsy of the Nail Bed
Technique
Nail Matrix Biopsy
Punch Biopsy of the Nail Matrix
Indications
Technique
Lateral Longitudinal Excision
Indication
Technique
Repair
Complications
Shave Biopsy of the Nail Matrix (Tangential Matrix Excision)
Indications
Contraindications
Technique
En Bloc Nail Unit Biopsy
Technique
Dressings
Complications
Malignant Tumors of the Nail Unit
Verrucae
Bowenβs Disease
Treatment
Squamous Cell Cancer
Treatment
Verrucous Carcinoma
Treatment
Basal Cell Carcinoma
Treatment
Metastatic Tumors
Treatment
Melanoma
Treatment
Summary
References
Practical Management of Melanoma
Medical History
Physical Examination
Imaging and Laboratory Tests
In Vivo Imaging
Radiologic Imaging
Laboratory Investigations
Staging of Melanoma
Management of Melanoma In Situ (Stage 0)
Excision of Melanoma In Situ
Mohs Surgery and Serial Excision of Melanoma In Situ
Medical Treatment of Melanoma In Situ (Stage 0)
Challenges of Melanoma In Situ Management
Management of Primary Melanoma (Stages I and II)
Surgical Management: Excisional Biopsy
Surgicial Management: Incisional Biopsy
Definitive Excision of Primary Melanoma
Surgical Management of Regional Melanoma (Stage III)
Elective Lymph Node Dissection
Sentinel Node Biopsy
Adjuvant Therapy for Intermediate Prognosis Melanoma (Stages IIB-III)
Melanoma Follow-Up
Regional Recurrences
Surgical Management of Metastatic Melanoma (Stage IV)
Evaluation of Patients with Suspected Metastatic Melanoma
Metastasectomy
Radiation Therapy for Advanced Melanoma (Stages II-IV)
Palliative Radiotherapy
Curative Radiotherapy
Chemotherapy of Advanced Melanoma (Surgically Unresectable Stages III, IV)
Immunotherapy of Advanced Melanoma (Surgically Unresectable Stages III, IV)
References
Skin Cancer in Skin of Color
Unique Features of Skin of Color
Role of the Ozone Layer
Basal Cell Carcinoma
Squamous Cell Carcinoma
Malignant Melanoma
Hypopigmented Mycosis Fungoides
Treatment Options and Operative Considerations
Summary
References
Management of Skin Cancers in Solid Organ Transplant Recipients
Epidemiology
Squamous Cell Carcinoma Following Organ Transplantation
Basal Cell Carcinoma Following Organ Transplantation
Melanoma Following Organ Transplantation
Skin Cancer Following Kidney Transplantation
Skin Cancer Following Heart Transplantion
Skin Cancer Following Liver Transplantation
Skin Cancer Following Stem Cell Transplantion
Pathogenesis
Immunosuppression and Skin Cancer
Azathioprine
Cyclosporine
Sirolimus
Presentation
Primary SCC in Transplant Patients
Extensive Field Disease
In-Transit Metastasis
Nodal Metastasis
Distant Metastasis
Basal Cell Carcinoma
Melanoma
Management
Primary Cutaneous SCC
Relapse
Management of Extensive Field Disease
Topical 5-Fluorouracil (5-FU)
Imiquimod
Diclofenac
Photodynamic Therapy (PDT)
Oral Retinoids
Reduction of Immunosuppression
Capecitabine
Management of Basal Cell Cancer in Transplant Recipients
Management of Melanoma in Transplant Recipients
Dermatologic Follow-Up and Screening in Transplant Recipients
Summary
References
Imaging of Head and Neck Skin Cancer
Anatomic Planes
Imaging Techniques
Computerized Tomography
Contraindications
Strengths and Limitations
Magnetic Resonance Imaging
Contraindications
Strengths and Limitations
Ultrasound
Strengths and Limitations
Positron-Emission Tomography
Lymphoscintigraphy
Strengths and Limitations
Imaging Pathology
Basal Cell Carcinoma
Illustrative Case 18.1
Cutaneous Squamous Cell Carcinoma
Illustrative Case 18.2
Illustrative Case 18.3
Illustrative Case 18.4
Melanoma
Illustrative Case 18.5
Dermatofibrosarcoma Protuberans
Illustrative Case 18.6
Merkel Cell Carcinoma
Illustrative Case 18.7
Sebaceous Carcinoma
Angiosarcoma
Illustrative Case 18.8
Summary
References
Radiation Oncology in Skin Cancer Treatment
Indications for Radiation
Radiation Modalities Used to Treat Skin Tumors
Radiation in the Treatment of Specific Skin Malignancies
Basal and Squamous Cell Carcinomas
Melanoma
Merkel Cell Carcinoma
Adnexal Carcinoma
Mycosis Fungoides
Radiation for Advanced Disease and for Palliation
Complications from Radiation
Summary
References
When to Refer Out
Reasons to Refer Out
The Lesion
The Patient
Psychological Referrals
The Doctor
The Doctorβs Colleagues
Specialists to Whom You May Need to Refer
Medical Oncology
Geneticists
Surgical Oncology
Radiation Oncology
Prosthetics
References
Chemoprevention of Skin Cancer
Systemic Retinoid Therapy
Indications
Contraindications
Dosing Recommendations
Adverse Effects
Routine Monitoring and Management of Adverse Effects
Mucocutaneous Side Effects
Laboratory Monitoring
Pregnancy Testing
Calcification
Use in Organ Transplant Recipients
Wound Healing
Chemoprevention of Nonmelanoma Skin Cancer: Other Agents
Topical Retinoid Therapy
Topical Tretinoin
Adapalene
Tazarotene
Application of Topical Retinoids
Nonsteroidal Anti-inflammatory Drugs
Diclofenac
Polyphenolic Antioxidants: Green Tea
Other Promising Chemopreventive Agents
Summary
References
Index