Definition
In this discussion we are talking about a lesion with some substance which may be ulcerated or have a palpable component. We are specifically excluding keratoses and other small surface rough patches which may be the precursors of skin cancer.
Use fingers to stretch lesion. Makes it easier to diagnose a BCC
Diagnosis
This is mostly clinical, by observation of the appearance and features of the lesion. Seeing a lot of these and submitting all lesions for histology will increase the accuracy of diagnosis. There are no tests that can compete with experience. Use of magnifying aid is recommended.
Biopsy is mainly used in the difficult cases where the result may alter the treatment. There is little point in doing a biopsy and then submitting the lesion for an excision. The only biopsy that is worth doing is an excision biopsy but this must be done in such a way that the lesion is adequately treated no matter what is the histological diagnosis. There is no place for biopsy of a lesions suspected of being a malignant melanoma. The false negative biopsy is the main danger as it may lead to incorrect advice or treatment.
Treatment
Cautery and Cryotherapy are fine for keratoses but have no place in the established lesion. The biopsy combined with this technique will confirm the diagnosis but there will be no specimen for the pathologist and will not be able to tell the operator whether he has completely excised the lesion. Another consideration is the cosmetic result, this is usually a ghastly white patch which after repeated treatment becomes resented by patients. If we are going to have patients present willingly with early lesions than we must also pay attention to the appearance of our work
Surgical excision with a scalpel will give a better looking result in the vast majority of locations. It also guarantees a specimen for the pathologist to comment on. Occasionally there will be an inadequate excision but this is preferable to not even knowing if the cautery was inadequate. Any one operator’s rate of inadequate excisions should decrease with experience and plastic surgeons tend to be more generous with their excision as they have the confidence of knowing techniques of repair to fit any case.
Recurrence
There are published papers comparing the results of the various treatment modalities, surgery has by far the lowest rate of all. This is an area where quality assurance has a place, A surgeon should look at his own rate and review the cases which were inadequately excised. With experience and knowledge of the disease this can be lowered to almost zero. There will always be the multifocal BCC which is difficult to judge in width.
Results
Can be looked at in several ways. A low recurrence rate is one of the most important goals but we must also remember the appearance of the patient. As most of these lesions are on the face or some exposed part of the body it is imperative that we pay attention and explain to the patient what kind of scars they are likely to get. There too many patients who are disfigured by repeated cryotherapy. This is not to say that the treatment should be compromised to make it look good. A neat surgical scar, particularly in the elderly blends in very well with their wrinkles and is the preferred treatment.
The neglected lesions
We all see the occasional case where the patient has ignored an obviously enlarging lesion but for whatever reason has not sought treatment. The most worrying case is where they had a biopsy and told it was nothing. The only treatment for these is surgical excision and histologic examination to judge the clearance. Attention to appearance and public education are the keys to earlier detection. Radiotherapy
There are some situations where this is the preferred form of treatment. An elderly and frail person will do better with radiotherapy than if they have extensive surgery. Do not forget that radiotherapy usually means several visits and this in itself may be a problem. It is also a costly form of treatment. There are areas such as eyelids, nose, ear, lower leg which are not suitable for radiotherapy.
Moh’s technique
This is an attempt to prevent recurrences by having histological control during the treatment process. In theory it is very inviting but is extremely time consuming and expensive. It has a place for some difficult lesions on the face but not as a routine method. Frozen sections during an operation are little different from this technique and are widely utilised by surgeons. The key is to recognise the difficult lesion, this takes experience.
Cost of treatment
In this era of everything being dominated by budgets and economic constraints, surgery is still cost effective. A surgeon’s fee is no larger than a dermatologists when you compare the cost of two visits vs many. The cost of hospitals can be significant but dermatologists do not provide their equipment for nothing either. Pathology costs should be similar.
The ideal setup
In a public hospital it should be a combined clinic where a dermatologist and a surgeon see patients together or at least discuss most cases. In private practice this is difficult to organise, a good working relationship with a dermatologist is desirable. This leads to a flow of cases both ways and benefiting the patients.
Summary
It is important to provide good treatment for a large population with skin cancers. Surgery is the preferred form of treatment in most cases
