Advances in Diagnosis, Treatment of Skin Cancer

The last two decades have seen many advances in the diagnosis and treatment of skin cancer, and one of the biggest steps forward has occurred in the management of advanced cases.

With the introduction of sentinel lymph node screening for the diagnosis and mapping of melanoma and non-melanoma skin cancers (NMSC) of the head and neck, improved training of otolaryngology residents and fellows in the removal of difficult tumors, and the innovative reconstructive work of facial and plastic surgeons, otolaryngologists are now considered the go-to specialty for performing these challenging surgeries.

“Historically, skin cancer of the head and neck has been treated by the dermatologist and the plastic surgeon,” said Stephen S. Park, MD, chair of the department of otolaryngology–head and neck surgery and director of the division of facial plastic and reconstructive surgery at the University of Virginia School of Medicine in Charlottesville. In fact, the vast majority of skin cancers are still treated fairly simply by dermatologists by either direct excision under local anesthesia or with Mohs micrographic surgery (MMS).

“In the last 20 years, Mohs surgery has become the standard of care for localized skin cancer,” said Adam M. Zanation, MD, the Harold C. Pillsbury Distinguished Professor and director of advanced rhinology, oncology and open/endoscopic skull base surgery fellowship at the University of North Carolina, Chapel Hill. But Mohs has its limitations, he noted. For larger, more complex lesions involving deep structures, or in the setting of invasive melanoma, the ability to clear the surgical margins using the technique is very limited. In those cases, he said, the dermatologist will usually refer to the otolaryngologist for treatment and repair.

According to the Centers for Disease Control and Prevention, skin cancer is reaching epidemic proportions (See “Risk Factors: Not Just Sun Exposure,” below). As the number of patients has increased, the role otolaryngologists play in the management of advanced skin cancer continues to evolve, especially in the treatment of melanoma of the head and neck and advanced basal cell and squamous cell carcinomas.

Our specialty [is]particularly suited to provide the best resection outcomes as well as the best reconstructive and long-term functional outcomes. —Adam Zanation, MD

Screening

Every board-certified otolaryngologist is qualified to manage facial skin cancers, Dr. Park said. One of the first things to do is screen patients for suspicious lesions, even those coming in for other issues. “If you don’t look for it, you won’t find it, especially in our aging patients, who grew up in an era that was unaware of the damages of sun exposure,” he added.

Once a suspicious lesion is found, Dr. Park encourages physicians to lower their threshold for performing a biopsy. The pathology report will determine the definitive diagnosis as well as the architecture in terms of its aggressive behavior.  “If it is a relatively small lesion [<1 mm] in a forgiving place, such as the cheek or the neck, and is well circumscribed—nodular and you can see the lesion very clearly and, more importantly, where it is not—the otolaryngologist is more than qualified to excise and close the lesion,” Dr. Park said. 

Dr. Zanation is less convinced: “In my practice, I still think Mohs surgery is a better treatment option for non-advanced skin cancers—with a primary excision, we removed more normal tissue than is needed.” But certainly, for anything beyond a localized lesion, the otolaryngologist should be called, he said.