Skin Cancer Management: A Practical Approach

Foreword
Preface
Acknowledgments
Contents
Contributors
Chapter 1: 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
Chapter 2: Topical Therapies for Nonmelanoma Skin Cancers
Imiquimod
Mechanism of Action
Side Effect Profile
5-Fluorouracil
Mechanism of Action
Side Effect Profile
Diclofenac
Mechanism of Action
Side Effect Profile
Ingenol Mebutate
Mechanism of Action
Side Effect Profile
Topical Therapy for Actinic Keratoses: The Authors’ Experience
Monotherapy for Actinic Keratoses
Imiquimod Versus 5-Fluorouracil for AKs
Imiquimod and 5-FU Combination Therapy
5-FU and Calcipotriol Combination Therapy
Combination Therapy with Cryotherapy
Ingenol Mebutate
Cost and Treatment Choice for Actinic Keratoses
Experimental Topical Therapies
Topical Therapy and Nonmelanoma Skin Cancer: The Authors’ Experience
Basal Cell Cancer Monotherapy
Imiquimod
5-Fluorouracil
Ingenol Mebutate
Diclofenac
Squamous Cell Cancer Monotherapy
Imiquimod
5-Fluorouracil
Diclofenac
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
Chapter 3: 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
Chapter 4: Photodynamic Therapy
Photosensitizers and Light Sources
Photodynamic Therapy for Actinic Keratoses
Patient Selection, Education, and Consent
Technique of Application for Actinic Keratoses
Treatment Schedule for Actinic Keratoses
Combination Therapies for Actinic Keratoses
PDT as a Prevention Modality
Photodynamic Therapy for Squamous Cell Carcinoma In Situ, Superficial Basal Cell Carcinoma, and Nodular Basal Cell Carcinoma
Patient Selection, Education, and Consent
Technique of Application for Superficial Non-Melanoma Skin Cancers
Treatment Schedule for Superficial Non-Melanoma Skin Cancers
Combination Therapies for Non-Melanoma Skin Cancers
Extramammary Paget’s Disease
Adverse Reactions and Pain Management
Summary
References
Chapter 5: Intralesional and Perilesional Treatment of Skin Cancers
Methotrexate
Indications and Contraindications
Pre-treatment Considerations
Preparing MTX for Injection
Description of Technique
Post-injection Care
Expected Course of Treatment and Follow-Up
Illustrative Case 5.1
Illustrative Case 5.2
Illustrative Case 5.3
Illustrative Case 5.4
Interferon
Indications and Contraindications
Pre-treatment Considerations: Basal Cell Cancers
Pre-treatment Considerations: Squamous Cell Cancers and Malignant Melanomas
Obtaining Interferon α2b
Description of Technique (BCC, SCC, MIS)
Administering Interferon α2b
Make Sure to Always
Post-injection Care
Expected Course of Treatment and Follow-Up (BCC, SCC, MIS)
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
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
Chapter 6: Electrodesiccation and Curettage
Indications
Contraindications
Preoperative Considerations
Description of Technique
Postoperative Care
Use of Curettage Alone
Complications
Summary
References
Chapter 7: Cryosurgery
Basic Cryobiology
Indications
Contraindications
Preoperative Considerations
Equipment
Techniques
Monitoring of Freeze Depth
Basal Cell and Squamous Cell Carcinoma 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
Long-Term Follow-Up Studies
Immunocryosurgery
Summary
References
Chapter 8: 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
Chapter 9: Anxiolysis, Anesthesia, and Analgesia
Preoperative Considerations
Local Anesthetic Agents
Indications and Contraindications
Topical Anesthesia
Infiltrative Anesthesia
Additives to Local Anesthetics
Epinephrine
Sodium Bicarbonate
Field Blocks
Regional Nerve Blocks
Facial Nerve Blocks
Digital Nerve Block
Hand Nerve Blocks
Foot Nerve Blocks
Penile Nerve Block
Tumescent Anesthesia
Postoperative Analgesia
Adverse Effects and Complications
Summary
References
Chapter 10: Excision Techniques and Materials
Patient Preparation
Antibiotic Prophylaxis
Site Preparation and Anesthesia
Preoperative Antisepsis
Anesthesia
Excision Margins
Specimen Handling
Hemostasis
Suture Materials
Natural Versus Synthetic
Absorbable Versus Nonabsorbable
Monofilament Versus Multifilament Versus Barbed
Size and Tensile Strength
Needles
Staples
Skin Adhesive
Skin Tape
Closure Techniques
Second Intention
Layered Closures: Suture Techniques
Deep Sutures
Buried Vertical Mattress/Set-Back Suture
Running Subcuticular Closure
Purse-String Repair
Epidermal Suture Techniques
Description of Procedure
Elliptical Excision
Standing Cones (Dog Ears)
Post-Procedure Care
Complications
Summary
References
Chapter 11: 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
Chapter 12: Principles of Cutaneous Flap Surgery
Indications and Contraindications to Flap Closure
Preoperative Considerations
Flap Design
Random Pattern Flaps
Advancement Flaps
The Island Pedicle Flap
Rotation Flaps
Transposition Flaps
Axial Flaps
Surgical Pearls for Cutaneous Flap Surgery
Complications in Cutaneous Flap Reconstruction
Acute Complications
Management of the Ischemic Flap
Delayed Complications
Summary
References
Chapter 13: Techniques in Skin Grafting
General Principles
Full-Thickness Skin Grafts
Technique
Preoperative Planning
Donor Site Considerations
Procedure
Immobilization
Postoperative 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
Chapter 14: Nail Surgery and Malignant Tumors of the Nail Unit
Anatomy
Preoperative Considerations
Instruments
Tourniquet
Radiographs
Anesthesia
Distal Wing Block
Technique
Distal Digital Block
Technique
Nail Avulsion
Technique
Punch Biopsy of the Nail Bed
Technique
Nail Matrix Biopsy
Punch Biopsy of the Nail Matrix
Technique
Shave Biopsy of the Nail Matrix (Tangential Matrix Excision)
Technique
Lateral Longitudinal Excision
Dressings
Complications
Malignant Tumors of the Nail Unit
Verrucae
Bowen’s Disease
Treatment
Squamous Cell Carcinoma
Treatment
Verrucous Carcinoma
Treatment
Basal Cell Carcinoma
Treatment
Metastatic Tumors
Treatment
Melanoma
Treatment
Summary
References
Chapter 15: Practical Management of Melanoma
Clinical Presentation and Initial Assessment
Medical History
Physical Examination
Biopsy
Imaging and Laboratory Tests
Radiologic Imaging
Laboratory Investigations
Staging of Melanoma
Management of Melanoma In Situ (Stage 0)
Biopsy and Diagnosis of Melanoma In Situ
Excision of Melanoma In Situ
Non-Surgical Treatment of Melanoma In Situ
Challenges of Melanoma In Situ Management
Management of Primary Melanoma (Stages I and II)
Definitive Excision of Primary Melanoma
Staging the Regional Lymph Node Basin
Management of Melanoma with Regional Metastasis (Stage III)
The Role of Completion Lymph Node Dissection
Adjuvant Therapies for High-Risk Melanoma
Regional Recurrences
Management of Unresectable Stage III and Metastatic (Stage IV) Melanoma
Evaluation of Patients with Suspected Metastatic Melanoma
Systemic Therapy for Unresectable Stage III and Stage IV Melanoma
Metastasectomy
Radiation Therapy
Intralesional Injection with T-VEC
Regional Therapy
Best Supportive Care
Surveillance
Conclusion
References
Chapter 16: 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
Mycosis Fungoides
Treatment Options and Operative Considerations
Summary
References
Chapter 17: Management of Skin Cancers in Solid Organ Transplant Recipients
Epidemiology
Keratinocyte Carcinoma Following Organ Transplantation
Melanoma Following Organ Transplantation
Pathogenesis
Immunosuppression and Skin Cancer
Azathioprine
Cyclosporine
Sirolimus
Voriconazole
Presentation and Natural History
Primary cSCC in Organ Transplant Patients
Field Cancerization
In-transit Metastasis
Nodal Metastasis
Distant Metastasis
Basal Cell Carcinoma
Melanoma
Management of Cutaneous Squamous Cell Carcinoma
Actinic Keratosis and Squamous Cell Carcinoma In Situ
Management of Field Cancerization
Topical 5-Fluorouracil (5-FU)
Imiquimod
Diclofenac
Photodynamic Therapy (PDT)
Oral Retinoids
Capecitabine
Nicotinamide
Primary Invasive Cutaneous SCC
Metastatic Cutaneous SCC
Modification of Immunosuppression
Cetuximab
Immune Checkpoint Inhibitors
Management of Basal Cell Cancer in Transplant Recipients
Vismodegib
Management of Melanoma in Transplant Recipients
Dermatologic Screening, Prevention, and Follow-up in Transplant Recipients
Summary
References
Chapter 18: 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
Chapter 19: 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
Chapter 20: When to Refer Out
Reasons to Refer Out
The Lesion
The Patient
Psychological Referrals
The Doctor
The Doctor’s Colleagues
Specialists to Whom You May Need to Refer
Medical Oncology
Geneticists
Surgical Oncology
Radiation Oncology
Prosthetics
References
Chapter 21: Chemoprevention of Keratinocyte Carcinomas
Oral Retinoids
Indications
Contraindications
Dosing Recommendations
Adverse Effects
Mucocutaneous Side Effects
Laboratory Monitoring
Pregnancy Testing
Skeletal Toxicities
Use in Organ Transplant Recipients
Wound Healing
Topical Retinoid Therapy
Topical Tretinoin
Adapalene
Tazarotene
Application of Topical Retinoids
Nicotinamide
Vismodegib
Nonsteroidal Anti-inflammatory Drugs
Topical Diclofenac
Solid Organ Transplant Recipients
Mammalian Target of Rapamycin Inhibitors (mTOR-I)
Capecitabine
Other Promising Agents
DNA Repair Enzymes
Conclusion
References
Chapter 22: Systemic Therapy for Locally Advanced and Metastatic Non-Melanoma Skin Cancer
Hedgehog Pathway Inhibitor
Vismodegib
Sonidegib
Laboratory Monitoring
Management of Adverse Events
Management of Muscle Spasm
Management of Alopecia
Management of Dysgeusia
Pregnancy and Fertility Warnings and Precautions
Treatment Resistance
Potential Risk for Squamous Cell Carcinoma Development
Immunotherapy
Program Death-1 Inhibitor
Pembrolizumab
Nivolumab
Cemiplimab
Laboratory Monitoring and Special Considerations
Cytotoxic T Lymphocyte-Associated Antigen 4 Inhibitor
Future Directions
Conclusion
References
Index