Skin Cancer Surgery

• These are the second most common skin cancers after Basal cell carcinoma (BCC)
• BCC and SCC are together referred to as non-melanoma skin cancers
• Australia has one of the highest rates of skin cancers in the world, with rates of skin cancer higher in the northern than the southern states
  • Incidence is higher in males (at all ages), and increases with age
  • People born in Australia have higher risk (although migrants risk increases the longer they have lived here)
• What causes SCC (skin cancers)?
  • There are both genetic and environmental factors with the latter being the most important
  • Environmental risk factors
    • Chronic sun exposure
      • Is the single most important risk factor
      • This is cumulative sun exposure throughout a person’s life
      • Specifically it is the UV radiation (wavelengths A and B) that contribute to skin cancer conversion
      • This highlights the importance of 2 things:
        • Sun protection throughout a person’s life: wearing a hat & sunglasses, covering up as much skin from exposure to direct sunlight, and applying (and regularly reapplying) high SPF sunscreen to sun exposed skin areas when out in the sun especially whilst outdoor swimming.
        • Regular skin checks – especially if one has had a skin cancer. This indicates that the entire skin has had the level of sun exposure (and therefore damage) to sprout a skin cancer that regular skin checks can lead to early detection and simpler treatment.
      • HPV
        • Have been associated with solar keratosis and SCC
        • Likely these viruses change (likely enhance) the effect of UV radiation on skin cells
      • Smoking – some evidence that increases risk
      • Others
        • Arsenic
        • Ionising radiation therapy
        • Scars, sinus tracts, chronic ulcers
        • Immunosuppression e.g.
          • those with large organ transplants taking immunosuppressive medication
          • HIV
          • In general higher dose of immunosuppression and larger dose of immunosuppression are associated with increased risk of non-melanoma skin cancer.
  • Genetic
    • In general there are risk factors such as
      • Being fair skinned – who often have skin that burns rather than tans
      • Blonde hair (Red hair also associated with increased risk)
      • Blue eyes
    • Specific Genetic diseases have much higher rates of skin cancer due to aberration in skin cells to repair the damage caused by UV radiation, such as
      • Xeroderma Pigmentosum
      • Epidermolysis Bullosa
• What do SCCs look like?
  • These are often red and scaly
  • Can sometimes have a horn
  • Therefore they can be difficult to distinguish from actinic keratosis
  • They can be ulcerated with frequent bleeding

• Where do SCCs occur?
  • Sun exposed sights
  • In males the head and neck is the most common site
  • In females the upper limbs (hands and arms) are the most common site, followed by the head and neck area
• What is the treatment for SCCs
  • Surgery is almost exclusively the mainstay of treatment for SCCs
  • The timing is often considered more critical than BCCs due to the faster growing nature of these tumour, and the potential to be aggressive and have the capacity to spread beyond the skin (in some cases)
  • How much skin is removed?
    • Dr Aggarwal will carefully mark you under bright lights and with loupes to clinically judge the extent of the skin cancer
    • A margin is then marked around the site which is an area of skin that appears normal, but may not be normal under a microscope. This is taken to increase the rate of clearance of the tumour at the primary excision.
  • What is the margin? What does it mean for SCCs?
    • A margin is an area of skin around the skin cancer that to the naked eye looks normal
    • However most skin cancers including SCCs extend microscopically beneath surrounding areas of normal skin to a short or moderate distance. The degree to which they do this is related to the subtype of skin cancer.
    • In general for SCCs:
      • That are less than 2 cm wide, a margin of 4mm of skin is taken around the skin cancer
      • Those that are larger than 2cm a margin up to 1cm may need to be taken. In some cases if the lesion is very large an even larger margin may be taken
    • How is the area of excision reconstructed after surgery?
      • This is through several methods:
        • Direct closure
        • Grafts
        • Flaps
      • Please see our section on reconstructive plastic surgery for skin cancer.
    • Can SCCs spread to lymph nodes and around the body?
      • Early detected SCCs are confined to the skin and have not been given the chance to spread beyond the skin
      • However some SCCs do have the potential to spread to lymph nodes and beyond. These include:
        • neglected SCCs that have grown well beyond 2cms
        • SCCs that have invaded deeper structures or nerves
        • recurrent SCCs
        • those that have arisen in radiated fields or chronic scars or wounds
        • Certain subtypes of SCC (these are largely to do with features under a microscope that are reported by a pathologist)
      • In general Dr Aggarwal will examine your lymph nodes at the time of consultation. If there is no suspicion for disease involvement of the lymph nodes, skin surgery is usually all that is needed.

Are there alternatives to surgery for SCC?

Yes these include:

• Radiation therapy
  • This is usually reserved for those cases where conventional surgery is not feasible or particularly problematic. This could be in
    • Multiple –mainly superficial-lesions when impractical to excise
    • when surgery will cause cosmetic or functional morbidity unacceptable to the patient
    • Older patients unfit for surgery or anaesthesia
    • Patients prone to keloid formation
  • Radiation causes both acute and chronic changes to skin in the field that is treated. The latter can have implications for blood supply that can make treatment down the track for a skin cancer in the field region problematic as reconstruction can become challenging.
  • Radiation also requires multiple visits for treatment as the entire radiation dose is delivered as small fractions at each visit.
  • Radiation is used as an adjunct to surgery in some cases where there may be incomplete margins, nerve involvement, lymph node involvement or any scenario where its use is thought to improve local control after surgery.
• Destructive therapies: unpredictable, do not provide reliable tissue that can be examined under a microscope but cheap, and quick.
  • Curettage and diathermy.

• If there is sufficient loose skin at the site of surgery, it may be possible to close the area directly
• However if a circle is excised in skin and closed, this would leave pleats in the surrounding skin
• The circular excision is therefore converted to an ellipse, with darts on either side. The length of the scar can therefore be up to 3 times as long as the circle that was excised for skin cancer treatment
• Wherever possible the scar is placed in the skin crease lines for the best long term cosmetic result

• Risks of anaesthetic – most skin cancer surgeries are performed with local anaesthetic or assisted local anaesthetic (with sedation). Few are performed under general anaesthesia. The risks of a general anaesthetic are often low in patients who are otherwise fit and healthy but can be higher in those with many medical problems.
• Bleeding – the risk is higher in those on blood thinning medication. Dr Aggarwal will discuss with you what you need to do with blood thinners and discuss the pros and cons of ceasing or continuing your medication. Dr Aggarwal may need to consult with your GP, cardiologist or other physicians involved in your care before a decision to change your medication is made. Any bleeding is controlled during surgery however unexpected bleeding can occur in the immediate postoperative period. If this occurs it can usually be controlled through direct sustained pressure.
• Infection– this is rare. You may be given a course of oral antibiotics after your surgery, depending on your reconstruction, to keep this risk to a minimum.

• Yes, firstly it is possible to claim a Medicare rebate of approximately $73 for the consultation if you have a referral
• Furthermore, skin cancer surgery is associated with Medicare Item Numbers – therefore rebates will be available from Medicare if the surgery is performed in rooms, or from both Medicare and health fund if it is performed in a day surgery or hospital.