Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Basal and squamous cell skin cancers are increasing in incidence 2- 3% annually with 700,000 new cases projected this year. The ratio of basal to squamous cell tumors is 4:1 with the overall age of detection of first tumors decreasing. Sun exposure is the main risk factor. UV-B is the primary carcinogen in sunlight with UV-A acting as a cofactor. Genetic conditions such as basal cell nevus syndrome and xeroderma pigmentosa predispose skin to tumor formation. Previous radiotherapy, arsenic exposure and immunosuppressed states have also been closely linked to the genesis of skin cancer.

Eighty percent of basal cell carcinomas are of the nodular variety with morpheaform (10%), superficial multicentric, pigmented variant, and basosquamous variant making up the remainder. The morpheaform variety resembles a scar and pathologically has finger-like projections making margin definition difficult. The superficial spreading looks like an eczematous patch without deep invasion. Pigmented basal cell carcinoma is often confused with melanoma and must be differentiated by biopsy. The basosquamous variant resembles both basal and squamous cell types pathologically and behaves clinically intermediate to both types.

Squamous cell tumors of the skin range from well to poorly differentiated. Lesions are typically elevated peripherally with ulcerated centers. Pathological variants include adenoid squamous, spindle cell, and clear cell. Size, depth of invasion, site of origin affect prognosis. Bowen's disease is a squamous cell variant which is often confused with psoriasis. It is most common in sun exposed areas and pathologically is limited to the epidermis. There is some speculation as to the relationship of internal malignancy to Bowen's disease.

Advanced basal and squamous cell tumors are larger than 2 centimeters, invade bone, muscle or nerves, or require excision of critical aesthetic units (eyelid, nose, lip, pinna). The workup of advanced lesions includes thorough physical examination, assessment of cranial nerves, and full thickness biopsy. Radiologic imaging provides a view in the third dimension and allows definition of anatomical landmarks in cases of planned surgical resections.

Treatment options include electrodesiccation, topical 5-FU (Effudex), cryosurgery, Mohs surgery, wide local excision, and radiotherapy. Premalignant lesions including actinic keratoses, and keratoacanthoma are amenable to Effudex application. Tumors less than 1.0 centimeter are usually managed with the more conservative techniques. Mohs surgery and wide local excision agree needed in larger and advanced tumors. Primary radiotherapy is most useful in basal cell carcinoma but can be used in patients at high risk for surgery. Adjunctive radiotherapy is reserved for positive margins, recurrent tumors, in cases with perineural invasion, and when lymph node metastasis is present. A multispecialty approach including the dermatologist, pathologist, surgeon, and radiotherapist is essential in managing advanced lesions.

When planning surgical excision reconstruction should always be kept in mind. Secondary intention, primary closure, skin grafting, local flaps, and free tissue transfer are the main options for treating resultant wounds. Care must be taken to avoid complex reconstruction in patients at high risk for recurrence to avoid "burying" recurrences.

In summary, skin cancers are increasing in frequency with most tumors requiring minor procedures for control. Advance lesions are less common and require a multidisciplinary approach to insure optimal chance for patient cure.

A 59-year-old white man was seen at the request of the Plastic Surgery service for evaluation of a recurrent basal cell carcinoma of the right cheek. The patient was seen in Plastic Surgery Clinic with a two-year history of a slowly growing lesion on his right cheek. Biopsy revealed basal cell carcinoma. He underwent wide local excision of the lesion with sacrifice of the buccal branch of the facial nerve. Margins were negative on frozen section (including periosteum). Primary reconstruction was performed using a facial nerve graft and a cervical advancement flap. He was noted to have a mass in the area of the reconstruction in March of 1994. Excisional biopsy revealed recurrent basal cell carcinoma. Otolaryngologic consultation was obtained. After evaluation and presentation at the Multidisciplinary Tumor Conference, wide local excision and partial maxillectomy were performed on April 8, 1994. Reconstruction consisted of local skin grafting with molds taken for prosthesis fitting. The patient tolerated the procedure well and was discharged on his fifth postoperative day. He will undergo postoperative radiotherapy.

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