Management of melanoma and non-melanoma skin cancers
Types of skin biopsy
Biopsy type
Shave biopsy
Equipment
Razor blade
Punch biopsy
Biopsy punch,
fine-toothed
forceps,
needle holder,
scissors,
suture
Excision
biopsy
Scalpel and
blade, finetoothed
forceps,
needle holder,
scissors,
suture
Curettage
Sharp-edged
metal or
disposable
curette
Indications
Superficial BCC.
For SCC when
punch or
excisional biopsy
is
contraindicated.
Most useful to
assess depth and
subtype of BCC.
To distinguish
SCC, its
precursors and
inflammation
Small nodular
BCC. To
distinguish SCC
from
keratoacanthoma.
To assess for SCC
at the base of the
cutaneous horn.
In combination
with
electrodessication
to treat
superficial BCCs
Advantages
Quick and
easy. No
suturing
Disadvantages
Base and
depth cannot
be assessed.
Rarely
removes whole
lesion
Requires
suturing and
correct
equipment.
Tips
Allows
histology
Time and
equipment
required
Hide scar in
skin creases.
Length should
be 3x width
Quick and
easy. No
sutures
Tissue
fragments are
hard to
interpret
histologically.
Slow healing.
Useful to
biopsy hardto-reach
areas (eg.
Conchal bowl)
Quick and
easy
Stretch skin at
right angles to
relaxed skin
Basal Cell Carcinoma:


Main aims of treatment:
o Cure the patient
o Preserve function
o Achieve an optimal cosmetic result
o Consider needs and desires of patient
Factors determining individual treatment of BCC
o Tumour factors: BCC subtype; depth of involvement; tumour size; site; clinical borders;
primary Vs recurrent; presence of perineural disease
o Patient factors: age; medications; cosmetic expectations; skin health; general health and
mobility; distance from specialist care; cost limitations

Options:
o Standard surgical excision
 For nodular and sometimes superficial BCC
 5-year cure rate: 90-98% for primary tumours
 Excision under local anaesthetic in an outpatient setting
 Pts should be referred if a flap or graft repair is required or the GP is not
confident performing minor surgical procedures
 Send specimen for histology
 Take care in areas where nerves or other structures are involved
 Margin: 4mm lateral margin with inclusion of subcutaneous fat
 But for morphoeic and infiltrating tumours, use a 1cm lateral margins with
subcutaneous fat being excised
 Advantages: definitive procedure; specimen for diagnosis and assessment of
margins
o Curettage and electrodessication
 For small, primary, superficial or nodular BCC with discrete borders
 Only use on trunk and limbs  poor cosmetic result
 96% cure if patients are selected appropriately
 2-3 cycles of curettage under local anaesthetic (each cycle should be followed
by electrodessication or diathermy at the base)
 Margin: 3-5mm
 Advantages: fewer bleeding problems in anticoagulated patients; quick and easy
 Disadvantages: electrical interference with pacemakers, if used on the legs of
diabetic patients, wound can take up to 8 weeks to heal
o Radiotherapy
 Used when surgery is contraindicated; or as palliation in advanced tumours
 95% success with small BCCs, but recurrence can occur
 Advantages: painless; good early cosmetic result
 Disadvantages: multiple treatments are usually required, not recommended for
patients under 60, poor long-term cosmetic results
 Curette biopsy can be useful to debulk the tumour
o Moh’s surgery
 For high-risk BCC; or for those in a young patient with a cosmetically important
site
 Performed under local anaesthetic by highly trained dermatologists
 Advantages: highest cure rates
 Disadvantages: training of specialist; expensive
 Send specimen for histological assessment
o Imiquimod
 For superficial BCCs
 Excellent cosmetic results

o
o
o
o
Disadvantages: protracted treatment (6 wks); unacceptably low cure rate for
nodular BCC
 Must have breaks in treatment if the area is markedly inflamed  reduces
scarring
Photodynamic therapy
 Superficial BCC; nodular BCC <2mm depth
 1. Apply a photosensitizing cream (eg. 5-aminoevulinic acid or its methyl ester)
 2. Occlude for 3-5 hours to allow absorption
 3. Expose area to a light source of appropriate wavelength to form reactive
oxygen species
 Usually 2 treatments 1-4 weeks apart  has 90% response rates
 Excellent cosmetic results
 Disadvantages: painful, expensive
 Can minimize pain using a local anaesthetic
 Ideally the BCC should be debulked before treatment
Cryotherapy
 Has limited use  only small, low-risk superficial BCC on trunk or proximal limbs
 Must biopsy first and mark out BCC and margin before treatment
 Advantages: quick, easy
 Disadvantages: slow to heal; white scar; poor cure rate; cannot use on head and
neck BCCs
Laser
 Can be used for superficial BCC, but at considerable cost to the patient
 Local anaesthetic, wound heals by secondary intention
Cytotoxic agents (eg. 5-fluorouracil)
 Topical, but with low cure rates
Squamous Cell Carcinoma


Aims of treatment
o Complete eradication of the lesion
o Preserve function
o Best possible cosmetic outcome
Options
o Standard surgery
 Most primary SCCs
 80-90% five-year success rate
 Margin: 4 or 10mm (for <2cm or >2cm diameter respectively)
 Advantages: specimen for assessment
 Disadvantages: must take care to avoid damaging other structures
o Mohs’ surgery
 For large, recurrent or incompletely excised SCCs
 Disadvantages: expensive; time-consuming; extra training for dermatologists
o
o
o
o
o
o
o
Radiotherapy
 Only use when surgery is contraindicated or inappropriate OR if the SC is
advanced (then use radiotherapy to complement surgery)
 Generally not for patients under 60
 About 10 treatments over several weeks
 Advantages: non-invasive; can treat multiple lesions in one setting; painless
Curettage and electrodessication
 For small, thin lesions on the trunk and limbs
 For solar keratoses, Bowen’s disease and keratoacanthomas, but not ideal for
invasive SCCs
 Not for very thin skin (eg. eyelids and lips)
 3-5mm margin with 2-3 cycles of curettage
 95% cure rate
 Wound heals by secondary intention in 2-4 weeks
Imiquimod
 For thin lesions (eg. solar keratoses, Bowen’s disease)
 Apply daily for 5 days per week over 6 weeks
 Very good cosmetic results
Photodynamic therapy
 For thin lesions (eg. solar keratoses or Bowen’s disease)  80-90% cure
 Excellent for sites of poor wound healing (eg. lower legs)
 Good cosmetic results
Cryotherapy
 For thin lesions (eg. solar keratoses or Bowen’s disease)
 Disadvantages: longer healing time, hypopigmented scar
Lasers
 For thin (not invasive) SCCS
5-FU cream
 For diffuse solar keratoses on a large area
 Cream is applied nightly for 4 weeks
Melanoma

Initial biopsy
o For suspected melanomas, the biopsy should be a complete excision  to help prevent
false negatives and to allow assessment of tumour thickness
o It is generally better not to attempt a wide definitive margin at the time of initial
excision and to avoid complex closure (eg. graft, flap) for excisional biopsy
 2mm margin is optimal for initial biopsy followed by definitive excision
 Do not want to use skin grafts or flaps because this compromises closure for the
definitive procedure


Management and follow-up
o Refer if:
 Difficult histopathology
 High risk primary melanoma
 Metastatic melanoma
 To evaluate other pigmented lesions
 Consider adjuvant protocols or research
 For specialised melanoma procedures
 Anxious patient
o Evaluate patients’ risks for developing future melanomas
o Be aware of atypical presentations of melanomas
o Listen carefully to the concerns expressed by the patient about changing lesion(s)
o Always examine the scalp, soles of feet and between the toes during a total-body skin
examination
o Ensure appropriate aids are used to diagnose melanomas  dermoscopy, total body
photography
o Multidisciplinary care should incorporate a reassessment of histological evidence and
fully explain the disease and treatment options to the patients.
o Complete skin examination is essential and performed at least annually
For palliative therapy, can use surgery, chemotherapy or radiation