Skin Cancer
& Melanoma

Procedure Information: Skin Disorders

Originally developed in the 1930s, Mohs micrographic surgery is the most advanced, precise, and effective treatment for an increasing variety of skin cancer types. With Mohs surgery, an entire tumour can be identified and removed while leaving the surrounding healthy tissue intact and unharmed.

Mohs surgery offers the highest cure rate (up to 99%) for the most common skin cancers in Australia. It involves surgically removing layers of skin cancer tissue in stages and examining the tissue under a microscope until healthy unaffected tissue is reached, signifying a clear margin. Dr Leow, as a fellow of the American College of Mohs Surgery, is specially trained in cancer surgery, pathology, and reconstructive surgery.

Mohs surgery is unique and more effective than standard tumour excision because of the way excised tissue is microscopically examined, to evaluate 100% of the surgical margin. The microscopic interpretation of tissue margins is performed on site by Dr Leow, who is specially trained in the reading of these tissue slides and is best able to correlate any microscopic finding with the surgical site. Advantages of Mohs surgery include:

• Complete cancer removal during surgery, virtually eliminating the chance of the cancer growing back
• Minimising the amount of healthy tissue lost
• Maximising functional and cosmetic outcome resulting from surgery
• Reconstructing the surgical site the same day the cancer is removed, in most cases
• Curing skin cancer when other methods have failed
• Other methods of treating skin cancer blindly approximate the amount of tissue to treat, which can result in the unnecessary removal of healthy skin tissue and tumour regrowth if any cancer is missed.

Because of the high success rate in Mohs surgery, most patients require only a single surgical visit. This usually includes reconstruction of the surgical site. Other methods might require additional surgery and pathology analysis, to close the wound and to treat any residual cancer. Each of these additional procedures involve separate fees and different specialists and technicians, while a single Mohs surgery visit incorporates all these components of skin cancer treatment, each performed by Dr Leow.

As Mohs surgery minimises the amount of healthy tissue removed, it also reduces the impact to surrounding tissue. The aesthetic outcome of the surgery is therefore optimised. Furthermore, the psychological impact of undergoing multiple procedures when cancer recurs can be significant. Mohs surgery minimises the risk of cancer recurrence, thereby reducing and often eliminating the cost of more complicated surgery for recurrent skin cancers.

Procedure Information: Excision

With standard excision, a benign or malignant lesion and a small margin of healthy tissue around it is excised, usually in the shape of an ellipse. Once tissue has been removed, wound edges are sutured together. The specimen is then is sent for pathology analysis.

Standard excision is often used for skin cancers at sites which are less prominent or complex (such as the trunk, upper arms and thighs), and for most melanomas that are confined to the skin and have not spread into deeper tissue or other parts of the body. If detected early, the procedure can cure melanoma. In other cases, additional treatment may be necessary.

Since excision requires the removal of some unaffected skin, it results in a wound larger than the visible lesion. At certain sites, such as the scalp and leg, it can be difficult to suture wound edges back together, necessitating the use of skin flaps and skin grafts to close the wound, by recruiting contiguous and non-contiguous skin, respectively. Recovery time can vary depending on the size and site of the lesion.

For malignant skin tumours, standard excision offers a high cure rate and allows for microscopic examination of the tumour and of surrounding tissue by a pathologist. Unlike chemotherapy and radiation, treatment can be completed in one session.

In general, the procedure is as follows:

• The surgical site is cleaned
• Local anaesthetic is injection to numb the skin, with the option of an oral or intravenous sedative
• The specimen is sent to a pathologist for analysis
• The wound is closed with sutures, or may be left to heal.

While standard excision is a safe and effective procedure, all medical procedures carry some risk, although these are minimised in the hands of a qualified practitioner. Risks include bleeding, infection, recurrence, allergic reactions to anaesthetic, and problems with healing.

It is important to mention the following relevant medical history:

• problems with healing.
• Any prescription, over-the-counter medication or supplements used regularly
• A history of bleeding or other medical problems
• Any allergy, especially to anaesthetic and antibiotics
• Pregnancy and breastfeeding.

After the procedure, a dressing is usually placed over surgical site and should be kept clean and dry. In general, the dressing may be removed after 24 hours and regular washing may resume, although sun exposure, hot water and abrasive products should be avoided. An return appointment is made for removal of sutures.

Procedure Information: Curettage

With curettage, superficial and uncomplicated benign or malignant skin lesions are removed by scraping the affected area using a metal spoon or loop instrument known as a curette. After it has been scraped, the wound typically is usually cauterised (see Cautery).

Curettage is effective on small, superficial basal and squamous cell carcinomas with well-defined borders. It often is used on the trunk and other areas of the body where scars from the healing process will not be objectionable.

Curettage is a good choice for patients who cannot tolerate more complex surgical procedures. For certain types of skin cancers it offers a high cure rate, and is efficient and cost-effective.

The treatment area is numbed with a local anaesthetic. Abnormal cells are then removed by scraping the skin. Cautery may then be performed. The wound is typically allowed to heal without sutures, under a dressing.

Procedure Information: Cyrotherapy

With cryotherapy, liquid nitrogen or liquid carbon dioxide (known as cryogen) is used to remove skin tags, sun spots and warts; fade age spots; and treat early basal and squamous cell carcinomas. Cryogen is applied with a cotton tip, metal probe or spray device. The goal is to freeze the skin quickly and then allow it to thaw slowly to maximise destruction of targeted skin cells. In some cases, additional cycles may be necessary.

No extensive preparation is required for cryosurgery. The treatment area must be clean and dry, but not necessarily sterile.

The procedure is well-tolerated by most patients, but may not be suitable for areas with poor circulation or for darker skin types. Patients may experience a burning or stinging sensation during treatment. Local anaesthetic usually is not required.

Possible complications and side effects of cryotherapy include:

• Prolonged swelling
• Scarring
• Loss of sensation at the treatment site
• Loss of pigmentation

Procedure Information: Ablative Laser & Cautery

With ablative laser, benign or malignant skin lesions are removed by vaporising the top layers of skin. This technique is used for benign lesions differing in colour or texture from surrounding skin, superficial basal and squamous cell skin cancers, as well as pre-cancerous conditions.

There are several types of pre-cancerous conditions, including:

Actinic or solar keratosis, which are caused when the skin has sustained too much sun exposure and damage. This may appear as crusty bumps that are flesh-coloured, brown, pink or red. Affected areas may be inflamed, itch or bleed. • Actinic cheilitis, which is similar to actinic keratosis, but affects the lips, causing dryness, cracking and scales. Lips may appear pale or white. • Bowen’s disease, a precursor to invasive squamous cell carcinoma, which appears as a brown and scaly lesion similar to eczema or psoriasis.

Laser surgery offers an effective method of removing epidermal skin cancers. The treatment also heats the layers underneath to promote collagen production, which stimulates skin in the treatment area to heal smoother and more evenly. This minimally invasive procedure causes little damage to surrounding tissue.

Possible complications and side effects of ablative laser include:

• Pain
• Swelling
• Bleeding
• Scarring
• Crusting
• Discoloration

Before the procedure, your medical history will be reviewed and a physical examination performed. This is the time for discussion of expectations, potential risks/benefits and outcomes of the procedure. Patients should:

• Discuss any susceptibility to cold sores around the mouth since the procedure can trigger breakouts in certain individuals
• Avoid medications or supplements that can affect blood clotting; such as aspirin, ibuprofen, vitamin E, fish oil and ginkgo biloba; for 10 days before surgery
• Avoid smoking for two weeks before and after the procedure.

Following treatment, a dressing may be applied to the treated area. Patients are required to clean the area after the first 24 hours, and then several times a day thereafter. An thick bland ointment, such as petroleum jelly, should be applied after cleaning to maintain a sheen to the treatment site. This aids in healing and helps prevent scabs from forming.

Patients can also expect the treated area to:

• Swell for 1 to 2 days after treatment
• Itch or sting for 1 to 3 days after treatment
• Shed old skin 5 to 7 days after treatment.

Healing typically takes 10 to 21 days, depending on the size and location of the treatment site. After the area has healed fully, patients should:

• Use only oil-free cosmetics for at least two to three months
• Avoid sun exposure and apply an appropriate sunscreen to the area, which will have a lighter or pinker appearance
• Keep new skin well-moisturised.

Procedure Information: Photodynamic Therapy

Photodynamic therapy treats premalignant growths by using special medications called photosensitising agents, in combination with light, to kill pre-cancerous or superficial cancerous cells. These abnormal cells take up more of the medication, and the application of certain types of light results in selective destruction of the cells while sparing normal cells. The process is also known as PDT, photoradiation therapy and photochemotherapy.

Photodynamic therapy can be used to treat premalignant conditions such as actinic keratosis, and superficial basal and squamous cell cancer. Benefits features of the procedure include:

• No long-term side effect
• Minimally invasive
• Can be administered multiple times to the same treatment area
• Little or no scarring
• Improved skin appearance, tone, colour and texture.

The procedure requires three steps: application of medication, incubation and light activation. First the medication is applied to the skin on the treatment area, usually in the form of a liquid or cream. It is left to allow absorption and incubation anywhere from 30 minutes up to 18 hours, depending on the condition and treatment site.

The skin is then exposed to a special light source. The patient may feel a slight tingling or warmth. Sometimes a fan is used to cool the treatment area. Occasionally topical anaesthetic is administered. Following treatment, the treated area is cleansed and a sunscreen applied.

The interaction between the photosensitising agent and light treatment activates oxygen molecules that can destroy affected cells. Once the treatment area has healed, it is re-examined to determine whether any additional treatment is necessary.

Possible complications and side effects of photodynamic therapy include:

• Inflammatory reaction similar to a sunburn
• A burning sensation
• Discolouration
• Pain
• Blistering
• Scab formation
• Allergic reaction
• Sun sensitivity

Before the procedure, your medical history will be reviewed and a physical examination performed. This is the time for discussion of expectations, potential risks/benefits and outcomes of the procedure. Patients should mention any:

• Extreme sensitivity to light
• Use of medications and supplements that make them sensitive to light
• Medical condition such as systemic lupus erythematosus or porphyria
• History of bacterial or viral skin infection, such as impetigo or cold sores.

On the day of treatment, patients should wear loose comfortable clothes and a wide-brimmed hat (for facial treatment). Most patients are able to drive themselves home after the procedure. Smoking is discouraged immediately following treatment.

Most patients experience mild dryness and a sunburn on the treatment site. Simple painkillers can be used to treat any discomfort.

Procedure Information: Superficial Radiotherapy

Radiation therapy uses high-energy rays (such as X-rays) or particles (such as photons, electrons, or protons) to kill cancer cells.

If a tumour is either very large, has failed previous surgical treatment, or is on an area of the skin that makes it difficult to remove with surgery, radiation therapy may be a suitable option. Radiation therapy can also be useful for some patients who, for other health reasons are unable to undergo surgery. Radiation therapy can often cure small basal or squamous cell skin cancers and can delay the growth of more advanced cancers.

Radiation is also useful when combined with other treatments. For example, radiation can be used after surgical excision as an additional treatment to kill any residual cancer cells that may not have been apparent during surgery. This lowers the risk of cancer recurring after surgery.

With superficial radiotherapy for skin cancer, radiation is focused from outside the body on to the tumour. This is often done X-rays (also known as gamma rays) or electron beam radiation, which do not penetrate deeper than the skin. This helps limit the side effects to other organs and body tissue.

Getting radiation treatment is much like getting an X-ray, but the radiation is stronger and aimed more precisely at the cancer. The procedure itself is painless. Each treatment lasts only a few minutes, although planning treatment frequency and dosages; and preparation during treatment, such as positioning of the patient; take longer. Radiotherapy can only be administered by licensed operators. Dr Leow is one of only a handful of dermatologists licensed in Australia to perform this treatment.

Side effects of radiation are usually limited to the treated area, and can include:

• Skin irritation, ranging from redness to blistering and peeling
• Changes in skin colour
• Hair loss in the area being treated
• Damage to saliva-making glands and teeth when treating cancers near these structures.