Once a suspicious lesion is found, Dr. Park encourages physicians to lower their threshold for performing a biopsy. The pathology report will determine the definitive diagnosis as well as the architecture in terms of its aggressive behavior. “If it is a relatively small lesion [<1 mm] in a forgiving place, such as the cheek or the neck, and is well circumscribed—nodular and you can see the lesion very clearly and, more importantly, where it is not—the otolaryngologist is more than qualified to excise and close the lesion,” Dr. Park said.
Dr. Zanation is less convinced: “In my practice, I still think Mohs surgery is a better treatment option for non-advanced skin cancers—with a primary excision, we removed more normal tissue than is needed.” But certainly, for anything beyond a localized lesion, the otolaryngologist should be called, he said.
Treatment Advances
Melanoma. According to the CDC, approximately 77,698 new cases of melanoma are diagnosed in the United States each year, and the overall incidence rate of melanoma is 21.8 per 100,000, making it the third most common skin cancer. Up to 20% of patients with melanoma who present with localized stage I and II disease will actually harbor occult regional metastasis despite a clinically and radiographically negative diagnosis, said Carol Bradford, MD, MS, executive vice dean for academic affairs and professor in the department of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor.
In 1996, Dr. Bradford was invited to participate in a multidisciplinary melanoma clinic led by Timothy M. Johnson, MD, now Lewis and Lillian Becker Professor of dermatology and otolaryngology–head and neck surgery at the University of Michigan Medical School. At the time, few—if any—otolaryngologists were performing sentinel lymph node biopsy (SLNB). But, after observing the positive results for staging melanoma in other parts of the body, Dr. Bradford asked a surgical oncologist to show her the technique. “It made sense that a head and neck surgeon should be performing these procedures because of the complexity of anatomy and the need to seed the lymph node biopsy, which is invariably close to nerves and blood vessels,” she said.
Since then, Dr. Bradford and her colleague, Cecelia Schmalbach, MD, MSc, the David Myers, MD Professor and Chair in Otolaryngology–Head and Neck Surgery (HNS) at the Lewis Katz School of Medicine at Temple University in Philadelphia, have lectured and trained thousands of otolaryngologists in the technique. In their latest collaboration, the authors note that the utility of melanoma SLNB has evolved. “The current focus has shifted from a staging modality to potentially a therapeutic intervention,” they wrote (Laryngoscope Investig Otolaryngol. 2018;3:43–48).