The most recent National Comprehensive Cancer Network (NCCN) guidelines advocate the use of SLNB for patients with localized stage I and II melanoma, as well as in patients with resectable satellite and in-transit disease (available at nccn.org). The guidelines state that patients with SLNB-positive stage III nodal disease should be offered complete lymph node dissection (CLND) with or without adjuvant therapy. However, that recommendation may change with the publication of the second Multicenter Selective Lymphadenectomy Trial (N Engl J Med. 2017;376:2211–2222). The MSLT-II team found that
immediate CLND increased the rate of regional control and provided prognostic information but did not affect overall survival of patients with stage III melanoma.
“This has been a paradigm shift,” Dr. Bradford said. “This is pretty new data that will necessitate a multidisciplinary conversation and a willingness to offer either a nodal dissection or observation and then referral to a medical oncologist,” she said.
Non-Melanoma Skin Cancers. Basal cell carcinoma (BCC) is by far the most common form of skin cancer in the United States, making up about 75% of cases. According to the NCCN, BCCs occur in two million Americans annually—more than the incidence of all other cancers combined (nccn.org). Although rarely life threatening, with a metastatic rate of <0.1%, BCC can be disfiguring if left unchecked, involving extensive areas of soft tissue, cartilage, and bone, according to Dr. Zanation.
MMS is the preferred surgical technique for localized BCC because it allows intraoperative biopsy of the entire excision margin. Published studies have found that MMS is associated with a five-year recurrence rate of 1.0% for primary BCC, and 5.6% for recurrent BCC (J Dermatol Surg Oncol 1989;15:315–328; J Dermatol Surg Oncol 1989;15:424–431).
Squamous cell carcinoma (SCC) is the second most common skin cancer. But unlike BCC, SCC may be more invasive, Dr. Zanation noted. Because of that, SLNB is now being applied to SCC. “SLNB or elective node dissection is absolutely essential for staging of the advanced SCC,” he added.
Reconstruction. Today, the trained facial plastic surgeon is very comfortable performing nasal surgery, both aesthetic and reconstructive. “We are regarded by many as having true expertise in this area of facial plastic surgery. Becoming the authority in rhinoplasty is relatively new,” Dr. Park said.
Forty percent of Dr. Park’s practice is performing facial reconstruction after skin cancer. This comes from a one-year intensive fellowship in facial plastic surgery that followed a five-year residency training in otolaryngology–head and neck surgery.