The last two decades have seen many advances in the diagnosis and treatment of skin cancer, and one of the biggest steps forward has occurred in the management of advanced cases.
With the introduction of sentinel lymph node screening for the diagnosis and mapping of melanoma and non-melanoma skin cancers (NMSC) of the head and neck, improved training of otolaryngology residents and fellows in the removal of difficult tumors, and the innovative reconstructive work of facial and plastic surgeons, otolaryngologists are now considered the go-to specialty for performing these challenging surgeries.
“Historically, skin cancer of the head and neck has been treated by the dermatologist and the plastic surgeon,” said Stephen S. Park, MD, chair of the department of otolaryngology–head and neck surgery and director of the division of facial plastic and reconstructive surgery at the University of Virginia School of Medicine in Charlottesville. In fact, the vast majority of skin cancers are still treated fairly simply by dermatologists by either direct excision under local anesthesia or with Mohs micrographic surgery (MMS).
“In the last 20 years, Mohs surgery has become the standard of care for localized skin cancer,” said Adam M. Zanation, MD, the Harold C. Pillsbury Distinguished Professor and director of advanced rhinology, oncology and open/endoscopic skull base surgery fellowship at the University of North Carolina, Chapel Hill. But Mohs has its limitations, he noted. For larger, more complex lesions involving deep structures, or in the setting of invasive melanoma, the ability to clear the surgical margins using the technique is very limited. In those cases, he said, the dermatologist will usually refer to the otolaryngologist for treatment and repair.
According to the Centers for Disease Control and Prevention, skin cancer is reaching epidemic proportions (See “Risk Factors: Not Just Sun Exposure,” below). As the number of patients has increased, the role otolaryngologists play in the management of advanced skin cancer continues to evolve, especially in the treatment of melanoma of the head and neck and advanced basal cell and squamous cell carcinomas.
Every board-certified otolaryngologist is qualified to manage facial skin cancers, Dr. Park said. One of the first things to do is screen patients for suspicious lesions, even those coming in for other issues. “If you don’t look for it, you won’t find it, especially in our aging patients, who grew up in an era that was unaware of the damages of sun exposure,” he added.
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.
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).
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.
When it comes to nasal reconstruction, most otolaryngologists are comfortable with simple repairs and recognize the importance of preserving function. Larger or more complex defects, however, usually require a fellowship-trained surgeon. “The bar today is to reconstruct the nose to a result where it is inconspicuous to casual observers and functions normally. This is today’s standard,” Dr. Park said.
“The specialty of otolaryngology–head and neck surgery has expanded the armamentarium of treatments for advanced skin cancers—from maximally to minimally invasive surgical and reconstructive techniques. This has made our specialty particularly suited to provide the best resection outcomes, as well as the best reconstructive and long-term functional outcomes,” Dr. Zanation concluded.
Nikki Kean is a freelance medical writer based in New Jersey.