Keeping Watch for Skin Cancers on the Head and Neck

A punch biopsy, which removes a deeper sample of all skin layers, can be used for larger tumors by taking the sample from the most raised area and properly orienting the biopsy specimen for the pathologist. If palpable regional lymph nodes are present, then fine needle aspiration may be necessary. Depending on the extent of the disease and presence of symptoms of local or distant metastases, a chest X-ray and CT, PET, and/or MRI may also be needed. The use of laser scanning devices and ultrasound for biopsy are still in the experimental stage.

Multidisciplinary Approach to Treatment Key

“Most patients will see their primary care physician or a dermatologist first if they suspect skin cancer,” said Dr. O’Brien. “Consequently, most otolaryngologists tend to see patients with more advanced stage, larger cutaneous cancers that may have metastasized.” These patients require a multidisciplinary approach to their treatment that involves not only the head and neck surgeon, but also a surgical dermatologist, facial plastic and reconstructive surgeon, dermatopathologist, and surgical, medical, and radiation oncologists.

“Through multidisciplinary consultation, we can offer patients a wider armamentarium of treatment modalities in order to do what’s best for them,” said Hugh Greenway, Jr., MD, Chairman of Dermatologic/Mohs Surgery and Director of Cutaneous Oncology and the Melanoma Center at Scripps Clinic in San Diego, Calif. Treatment plans will depend on the location, size, and stage of the cancer, status of tumor borders, risk factors for recurrence, and previous irradiation, as well as the patient’s age and general health.

“The primary treatment for cutaneous cancer is excisional surgery, with radiotherapy used as an adjuvant if negative pathological prognostic factors are identified,” said Dr. O’Brien. “Chemotherapy does not have a role in the standard management of skin cancers of the head and neck.”

Treatment Guidelines

Standard treatment of BCC and SCC is outlined in the National Comprehensive Cancer Network’s (NCCN) Clinical Practice Guidelines in Oncology, Basal Cell and Squamous Cell Skin Cancers (available online at www.nccn.org/professionals/physician_gls/PDF/nmsc.pdf ). In general, low-risk local BCC requires an excision with narrower clinical margins (2.0–3.0 mm) than low-risk local SCC (4.0–5.0 mm), when there is no lymph node involvement. If there are palpable regional lymph nodes in SCC, then a regional lymph node dissection may be necessary.

Because removing all cancer cells to minimize the chance of cancer regrowth is as important as achieving optimal cosmetic results from surgery on the head and neck, Mohs micrographic surgery is often the treatment used for patients with localized BCC and SCC. Clinical studies have shown that there is a five-year cure rate of up to 99% for these lesions. For patients with aggressive SCC that demonstrates perineural invasion or parotid gland or cervical metastasis, a head and neck oncologic surgeon and radiation oncologist should be consulted.

“The gold standard for a definitive diagnosis is still biopsy of the primary with postoperative margin assessment. Shave biopsies of pigmented lesions should never be performed.” – —Randal Weber, MD