Nonpharmacologic Therapy

Surgery

Surgery is the primary treatment modality for all patients diagnosed with either BCC or SCC. Full-thickness ablative procedure in the form of surgical excision of the tumor along with a margin of normal tissue surrounding the tumor is the preferred method for high-risk tumors. Obtaining negative surgical margins is critical for cure and decreasing the risk of tumor recurrence. For lesions that are less than 2 cm in diameter, a

minimum margin of 4 mm is usually adequate. Depending on the tumor size, degree of differentiation, and invasion of surrounding structures, larger margins of resection may be necessary.

Low-risk tumors can be treated with superficial ablative techniques, including electrodessication and curettage (ED&C) and cryotherapy.19 ED&C is a simple, cost-effective technique that utilizes repeated cycles of using a curette to cut through malignant tissue, followed by electrodesiccation, which involves the application of high voltage, low current to the skin, causing drying or desiccation of the tissue. ED&C is most appropriate for well-defined superficial lesions that are not located in areas with increased risk for metastasis.

Cryotherapy is a procedure used primarily for smaller, low-risk NMSCs with clearly defined margins. It involves delivering liquid nitrogen at subzero temperatures as a spray or with a supercooled metal probe to destroy the malignant tissue.18 While cryotherapy is cost-effective and easy to deliver, the recurrence rate is high.18

NMSC is considered to be high risk if it has any of the following features: it is recurrent, the location is at a high risk site (e.g., mask areas of the face, lips, ears, hands, and feet), it is larger than 2 cm in diameter or greater than or equal to 4 mm in depth, it is moderately or poorly differentiated, it is fast growing, it has ill-defined borders, there is positive perineural or vascular invasion, the patient is immunosuppressed, or it is the morpheaform or metatypical subtype of BCC.19 If the tumor is located on the trunk or extremities, less than 2 cm in diameter and less than 4 mm in depth, well differentiated, slow growing, has well-defined borders, and is the nodular or superficial subtype of BCC, then it is considered to be low risk.19 For high risk NMSC, Mohs' micrographic surgery (MMS) provides the highest cure rate.18 The goal of this therapy is complete removal of the cancer with preservation of as much surrounding normal tissue as possible. MMS involves careful dissection, staining of frozen sections, and anatomic mapping of the tumor specimen. Sections are assessed immediately under the microscope in the operating theater and the process is repeated until a tumorfree margin is attained.18

The 5-year survival rate for surgical excision, electro-desiccation and curettage, and MMS is 90% or better for NMSC.19

Radiation

Radiation is not standard therapy for the treatment of skin cancer; however, there are circumstances in which radiation may be preferred. Older patients or patients who are poor candidates for surgery may be offered radiation as an option. 8 Radiation offers good cosmetic results, but it requires multiple visits over the course of several months, making it inconvenient for patients.19 In the treatment of NMSC, radiation

results in poorer cosmetic outcomes than surgery or electrodesiccation and curettage.

Disadvantages of radiation include radiation-induced dermatitis, high cost, and the in-

creased risk of secondary malignancy, including SCC and BCC. Photodynamic Therapy

Photodynamic therapy is a noninvasive treatment option for actinic keratoses and is being investigated in the treatment of superficial BCC and SCC. A photosensitizing agent is administered IV or topically to the target area, followed by exposure to a light source. The energy absorbed by the sensitizer is transferred to molecular oxygen to create an activated form of oxygen called singlet oxygen, which reacts with cellular component to cause cell damage and death.60 One of the most commonly used photosensitizing agents is topical 5-aminolevulinic acid, a solution that is applied for 14

to 18 hours to the lesion and irradiated for 5 to 20 minutes.61 Response rates for superficial SCC have ranged from 75% to 100%, while those for superficial BCC range from 90% to 100%. Side effects of topical agents are usually limited to local skin reactions, while those of IV agents often include generalized photosensitivity.

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