Skin Cancer of the Head and Neck – April 2013

In Colorado, we enjoy over 300 sunny days a year. Not only is sunlight conducive to outdoor activities, exposure to it can enhance mood, increase Vitamin D levels and treat seasonal depression. However, the combination of sun exposure and certain genetic tendencies gives rise to a very high rate of skin cancer in our climate.

Virtually all other areas of the body are sun-protected by clothing at various times, but the face, scalp and neck are the most common sites of skin cancer since these areas are more difficult to shield. Even with diligent use of sunblock, hats, visors and sunglasses, long term sun exposure will eventually take its toll with premature aging of the skin and the development of benign and malignant growths.

In my practice and specialty (Head and Neck Surgery), I routinely treat skin cancers that arise on the face, ears, nose, forehead and scalp. The most common variety (70%) of skin cancer is the “basal cell” carcinoma (Figures 1-3). This malignancy was once called the “rodent ulcer” as it tends to chew in to deeper layers of surrounding tissue through expansion. Basal cell only very rarely metastasizes through the lymph system or blood vessels, but can destroy crucial areas of the face, and if not treated aggressively and properly, cause death.

Figures 1-3:  Basal cell carcinoma
Basal Cell Carcinoma

Basal Cell Carcinoma

Cancer-3

Squamous cell carcinoma is the second most common skin cancer (20%) and at times these growths are not easy to distinguish from basal cell cancer (Figures 4-5). Squamous cell cancer can also cause destruction of skin, cartilage and bone of the face if left unattended, but also have the power to metastasize to the lymph nodes of the neck, or beyond, thereby being more threatening than its cousin the basal cell cancer.

Figures 4 and 5:  Squamous cell carcinoma
Squamous cell carcinoma

Squamous cell carcinoma

The most deadly of these three common skin cancers is melanoma which makes up about 5-7% of skin cancers of the head and neck (Figure 6).  Although sun exposure plays a direct role in this cancer, there is also a genetic component in developing this disease. Melanoma, depending on how deep it has grown, tends to metastasize rapidly. Once this occurs, the survival from this disease is poor.

Figure 6:  Amelanotic melanoma (typical melanomas are dark or speckled – this is an unusual form that has no black pigment)
Amelanotic melanoma

General warning signs are:
1. Skin sores that enlarge and do not heal
2. Bumps or nodules of the skin that enlarge
3. Any changes (darkening, mottling, crusting, bleeding) of an existing mole or dark spot

Prevention and Treatment

Since we cannot control our genetic heredity, the only protection we can manage is sun protection. Unfortunately, at least in my generation, the concept of sun protection is a relatively recent consideration. Many of us spent much of our youth trying to accelerate tanning with baby oil and sun lamps. Although many may be destined to develop skin cancer based solely on their exposure decades ago, the use of sunblock with SPF over 30, and coverage with hats and clothing is always recommended.

In my opinion, the most crucial step in management of these diseases is careful surveillance of exposed skin surfaces by each individual, bringing any unusual lesions to the attention of your primary physician, regardless of size. It is always appropriate to take a small biopsy of a suspicious lesion.

I do not believe repeatedly burning or freezing lesions that are suspicious for malignancy is a good idea, especially if they do not respond to the initial treatment. Some of the most complicated, life threatening skin cancers I have managed began with a failed cryotherapy (freezing) or cautery (burning) treatment.

Much has been made, at least by the Dermatology specialty, of what is termed “Moh’s Chemosurgery”, a tedious technique in which a skin cancer is removed in layers until normal tissue is encountered. These costly procedures may take hours, and in my 30+ years of practice, I have seen many deep recurrent cancers from failed Moh’s procedures that have required major operations to correct. In Figure 7, you can see a large mass under a scar representing tumor left behind after a year of growth following a Moh’s procedure. Very often, after a Moh’s procedure, the hole (defect) of the cancer is left open and reconstructed in a separate, future operation resulting in two separate operations instead of one.

Figure 7: Deep neck extension of squamous cell cancer (see scar) incompletely removed a year before with Moh’s technique
Deep neck extension of squamous cell cancer

When faced with a suspicious lesion, I usually will carefully remove it for biopsy and repair       the area with a “plastics” closure. If I am faced with larger lesions, an initial small biopsy is taken to confirm the diagnosis and a one-step removal and reconstruction procedure is then done. The results (cosmetic and curative) of this one step procedure are equal to, or superior to most Moh’s techniques.

Bottom line: Let your primary doctor be the initial judge or whether a lesion is suspicious, and don’t procrastinate about a biopsy. Eliminating these cancers is much easier when they are 2mm as opposed to an inch in diameter!

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