After determining a diagnosis and completing a full pre-treatment evaluation, complete with a skin examination, doctors will recommend a course of treatment for their patients. The specific treatment plan varies for each type of skin cancer (Basal Cell Skin Cancer, Squamous Cell Carcinoma, and Malignant Melanoma), and will be discussed further below. In general, there are three different options for the treatment of skin cancers that can be used alone or in combination.
Surgery
Surgical removal is generally the first line of treatment for skin cancers, and could involve multiple different methods of resection. In general, recommended procedures could include a soft tissue resection, parotidectomy, skin graft, skin flap, or a local or regional flap.
Specific Procedures for the Removal of Skin Cancers
Cryosurgery, Curettage, and Electrodessication
Cryosurgery involves destroying a skin lesion by freezing it off. Curettage involves scraping off the suspicious growth, while electrodessication involves burning it off. These methods work quite well for non-cancerous growths, but dermatologists might also use them for very small basal cell and squamous cell carcinomas of the skin that do not invade very deeply. However, with these methods of resection, the cancerous cells are destroyed, so there is no way to assess the details or features of the cancer or to determine whether all of the cancer was eliminated.
Wide Local Excision
This method is performed by a surgeon, and involves the complete removal of the cancer, along with a rim of normal-appearing tissue around it.
- This method can be done with numbing medicine in the office, or under general anesthesia in the operating room. The surgeon will send a sample of the normal tissue that was left behind around the site of resection (called the margins) for pathological frozen section analysis during the surgery to see if all of the cancer was removed.
- Once the suspicious growth is removed, the surgeon can then reconstruct the area. Sometimes, the reconstruction might be delayed to a later date so that a pathologist can check if more tissue should be removed to make sure that all of the cancer is gone.
Mohs Micrographic Surgery
This method is used mainly for NMSC by a surgeon or a dermatologist who has special training in the technique. Mohs is not typically used for malignant melanoma.
- This technique is particularly useful for skin cancers on the face, because it allows the surgeon to remove all of the cancer (with negative margins) while sparing as much normal facial skin as possible.
- In this technique, the surgeon uses numbing medicine and does this in the office.
- The surgeon uses a knife to remove the suspicious growth, along with a small margin.
- The margin is carefully mapped out. The surgeon then acts as a pathologist and looks at the entire margin for any signs of residual cancer. If there is any cancer on the margin, the surgeon is able to use the map he or she created to remove cancer from the areas that still have cancer. This will be repeated until all of the margins are negative for signs of cancer. Perhaps the best way to understand this is to use the analogy of peeling the layers of an onion and looking for evidence of cancer cells in each layer. While the absence of cancer is the desired goal, the presence of cancer cells can lead to a directed removal of further skin at the precise location of remaining cancer identified under the microscope.
- In some cases, when a dermatologist performs the procedure, he or she will get negative margins all around the cancer on the skin but leave some cancer in the deep areas. Then the dermatologist will send the patient to a surgeon who can remove the rest of the deeper cancer and reconstruct the area that was removed.
Cancer-Specific Treatment Guidelines
Treatment of Basal Cell Skin Cancers (BCC)
Disease Characteristics That Indicate a Higher Risk of Recurrence
- Tumor Area M > 10 mm or Area H > 6 mm (see diagram below).
- Poorly-defined borders of the cancer.
- Recurrent BCC in the same area.
- Patient undergoing immune system suppression or having a disease that has compromised the immune system.
- Previous radiation therapy in the area.
- BCC with an aggressive growth pattern.
- BCC invasion into or near nerves.
Disease Characteristics That Indicate a Lower Risk of Recurrence
- Tumor Area M < 10 mm or Area H > 6 mm (see diagram below)
- Well-defined borders of the cancer.
- First-time BCC in the area.
- Patient not undergoing immune system suppression or having a disease that has compromised the immune system.
- No previous radiation therapy in the area.
- Nodular or superficial BCC.
- No invasion into or near nerves.
Treatment Options for High-Risk BCC
- Excision with assessment of margins. If the margins are positive, more tissue should be removed, and radiation should be considered.
- Mohs or conventional surgical resection resection with complete margin assessment of margins all around the border of the tumor followed by radiation if the margins are still positive or if there is invasion into or around nerves.
- Radiation therapy can be used alone for patients who are not fit to undergo surgery.
Treatment Options for Low-Risk BCC
- Curettage and electrodessication.
- Excision with assessment of margins. If the margins are positive, more tissue should be removed, and radiation should be considered.
- Radiation therapy can be used alone for patients who are not fit to undergo surgery.
- For extremely low-risk superficial BCC, if surgery and radiation are not feasible, certain creams, phototherapy, and/or aggressive cryotherapy can be considered.
If the BCC has spread to lymph nodes (either nearby or somewhere else in the body), a team of doctors should meet to discuss the best options to effectively treat the disease.
Treatment of Squamous Cell Carcinoma of the Skin (SCC)
The main goal of treatment for SCC is to remove all of the cancer while maintaining as much of the normal facial appearance and function as possible.
Treatment recommendations depend on the risk that the SCC will come back.
Disease Characteristics That Indicate a Higher Risk of Recurrence
- Tumor diameter > 2 cm.
- Poorly-defined borders of the cancer.
- Recurrent SCC in the area.
- Patient undergoing immune system suppression or having a disease that has compromised the immune system.
- Previous radiation therapy in the area.
- Long-term inflammation in the area.
- Rapidly-growing tumor.
- Nerve-related symptoms.
- Poorly differentiated disease.
- Adenoid, adenosquamous, metaplastic, or desmoplastic SCC subtype.
- Tumor depth > 2 mm or Clark Level of Invasion IV/V.
- Invasion into or near nerves.
Disease Characteristics That Indicate a Lower Risk of Recurrence
- Tumor diameter < 2 cm.
- Well-defined borders of the cancer.
- First-time SCC in the area.
- Patient not undergoing immune system suppression or having a disease that has compromised the immune system.
- No previous radiation therapy in the area.
- No rapidly-growing tumor.
- No nerve-related symptoms.
- Well or moderately differentiated disease.
- Tumor depth < 2 mm or Clark Level of Invasion I/II/III.
- No invasion into or near nerves.
Treatment Options for High-Risk SCC
- Excision with assessment of margins. If the margins are positive, more tissue should be removed, and radiation should be considered.
- Mohs or conventional surgical resection with complete assessment of margins around the tumor followed by radiation if the margins are still positive or if there is invasion into or around nerves.
- Radiation therapy can be used alone for patients who are not fit to undergo surgery.
- Assessment of regional lymph nodes with either sentinel lymph node biopsy or elective neck dissection.
- Systemic therapies may be considered for patients who have advanced and systemic disease and who therefore will not benefit from surgical resection or primary radiation therapy.
Treatment Options for Low-Risk SCC
- Curettage and electrodessication can be used in areas without hair. If the curettage begins to extend down into the fat, then a doctor should switch the procedure to an excision.
- Excision with assessment of margins. If the margins are positive, more tissue should be removed, and radiation should be considered.
- Radiation therapy can be used alone for patients who are not fit to undergo surgery.
If the SCC has spread to lymph nodes (either nearby in the neck or somewhere else in the body), the affected area will require treatment. For further information, see the page on metastatic lymph nodes.
Treatment of Malignant Melanoma of the Skin
Treatment for malignant melanoma should be carried out by a team that is experienced with all of the latest advances in the treatment of melanoma
Melanoma Staging
The treatment of melanoma varies by stage.
Stage 0
Also called, “in situ melanoma,” is treated with wide excision.
Stage IA
- ≤ 0.75 mm thick: Wide excision.
- 0.76 to 1 mm thick: Wide excision and potentially a sentinel lymph node biopsy (SLNB).
Stage IB
- ≤ 0.75 mm thick: Wide excision
- 0.76 – 1 mm thick: Wide excision and potentially a sentinel lymph node biopsy (SLNB)
- Negative SLNB: continue with observation or a clinical trial
- Positive SLNB: continue with the treatment recommendations for Stage III
Stage II
See sentinel lymph node biopsy (SLNB) for more information.
Stage IIa: a negative SLNB can be followed with observation or a clinical trial.
Stage IIb or IIc:
- Negative SLNB: continue with observation, interferon-alfa therapy, or a clinical trial.
- Positive SLNB: continue with the treatment recommendations for Stage III.
Stage III
Treatment involves wide excision of the primary tumor and a lymph node dissection.
- This should be followed by observation, a clinical trial, or interferon-alfa therapy.
- A doctor may also consider treating the lymph node region with radiation.
Treatment for Stage III Based on a Positive SLNB
The options include a parotidectomy, neck dissection or clinical trial. This should be followed by either observation, interferon-alfa therapy, or a clinical trial.
Treatment for Stage III Based on In-transit Metastases
In-transit metastases are tumor deposits in the lymph channels of the skin between the primary tumor and the closest neck lymph node basin.
- Complete surgical excision of the metastatic tumor, if possible.
- Local treatments such as biologic injections, local ablation, topical creams, or even radiation in some situations.
- Medication infusions.
- Biologic or chemotherapy treatments.
- Enrollment in a clinical trial.
- Treatment should be followed by observation, interferon-alfa therapy, or a clinical trial.
Stage IV
For malignant cutaneous melanoma spread to a distant site in the body, the treatment options include:
- Surgical removal of the melanoma (if the spread is limited).
- Whole body treatment using chemotherapy.
Recommended Margins of Resection
In general, when doing a wide local excision for melanoma, the recommended size for the margin of resection depends on the thickness of the tumor. Keep in mind that the standard margin recommendations may be modified to avoid distortion of certain parts of the face.
Tumor Thickness Recommended Clinical Margins In situ 0.5 cm ≤ 1.0 mm 1.0 cm 1.01 to 2 mm 1 to 2 cm 2.01 to 4 mm 2.0 cm ≥ 4 mm 2.0 cm
Treatment of Advanced Cutaneous Squamous Cell Carcinoma
Cutaneous squamous cell carcinoma (SCC) is considered “advanced” when it has metastasized to distant sites or has progressed locally beyond what can be adequately treated with surgical resection or radiation therapy. Overall, advanced cutaneous SCC makes up a very small percentage of all squamous cell carcinomas.
Despite being unresponsive to conventional therapies, other treatments such as targeted agents or checkpoint immunotherapies may be used in these rare cases. Promising data has been recently published in the medical literature about anti-PD-1 (cemiplimab-rwlc, nivolumab, pembrolizumab) and anti-CTLA-4 (iplimumab) agents that may help a cancer patient’s immune system fight back against cancerous cells.
In September of 2018, cemiplimab-rwlc (Libtayo) became the first and only FDA-approved treatment for advanced cutaneous squamous cell carcinoma after showing encouraging results in 2 clinical trials. However, due to the rarity of advanced cutaneous SCC, evidence regarding these new systemic therapies is limited and treatment must be decided on a case by case basis by your doctor.
We encourage you to speak with your doctor about FDA-approved therapies or participating in clinical trials for advanced cutaneous SCC.
Treatment of Advanced Basal Cell Carcinoma
Basal cell carcinoma (BCC) is considered “advanced” if it has metastasized or if it has progressed or recurred locally beyond what is treatable with surgery or radiation therapy. In these rare cases, specific targeted agents and immunotherapies may also be used. The FDA has approved 2 different targeted agents, Vismodegib and Sonidegib, for the treatment of advanced BCC.
Both of these drugs target a cellular pathway responsible for basal cell tumor growth called the hedgehog pathway. Patients treated with these agents demonstrated improved progression-free survival times and relatively low grade side effects (muscle spasms, alopecia, taste loss, weight loss, decreased appetite, fatigue, nausea, and diarrhea).
A major limitation to Vismodegib and Sonidegib therapies is that patients can eventually develop resistance to the drugs. Currently, there are ongoing trials testing the rate of response and durability of response in these types of agents.
We encourage you to speak with your doctor about whether you qualify for these therapies or ongoing clinical trials for advanced BCC.
