Remove or Refer - Common skin malignancies Remove or Refer

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					Planning lesion removal on the
             Remove or Refer?

      A/Prof Frank Kimble
     Dept of Plastic Surgery
     Royal Hobart Hospital
Be aware that
guidelines do
exist, deviate from
these at your own
                     Melanoma: Refer!
Most invasive
melanomas (ie
anything more than
in situ) should be
referred to a
 In Australia,most suspicious skin
lesions are diagnosed and treated
                          by GP’s

   Del Mar CB, Lowe JB. The skin cancer load in Australian
     general practice. Australian Fam Physician 1997:26
                       Suppl 1:S24-s27
                       Treat or Refer?

Your decision to treat depends upon your
 experience, skills, facilities, location,
available specialists, patient factors, and
            litigation issues
                  Principals of Surgical
• Inform pt of options     • Cosmesis and function
• Margin and Depth         • Knowledge of local
• ?Biopsy first              anatomy
• Most excised under       • If direct closure not
  local anaesthetic with     possible, local flap
  direct closure           • Histology/orientation
• Mark first then inject     suture
            Inform patient of options:
• Informed consent requires the patient to be
  informed of the diagnosis, what the proposed
  management is, consequences or potential
  complications of the proposed management,
  options of treatment that may exist, and the
  consequences of not treating the lesion.
• Unless you have covered these areas, you do not
  have informed consent!
                    Who to biopsy first?
• Diagnosis not obvious
• Suspected recurrent BCC (can look like scar
• Large tumour requiring extensive or mutilating
• Tumours in areas of cosmetic/functional
• Prior to destructive therapy eg cryotherapy,
• To delineate poorly defined tumour edges
                       Biopsy Options:

•   Excision biopsy 3 mm margin
•   Incision biopsy
•   Punch biopsy
•   Shave biopsy
•   Curettage
                                                         Incision biopsy

An incision biopsy is performed by excising an ellipse
from the edge of the lesion including some of the
normal skin in a ratio of 1:1:ie includes some of the
lesion, the edge and some normal skin. The centre of
some tumours may be necrotic and a biopsy from here
may be unhelpful
                                                            Punch biopsy

A punch biopsy is useful in getting material from non
necrotic, non ulcerated, solid lesion such as this BCC of
the nose. The photo on your right shows the equipment
required to perform a punch biopsy. If a small punch is
used, say 3 mm or less, the hole can be left unsutured
but I tend to close holes with some Nylon suture as it
helps with haemostasis, and also leaves a suture as a
mark of where the biopsy was taken from, and if the
lesion happens to be benign, the cosmetic result will be
This patient has a
SCC and will have a
punch biopsy
performed. Click on
the image to play the
          Decide on margin and depth of
• Your surgical margin will depend on your provisional
  diagnosis eg most BCCs can be removed with a 3mm
  margin. SCCs and Melanomas require wider margins.
• Remember that your surgical defect is as big as the
• Not only do you have to decide on your lateral margin, but
  you also need to know how deep to go. Lesions that are
  thick or fixed to deep structures need a decent deep
  margin taking one anatomical layer more than the involved
  layer eg if a lesion on the ear is stuck to the perichondrium,
  you need to take the underlying cartilage
         Mark first and then inject;

• This lady has a BCC of the lower lip.
  Excision with 3 mm margin is treatment of
First mark with dots the
edge of the tumour.
Magnification will
improve your accuracy.
Stretching the skin in a
BCC helps delineate the
Next mark out your surgical margin which in this case is 3 mm
Once your margin has been marked,
you can decide how you will excise
the lesion. Options include elliptical
excision, wedge excision, or a
modified wedge as shown here,
circular excision or removal of the
anatomical unit
Only once you have planned your excision and
marked it, should you infiltrate the local anaesthetic.
If you infiltrated before, you will distort tissues,
marking the lesion’s edge becomes very difficult and
when the swelling goes down the result may not be
so good
The immediate post
operative result

• Give the pathologist adequate details
  including prior therapy to the lesion
• Orientate the specimen with a marking
  suture to help in interpreting incomplete
  excisions on histological examination
          Problem Areas in the face
      requiring experience and care

•   Cosmesis
•   Function
•   Nerve damage
•   Lips,ears,nose,eyelids,scalp
•   Embryonal fusion points:canthii,grooves
    and folds
•   Always refer patients who express concerns about the cosmetic outcome of
    your surgery
•   Try to keep scars in Langer’s lines or following the junctions of the cosmetic
•   Do a pinch test to see if adjacent anatomical structures will be distorted by
    your excision e.g. lifting an eyebrow by excising a lesion on the forehead (the
    quizzical look is not in fashion!)
•   Remember that young patients (<35 years) tend to form noticeable scars
•   Patients with thick, sebaceous skin can form depressed scars
•   Always tell patients that they will have a scar and explain to them why it needs
    to be “so long’. I often, at consultation, draw out my surgical plan on the
    patients face, showing the edge of the lesion, the surgical margin, and the
    proposed excision, and why the scar is so long! Doing it before surgery is
    informed consent, doing it after surgery is an excuse the patient may not buy.
• Good surgery on the face is a marriage of
  form (cosmesis) and function
• For example, if you excise a lower
  eyelid/cheek BCC and cause a lid
  ectropion, the patient will suffer from
  epiphora. Despite getting a good scar, the
  persistent tearing will make for a very
  unhappy patient
                           Nerve Damage:
• In some areas of the face and neck, nerves can be
  surprisingly superficial and can be damaged by
  your excision
• Prior warning is informed consent, subsequent
  explanation is an excuse!
• Examples include the temporal branch of Facial
  nerve, the greater auricular nerve,
  auriculotemporal nerve, accessory nerve. Consult
  your anatomical atlases!
• If in doubt, refer!
      Lips,ears,noses,eyelids, scalp

• You should have fairly advanced surgical
  skills to deal with challenges these areas
• Refer to a specialist!
                     Embryonal fusion lines:
• Skin cancers that occur in these areas tend
  to penetrate deeply and incomplete excision
  in the deep margin is common
• Includes the nasolabial folds, alar grooves,
  alar base, inner and outer canthal areas of
  the eyes, the pre and post auricular sulcii
• Referral is advised
                     Who to refer: BCC
• Tumours>1cm            • Infiltrating, morpheic,
• Recurrent tumours        poorly defined BCCs
• Incompletely excised   • Cosmetic/functional
  tumours                  concern
• Beyond surgical         •GP unavailable for follow up
  skills:anatomy or
• Pathology of concern
          Pathology of concern:BCC

•   Incompletely excised BCC
•   Basisquamous or metatypical BCC
•   Desmoplasia
•   Large tumour size
•   Perineural invasion
•   Multifocal
       Other treatment options:BCC

•   Cryotherapy
•   Radiotherapy
•   Curettage/diathermy
•   Other: Interferon,Imiquimod,photodynamic

• For BCC, if inappropriately performed, the
  recurrence rate can exceed 40%
• Requires training just as surgery does
• Treat the lesion and its margin!
• Use 2 freeze/ thaw cycles per treatment
    Radiotherapy and non-melanoma
                       skin cancer:

• “Radiotherapy should be reserved for the
  small minority of primary BCC and SCC
  that present peculiar problems for
  conventional surgery, and for cases of
  persistent,recurrent or advanced BCC and
  SCC where surgery can be complimented
  by radiotherapy to improve control rates in
  this small poor prognosis category”
                       Solar keratosis:

• 1 in 1000/year become SCC
• Beware of thickening and tenderness
• Options:watch,cryotherapy,5FU,laser,shave,
  chemical peel,sunscreens,retinoids
             SCC in situ aka Bowens

• Sharply defined,erythematous,
• Low rate of transformation
• Surgery,radiotherapy,cryotherapy,
                           Invasive SCC

• More aggressive,local recurrence, nodal
• Surgery treatment of choice (margin 4-
• Refer large(>1cm),scalp,lip,ear,nose,
  perineural invasion,recurrence,?nodal

• Is a well differentiated SCC that is
  characterised by spontaneous resolution
• Punch biopsy unhelpful, whole lesion
  required to make a diagnosis
• Excision biopsy recommended
This 28 year old male, a smoker
and out door worker, has an
invasive moderately
differentiated SCC of the lower
lip. The lesion is to be removed
with a 1 cm margin requiring
sacrifice of the left half of the
lower lip. Rather than a circular
excision, the hemi cosmetic unit
is removed to facilitate a good
The immediate post operative result
with the lip having been
reconstructed with a cheek
advancement flap. SCCs are more
aggressive and require more
aggressive surgery with wider
margins. Nodal spread is more
common in lip, nose, ear, eyelid and
scalp lesions.
        Cure first, then reconstruct!
• Your first obligation to the patient is to do
  your best to cure them
• Never scrimp on your surgical margin to
  tailor it to your reconstructive abilities
• If a decent hole needs to be made and you
  don’t know how to close it, refer it to
  someone who can! And before you make
  the hole!!!!!!
          The end

FK 2006

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