General Information About Skin Cancer
Skin cancer is a disease in which malignant (cancer) cells form in
the tissues of the skin.
The skin is the body’s largest organ. It protects against heat,
sunlight, injury, and infection. Skin also helps control body temperature and stores water, fat, and vitamin D. The skin has several layers, but the two main layers are the epidermis (upper or outer layer) and the dermis (lower or inner layer). Skin cancer begins in the epidermis, which is made up of 3 kinds of cells:
- Squamous cells: Thin, flat cells that form the top layer of the epidermis.
- Basal cells: Round cells under the squamous cells.
- Melanocytes: Found
in the lower part of the epidermis, these cells make melanin, the pigment
that gives skin its natural color. When skin is exposed to the sun, melanocytes
make more pigment, causing the skin to darken.
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| Anatomy of the skin, showing the epidermis, dermis, and subcutaneous tissue. |
Skin cancer can occur anywhere on the body, but it is most common in skin that is often exposed to sunlight, such as the face, neck, hands, and arms. There are several types of cancer that start in the skin. The most common types are basal cell carcinoma and squamous cell carcinoma, which are nonmelanoma skin cancers. Actinic keratosis is a skin condition that sometimes develops into squamous cell carcinoma.
This summary refers to the treatment of nonmelanoma skin cancer and actinic keratosis. Nonmelanoma skin cancers rarely spread to other parts of the body. Melanoma, the rarest form of skin cancer, is more likely to invade nearby tissues and spread to other parts of the body. See the following PDQ summaries for information on melanoma and other kinds of skin cancer:
- Melanoma Treatment
- Mycosis Fungoides and the Sézary Syndrome Treatment
- Kaposi Sarcoma Treatment
Skin color and exposure to sunlight can affect the risk of developing nonmelanoma skin cancer and actinic keratosis.
Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for basal cell carcinoma and squamous cell carcinoma include the following:
- Being exposed to a lot of natural or artificial sunlight.
- Having a fair complexion (blond or red hair, fair skin, green or blue eyes, history of freckling).
- Having scars or burns on the skin.
- Being exposed to arsenic.
- Having chronic skin inflammation or skin ulcers.
- Being treated with radiation.
- Taking immunosuppressivedrugs (for example, after an organ transplant).
- Having actinic keratosis.
Risk factors for actinic keratosis include the following:
- Being exposed to a lot of sunlight.
- Having a fair complexion (blond or red hair, fair skin, green or blue eyes, history of freckling).
Nonmelanoma skin cancer and actinic keratosis often appear as a change in the skin.
Not all changes in the skin are a sign of nonmelanoma skin cancer or actinic keratosis, but a doctor should be consulted if changes in the skin are seen.
Possible signs of nonmelanoma skin cancer include the following:
- A sore that does not heal.
- Areas of the skin that are:
- Small, raised, smooth, shiny, and waxy.
- Small, raised, and red or reddish-brown.
- Flat, rough, red or brown, and scaly.
- Scaly, bleeding, or crusty.
- Similar to a scar and firm.
Possible signs of actinic keratosis include the following:
- A rough, red, pink, or brown, raised, scaly patch on the skin.
- Cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.
Tests or procedures that examine the skin are used to detect (find)
and diagnose nonmelanoma skin cancer and actinic keratosis.
The following procedures may be used:
- Skin examination: A doctor or nurse checks the skin for bumps or spots that look abnormal in color, size, shape, or texture.
- Biopsy: All or part of the abnormal-looking growth is cut from the skin and viewed under a microscope by a pathologist to see if cancer cells are present. There are 3 main types of skin biopsies:
- Shave biopsy: A sterile razor blade is used to “shave-off” the abnormal-looking growth.
- Punch biopsy: A special instrument called a punch or a trephine is used to remove a circle of tissue from the abnormal-looking growth.
 |
| Punch biopsy. A hollow, circular scalpel is used to cut into a lesion on the skin. The instrument is turned clockwise and counterclockwise to cut down about 4 millimeters (mm) to the layer of fatty tissue below the dermis. A small sample of tissue is removed to be checked under a microscope. Skin thickness is different on different parts of the body. |
- Excisional biopsy: A scalpel is used to remove the entire growth.
Certain factors affect prognosis (chance
of recovery) and treatment options.
The prognosis (chance of recovery) depends mostly on the stage of the cancer and the type of treatment used to remove the cancer.
Treatment options depend on the following:
- The stage of the cancer (whether it has spread deeper into the skin or to other places in the body).
- The type of cancer.
- The size and location of the tumor.
- The patient’s general health.
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Stages of Skin Cancer
After nonmelanoma skin cancer has been diagnosed, tests are done to find out
if cancer cells have spread within the skin or to other parts of the body.
The process used to find out if cancer has spread within the skin or
to other parts of the body is called staging. The information gathered from the
staging process determines the stage of the disease. It is important to know
the stage in order to plan treatment. A biopsy is often the only test needed to determine the stage of nonmelanoma skin cancer. Lymph nodes may be examined in cases of squamous cell carcinoma to see if cancer has spread to them.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
- Through tissue. Cancer invades the surrounding normal tissue.
- Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
- Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
The following stages are used for nonmelanoma skin cancer:
Stage 0 (Carcinoma in Situ)
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| Stage 0 nonmelanoma. Abnormal cells are shown in the epidermis (outer layer of the skin). |
In stage 0, abnormalcells are found in the squamous cell or basal cell layer of the epidermis (topmost layer of the skin). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also
called carcinoma in situ.
|
| Pea, peanut, walnut, and lime show tumor sizes. |
Stage I
|
| Stage I nonmelanoma skin cancer. The tumor is no more than 2 centimeters. |
In stage I, cancer has formed and the
tumor is 2 centimeters or smaller.
Stage II
|
| Stage II nonmelanoma skin cancer. The tumor is more than 2 centimeters wide. |
In stage II, the
tumor is larger than 2 centimeters.
Stage III
|
| Stage III nonmelanoma skin cancer. The tumor has spread below the skin to nearby tissues and/or lymph nodes. |
In stage III, cancer
has spread below the skin to cartilage, muscle, or bone and/or to nearby lymph nodes, but not to other parts of the body.
Stage IV
|
| Stage IV nonmelanoma skin cancer. The tumor has spread to other places in the body, such as the brain or lung. |
In stage IV, cancer
has spread to other parts of the body.
Treatment choices are based on the type of nonmelanoma skin cancer or precancerous skin condition diagnosed:
Basal cell carcinoma
Basal cell carcinoma is the most common type of skin cancer. It usually occurs on areas of the skin that have been in the sun, most often the nose. Often this cancer appears as a small raised bump that has a smooth, pearly appearance. Another type looks like a scar and is flat and firm to the touch. Basal cell carcinoma may spread to tissues around the cancer, but it usually does not spread to other parts of the body.
Squamous cell carcinoma
Squamous cell carcinoma occurs on areas of the skin that have been in the sun, such as the ears, lower lip, and the back of the hands. Squamous cell carcinoma may also appear on areas of the skin that have been burned or exposed to chemicals or radiation. Often this cancer appears as a firm red bump. Sometimes the tumor may feel scaly or bleed or develop a crust. Squamous cell tumors may spread to nearby lymph nodes.
Actinic keratosis
Actinic keratosis is a skin condition that is not cancer, but sometimes changes into squamous cell carcinoma. It usually occurs in areas that have been exposed to the sun, such as the face, the back of the hands, and the lower lip. It appears as rough, red, pink, or brown, raised, scaly patches on the skin, or cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.
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Treatment Option Overview
There are different types of treatment for patients with nonmelanoma skin
cancer and actinic keratosis.
Different types of treatment are available for patients with nonmelanoma skin
cancer and actinic keratosis. Some treatments are standard (the currently used treatment), and some
are being tested in clinical trials.
A treatment clinical trial is a research study meant to help
improve current treatments or obtain information on new treatments for patients
with cancer. When clinical trials show that a new treatment is better than the
standard treatment, the new
treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Four types of standard treatment are used:
Surgery
One or more of the following surgical procedures may be used to treat nonmelanoma skin cancer or actinic keratosis:
- Mohs micrographic surgery: The tumor is cut from the skin in thin layers. During surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used to remove skin cancer on the face.
 |
| Mohs surgery. A surgical procedure to remove skin cancer in several steps. First, a thin layer of cancerous tissue is removed. Then, a second thin layer of tissue is removed and viewed under a microscope to check for cancer cells. More layers are removed one at a time until the tissue viewed under a microscope shows no remaining cancer. This type of surgery is used to remove as little normal tissue as possible and is often used to remove skin cancer on the face. |
- Simple excision: The tumor is cut from the skin along with some of the normal skin around it.
- Shave excision: The abnormal area is shaved off the surface of the skin with a small blade.
- Electrodesiccation and curettage: The tumor is cut from the skin with a curette (a sharp, spoon-shaped tool). A needle-shaped electrode is then used to treat the area with an electric current that stops the bleeding and destroys cancer cells that remain around the edge of the wound. The process may be repeated one to three times during the surgery to remove all of the cancer.
- Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormaltissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
 |
| Cryosurgery. An instrument with a nozzle is used to spray liquid nitrogen or liquid carbon dioxide to freeze and destroy abnormal tissue. |
- Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
- Dermabrasion: Removal of the top layer of skin using a rotating wheel or small particles to rub away skin cells.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Chemotherapy for nonmelanoma skin cancer and actinic keratosis is usually topical (applied to the skin in a cream or lotion). The way the chemotherapy is given depends on the condition being treated.
Retinoids (drugs related to vitamin A) are sometimes used to treat or prevent nonmelanoma skin cancer. The retinoids may be taken by mouth or applied to the skin. The use of retinoids is being studied in clinical trials for treatment of squamous cell carcinoma.
Photodynamic therapy
Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. For skin cancer, laser light is shined onto the skin and the drug becomes active and kills the cancer cells. Photodynamic therapy causes little damage to healthy tissue.
New types of treatment are being tested in clinical trials.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web
site.
Biologic therapy
Biologic
therapy is a treatment that uses the patient’s immune system to fight
cancer. Substances made by the body or made in a laboratory are used to boost,
direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's clinical trials database.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
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Treatment Options for Nonmelanoma Skin Cancer
A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.
Basal Cell Carcinoma
Treatment of basal cell carcinoma may include the following:
- Mohs micrographic surgery.
- Simple excision.
- Electrodesiccation and curettage.
- Cryosurgery.
- Radiation therapy.
- Laser surgery.
- Topical chemotherapy with fluorouracil.
- Photodynamic therapy.
- A clinical trial of biologic therapy.
Follow-up skin exams are important for people with basal cell carcinoma because they are likely to have a new or recurrent tumor within 5 years of the first one. After treatment, the patient should have skin exams every 6 months for 5 years and once a year after that.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with basal cell carcinoma of the skin. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Squamous Cell Carcinoma
Treatment of squamous cell carcinoma may include the following:
- Mohs micrographic surgery.
- Simple excision.
- Electrodesiccation and curettage.
- Cryosurgery.
- Radiation therapy.
- Topical chemotherapy with fluorouracil.
- Laser surgery.
- A clinical trial of biologic therapy.
- A clinical trial of biologic therapy and retinoids.
Follow-up skin exams are important for people with squamous cell carcinoma. Because squamous cell carcinoma can spread, patients should have skin exams every 3 months for several years after treatment and then every 6 months.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with squamous cell carcinoma of the skin. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
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Treatment Options for Actinic Keratosis
Actinic keratosis is not cancer but is treated because it may develop into cancer. Treatment of actinic keratosis may include the following:
- Topical chemotherapy.
- Cryosurgery.
- Electrodesiccation and curettage.
- Dermabrasion.
- Shave excision.
- Laser surgery.
- Photodynamic therapy.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with actinic keratosis. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
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To Learn More About Skin Cancer
For more information from the National Cancer Institute about skin cancer, see the following:
For general cancer information and other resources from the National Cancer Institute, see the following:
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This information is provided by the National Cancer Institute.
This information was last updated on March 31, 2009.
Purpose of This PDQ Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of skin cancer. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board.
Information about the following is included in this summary:
- Clinical features.
- Cellular classification.
- Staging.
- Treatment options for different types of tumors.
This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for reimbursement determinations.
This summary is available in a patient version, written in less technical language, and in Spanish.
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General Information
Note: Separate PDQ summaries on Screening for Skin Cancer and Prevention of
Skin Cancer are also available.
Basal cell carcinoma is the most common form of skin cancer, and squamous cell carcinoma is the second most
common type of skin malignancy. Although the two
types of skin cancer are the most common of all malignancies, they account for less than 0.1% of patient deaths caused by cancer. Both of these types of skin
cancer are more likely to occur in individuals of light complexion who have had
significant exposure to sunlight, and both types of skin cancer are more
common in the southern latitudes of the Northern hemisphere.[1]
The overall
cure rate for basal cell carcinoma and squamous cell carcinoma is directly related to the stage of the
disease and the type of treatment used.[2] Since neither basal
cell carcinoma nor squamous cell carcinoma are reportable diseases,
precise 5-year cure rates are not known.
Although basal cell carcinoma and
squamous cell carcinoma are by far the most frequent types of skin tumors, the
skin can also be the site of a large variety of malignant neoplasms. Other types of malignant disease include malignant melanoma, cutaneous T-cell
lymphomas (e.g., mycosis fungoides), Kaposi sarcoma, extramammary Paget disease,
apocrine carcinoma of the skin, and metastatic malignancies from various
primary sites. (Refer to the PDQ summaries on Melanoma Treatment; Mycosis Fungoides and the Sézary Syndrome Treatment; and Kaposi Sarcoma Treatment for more
information.) Guidelines for the care of cutaneous squamous cell carcinoma
have been published.[3]
References:
Wagner RF, Casciato DA: Skin cancers. In: Casciato DA, Lowitz BB, eds.: Manual of Clinical Oncology. 4th ed. Philadelphia, Pa: Lippincott, Williams, and Wilkins, 2000, pp 336-373.
Rowe DE, Carroll RJ, Day CL Jr: Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 15 (3): 315-28, 1989.
Guidelines of care for cutaneous squamous cell carcinoma. Committee on Guidelines of Care. Task Force on Cutaneous Squamous Cell Carcinoma. J Am Acad Dermatol 28 (4): 628-31, 1993.
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Cellular Classification
Basal cell carcinoma and squamous cell carcinoma are both of epithelial origin.
They are usually diagnosed on the basis of routine histopathology.[1] Squamous
cell carcinoma is graded 1 to 4 based on the proportion of differentiating
cells present, the degree of atypicality of tumor cells, and the depth of tumor
penetration.[2] Apocrine carcinomas, which are rare, are associated with an
indolent course and usually arise in the axilla.[3]
References:
Lever WF, Schaumburg-Lever G: Histopathology of the Skin. New York: JB Lippincott, 6th ed., 1983.
Immerman SC, Scanlon EF, Christ M, et al.: Recurrent squamous cell carcinoma of the skin. Cancer 51 (8): 1537-40, 1983.
Paties C, Taccagni GL, Papotti M, et al.: Apocrine carcinoma of the skin. A clinicopathologic, immunocytochemical, and ultrastructural study. Cancer 71 (2): 375-81, 1993.
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Stage Information
Basal cell carcinoma rarely metastasizes, and thus a metastatic work-up is
usually not necessary.[1] Regional lymph nodes should be routinely examined in
all cases of squamous cell carcinoma, especially for high-risk tumors appearing
on the lips, ears, perianal and perigenital regions, or high-risk areas of the
hand.[2] In addition, regional lymph nodes should be examined in cases of
squamous cell carcinoma arising in sites of chronic ulceration or inflammation,
burn scars, or sites of previous radiation therapy treatment.
The American Joint Committee on Cancer (AJCC) has designated staging by TNM
classification.[3] The TNM classification is used to stage both basal cell
carcinoma and squamous cell carcinoma.
TNM Definitions
Primary tumor (T)
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in situ
- T1: Tumor not larger than 2 cm in greatest dimension
- T2: Tumor larger than 2 cm but not larger than 5 cm in greatest dimension
- T3: Tumor larger than 5 cm in greatest dimension
- T4: Tumor invades deep extradermal structures (e.g., cartilage, skeletal
muscle, or bone)
In the case of multiple simultaneous tumors, the tumor with the highest T
category will be classified, and the number of separate tumors will be indicated
in parentheses, e.g., T2 (5).
Regional lymph nodes (N)
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Regional lymph node metastasis
Distant metastasis (M)
- MX: Distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
AJCC Stage Groupings
Stage 0
Stage I
Stage II
Stage III
Stage IV
Basal cell carcinoma
Basal cell carcinoma is at least three times more common than squamous cell
carcinoma in nonimmunocompromised patients. It usually occurs on sun-exposed
areas of skin, and the nose is the most frequent site. Although there are many
different clinical presentations for basal cell carcinoma, the most
characteristic type is the asymptomatic nodular or nodular ulcerative lesion
that is elevated from the surrounding skin and has a pearly quality and
contains telangiectatic vessels. Basal cell carcinoma
has a tendency to be locally destructive. High-risk areas for tumor recurrence
include the central face (e.g., periorbital region, eyelids, nasolabial fold,
or nose-cheek angle), postauricular region, pinna, ear canal, forehead, and
scalp.[4] A specific subtype of basal cell carcinoma is the morpheaform type.
This subtype typically appears as a scar-like, firm plaque. Because of indistinct
clinical tumor margins, the morpheaform type is difficult to treat adequately with traditional
treatments.[1]
Squamous cell carcinoma
Squamous cell tumors also tend to occur on sun-exposed portions of the skin
such as the ears, lower lip, and dorsa of the hand. However, squamous cell
carcinomas that arise in areas of non–sun-exposed skin or that originate de
novo on areas of sun-exposed skin are prognostically worse since they have a
greater tendency to metastasize. Chronic sun damage, sites of prior burns,
arsenic exposure, chronic cutaneous inflammation as seen in long standing skin
ulcers, and sites of previous x-ray therapy are predisposed to the development
of squamous cell carcinoma.[1]
Actinic keratosis
Actinic keratoses are potential precursors of squamous cell carcinoma. These
typical red scaly patches usually arise on areas of chronically sun-exposed
skin, and are likely to be found on the face and dorsal aspects of the hand.
Although the vast majority of actinic keratoses do not become squamous cell
carcinomas, as many as 5% of actinic keratoses will evolve
into this locally invasive carcinoma. Due to this premalignant potential, the
destruction of actinic keratoses is advocated.[1]
References:
Wagner RF, Casciato DA: Skin cancers. In: Casciato DA, Lowitz BB, eds.: Manual of Clinical Oncology. 4th ed. Philadelphia, Pa: Lippincott, Williams, and Wilkins, 2000, pp 336-373.
Rayner CR: The results of treatment of two hundred and seventy-three carcinomas of the hand. Hand 13 (2): 183-6, 1981.
Carcinoma of the skin (excluding eyelid, vulva, and penis). In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 203-208.
Dubin N, Kopf AW: Multivariate risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 119 (5): 373-7, 1983.
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Basal Cell Carcinoma of the Skin
The traditional methods of treatment involve the use of cryosurgery, radiation
therapy, electrodesiccation and curettage, and simple excision. Each of these
methods is useful in specific clinical situations.[1] Depending on case
selection, these methods have cure rates ranging from 85% to 95%.
Mohs
micrographic surgery has the highest 5-year cure
rates for surgical treatment of both primary (96%) and recurrent (90%) tumors.
This method uses microscopic control to evaluate the extent of tumor invasion.
Treatment options:
- Mohs micrographic surgery.[2][3] Although this method is complicated and
requires special training, it has the highest cure rate of all surgical
treatments because the tumor is microscopically delineated until it is
completely removed. While other treatment methods for recurrent basal cell
carcinoma have failure rates of about 50%, cure rates have been reported at 96%
when treated by Mohs micrographic surgery. In addition, its use is indicated for
the treatment of primary basal cell carcinomas when they occur at sites known
to have a high initial-treatment failure rate with traditional methods
(e.g., periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus,
pinna, ear canal, forehead, scalp, or tumors arising in a scar). Mohs
micrographic surgery is also indicated for:
- Tumors with poorly defined clinical
borders.
- Tumors with diameters more than 2 cm.
- Tumors with histopathologic
features showing morpheaform or sclerotic patterns.
- Tumors arising in
regions where maximum preservation of uninvolved tissue is desirable such as
the eyelid, nose, finger, and genitalia.
- Simple excision with frozen or permanent sectioning for margin evaluation.
This traditional surgical treatment usually relies on surgical margins ranging
from 3 mm to 10 mm, depending on the diameter of the tumor.[4]
Tumor recurrence
is not uncommon because only a small fraction of the total tumor margin is
examined pathologically. Recurrence rate for primary tumors more than 1.5
cm in diameter is at least 12% within 5 years; if the primary tumor measures
more than 3 cm, the 5-year recurrence rate is 23.1%. Primary tumors of the
ears, eyes, scalp, and nose have recurrence rates ranging from 12.9% to 25%.
- Electrodesiccation and curettage. This method is the most widely employed
method for removing primary basal cell carcinomas. Although it is a quick
method for destroying the tumor, adequacy of treatment cannot be assessed
immediately since the surgeon cannot visually detect the depth of microscopic
tumor invasion.
Tumors with diameters ranging from 2 mm to 5 mm have a 15% recurrence rate after
treatment with electrodesiccation and curettage. When tumors more than 3 cm
are treated with electrodesiccation and curettage, a 50% recurrence rate should
be expected within 5 years.
- Cryosurgery. Cryosurgery may be considered for patients with small, clinically well-defined primary tumors. It is especially useful for debilitated patients with
medical conditions that preclude other types of surgery.
Absolute
contraindications for cryosurgery include abnormal cold
tolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud disease (only for
treatment of lesions on hands and feet), and platelet deficiency disorders.
Morphea or sclerosing basal cell carcinoma should not be treated by
cryosurgery. Relative contraindications to cryosurgery include tumors of the
scalp, ala nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid
margin, upper lip vermillion border, and lower legs. Caution should also be used before treating nodular ulcerative neoplasia more than 3 cm,
carcinomas fixed to the underlying bone or cartilage, tumors situated on the
lateral margins of the fingers and at the ulnar fossa of the elbow, or
recurrent carcinomas following surgical excision. Significant
morbidity is associated with the use of cryosurgery.
Edema is common following
treatment, especially around the periorbital region, temple, and forehead.
Treated tumors usually exude necrotic material after which an eschar forms and
persists for about 4 weeks. Permanent pigment loss at the treatment site is
unavoidable. Atrophy and hypertrophic scarring have been reported as well as
instances of motor and sensory neuropathy.
- Radiation therapy. Radiation therapy is a logical treatment choice, particularly
for patients with primary lesions requiring difficult or extensive surgery (e.g., eyelids,
nose, or ears).[5] Radiation therapy eliminates the need for skin grafting when surgery would
result in an extensive defect. Cosmetic results are generally good to excellent with a small amount of hypopigmentation or telangiectasia in the
treatment port. Radiation therapy can also be used for lesions that recur
after a primary surgical approach.[6]
Radiation therapy is contraindicated for
patients with xeroderma pigmentosum, epidermodysplasia verruciformis, or the
basal cell nevus syndrome because it may induce more tumors in the treatment
area.
- Carbon dioxide laser. This method is most frequently applied to the
superficial type of basal cell carcinoma. It may be considered when a bleeding
diathesis is present, since bleeding is unusual when this laser is used.
- Topical fluorouracil (5-FU). This method may be helpful in the management
of selected patients with superficial basal cell carcinomas. Careful and prolonged follow-up
is required, since deep follicular portions of the tumor may escape treatment
and result in future tumor recurrence.[7]
- Interferon alpha. Several early studies have shown variable responses of
basal cell carcinoma to intralesional interferon alpha.[8][9] Further reports
are awaited until this treatment may be recommended for routine clinical
practice.
- Photodynamic therapy.[10] Photodynamic therapy with photosensitizers may be
effective treatment for patients with superficial epithelial skin tumors.[11]
Follow-up:
- Following treatment for basal cell carcinoma, patients should be clinically
examined every 6 months for 5 years.[12] Thereafter, patients should be
examined for recurrent tumors or new primary tumors at yearly intervals. Of the patients who develop a basal cell
carcinoma, 36% will develop a second primary basal cell carcinoma within the next 5
years. Early diagnosis and treatment of recurrent basal cell carcinomas or
another primary basal cell carcinoma is desirable since the treatment of the
disease in its earliest stages results in less patient morbidity.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
basal cell carcinoma of the skin. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.
Malhotra R, Huilgol SC, Huynh NT, et al.: The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology 111 (4): 631-6, 2004.
Thomas RM, Amonette RA: Mohs micrographic surgery. Am Fam Physician 37 (3): 135-42, 1988.
Abide JM, Nahai F, Bennett RG: The meaning of surgical margins. Plast Reconstr Surg 73 (3): 492-7, 1984.
Caccialanza M, Piccinno R, Moretti D, et al.: Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: results in 405 lesions. Eur J Dermatol 13 (5): 462-5, 2003 Sep-Oct.
Lovett RD, Perez CA, Shapiro SJ, et al.: External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 19 (2): 235-42, 1990.
Dabski K, Helm F: Topical chemotherapy. In: Schwartz RA: Skin Cancer: Recognition and Management. New York, NY: Springer-Verlag, 1988, pp 378-389.
Greenway HT, Cornell RC, Tanner DJ, et al.: Treatment of basal cell carcinoma with intralesional interferon. J Am Acad Dermatol 15 (3): 437-43, 1986.
Padovan I, Brodarec I, Ikić D, et al.: Effect of interferon in therapy of skin and head and neck tumors. J Cancer Res Clin Oncol 100 (3): 295-310, 1981.
Wilson BD, Mang TS, Stoll H, et al.: Photodynamic therapy for the treatment of basal cell carcinoma. Arch Dermatol 128 (12): 1597-601, 1992.
Wolf P, Rieger E, Kerl H: Topical photodynamic therapy with endogenous porphyrins after application of 5-aminolevulinic acid. An alternative treatment modality for solar keratoses, superficial squamous cell carcinomas, and basal cell carcinomas? J Am Acad Dermatol 28 (1): 17-21, 1993.
Rowe DE, Carroll RJ, Day CL Jr: Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 15 (3): 315-28, 1989.
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Squamous Cell Carcinoma of the Skin
Localized squamous cell carcinoma of the skin is a highly curable disease.[1]
The traditional methods of treatment involve the use of cryosurgery, radiation
therapy, electrodesiccation and curettage, and simple excision. Each of these
methods may be useful in specific clinical situations.
Of all treatment
methods available, Mohs micrographic surgery has the highest 5-year cure rate
for both primary and recurrent tumors. This method uses microscopic control to
evaluate the extent of tumor invasion. Lymphadenectomy is indicated when
regional lymph nodes are involved.
Treatment options:
- Mohs micrographic surgery.[2] Although this method is complicated and
requires special training, it has the highest cure rate of all surgical
treatments because the tumor is microscopically delineated until it is
completely removed. It is indicated for the treatment of:
- primary squamous cell
carcinomas when they occur at sites known to have a high initial treatment
failure rate following traditional methods;
- primary tumors with poorly defined
clinical borders, primary tumors with diameters more than 2 cm; or
- primary
tumors arising in regions where the maximum preservation of uninvolved tissue
is desirable such as the face, head, and genitalia.
Mohs micrographic surgery should be used for
squamous cell carcinomas that show perineural invasion since tumor transit
along nerves may extend many centimeters away from the primary or recurrent
tumor site.[3] Recurrent squamous cell carcinomas can also be treated with
this technique.
- Simple excision with frozen or permanent sectioning for margin evaluation.
This traditional surgical treatment usually relies on surgical margins ranging
from 3 mm to 10 mm, depending on the diameter of the original tumor.[4] Tumor
recurrence is not uncommon because only a small fraction of the total tumor
margin is examined pathologically.
- Electrodesiccation and curettage. This is a quick method for destroying the
tumor, but the adequacy of treatment cannot be assessed immediately since the
surgeon cannot visually detect the depth of microscopic tumor invasion. It
should be reserved for very small primary tumors since this disease has
metastatic potential.
- Cryosurgery. Cryosurgery is used for patients with clinically well-defined in situ tumors.
It is especially useful for debilitated patients with medical conditions that
preclude other types of surgery.
Absolute contraindications for
cryosurgery include abnormal cold tolerance, cryoglobulinemia,
cryofibrinogenemia, Raynaud disease, and platelet deficiency disorders.
Relative contraindications to cryosurgery include tumors of the scalp, ala
nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid margin, upper
lip vermillion border, and lower legs. Caution should also be used before
treating nodular ulcerative neoplasia more than 3 cm, carcinomas fixed to
the underlying bone or cartilage, tumors situated on the lateral margins of the
fingers and at the ulnar fossa of the elbow, or recurrent carcinomas following
surgical excision. Significant morbidity is associated with the use of
cryosurgery.
Edema is common following treatment, especially around the
periorbital region, temple, and forehead. Treated tumors usually exude
necrotic material after which an eschar forms and persists for about 4 weeks.
Permanent pigment loss at the treatment site is unavoidable. Atrophy and
hypertrophic scarring have been reported as well as instances of motor and
sensory neuropathy.
- Radiation therapy. Radiation therapy is a logical treatment choice, particularly for
patients with primary lesions requiring difficult or extensive surgery (e.g., eyelids, nose,
or ears).[5] Radiaiton therapy eliminates the need for skin grafting when surgery would result in
an extensive defect. Cosmetic results are generally good to excellent with a
small amount of hypopigmentation or telangiectasia in the treatment port.
Radiation therapy can also be utilized for lesions that recur after a primary
surgical approach.[6]
Radiation therapy is contraindicated for patients with
xeroderma pigmentosum, epidermodysplasia verruciformis, or the basal cell nevus
syndrome because it may induce more tumors in the treatment area.
- Topical fluorouracil (5-FU). This method may be helpful in the management of
selected in situ squamous cell carcinomas (Bowen disease). Careful and
prolonged follow-up is required since deep follicular portions of the tumor may
escape treatment and result in future tumor recurrence.[7]
- Carbon dioxide laser. This method may be helpful in the management of
selected squamous cell carcinoma in situ. It may be considered when a bleeding
diathesis is present, since bleeding is unusual when this laser is used.
- Interferon alpha. Clinical trials are ongoing to treat squamous cell
carcinoma with intralesional interferon alpha.[8] The results should be
available in several years. One report shows the combination of interferon
alpha and retinoids is effective treatment for squamous cell carcinoma.[9]
Follow-up:
- Since squamous cell carcinomas have definite metastatic potential, patients should be re-examined every 3 months for the first several years and
then followed indefinitely at 6-month intervals.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
squamous cell carcinoma of the skin. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.
Thomas RM, Amonette RA: Mohs micrographic surgery. Am Fam Physician 37 (3): 135-42, 1988.
Cottel WI: Perineural invasion by squamous-cell carcinoma. J Dermatol Surg Oncol 8 (7): 589-600, 1982.
Abide JM, Nahai F, Bennett RG: The meaning of surgical margins. Plast Reconstr Surg 73 (3): 492-7, 1984.
Caccialanza M, Piccinno R, Moretti D, et al.: Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: results in 405 lesions. Eur J Dermatol 13 (5): 462-5, 2003 Sep-Oct.
Lovett RD, Perez CA, Shapiro SJ, et al.: External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 19 (2): 235-42, 1990.
Dabski K, Helm F: Topical chemotherapy. In: Schwartz RA: Skin Cancer: Recognition and Management. New York, NY: Springer-Verlag, 1988, pp 378-389.
Padovan I, Brodarec I, Ikić D, et al.: Effect of interferon in therapy of skin and head and neck tumors. J Cancer Res Clin Oncol 100 (3): 295-310, 1981.
Lippman SM, Parkinson DR, Itri LM, et al.: 13-cis-retinoic acid and interferon alpha-2a: effective combination therapy for advanced squamous cell carcinoma of the skin. J Natl Cancer Inst 84 (4): 235-41, 1992.
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Actinic Keratosis
Actinic keratosis commonly appears in regions of chronic sun exposure such as
the face and dorsa of the hands. Actinic cheilitis is a related condition that
usually appears on the lower lips.[1] These conditions represent early epithelial
transformation that may eventually evolve into invasive squamous cell
carcinoma. Actinic keratosis is a premalignant condition that should be
treated with one of the methods available.[2]
Treatment options:
- Topical agents:
- Fluorouracil (5-FU): Treats the clinically obvious disease as well
as regions of subclinical involvement.
- Imiquimod 5% cream.[3][4][5]
- Diclofenac sodium 3% gel.
- Trichloroacetic acid.
- Phenol.
- Cryosurgery.
- Electrodesiccation and curettage.
- Dermabrasion.
- Shave excision.
- Carbon dioxide laser.
- Photodynamic therapy.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
actinic keratosis. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Picascia DD, Robinson JK: Actinic cheilitis: a review of the etiology, differential diagnosis, and treatment. J Am Acad Dermatol 17 (2 Pt 1): 255-64, 1987.
Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.
Lebwohl M, Dinehart S, Whiting D, et al.: Imiquimod 5% cream for the treatment of actinic keratosis: results from two phase III, randomized, double-blind, parallel group, vehicle-controlled trials. J Am Acad Dermatol 50 (5): 714-21, 2004.
Tran H, Chen K, Shumack S: Summary of actinic keratosis studies with imiquimod 5% cream. Br J Dermatol 149 (Suppl 66): 37-9, 2003.
Lee PK, Harwell WB, Loven KH, et al.: Long-term clinical outcomes following treatment of actinic keratosis with imiquimod 5% cream. Dermatol Surg 31 (6): 659-64, 2005.
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More Information
About PDQ
Additional PDQ Summaries
Important:
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
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This information is provided by the National Cancer Institute.
This information was last updated on January 4, 2008.