COMMONLY PERFORMED PROCEDURES SKIN CANCER SURGERY In many instances, you will arrive at the surgeon's office with a diagnosis of skin cancer already having been made. Typically, a lesion on the skin is biopsied in the office by your primary care physician or dermatologist, and you are sent to the surgeon for definitive treatment of the skin cancer. The three most common types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and melanoma. Office biopsy procedures include shave biopsies and punch biopsies and are performed under local anesthesia. A shave biopsy involves removing a superficial sample of skin, and is generally adequate for establishing a diagnosis. However, if a melanoma is diagnosed, an additional biopsy is usually necessary to determine how deep through the skin the cancer penetrates. A punch biopsy, on the other hand, samples the full thickness of the skin, so the depth of a melanoma can usually be accurately assessed. However, if the lesion is large, the punch biopsy may not adequately sample the entire lesion, so an excisional biopsy may become necessary. An excisional biopsy is usually not performed in the office, but requires a minor procedure room, and involves removing the entire lesion for assessment. Treatment of skin cancers varies with the type of cancer, but operative excision is the primary method of treatment. For small basal cell cancers and squamous cell cancers, excision of the lesion with a normal rim of skin is usually adequate for cure. For larger lesions, removing a wider margin of 1 cm around the lesion may be necessary. In general, basal cell cancers and squamous cell cancers have a low propensity to spread, so lymph nodes do not need to be examined. The larger the lesion, however, the greater the chance for spread, so treatment is tailored to the individual patient. Also, basal cell cancers and squamous cell cancers can recur, so follow-up is important. Unlike non-melanoma skin cancers, melanoma does have a tendency to spread or metastasize. The treatment of melanoma is primarily operative, involving wide excision with appropriate margins and sampling of lymph nodes if indicated. The deeper the melanoma, the greater the chance for spread to lymph nodes. Melanomas less than 1 mm thick (also known as thin melanomas) have a low likelihood of spread, and wide excision with 1 cm margins is adequate treatment. Melanoma in situ, which is a premalignant lesion, does not spread, and can be cured with wide excision as well. In certain instances, however, thin melanomas may display worrisome features, and require a lymph node biopsy (the sentinel lymph node procedure is explained below). The treatment of melanoma is tailored to the individual patient. If a melanoma is intermediate in thickness (1-4 mm) or thick (> 4mm), wide excision with 2 cm margins (almost one inch) around the cancer and a sentinel lymph node biopsy is recommended. A complete lymph node dissection, rather than a sentinel node procedure, is indicated if lymph nodes are enlarged and able to be felt on examination. This is more likely to occur with thick melanomas, because they have a greater tendency to spread. Patients with thick melanomas also need to have their whole body examined with radiologic tests to rule out metastatic disease before having surgery. If melanoma has spread to the lungs or elsewhere, it becomes very difficult to cure. Often, enrollment in a clinical trial for the most up-to-date, though not yet conventional, treatment is beneficial. When a wide excision with 2 cm margins is necessary for treatment of the melanoma, the goal is to close the incision with sutures without tension. Occasionally, depending on the site of the melanoma and the size of the lesion, a skin graft is needed to close the defect because a significant amount of skin needed to be removed during the operation, and the area cannot be closed. When a melanoma is thick (i.e. > 4mm in depth), wide excision with 2 cm margins is still appropriate, just like for intermediate lesions. Studies have shown that greater margins do not improve overall outcome, and they result in greater need for skin grafting. The most advanced and up-to-date method of sampling lymph nodes is the sentinel lymph node biopsy. This is a relatively new procedure that has gained acceptance as a reliable and lower risk procedure for adequately determining the status of the lymph nodes. The procedure should only be performed by surgeons trained in this technique. Dr. DiNome is well-trained in the sentinel node procedure. Sentinel lymph node biopsy involves removing only the first lymph node(s) in the armpit or groin into which the tumor drains. Usually, 1-3 sentinel lymph nodes will be identified. The procedure involves receiving an injection of a radioactive isotope into the skin around the melanoma on the morning of surgery by a nuclear medicine radiologist. An x-ray picture is then taken to demonstrate the lymph node basin into which the tracer has migrated. Once you reach the operating room, the surgeon will inject a blue dye around the tumor site as well. Using both the blue dye as a visual marker, and the radioactive isotope as an audible marker, the surgeon is able to identify the lymph node(s) that have taken up the dye and radioactive tracer. These lymph nodes are termed the sentinel nodes, and these nodes are removed. If the sentinel lymph nodes are found to be negative, then this is a reasonable indicator that the rest of the lymph nodes are also negative, and no additional lymph node surgery is necessary. If tumor cells are found within any of the sentinel nodes, then a complete lymph node dissection is indicated.