Melanoma is the most dangerous form of skin cancer. When not caught at an early stage, it has a high probability of spreading (metastasizing) and potentially becoming lethal.
However, the two other major skin cancers — basal cell and squamous cell carcinoma (BCC and SCC) — are no trifles. While not often fatal, these nonmelanoma skin cancers can be extremely destructive if not detected and treated early.
Bigger and Badder
Now, research from the Hospital of the University of Pennsylvania, in Philadelphia, shows that a substantial group of these basal cell carcinomas and squamous cell carcinomas can be especially aggressive and dangerous, growing and spreading quickly. Physicians call these malignancies "aggressive nonmelanoma cancers," or ANMSCs. They recur more often and lead to death more often than other types of basal cell carcinoma and squamous cell carcinoma.
Mainly occurring on the head, face, and neck, they are difficult to treat, because they tend to grow large — to diameters of 2 centimeters (almost 1") or more. Thus, removing them from these areas can be quite disfiguring. For cosmetic reasons, some patients and their surgeons opt for less aggressive surgery. Unfortunately, because ANMSCs invade the skin more deeply than other nonmelanoma skin cancers, the malignancy may recur, often in a more virulent form.
In the University of Pennsylvania study, of the 54 ANMSC patients (32 with squamous cell carcinomas and 22 with basal cell carcinomas), 25 had recurrent disease. Eight of the 25 had facial weakness or paralysis and 12 showed evidence of regional metastasis (where the disease spreads to nearby lymph nodes).
"When you're treating skin cancer, your best chance of success is the initial treatment," says study leader Stephen Y. Lai, MD, PhD, assistant instructor, and staff physician in Department of Otorhinolaryngology/Head and Neck Surgery. "Even for cosmetically sensitive areas on the face, treatment has to be intensive enough to remove all of the cancer. Otherwise, it may recur as a much more dangerous growth, with survival probabilities decreasing."
Extra Measures
Two common initial treatments for head and neck basal cell carcinoma and squamous cell carcinoma are standard surgical excision and Mohs micrographic surgery. For standard excision, the physician removes the growth along with a surrounding safety margin of apparently normal skin. With Mohs surgery, the physician excises the obvious tumor cells, then removes very thin layers of the remaining, surrounding skin, checking each layer in tum under a microscope until the last layer viewed is cancer-free. This technique saves the greatest amount of healthy tissue.
In the study, all patients with recurrences had previously undergone Mohs surgery. Six had also received radiation therapy. "In most cases, simple excision or Mohs surgery is all that is needed. But in a small subset of cases, tumors can spread insidiously," notes Dr. Lai. "The doctor needs to be wary of these tumors and pursue aggressive treatment. As with other head and neck cancers, a multidisciplinary approach involving a dermatologic surgeon, head and neck surgeon, and radiation oncologist may provide the most comprehensive initial treatment."
Patients should examine their skin monthly, staying alert to signs that could indicate an ANMSC. Any lesion that grows to 2 cm or greater is cause for concern. Special vigilance is also called for if the patient has:
a tumor that rapidly changes in size or shape.
any recurrence of a basal cell carcinoma or squamous cell carcinoma.
any skin cancer that occurs in the mid-face "H-zone," the area of the face including the ears, eyes, and nose.
a strong family history of skin cancer.
If an ANMSC is suspected, the doctor may opt at the outset for aggressive excision with wide margins, along with possible radiation treatment. "Because people are so sensitive to changes to the head and face, both doctors and may hesitate to pursue aggressive treatment, but you have to balance the functional with the cosmetic," concludes Dr. Lai. "Above all you want to cure the problem."
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