BASAL CELL CARCINOMA & SQUAMOUS CELL CARCINOMA

BCC is the most common form of cancer in the world. It is a cancer of the deepest layer of the epidermis. The epidermis is the most superficial layer of the skin. BCCs can occur anywhere on the body but most commonly occur on areas of high sun exposure such as the head, face, neck, shoulders and back.

SCC is the second most common form of skin cancer. It occurs in the more superficial layers of the epidermis. SCC can also occur anywhere on the body, but most commonly occurs on sun exposed areas such as the face, lip, ears, head, neck, shoulders, hands, forearms and lower legs.

Between 95-99% skin cancers in Australia are caused by exposure to ultraviolet (UV) radiation from the sun. Risk factors for development of skin cancers include, being over 50 years old and male, fair or red hair, fair skin, a tendency to burn rather than tan, blue eyes, freckles, and a previous history of skin cancer.

Other contributing factors to skin cancer development include immunosuppression, radiation from sources other than the sun e.g. tanning beds, chronic skin inflammation, certain industrial chemicals, and some rare genetic syndromes e.g xeroderma pigmentosa.

BCC tends to have no symptoms, grows slowly and does not spread to other parts of the body. The have a variable appearance in different people. Open sores, red patches, pink growths, shiny bumps, scars or growths with elevated rolled edges and/or central indentation are common. They may ooze, crust, itch, or bleed.

SCC tend to have few symptoms. The speed of their growth can vary. They can appears as thick, rough, scaly patches and may crust or bleed. They may also resemble warts, ulcers with a raised edge, or open sore that will not heal.

The best way to diagnose BCC and SCC is by removing the part of or all of the lesion and submitting it for examination by a pathologist. This is usually done under local anaesthetic and is called a biopsy.

BCCs rarely spread beyond the original tumour site (metastasise). However, if allowed to grow, they invade local structures, growing widely and deeply and destroying skin, soft tissue and even bone. The longer you wait, the more difficult a BCC is to treat and the higher the risk of it recurring.

The majority of SCCs are treated easily provided they are treated early. If allowed to grow, they enlarge, can invade deeper skin layers, soft tissue and even bone and can metastasise to other parts of the body such as the local lymph nodes, and lungs.

There are several effective treatments for BCC and SCC. The choice is dependent on the tumour type, size, location, depth, as well as your age and overall health. Options include:

1. Excisional Surgery
Under local or general anaesthetic, the tumour is removed with a margin of healthy tissue. The specimen is sent to a laboratory to check that the tumour has been completely removed. If there are tumour cells at the margin of excision, more surgery may be required.

2. Moh’s Surgery
Under local or general anaesthetic, the tumour is removed in pieces with a small margin of healthy tissue. The tumour is mapped, and the margins examined in the operating theatre under the microscope by the surgeon to see if any cancer cells remain. If so, the surgery continues until there is no evidence of tumour. This is conducted by specialist Moh’s surgeons and is often recommended for surgery around the eyes, nose, lips, ears, scalp, digits, and genitals.

3. Radiation Therapy
Radiation is used to destroy the tumour without the need for surgery. Treatments are daily for a few weeks. This is used for tumours that are hard to treat surgically or in patients who cannot have surgery because of their age or other medical conditions. Radiation may also be used after surgery if the tumour was particularly aggressive or involved nerves.

4. Topical Medications
These creams or gels are used to treat superficial SCCs and BCCs only. Imiquimod activates the body’s own immune system to kill BCC. 5-Fluorouracil is topical chemotherapy which kills cancer cells directly. Cure rates are 80-90%

5. Other
Other treatment modalities include curettage and electrodesiccation, cryosurgery, laser surgery, and photodynamic therapy. These are only appropriate for superficial SCCs and BCCs.

The drawback of all non-surgical treatments including radiation, medications, curettage and electrodissection, cryosurgery, laser surgery and photodynamic therapy, is that no tissue is examined under the microscope and so there is no way of knowing if the tumour has been completely removed.

Advanced BCCs and SCCs are those that have penetrated deeply, have been resistant to other forms of therapy or have repeatedly recurred. These tumours include:

• Locally advanced SCC – these are large or have penetrated deeply into underlying tissue
  
• Metastatic SCC – these have spread to the regional lymph nodes or beyond and can be life-threatening.

Advanced SCC is usually treated with a combination of surgery, radiation therapy and immunotherapy.

1. Surgery
This is usually done under general anaesthetic. It involved removal of the primary tumour with a margin of healthy tissue. If the regional lymph nodes are involved, they are also removed. If a large defect is left, reconstructive surgery is sometimes required. This is done with the assistance of a Plastics & Reconstructive Surgeon and may involve local skin grafts and flaps, or movement of tissue from a distant part of the body along with its blood supply.

2. Radiation Therapy
Radiation therapy is often used to consolidate gains made during surgery for advanced or aggressive SCC. It helps to decrease the chance of tumour recurrence. It may also be used instead of surgery in patients in whom the SCC is not amenable to surgical resection, or who are unable to have surgery because of advanced age or poor health.

3. Medications

• SCC - In patients who have metastatic SCC and those who have locally advanced, inoperable SCC for whom curative surgery or radiation are not options Immunotherapy harnesses the body’s own immune system to attack and kill tumour cells.
  
• BCC - Medications (Vismodegib and Sonidegib) are now available that block the ‘hedgehog’ signalling pathway that is important in BCC growth. They are indicated in patients who have locally advanced, inoperable BCC for whom curative surgery or radiation are not options, and in those very rare patients with metastatic BCC.

Prior to your operation you may need to attend a Preadmissions Clinic. Your fitness for surgery will be assessed, tests may be ordered and referrals to other specialists arranged if required.

You cannot eat for 6 hours prior to your operation. You may sip water for up to 2 hours prior to your operation. Fasting decreases the risk of vomiting and aspiration during induction of anaesthesia. Aspiration can cause pneumonia and a prolonged stay in hospital.

Skin cancer surgery is sometimes done under local anaesthesia but usually done under general anaesthesia. If your surgery is to be done under general anaesthesia, you will be asleep during the whole procedure. The anaesthetist will discuss the anaesthetic with you prior to your operation. They will see you in the pre-operative area and accompany you to the operating theatre.

Following general anaesthesia, you are positioned on the operating table, the skin cancer is marked with appropriate margins, and local anaesthetic is injected to decrease post-operative discomfort. A skin incision is made along the marks and the skin cancer is removed. If the wound can be closed it is done in layers. Depending on the characteristics of the wound, absorbable or non-absorbable (nylon) sutures are used. The nylon sutures will need to be removed 5 days to 3 weeks after your operation.

This does not apply to most patients who undergo skin cancer surgery.

If the skin defect is too large to close, skin can be moved over from an adjacent area to cover it. This is called a ‘local flap’.

Sometimes a skin graft is used. The graft is taken from a different area of the body and fastened to the defect. Grafts can be ‘full thickness’ or partial thickness (split skin) grafts. Full thickness grafts are often taken from areas with skin redundancy like the inner arm or neck. Split skin grafts are often taken from the thigh. Donor and recipient site skin graft dressings should stay in-tact for 2 weeks.

Some reconstructive operations are highly specialised and require the services of a Plastic and Reconstructive Surgeon.

Following the operation, you will wake up in the recovery area. You will feel a little disoriented and may feel a little nauseous. The staff in recovery are equipped to help you. Immediate post-operative pain is usually minimal. Once you are awake and oriented, you will be taken to a ward bed. After a few hours, and once the nurses are satisfied that it is safe, you can get out of bed.

Post-operative swelling around the wound is normal and usually resolves within a month or so. No specific wound management is needed in the first two weeks while the dressings are on. After this, gentle scar massage is advisable for 10 minutes two or three time a day for 6 months. You may use whatever moisturising lotion you like (e.g. sorbolene, bio-oil etc.) but creams with Vitamin E should be avoided for the first post-operative month. Alternatively, you can keep the scar covered with a silicon strip for 12 hours a day for 6 months. These strips are available from the chemist but are quite costly.

Initially the scar will be pink. Over 6-12 months, the scar will fade until it becomes pale.

There are no dietary restrictions or special dietary supplements that are required after skin cancer surgery. You may eat whatever you choose. Oral analgesia including paracetamol is usually all that is required for pain relief. You may bathe and shower. The wound is waterproof and can get wet.

You should avoid strenuous physical activity for two weeks after your operation. It increases the risk of post-operative wound complications which could result in a trip back to the operating theatre. Once this period has passed and you feel that you have recovered, you may return to your normal physical activities.

Bleeding
This is uncommon. If it occurs, blood collects under the skin which can be uncomfortable. Occasionally this requires a trip back to the operating theatre so that the blood can be evacuated.

Infection
These can complicate any type of surgery and can usually be treated with a short course of oral antibiotics. Uncommonly, IV antibiotics or further surgery is required

Seroma
This is a collection of fluid in the wound bed beneath the skin. They usually resolve on their own but can be uncomfortable and sometimes need to be aspirated. Occasionally they can get infected.

A follow-up appointment should be arranged in rooms 2 weeks after your operation for a discussion regarding pathology. Another appointment will be required 4-6 weeks after surgery for a post-operative check-up. At this appointment, your wounds will be assessed, and any further investigations and management arranged. Please call to arrange a convenient time.

There is no specific law covering surgery and driving. It is not advisable to drive immediately after surgery. In general, in order to return to driving, you must:

1. Have a valid drivers’ licence
   
2. Be able to control your vehicle during an emergency
   
3. Be able to testify in court as to your capacity to drive

Your car insurer may not cover you following an accident if:

1. You have had recent surgery (‘recent’ is not clearly defined)
   
2. You are taking pain or sedative medications that may impair your concentration or judgement

Aim to return to driving when:

1. You are pain free
   
2. You have full range of motion
   
3. You are not taking strong pain medications or sedatives
   
4. Your reaction time is not compromised

If you are in doubt, do not drive. Call your insurer for advice.

  - Driving Safety and Medicines PDF
NSW Government fact sheet

If you have any questions, please do not hesitate to contact us.

Ph: 02 8307 0977
Fax: 02 8088 7420
Email: info@drgideonsandler.com

Please refer to the following resources for more information:

1. Basal Cell Carcinoma
   The Skin Cancer Foundation
   
2. Squamous Cell Carcinoma
   The Skin Cancer Foundation
   
3. Non-melanoma Skin Cancer
   Cancer Council Australia