Skin Cancer
The
diagnosis is mostly made by clinically observation of the appearance and
features of the lesion. Seeing a lot of these and submitting all lesions
for histology will increase the accuracy of diagnosis. There are no tests
that can compete with experience. Biopsy is used in the difficult cases
such as large lesions where the result may alter the treatment. There is
little point in doing a biopsy and then submitting the lesion for an excision.
The only biopsy that is worth doing is an excisional biopsy but this must
be done in such a way that the lesion is adequately treated no matter what
is the histological diagnosis.
Treatment
Cautery and Cryotherapy are fine for keratoses but have no place in the
established lesion. The biopsy combined with this technique will confirm
the diagnosis but there will be no specimen for the pathologist and will
not be able to tell the operator whether he has completely excised the lesion.
Another consideration is the cosmetic result, which is better by surgical
excision which also guarantees a specimen for the pathologist to comment
on. Occasionally there will be an inadequate excision but this is preferable
to not even knowing if the cautery was inadequate. Any one operator's rate
of inadequate excisions should decrease with experience and plastic surgeons
tend to be more generous with their excision as they have the confidence
of knowing techniques of repair to fit any case.
Recurrence
There are many published papers comparing the results of the various treatment
modalities, surgery has by far the lowest rate of all. With experience and
knowledge of the disease this can be lowered to almost zero.
Results
A low recurrence rate is one of the most important goals but we must also
remember the cosmetic appearance of the patient. As most of these lesions
are on the face or some exposed part of the body it is imperative that we
pay attention and explain to the patient what kind of scars they are likely
to get. There are too many patients who are disfigured by repeated treatment.
This is not to say that the treatment should be compromised to make it look
good.
Radiotherapy
There are some situations where this is the preferred form of treatment.
An elderly patient will do better with radiotherapy than if they have extensive
surgery. Do not forget that radiotherapy usually means several visits and
this in itself may be a problem. It is also a costly form of treatment.
There are areas such as eyelids, nose, ear, lower leg which are not suitable
for radiotherapy.
