Skin malignancies usually take the form of basal cell carcinoma, squamous cell carcinoma and malignant melanoma. The head and neck malignant tumor pathology can be addressed by multiple medical specialists: maxillofacial surgeons, dermatologists and plastic surgeons. Although considered a less aggressive type of malignancy, the basal-cell carcinoma can extend to profound regions and require extensive surgery and immediate reconstructions of the defect area with regional or distant flaps. The treatment does not end with the surgical phase, the follow-up being as equally important, as there is a 50% higher risk for developing a second skin malignancy in the next 5-10 years postoperatively.
basal-cell carcinoma, surgical extirpation, relapse, local flap
Tegumentul poate fi afectat de tumori maligne, cu preponderenţă carcinomul bazocelular, urmat de cel spinocelular şi melanomul malign. Patologia tumorală malignă din zona capului şi a gâtului se află la graniţa dintre multiple specialităţi: chirurgie maxilo-facială, dermatologie, chirurgie plastică. Deşi considerat o formă mai puţin agresivă local, carcinomul bazocelular poate avea o evoluţie locoregională infiltrativă în părţile profunde, implicând rezecţii largi şi reconstrucţie imediată cu lambouri locoregionale sau de la distanţă. De asemenea, diagnosticarea cu o formă de neoplazie tegumentară creşte riscul de apariţie a unei noi neoplazii în următorii 5-10 ani cu peste 50%, astfel încât tratamentul nu este considerat încheiat odată cu etapa rezectivă chirurgicală.
Skin cancer is the most frequent malignancy worldwide. The most encountered histological subtypes are basal-cell carcinoma and squamous cell carcinoma. Only in 2012, in USA, up to 5 million patients received treatment for these two types of cancer(1). Australia has the highest number of new cases of skin cancer in the world(2), due to climate (extensive sun exposure); the vast majority of skin malignant tumours are UV radiation dependent.
In the European Union, there is a 2-3% increase in new cases, according to a 10-year retrospective study(3).
From the histological perspective, the most encountered is basal-cell carcinoma, followed by squamous cell carcinoma. Most of the basal-cell carcinomas are found in the head and neck region (over 80%).
The management of skin malignancies is divided into two major branches: surgery (radical tumor resection, Mohs surgery, electrodessication), and conservative treatment (photodynamic therapy, radiotherapy, cryotherapy and topical agents).
Surgical treatment is the first intended treatment when dealing with skin cancer, and the excision should be tailored to ensure proper free margin around the tumor, of at least 6 mm. If the lesion is found to be generated from the squamous layer, the lymph nodes should also be investigated.
The relapse or lymph metastasis risk is associated with the characteristics of the tumour: histological subtype, size, profound invasion, localization, and also the general condition of the patients (immunosuppression, severe associated diseases). The tumors associated with a high risk of relapse or metastases have poor differentiated morphology, have more than 2 cm in size, and are situated in the eye or in perioral region(4).
The follow-up for these patients should be on an annual base; over 90% of relapses occur in the first five years postoperatively(5). Usually, when dealing with skin cancer, the prognosis is good, except when there is lymph node involvement or distant metastasis; then the survival rate drops by 50% for women and by 30% for men(6).
An 82-year-old male patient was admitted to our department for a frontal region tumor developed approximately six months ago (Figure 1.1). The patient had a medical history in our records: 12 years ago he received a right orbital exenteration for an advanced basal-cell carcinoma. The clinical examination revealed an ulcerated endophytic tumor in the right paramedian frontal region, of irregular shape, 3/2 cm in diameter, with ill-differentiated, firm borders and the bottom of the ulceration covered with crusts; the tumor was not fixed to the underlying bony bed. The biopsy confirmed a secondary basal-cell carcinoma. A surgical plan was established: wide surgical excision and immediate reconstruction of the defect with advanced horizontal frontal flap (Figure 1.2). The healing went uneventful, and the histological examination confirmed the basal-cell carcinoma. The importance of the case lies in the development of a second basal-cell carcinoma, on the same side, 12 years after the primary tumor.
An 81-year-old female patient was sent to our department by her general practitioner for an ulcerated left cheek tumor, with a five-year onset (Figure 2.1). After the clinical and computed tomography examinations (Figure 2.2), the preliminary diagnosis was basal-cell carcinoma of the left cheek region extending in the orbital and nasal region. The tumor was ulcerated, exophytic, covered by crusts, with irregular borders and fixed to the underlying maxillary wall, 35/30 mm in size, with multiple blood vessels on the tumor’s surface. The ophthalmic examination revealed important eyesight impairment. The patient did not have other illnesses.
The biopsy confirmed the clinical diagnosis: basal-cell carcinoma. A surgical procedure was planned: wide surgical excision en bloc with left exenteration and anterior maxillary wall resection, and immediate reconstruction of the soft tissue defect with frontal and advanced cheek flap (Figure 2.3). A second-stage procedure will be carried on after three weeks for adjusting the frontal flap pedicle. Healing went uneventful (Figure 2.4). The patient refused other surgical procedures.
There are numerous reports in literature that show an increase in skin cancer incidence, but an exact number cannot be determined because of a variety of factors: not all excised specimens are sent for histological examination, many patients are treated in one-day surgery procedures in private centres that do not usually report all their malignant cases and, last but not least, because skin malignancies are often seen in elderly patients which may not receive adequate treatment due to their health condition.
Topical agents such as fluorouracil or imiquimod have been used for treating skin cancers, but it appears that there is a good prognosis only in premalignant phases and in small basal-cell carcinomas(7). Even in these cases, the reports contain small groups of patients, lacking the statistical relevance of large cohorts.
Cryotherapy has a high relapse rate – over 40%(8) – because the clinician cannot ensure rigorous safety margins.
It is best suited for a palliative method of treatment in patients who are not good candidates for surgical treatment.
Radiotherapy can enhance the prognosis when dealing with relapse or node involvement, when it is used after the surgical treatment in the multimodal treatment of skin cancers.
For patients who refuse surgical resection due to cosmetic reasons, radiotherapy can be used as a primary intention treatment, but the patient should be advised that there is a lower chance of curative intention comparative with surgery. When used alone, in advanced stages, there is a recurrence rate of up to 50% during the first five years post-treatment(9).
For late stages of squamous cell carcinomas with lymph node involvement, the most efficient therapy is the surgical treatment (resection and neck dissection) followed by radiotherapy.
When dealing with N0 stages, neck management must be carefully planned and the cervical nodes should be addressed when there is perineural or perivascular infiltration, poorly differentiated histological types, immunosuppression, more than 2 cm in size or 8 mm depth of the primary tumor(10). Patients who have developed a skin malignancy pose a greater risk of acquiring a second tumor in time and they are three times more likely to develop a malignant melanoma(11).
Specialists recommend to have check-ups twice a year and protection against UV.
The various drug therapies have not yet been proved to play a major role in fighting relapse or metastasis.
The European population tends to get older and as skin cancers are age-dependent, the clinicians will have to deal in the future with an increasing number of patients. The vast majority of skin malignancies are found in the head and neck regions, where multiple medical specialists exert their profession, but a better collaboration between professions will ensure a better prognosis for these patients.
Conflict of interests: The authors declare no conflict of interests.
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