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Cirugía Plástica - SKIN CANCER UNIT


Cosmetic Surgery /


Our Skin Cancer Unit is a multidisciplinary unit where we join forces with Dr. Garcés, a world-renowned specialist in Dermatology, for the treatment of skin caner using Mohs surgical techniques. Dr. Paloma and his team of plastic surgery specialists, provide their expertise in reconstructive surgery for skin defects, and the Teknon Medical Center's Radiotherapy and Oncology department provide them will all of the supporting additional therapies.

What is skin cancer?

Skin cancer is a disease caused by the development of cancer cells on any of the skin's layers.
There are two distinguishable type of skin cancer: the non-melanoma type and melanoma type.
Non-melanoma skin cancer is more frequent and is called non-melanoma because it is formed from other skin cells and not those where pigments are accumulated (melanocytes). Within this type, all types of skin cancer except malignant melanoma, which is less frequent and explained below, are included.
Skin cancer is more common in people who have white skin and who have spent a lot of time exposed to the sun, mainly when sun exposure took place during infancy and there have been numerous sunburns. Although it can appear on any part of the skin, it is most common on the face, neck, hands, and arms. This type of skin cancer is one of the most frequents of all skin cancers, and about two million new cases are diagnosed every year in the world.
In recent years, the incidence of malignant melanoma has increased spectacularly, having multiplied by 3.3% in men and 2.5% in women. In spite of this, it represents less than 3% of all tumors and early diagnostic campaigns have allowed for the mortality to be reduced by 30% since the 1970s. 
Skin cancer can be recognized by a change in skin's appearance, like a wound that does not heal or a small protrusion. A red stain, with a rough or scaly look and a tendency to grow, can also appear.
If you notice any change or abnormality in the skin, you should visit your doctor who can take a sample and analyze it (biopsy) in order to check if it is a malignant tumor or not.

  • Risk factors


    The cause of this type of cancer is not completely known, Certain factors that can cause it to arise have been studied.

    Atmospheric factors
    Excessive exposure to the sun influences the production of these cancers. People who work outdoors, such as agricultural workers, or seamen, demonstrate a higher incidence, normally occurring on exposed skin, frequently on the head and neck.
    Although solar light helps to synthesize vitamins A and D, excessive exposure, whether it causes burns or not, increases the risk of developing skin cancer, including malignant melanoma.
    A correlation between the risk of melanoma and latitude also exists. The period of time a person has live in equatorial latitude countries also has an influence, meaning excess exposure to the sun during a certain period of life.
    Not only does prolonged exposure have an influence, but intense exposure to the sun, during a short period, like a vacation for example, is also a risk factor for both basal-cell carcinoma and melanoma.
    Melanomas differ from malignant skin tumors of the the non-melanoma type with respect to sex, age, and location on the body. Most malignant skin melanomas do not appear in the areas that receive the largest dose of accumulated ultra-violet exposure.
    Although the most dangerous sun exposure scenario is not known, some studies support the hypothesis that intense and intermittent ultra-violet radiation exposure of skin that is normally protected is responsible for forming melanoma.
    Age can also have an influence and burns produced by the sun before the age of 15 double the risk of melanoma.
    Physical characteristics
    White people of Scottish, English, or Irish origin with blond or reddish hair, light-colored eyes, and a lot of freckles are especially susceptible.
    Melanoma is very rare among Black and Asian people, being predominant, in cases where it appears, in areas with little pigmentation, such as palms and soles and with a worsened prognosis.
    The skin's sensibility to the sun and difficulty in tanning, increases the risk of melanoma.
    The skin's reaction to solar light is related to factors such as the skin's pigmentation, the number of freckles in childhood and adulthood, and the number of nevus (formations similar to moles that are benign melanocytical tumors), all of which make up risk factors for malignant skin cancer.
    The larger incidence of nevus in white individuals leads to the idea that ultra-violet radiation plays an important part in the development of nevus. It has been proven that there are a larger number of nevus in areas exposed to the sun as opposed to protected areas. This increased number is associated with a higher propensity to sunburns instead of tanning, the number of sunburns, the tendency to have freckles, and a lifestyle implying more sun exposure.
    A person who has skin that is sensitive to the sun, more than 150 melanocytic nevus, and a few dysplastic nevus (with a microscopic appearance similar to malignant melanoma cells) could have 50 times more of a chance of melanoma than a person without these characteristics.
    Genetic factors
    Nevoid basal cell carcinoma is a hereditary disorder in which patients develop a large number of carcinoma basal cells from the second decade of life, and it can affect any area of the skin.
    Xeroderma pigmentosum is a hereditary disorder that is due to an alteration in DNA repair, which is also associated with multiple skin carcinomas.
    In malignant melanoma a family history has been described. The estimated risk is 70% in patients with neurocutaneous melanosis and different types of xerodermia pigmentosa, 1% of children of patients with melanoma without a family history, and 6% in families with dysplastic nevus syndrome and a history of two or more malignant melanomas.
    People who have been treated with medications that suppress their immunological system, are more likely to develop melanoma.
    Overexposure to sun lamps and tanning booths
    Sunlamps and tanning booths are a source of ultra-violet radiation. Excessive exposure increases the risk of developing skin cancer.
    About half of melanoma cases appear in people over 50 years-old.
    Other factors
    Exposure to carcinogens, injuries or scars, lesions from chronic radiation, and viral infections, are some of the factors that predispose the appearance of skin cancer.

  • Diagnostic


    The doctor will base his diagnostic on the symptoms present in the patient's skin and on his or her medical history.
    When an abnormality is suspected, a biopsy will be performed. The biopsy will analyze the tissue with a microscope in order to examine the type of cells that are present.
    Depending on where the skin alteration is found and the type of alteration, a certain type of biopsy will be performed.
    A shave biopsy: the area of the skin where the biopsy will be performed is numbed with local anesthesia and the upper layers of the skin are shaved with a scalpel blade.
    Excisional or incisional biopsy: A wedge of skin is removed. This type of biopsy is performed in deeper tumors. With incisional biopsy only a portion of the tumor is removed for analysis. With excisional biopsy the entire tumor is removed. If there is a large extension of affected skin, an incisional biopsy will be performed at first, so as to not greatly affect the patients appearance.
    Fine needle aspiration: a syringe with a fine needle is used to extract small particles from the tumor. This technique is not used for the diagnostic of a suspicious mole but for the lymph nodes close to the melanoma.
    When the suspicion of cancer is high, other tests are performed to diagnose the breadth, like scanners, analysis, or nuclear medicine tests.

  • Treatment


    Non-melanoma cancer

    Most basal cell carcinomas and squamous cell carcinoma are cured through minor surgery. There are several types of surgery used depending on the location and type of tumor.

    Simple incision: the tumor and a part of the tissue around it are removed with a scalpel. Then the edges are sewn, maintaining the best possible appearance.
    Cryosurgery: liquid nitrogen is used to freeze and destroy the malignant cells. Currently this is used for actinic keratoses (pre-cancerous lesions) and some superficial carcinomas.
    Mohs surgery: this surgical procedure is used to treat non-melanoma skin cancer, mainly in base cell cancer of the face, consists of extracting individual layers of cancer tissue and examining them one-by-one in the microscope to evaluate if the cancer is completely removed, both in terms of surface and depth. This techniques allows a maximum of healthy tissue to be conserved. This type of surgery is used for the treatment of aggressive tumors, located in certain critical areas, and that have reappeared after other treatments.
    Laser surgery: laser rays are used to vaporize cancer cells. This technique is used in very superficial base cell carcinoma and in squamous cell carcinoma in situ.

    Lymph node surgery: if the lymph nodes close to the cancer have been affected, they will have to be removed through surgery. Currently the sentinel technique is used in many melanoma cases.
    There are different ways it can be administered and numerous treatments that advance rapidly as science progresses.

    When it is used locally, the drugs get to the cells that are closest to the surface of the skin so this format will only be used in pre-malignant cases or superficially malignant of the non-melanoma type. These drugs redden the area where they are applied, making it more sensitive to the sun, so it much be protected from the sun for weeks.
    If the cancer is in an advanced state, systematic chemotherapy will be used, meaning that it will cover all areas of the body.

    It somewhat improves the prognosis of patients operated for melanoma, decreasing the risk of metastasis. It is an injected treatment, lasting about one year and with a certain number of side effects, thus it is normally reserved for high risk cases of melanoma, like those which are deep or which have effected the lymph nodes.

    It consists of the use of high energy rays, like X-rays, to destroy or reduce the number of cancer cells. It is a local treatment. It is performed over a period of a few days, and the patient goes to the hospital, or clinic where the radiotherapy is performed, on an out-patient basis; the patient does not have to spend the night in the hospital.
    The treatment itself lasts for a few minutes. It is not painful and similar to an X-ray except for the fact that more radiation is used and it is concentrated in the affected area.
    Radiotherapy is used in this type of cancer for patients who cannot undergo surgery due to their overall state of health, for whom the characteristics of the lesion make it recommendable, or as a palliative or additional treatment. In principal, elderly people may have difficulty in undergoing surgery, therefore, the treatment used is radiotherapy.

    This kind of treatment can cure cancers that are in lower stages. It can also retard the growth of tumors in advanced stages.
    Radiotherapy can also be used to help surgical treatment. After surgery, and to insure that no cancer cells are left, a radiotherapy treatment is performed. It can also be used to radiate metastases in other organs.
    Photodynamic therapy
    There is currently a new treatment with a sophisticated mechanism for the treatment of non-melanoma skin cancer. It consists of applying a topical product, in cream format, that acts as a photosensitizer (aminolevulinic acid). The product is captured specifically by the tumor cells in about two to three hours. After this time the patient is subjected to a special light, of a certain wavelength. The tumor cells sensitized by the acid are destroyed when they are lit up for a few minutes. This procedure must be repeated after about one month.
    This treatment is indicated for actinic keratosis, superficial base cell carcinomas, and Bowen's disease (squamous cell cancer in situ).

    Localized states of melanoma have a good chance of being cured with surgery. The use of surgery of disseminated states is used as palliative therapy, to reduce symptoms.

    The main lesion must be removed, including the skin and the subcutaneous cell tissue up to the muscular fascia. Due to the fact that an exciosional biopsy will have already been carried out to obtain a diagnosis, the incision should be made through the scar with a wide margin, up to three centimeters depending on certain prognosis values (mainly the Breslow and Clark scales).
    For melanomas under 0,76 mm, extracting a margin of 1cm will be sufficient.
    When there are affected nodes, they will be removed as well. This will be done when there is evidence that the nodes have been invaded.
    Biopsy of sentinel nodes
    This technique can be carried out based on medical criterion, depending on certain prognosis factors. It consists of finding out which node drains lymphatic fluid in the melanoma area and analyze it. In order to do so a colored substance with a radioactive component is injected in the melanoma area. After a while, the node that has absorbed the substance will take on a color and the radioactive component; this node is the one that will probably contain the most cancer cells if the cancer has spread. When the node is found, a sample is taken and analyzed in the microscope. If it has cancer cells, it will be removed. The remaining lymph nodes in the area will also be removed.
    If there is evidence of metastases in other organs, surgery can be carried out although the objective of this surgery is not healing. Sometimes the removal of metastases in other organs can prolong the life of the patient, or, at least, improve the patient's symptoms.
    Systematic chemotherapy is used as a palliative treatment for the symptoms. It is used after surgical treatment of certain dermal, cerebral, intestinal and bone metastases.
    Treatment with a single drug o with a combination of drugs is not very effective, and the response rates are not over 30%. The amount of time healing lasts is not long. However, research continues to be carried out combining various drugs. The most frequently-used drugs are Dacarbacine (DTIC), Carmustine (BCNU), Taxol, Platinum, Vinblastine, and Vincristine. Different combinations of these drugs can be used and recently, promising results have been observed with the combination of DTIC, Platinum, BCNU and Tamoxifen.
    Certain combinations of chemotherapy can be associated with immune therapy drugs such as interferon, interleukine-2 and monoclonal antibodies.