Primary Care Otolaryngology

Chapter 17

Skin Cancer

The great majority of skin cancers arising on the skin of the face, scalp, and neck are basal cell carcinoma , followed by squamous cell carcinoma, then malignant melanoma . Basal cell carcinoma is very common and most often occurs on the face, so the otolaryngologist–facial plastic sur- geon sees many cases. The typical basal cell carcinoma is a nodular lesion with a raised, pearly- white border . These lesions are usually brought to the physicians’ atten- tion before they become very large. They do not metastasize and can be treated in a variety of ways. Dermatologists may freeze or curette them. When the patient is referred to an otolaryngologist–head and neck sur-

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geon, the lesions are usually excised with a three- to four-mm margin, followed by a meticulous closure of the defect, which occasionally requires a rotation or advancement flap from the neighboring skin. These flaps restore cosmetic integrity to the facial unit affected by the tumor. Another approach to resecting basal cell and some squamous cell cancers involves Mohs’ fresh tissue chemosurgery technique. This technique requires tumor mapping: using small, sequential tumor resection in layers with immediate pathologic exam- ination under a microscope to ensure complete removal. This technique takes significantly longer than any of the other methods, but the recurrence rate can be lower. For this reason, certain tumors with a higher-than-usual chance of recurrence with conventional excisions may be better managed with Mohs’ surgery. It is also performed near cosmeti- cally and functionally sensitive structures, such as the eyelids, nose, and ears, in order to preserve as

Figure 17.1. Very large basal cell

carcinoma of the facial skin. Note the rolled edges with central ulceration, indicating subepithelial extension. Excision must ensure that the tumor is completely removed or recurrence is highly likely.

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