Juan-Carlos Martinez

The Management of Melanoma and Nonmelanoma Skin Cancer: A Review for the Primary Care Physician

In the United States, the incidence of skin cancer is greater than that of all other cancers combined, and early diagnosis can be lifesaving. A substantial public health concern, skin cancer is increasingly being diagnosed and managed by primary care physicians. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) (known collectively as nonmelanoma skin cancer) and malignant melanoma are the most common cutaneous malignancies. Shave biopsy is usually performed if BCC is suspected; punch biopsy is preferred if SCC is thought to be present. The choice of biopsy techniques depends on the presumed depth of the lesion. Treatment has 3 goals: complete eradication of the cancer and preservation or restoration of normal function and cosmesis. Risk of recurrence or metastasis determines whether the tumor is high risk or low risk. Based on the level of risk, treatment options are considered, including whether the patient can be treated by a primary care physician or should be referred to a dermatologist. Choice of treatment approach depends on the tumors location, size, borders, and growth rate. The standard treatment approaches are superficial ablative techniques (electro-desiccation and curettage and cryotherapy) used primarily for low-risk tumors and full-thickness techniques (Mohs micrographic surgery, excisional surgery, and radiotherapy) used to treat high-risk tumors. Removal of the entire tumor is essential to limit and prevent tumor recurrence.

Commentary: Electrosurgery and implantable electronic devices.

&NA; Martinez, MD, has indicated no significant interest with commercial supporters.

Standardized photography in facial reconstructive surgery: clinical pearls to simplify a complicated task.

&NA; Juan‐Carlos Martinez, MD, has indicated no significant interest with commercial supporters.

Commentary: Bilobed Flap for Reconstruction of Small Alar Rim Defects

The authors describe and illustrate the use of a bilobed transposition flap to repair alar rim defects. Given the small size of the photographs, it is difficult to judge them critically, but the cosmetic outcomes they have achieved seem to be nice. Furthermore, they comment that there were no complaints of functional impairment, and I take them at their word. Their caution for appropriate patient selection is critical, because misadventures in flap design or execution in this anatomic location can lead not only to poor cosmetic outcomes but also to significant functional impairment.

Complications of Skin Cancer Treatment

Treatment of skin cancers has an inherent risk of complications, as with any other medical treatment. The main complications seen with the surgical treatment of skin cancers are the same as with any other surgery. They include infection, bleeding, dehiscence, and necrosis. These four interrelated complications are often referred to as the “terrible tetrad” (Hendi 2007). The rate of these complications is relatively low with dermatologic surgery procedures (Cook and Perone 2003; Aasi and Leffell 2003).

Nonmelanoma Skin Cancer

Skin cancers are broadly divided into melanoma and nonmelanoma skin cancers (NMSC). Due to the relatively low risk of metastasis from squamous cell carcinoma (SCC) and the extremely low risk of metastasis from basal cell carcinoma (BCC), these, the two most common cutaneous malignancies, are, for the most part, considered jointly as NMSC. This term is a bit of a misnomer; there are many other cutaneous malignancies that are not melanoma, but because of their more aggressive clinical behavior, they tend not to be grouped under this moniker.

Miscellaneous Cutaneous Neoplasms

Because of their low incidence and aggressive malignant potential, rare tumors such as atypical fibroxanthoma (AFX), dermatofibrosarcoma protuberans (DFSP), Merkel cell carcinoma, and sebaceous carcinoma are not discussed in greater detail in this atlas. For the sake of familiarization with the appearance of some of these benign and malignant neoplasms, the following images are included (Figs. 5.1–5.17).