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Introduction
CHAPTER 48 Nonmelanoma Skin
Cancer
Alex M. Glazer Aaron S. Farberg Darrell S. Rigel
SUMMARY
Nonmelanoma skin cancers are extraordinarily common, accounting for
approximately 3 million new cases per year in the United States alone.
Multiple treatment options are available, ranging from EDC to excision to Mohs
surgery.
Treatment decisions should be guided by both patient and tumor characteristics,
and should always be individually tailored.
Beginner Tips
Common treatment options for NMSC include EDC, excision, and Mohs micrographic
surgery.
The cost and ease of simple options such as EDC should always be weighed against
both the increased healing time and decreased efficacy of these approaches when compared with excision or Mohs.
Expert Tips
High-risk tumors may benefit from management in a multidisciplinary fashion.
Adjuvant radiation therapy may be useful for select tumors at very high risk of
recurrence.
Donโt Forget!
Select patients and tumors may benefit from primary medical management with topical
or intralesional therapies.
All surgical therapies entail risk, but this should be weighed against their
effectiveness, rapid healing, and low recurrence rates.
LN2 treatment for NMSC is fundamentally different from AK treatment; intensity and
depth of freeze must be significantly greater in order to lead to tumor destruction, and this will likely lead to significant surrounding tissue damage and hypopigmentation.
Pitfalls and Cautions
Simple approaches such as cryotherapy and EDC should not be used on tumors at
significant risk of recurrence.
Appropriate tumor and patient selection for medical management or treatment with
cryotherapy or EDC is critical; for example, some BCCs demonstrate both superficial and nodular growth patterns.
Patient Education Points
Full informed consent includes a discussion of both the ease of a particular procedure
and the length and complexity of the healing process.
Remind patients that even with very low rates of recurrence or complications, those
numbers are not zero. Patients may otherwise fail to appreciate that a 98% chance of tumor clearance without complications means that, for a surgeon who treats 100 patients per week, 2 patients weekly may have these undesirable outcomes.
Billing Pearls
The AUC for MMS represent a guideline for patient and tumor selection, but
individual LCDs also govern these decisions.
Documentation is critical, and medical necessity is the ultimate arbiter of
appropriateness.
Some patients have poor (or no) prescription medication coverage; for them, medical
management is generally not desirable.
CHAPTER 48 Nonmelanoma Skin