By Kishwer Nehal, MD
Kishwer Nehal, MD, is the Director of Mohs and Dermatologic Surgery at Memorial Sloan-Kettering Cancer Center (MSKCC). She is an associate professor of Dermatology at Weill Medical College of Cornell University and Program Director of the Procedural Dermatology and Mohs Fellowship Program at MSKCC/Cornell. Dr. Nehal has served on the American Joint Committee on Cancer for skin cancer staging and the National Comprehensive Cancer Network panel for nonmelanoma skin cancer practice guidelines.
Q. I’m scheduled for surgery to remove a basal cell carcinoma. It’s just a small spot, though. Why do I have to have surgery?
A. Although the nonmelanoma skin cancer basal cell carcinoma (BCC) is rarely life-threatening, it can be troublesome, especially because 80 percent of BCCs develop on highly visible areas of the head and neck. These BCCs can have a substantial impact on a person’s appearance and can even cause significant disfigurement if not treated appropriately in a timely manner.
The fact is, BCCs can appear much smaller than they actually are. On critical areas of the face such as the eyes, nose, ears, and lips, they are more likely to grow irregularly and extensively under the skin’s surface, and the surgery will have a greater impact on appearance than might have been guessed. Even a small BCC on the face can be deceptively large and deep; the extent of the cancer cannot be seen with the naked eye.
If such a BCC is treated nonsurgically (for example, with cryosurgery, which involves freezing the lesion with liquid nitrogen, causing it to crust, scab, and then fall off), the chance of the cancer recurring is high. Unfortunately, treating a BCC that has returned is usually much more difficult than treating it precisely and completely when initially diagnosed.
BCCs on the trunk, arms, and legs that cause concern are typically larger in size, but even a small BCC in these areas can have an irregular growth pattern under the skin if the initial biopsy shows the tumor is aggressive. In addition, a small BCC in an area previously treated with radiation may be much more aggressive than it appears on the surface. Again, treating such a tumor nonsurgically is likely to leave cancer cells behind.
The recommendation is to treat even small BCCs (and many squamous cell carcinomas) in critical areas of the face with Mohs surgery. In this technique, the surgeon removes the entire visible portion of the tumor, then carefully maps where the tissue was removed from the surgical site so that under a microscope, it can be determined exactly where any as-yet-unremoved skin cancer is located. Thin tissue samples are then removed one by one, each sample mapped and then examined to see if any traces of cancer yet remain. This precision produces high cure rates and preserves the maximum amount of healthy tissue. Patients should also consider Mohs surgery when a BCC has recurred, or has an aggressive growth pattern or poorly defined borders.
Mohs surgery is a first-line choice for many BCC patients, but discuss treatment options with your dermatologist. Choice of treatment is determined by factors such as the skin cancer’s size, location, and your overall health.