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Basal cell carcinoma and squamous cell carcinoma are both common types of skin cancer. They are not melanomas, indeed they are collectively often called None Melanoma Skin Cancer (NMSC). They typically occur in areas of chronic sun exposure such as the face or ears. However they may appear anywhere that there is skin While basal cell cancers very rarely spread internally they can erode into nerves and blood vessels and destroy local structures such as an eyelid. Squamous cell cancers are even more concerning as up to 5% of them metastasize and can then quickly become life threatening. About 2500 people die from cutaneous squamous cell carcinoma each year.
The most common appearance of basal cell cancer is that of a small dome-shaped bump that has a pearly, translucent color. Blood vessels may be seen on the surface and often bleed with minimal trauma. Squamous cell cancer often appears as a small pimple like growth that never goes away and may grow or bleed. (Figures 1 & 2)
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| (Fig 1) Basal Cell Carcinoma |
(Fig) 2 Squamous Cell Carcinoma
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However, both can grow into large, destructive tumors if left untreated. (Figure 3)
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(Fig 3) Large Facial SCC |
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If a person already had one basal cell cancer they are at a 30-50% risk of getting a second basal cell cancer within five years. For squamous cell cancer the risk of a second tumor is about 20%. It is important to follow closely with your dermatologist and be alert to any suspicious lesions or non-healing sores that develop on your skin. Both None Melanoma Skin Cancer (NMSC) and melanoma most often occur in fair skinned patients with a history of excess sun exposure. Perhaps because of this similar risk profile, individuals who have had multiple basal cell cancers are statistically at an increased risk for melanoma. However, it is important to know that basal cell and squamous cell cancers do NOT turn into melanoma.
Ultraviolet radiation is the single most important cause of both melanoma and none melanoma skin cancer. Limiting exposure to the sun and avoiding tanning beds is therefore the cornerstone of skin cancer prevention. Follow these simple protective measures:
Avoid "peak" sunlight hours -- 10 a.m. until 4 p.m. -- when the sun's rays are the strongest.
Seek shade whenever possible. Remember "No shadow, seek the shade!" If your shadow is shorter than you are, the damaging rays of the sun are at their strongest.
Wear protective clothing, including a wide-brimmed hat, sunglasses and long-sleeved shirt and pants during prolonged periods of sun exposure.
Use a broad spectrum sunscreen, with UVA and UVB protection, and a Sun Protection Factor (SPF) 15 or higher. Apply it generously 15 - 30 minutes before going outdoors and reapply every two hours, especially when involved in outdoor activities such as gardening or swimming.
There are many different options for the treatment of Basal Cell and Squamous Cell Cancers (NMSC). Which approach is most appropriate for any individual patient will depend on the type of cancer, its location, whether any previous treatments have been tried and of cause the patients general health and desires.
- Small, superficial skin cancers, especially those on the trunk can be treated by local destruction. Curettage and electrodessication (“scrape and burning”) cryotherapy (freezing) and CO2 laser vaporization are all examples of this. However these forms of treatment do not allow for pathological confirmation that the cancer has been completely removed and is not usually used in many cases such as: large skin cancers, aggressive subtypes, cancers in high-risk areas such as the face, ears or scalp and cancers in areas where cosmetically unacceptable scars may result.
- This is the most common treatment for low-risk skin cancers. It allows some sampling of the margins to asses if it is likely that the cancer has been removed. However, because complete margin control is not possible, the cure rate is not as high as with Mohs micrographic surgery and a relatively wide margin needs to be excised increasing the amount of skin that is removed.
- Both topical chemotherapy with 5-flurouracil and topical imiquimod have shown some success in treating superficial skin cancers. However the cure rates are generally lower than with other treatments and intense inflammation and swelling over a period of several weeks can make these difficult to tolerate. None the less in selected cases use of the topical agents alone or in combination with surgical therapy may be the best choice.
- Radiation may be an appropriate treatment for NMSC in patients who are poor surgical candidates. Also radiation is sometimes useful as an adjunct used in combination with surgical treatment of aggressive tumors. However radiation treatment usually requires several treatments per week for several weeks, and can result in painful inflammation, skin breakdown and unsightly scars. Radiation can sometimes leave patients feeling tired and exhausted during the treatment period. Ironically radiation can be the cause skin cancers years latter. Still, in selected patients this may be the most appropriate option.
- This is the gold standard of skin cancer treatment. It offers the highest cure rate possible and removes the least amount of tissue possible. However it is not needed for many small, simple skin cancers on low risk areas, and it may require more time and expertise than some of the simpler treatments.
Mohs surgery is a highly specialized form of skin cancer surgery. Most skin cancers extend under the skin beyond what is seen on the surface. Therefore, Mohs surgery has two stages: first all the visible tumor is removed, then while the patient waits, the tissue is carefully examined under the microscope. If there is any cancer remaining, another thin layer of skin is removed, and this is again examined. The whole process is repeated until all the cancer has been removed.
Mohs surgery has two main advantages over other skin cancer treatments. First, for most skin cancers Mohs surgery offers the highest cure rate possible, approximately 99%. Second, as Mohs surgery is guided by what is found under the microscope, it removes the least possible amount of skin while still removing all the cancer. This is especially important for lesions on areas such as the ear or face.
It is impossible to know before the surgery exactly how extensive the cancer is below the surface. If the cancer is limited to what is seen clinically then only one or two layers of Mohs surgery may be needed to eradicate the tumor. However, occasionally the cancer extends far beyond what might have been expected and so several layers are required to achieve a cure. As a result, patients may be in the office for just a couple of hours or literally the whole day. Most of this time is spent in the waiting room, talking, eating and reading, while the tissue is being processed and examined under the microscope.
No. Mohs surgery is performed with local anesthetic. This means that the area will be made totally numb, so the patient is awake but does not feel any pain.
Mohs surgery is not indicated for every skin cancer. It is most commonly used for:
- Skin cancers on important or high-risk locations such as the face or hands.
- Tumors that have reoccurred after a previous treatment.
- Large or rapidly growing tumors.
- Patients who have a predisposition to multiple skin cancers.
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(Fig 4)
Small MOHS Defect & Reconstruction
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(Fig 5) Large MOHS Defect & Reconstruction
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Melanoma, is a type of skin cancer. It is characterized by the uncontrolled growth of "melanocytes", pigment-producing tanning cells. Melanomas may suddenly appear without warning, but can also develop from a preexisting mole. They are found most frequently on the sun-exposed areas, but can occur anywhere on the body.
The overall incidence of melanoma is rising at an alarming rate. At current rates one in 65 Americans have a lifetime risk of developing invasive melanoma, a 2000% increase from 1930. In addition, with the inclusion of the earliest stages of melanoma, melanoma in situ, one in 37 Americans have a lifetime risk of developing melanoma. Melanoma can spread to internal organs and may result in death. One person each hour dies from melanoma in the U.S.. However, if detected in the early stages, melanoma can usually be treated successfully.
While not all melanomas are sun related, excessive exposure to ultraviolet radiation from the sun is the most important preventable cause of melanoma. People in southern regions, where the sunlight is more intense, are more likely to develop melanoma than those in northern regions. Melanoma has been particularly linked to excessive sun exposure in the first 10 to 18 years of life. Other possible factors include genetic factors and immune system deficiencies.
Melanoma can strike anyone. However, Caucasians are ten times more likely to be diagnosed with melanoma than other races. Even among Caucasians, certain individuals are at higher risk than others. For example:
- You have a substantially increased risk of developing melanoma if you have many moles, large moles or atypical (unusual) moles.
- Your risk is increased if your parents, children or siblings have had melanoma.
- If you are a Caucasian with fair skin, your risk is four times as great as a Caucasian with olive skin.
- Redheads and blondes have a twofold to fourfold increased risk of developing melanoma.
- Your chances increase significantly if you've already had one melanoma.
Most people have moles (also known as nevi). Atypical moles are unusual moles that are generally larger than normal moles, variable in color, often have irregular borders and may occur in far greater number than regular moles. Atypical moles occur most often on the back and also commonly occur on the chest, abdomen and legs in women. It is important to recognize that atypical moles are not limited to any specific body area; they may occur anywhere. The presence of multiple atypical moles may mark a greater risk of melanoma developing either in a mole or on apparently normal skin.
Recognition of changes in the skin is the best way to detect early melanoma. Melanoma generally begins as a mottled, light brown to black flat blemish with irregular borders. Occasionally, it may turn shades of red, blue or white, crust on the surface and bleed. They most frequently appear on the upper back, torso, lower legs, head and neck. A changing mole, a new mole, or a mole that is different or "ugly" or begins to grow should be examined carefully.
If you notice a mole on your skin, you should follow the simple ABCDE rule which outlines the warning signs of melanoma: (Figures 6 & 7)
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(Fig 6) Melanoma
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(Fig 7) Melanoma
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symmetry : One half does not match the other half.
order irregularity : The edges are ragged, notched or blurred.
olor : The pigmentation is not uniform. Shades of tan, brown or black are present. Occasionally dashes of red, white, and blue add to the mottled appearance.
iameter : The width is greater than six millimeters (about the size of a pencil eraser).
volution: Any change or growth of a mole should be of concern.
We urge everyone to examine their skin regularly. This means looking over your entire body including your back, your scalp, the soles of your feet, between your toes and the palms of your hands. If there are any changes in the size, color, shape or texture of a mole, the development of a new mole, or any other unusual changes in the skin, see your dermatologist immediately.
When detected in its earliest stages, melanoma is highly curable. The average five-year survival rate for individuals with melanoma is 89 percent. For localized melanoma, melanoma that has not spread beyond the outer layers of the skin at the time of detection, the average five-year survival rate is 96 percent. Approximately 82 percent of melanomas are diagnosed at a localized stage.
When detected early, surgical removal of thin melanomas can cure the disease in most cases. Early detection is essential; there is a direct correlation between the thickness of the melanoma and survival rate. We recommend a regular self-examination of the skin to detect changes in its appearance. Additionally, patients with risk factors should have a complete skin examination by a dermatologist annually. Patients with a history of skin cancer need more frequent checks. To assist with monitoring full body photographic mole mapping is recommended.
T Classification |
Thickness |
Ulceration |
T1 |
Less than 1.0 mm |
a: w/o ulceration
b: with ucleration |
T2 |
1.1-2.0 mm |
a: w/o ulceration
b: with ucleration |
T3 |
2.1-4.0 mm |
a: w/o ulceration
b: with ucleration |
T4 |
More than 4.0 mm |
a: w/o ulceration
b: with ucleration |
The most appropriate treatment for any particular patient with melanoma depends upon the “stage” of the melanoma. The factors that determine the stage of a melanoma include; the thickness of the tumor within the skin and whether or not it has spread beyond the skin.
- In the stages of melanoma, “”, the disease is limited to the epidermis and has not yet started to invaded into the dermis below. At this stage surgical removal with a 0.5 cm. margin of normal appearing skin is the standard. However in cases involving the face or hands there is good evidence showing that Mohs Micrographic surgery may be advantageous.
- For early melanomas that are unlikely to have gone beyond the skin, surgical excision of the tumor with a 1 cm. wide safety margin is all that is required.
- For tumors that may have spread to local lymph nodes a “sentinel node biopsy” should be considered. This is a method of sampling the group of local lymph nodes to asses if the melanoma has spread or not.
- For tumors and those that have spread to local nodes then four additional steps should be considered:
- CT and PET scans that help evaluate internal organs for possible spread of the melanoma.
- Surgical removal of the whole group of nodes where the sentinel node biopsy found tumor.
- A course of immunotherapy with high dose interferon, and for more advanced cases possibly interleukin-2 (IL-2) perhaps with the addition of chemotherapy.
- Entry into an experimental protocol for newer, as yet unproven treatments such as vaccine therapy.
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