Skin cancer, the most common form of cancer in the country, affects millions of Australians. It arises from uncontrolled growth of abnormal skin cells, primarily caused by exposure to ultraviolet (UV) radiation from the sun. The three main types of skin cancer are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. While BCC and SCC are typically localized and highly curable, melanoma can spread to other parts of the body, making it the most dangerous form of skin cancer.

Understanding the Common Types of Skin Cancer

1. Basal Cell Carcinoma (BCC): The most common type of skin cancer, BCC accounts for approximately 80% of all cases. It typically appears as a pearly or waxy bump, often on the face, ears, or scalp. While BCC rarely spread, it can locally invade surrounding tissues if left untreated. There are three main types of BCC
   1. Superficial BCC: As the name suggests, these skin cancers tend to be like scaly plaques and a just on the surface of the skin. The can cover an extensive area, even if they do not invade deeply into the skin and fat. These can sometimes be cured without surgery using specialised creams, light treatments or scraping. For cases that recur after non surgical treatment, or where complete tumour clearance is important, surgery may be required.
   2. Nodular BCC: These nodules of BCC a skin lumps which have definite edges. They may have a central ulcer. Surgical excision is the best recommended treatment.

• Infiltrative BCC: These are the hardest to treat, as the edges of the cancer are indistinct and there may be “fingers” or “roots” that extend deeply into the skin and underlying tissue. Surgery is required to treat these cancers. Sometimes patients need further treatment after surgery, such as radiotherapy, especially if the BCC has invaded a nerve.

2. Squamous Cell Carcinoma (SCC): The second most common skin cancer, SCC arises from squamous cells, the flat cells that make up the outer layer of the skin. It often presents as a red, scaly patch or as a rough, open sore. SCC can spread to nearby lymph nodes if not treated promptly. BCC and SCC often look very similar.
3. Melanoma: The most serious type of skin cancer, melanoma develops from melanocytes, the cells that produce melanin, the pigment that gives skin its color. It can appear as any mole or skin lesion that changes in size, shape, or color. Melanoma can metastasize, spreading to other organs through the lymphatic system and bloodstream.The risk of a melanoma spreading is related to how thick the cancer is when the pathologist looks at it under a microscope. Melanomas more that 1mm in thickness should ideally be treated in a specialised melanoma unit.

Diagnosing Skin Cancer: Early Detection is Key

Early detection is crucial for successful skin cancer treatment. Regular self-skin exams are essential, checking for any new or changing moles or skin lesions. If you notice any suspicious changes, consult your GP, skin cancer clinic or dermatologist promptly.

GP’s, skin cancer clinics and dermatologists employ various diagnostic techniques to assess skin lesions:

1. Physical examination: Many skin cancers can be diagnosed pretty accurately just by looking at them. New scaly lumps in sun exposed areas that bleed when you rub them are highly suspicious for being skin cancers.
2. Dermatoscopy: Using a special magnifying device, GP’s and dermatologists closely examine the skin lesion’s structure, colours, and patterns to detect subtle abnormalities.
3. Biopsy: This is the best way of diagnosis a skin cancer, but does not need to be performed in every case. A biopsy is a minor surgical procedure where some local anaesthetic is injected under the skin lesion, and a 2mm or 3mm punch of tissue is taken. This punch biopsy is then sent off to the pathology lab, where a pathologist will be able to diagnose what the skin lesion is – whether it is a cancer or not, and if it is a cancer, what type. This biopsy guides future treatment. If the biopsy demonstrates a skin cancer, that cancer will need to be treated.

Treatment Options for Skin Cancer

The choice of skin cancer treatment depends on the type, stage, and location of the lesion. Common treatment options include:

1. Surgical Excision: The standard treatment for BCC and SCC, surgical excision involves removing the cancerous tissue along with a margin of healthy surrounding skin.
2. Mohs Micrographic Surgery: This is a highly specialized technique, where skin cancer is removed in pieces, with the edge of each piece examined under a microscope at the time of surgery to make sure that the cancer has been completely removed. The surgery is performed by a specially trained dermatologist with A/Prof Marucci doing the later reconstruction. Mohs surgery does have a high cure rate but it may take any thing from 30 minutes to 2 hours to perform. A/Prof Marucci refers patients for Mohs when it is difficult to determine how much tissue needs to be taken – either due to a vague tumour outline or due to cancer re-occuring within a scar.
3. Curettage and Electrodesiccation (C&E): A simple procedure often used for small, superficial BCCs, C&E involves scraping the cancerous tissue and cauterizing the base with an electrical current. This kind of treatment is offered by many dermatologists and skin cancer clinics. A/Prof Marucci does not perform C&E as it not always possible to determine whether the cancer has been adequately treated.
4. Cryotherapy: Liquid nitrogen is used to freeze and destroy cancerous cells. It is commonly used for small BCCs and SCCs on the face, hands, or feet. Again, A/Prof Marucci does not perform cryptherapy as it not always possible to determine whether the cancer has been adequately treated.
5. Radiation Therapy: High-energy radiation beams are used to kill cancerous cells. Radiation therapy can be used in addition to surgery, for skin cancers that have invaded nerves or blood vessels, or skin cancers that are thick and aggressive when looked at under the microscope. A/Prof Marucci is part of the St George Hospital Head and Neck Cancer Multi Disciplinary Team (MDT), where difficult cases are discussed.
6. Chemotherapy: There are topical chemotherapy medications that can be used to treat very superficial skin cancers. Systemic chemotherapy (chemotherapy given either into veins or taken as tablets) may be required for advanced cancers after discussion in an MDT with specialist oncologists.

Surgical Reconstruction After Skin Cancer

Following surgical removal of skin cancer, reconstruction may be necessary to restore form and function to the affected area. Reconstruction techniques vary depending on the size, location, and depth of the defect.

1. Primary closure: This is where the cancer is cut out and the wound put back together again with stitches, without having to move any skin around. This is appropriate for smaller lesions and is usually performed under local anaesthetic.
2. Skin Graft Surgery: Sometimes, after a skin cancer has been cut out, the wound is too big to be simply stitched back together. One option to take some skin from elsewhere on the body and stich that skin into the hole left by the skin cancer removal. This skin is “grafted” onto the new site and will hopefully develop a blood supply at its new location. The wound where the skin graft came from is either closed primarily with stiches or can be dressed to heal on its own. Skin grafts often have a different colour and contour to the surrounding skin and may take a while to heal
3. Local Flap Surgery: This is another option to reconstruct a wound after a skin cancer has been cut out, and there is not enough surrounding skin to put the wound back together. A “flap” of skin is where some adjacent skin, which is loose, is cut in a way that its blood supply can be preserved and that it can be moved into the defect left by the skin cancer. Local flaps tend to give a better cosmetic result as “like is being replaced with like”.

Potential Risks and Complications of Skin Cancer Treatment

While skin cancer treatments are generally effective, they may carry certain risks and complications, including:

1. Scarring: Surgical procedures will result in scars, which may vary in size and appearance depending on the location and extent of skin removal. Different people scar differently – some scars can stretch, some scars can be indented, sometimes there is raised skin at either end of a scar (called a “dog ear”). Sometime excess scar tissue can be produced (called a “keloid” scar)
2. Infection: Infections can occur at the surgical site, requiring treatment with antibiotics.
3. Bleeding: Excessive bleeding may occur during or after surgery. Some bruising is normal. Most bleeding stops with firm pressure for 10 minutes over the surgical site. Rarely, further surgery is required to stop bleeding.
4. Nerve Damage: Surgical procedures near nerves may cause temporary or permanent numbness or weakness in the affected area.
5. Recurrence: Skin cancer may recur, requiring further treatment