There are a range of procedures which may be necessary and will depend on history, clinical examination and investigations. The procedures can be divided into those:
- Relating to the skin cancer itself
- Reconstruction of the defect
Special investigations are necessary for melanomas, but will depend on the depth of melanoma and stage of disease. Common investigations done include:
- Full blood count
- Liver function tests
- Chest X-ray
- Ultrasound abdomen
- CT scan of different parts of the body
This is the simplest procedure which is done on an outpatient basis. It is typically done when the nature of the lesion is not obvious. Also it is a good procedure to get a diagnosis if the lesion is in a cosmetically sensitive area. Removal of such a lesion without knowing the diagnosis could result in unnecessary disfigurement and for this reason, a punch biopsy becomes a reasonable first option.
The procedure is done under local anaesthetic and essentially a punch of tissue (3-4mm) from the suspected lesion is removed. The site of the punch is cauterised if necessary (for any oozing of blood) and occasionally a stitch is required which will need to be removed after 5-7 days.
Punch Biopsy is a useful procedure but may not give the entire picture, especially in patients with suspected melanomas.
This is similar to punch biopsy and involves removing a sliver of tissue, rather than a punch, and is also done under local anaesthetic but as a daycase. Its advantage is that with incision biopsy one can go into the bordering normal tissue and that can give a better assessment.
This is a procedure which is done as a daycase procedure under local anaesthetic. It is done for lesions where one is not sure of diagnosis but the defect can be closed easily. The lesion is removed with a 1-2 mm margin of normal tissue and then the skin edges are drawn together. Removal of the complete lesion is particularly desirable in treating melanomas, where the treatment will depend on the depth of the lesion, which is assessed under the microscope. Deeper the lesion, more of a margin is necessary.
Excision Biopsy Without Wound Closure
This is sometimes necessary when the lesion is large and pigmented. After doing an excision biopsy it is not possible to close the lesion by drawing the skin edges together. Wound closure would entail a skin graft or local flap. In this situation we need to know the diagnosis and depth of the melanoma, so that a definitive margin of tissue can be excised. If the lesion was excised and wound closed with say a skin graft; results from the laboratory may mean another procedure where the original skin graft has to be removed to take out more tissue.
To avoid all these problems, sometimes the lesion is excised and a damp dressing placed on the wound. The lesion is sent to the laboratory and the patient is sent home. The dressing will need to be changed couple of times every week. When the results are available, then another procedure is required, which may involve taking out more tissue and some form of wound closure like skin grafting or local flap.
Excision Bipsy and Frozen Section/MOHS Surgery
In cases of diagnostic difficulty or a lesion with ill defined margins, one can remove the lesion and send it off to the laboratory at the same time. The laboratory can give a result straightaway and a definitive procedure can then carried out. This is the procedure of Frozen section.
Tissue assessed by Frozen section techniques has to be assessed further like every other tissue sent to the laboratory. There is sometimes a difference in the frozen section result and the definitive histology result.
Mohs surgery is a refinement of the above mentioned procedure. It involves doing definitive sections at the same time as the procedure. It is obviously time consuming but leads to maximum tissue preservation. This is a technique which is done by only a few specialised dermatologists. The reconstruction of the defect created is staged typically to another day.
Excision Biopsy of Skin Cancer with Definitive Margins
The lesion is removed with a definitive margin which is a minimum of 3-4 mm of normal tissue. This is done in patients with typical Basal cell carcinoma (BCC) or Squamous cell carincoma (SCC). These are the commonest lesions and largely have a typical appearance.
The procedure is done as a daycase under local anaesthetic. The visible edge of the lesion is marked and then a margin of tissue is inked in. The area is infiltrated with local anaesthetic and then the lesion is excised. Reconstruction of the defect created is done simultaneously and will depend on site, size and tissue characteristics.
The operation is done using magnifying loupes, but it is only possible to assess complete clearance, when the tissue sent, is examined in the laboratory under the microscope. Sometimes the lesion is of an infiltrating nature and the clearance is not complete. The surgeon will discuss with you about further possible methods of treatment, which is normally one of the three:
- Continued close observation
- Further surgery
The decision about best further treatment would have been discussed in a multi-disciplinary team meeting involving various specialists. Mr Azad will inform you of this aspect, but the final decision is that of the patient.
Wide Local Excision
This term is typically used for patient with melanomas. There are UK guidelines for the amount of tissue to be taken, depending on the depth of the melanoma. The deeper the melanoma on histology, more of the tissue has to be excised. Tissue excision from the margin of the lesion or the scar from a previous excision biopsy varies from 1-3 cm.
The typical journey of a melanoma patient is an excision biopsy for diagnosis. This is followed by wide local excision to remove a margin of tissue for complete safety. Lesions excised with larger margins of tissue will need reconstructive surgery to fill the defect.
FNAC (Fine needle aspiration cytology)
This is a long term which basically means that a needle is inserted into an enlarged lymph node in neck, armpit or groin and a sample of cells is taken for assessment. This is done if there is a skin cancer in an area with a suspicion of spread to the lymph nodes. Lymph nodes are glands which are the first to get involved with spread of cancer.
The FNAC test is useful and is done as an outpatient procedure with or without local anaesthetic. If there is diagnostic confusion about the result, then it will necessitate a biopsy of the lymph node which is done as a day case procedure under local anaesthetic.
Lymph Node Biopsy
This is a daycase local anaesthetic procedure involving a small scar in the neck, armpit or groin. The lymph gland is removed and sent to the laboratory for assessment. The wound is closed with dissolving stitches.
The procedure is not particularly painful and simple painkillers are adequate. Sometimes yellow coloured fluid (seroma) can collect and needs to be aspirated in the outpatient. It settles in due course.
Sentinel Lymph Node Biopsy
This is a new technique which is not available in all centres. Skin cancer can spread to the rest of the body either through lymph channels (commoner method) or via the blood stream. In the body there are numerous lymph channels which drain to lymph nodes arranged in the areas of the neck, armpit and groin. The lymph nodes are the defence mechanism of the body from further spread. Affected lymph nodes typically get enlarged and can be felt through the skin.
It would be useful if there was a technique to detect spread to the lymph nodes even before they became enlarged. Research has shown us that with spread of cancer, there is one or more lymph glands which gets involved first in an area of lymph nodes. This first gland is termed as the SENTINEL LYMPH NODE, as it is in effect the sentinel to all the glands in that region. Removal of this gland and laboratory assessment would be representative of all the lymph glands in that particular region.
Techniques have been now developed, to detect this sentinel lymph gland, and involve use of radioisotope material with injectable blue dye. These materials are injected around the site of melanoma and using a combination of gamma camera and operative visualisation, one can remove the sentinel lymph gland. If the sentinel lymph gland is involved, it will necessitate a bigger operation to clear all the lymph nodes in the region.
Sentinel lymph node biopsy is fast emerging as a key method of diagnosis and for prognosis of malignant melanoma.
Block Dissection of Neck/Armpit/Grion
This procedure involves removal of all lymph glands in an affected region. The procedure is done in the main centres by a few specialist skin oncology surgeons. This helps in standardization and better results for the patients.
This operation is a major procedure under general anaesthetic. Fair size incisions are made in the neck, armpit or groin and the lymph glands are removed. The area is drained for a few days after surgery. Hospital stay is typically for one week.
There are well known complications from this procedure including infection, seroma (collection of yellow fluid), swelling, bruising, nerve injury, contour defect and lymphoedema. Lymphoedema is an unfortunate complication and will need aggressive management in a specialist hospital.
Common methods of wound closure are:
- Direct closure
- Skin grafts
- Local flaps
This is done when the skin can be drawn together without tension. This is the simplest and most common method of wound closure. The lesion is marked with a margin and then excised in a boat shaped manner (elliptical excision). The scar is considerably longer than the lesion which comes as a surprise to many patients. Stitches can be dissolving or non-dissolvable depending on the area. The stitch line can be left exposed or kept dressed.
This involves taking a piece of skin to reconstruct a defect. The skin can be either partial thickness or full thickness.
Partial thickness skin grafts are normally taken from the thigh area. It is like a graze and can be quite sore, so you will need to take regular pain killers. It takes about 10-14 days to heal up completely and leaves a pink patch, which will gradually fade away. Occasionally the skin graft donor site healing can become an issue, especially so in those with thin skin and patients on steroids. It will then require regular dressings to make the area heal up.
Full thickness grafts are useful for smaller defects in cosmetically sensitive areas like the face. The graft is harvested from behind the ear, neck, inner arm or groin. It shrinks less in the healing phase and gives a better final appearance in comparison to the partial thickness skin graft.
The skin graft is stitched into the defect and a tie-over dressing is used, to avoid the graft from shearing on its bed. This is removed in 5-7 days. The grafted area will have a significant indentation and will take time to settle down.
A flap is basically a piece of tissue with its own blood supply. The piece of tissue which is adjacent to the defect is either transposed, advanced or rotated to fill the defect. Local flaps have the advantage of better colour match and less shrinkage in comparison to skin grafts. They also avoid the issues of skin graft donor site.
Top of Page