Nonmelanoma Skin Cancer ofthe Head and NeckCurrent Diagnosis and Treatment

Görkem Eskiizmir, MDa, Cemal Cingi, MDb,*

KEYWORDS

� Head and neck cancer � Non melanoma skin cancer � Skin cancer epidemiology� Skin cancer demographics

KEY POINTS

� Skin cancers, mainly classified as melanoma and nonmelanoma skin cancers (NMSCs), are the mostcommon cancers in humans.

� The most common types of NMSCs are basal cell carcinoma and squamous cell carcinoma.

� Nonmelanoma skin cancers are generally considered as a neglected health problem owing to theirlowmorbidity andmortality; however, the economic burden of health interventions in NMSC is on theincrease.

� Patients with a NMSC are generally complained of a nonhealing, ulcerative, and bleeding lesion.

� A dermoscopic examination of a suspicious lesion is helpful for differential diagnosis; and excision orbiopsy is generally recommended for histopathological evaluation.

� The gold standard treatment modality for NMSCs is surgical resection.

� Surgical margin control has a paramount importance for decreasing the rate of tumor recurrence.

SKIN CANCER INCIDENCE NMSCs in Australia was 1170/100,000 and the

om

Skin cancers are the most common cancers inhumans, especially in the white population. Theyaremainly classified asmelanomaandnonmelano-ma skin cancers (NMSCs). Unfortunately, theworldwide incidence of NMSCs is not knownexactly; they are generally considered a neglectedhealth problem owing to their low morbidity andmortality. Therefore, the cancer registration data-bases are unreliable even in most of the developedcountries; however, evidence demonstrates thatthe incidence of NMSC has continually and dra-matically increased over the past decades in thewestern world.1–4 A recent systematic review thatevaluated the global incidence for NMSCs deter-mined that Australia has the highest incidence inthe world.5 In 2002, the reported incidence for

a Department of Otolaryngology-Head & Neck Surgery,Manisa, Turkey; b Department of Otorhinolaryngology-HMes‚elik Kampusu, 26480, Eskisehir, Turkey* Corresponding author.E-mail address: ccingi@gmail.com

Facial Plast Surg Clin N Am 20 (2012) 415–417http://dx.doi.org/10.1016/j.fsc.2012.07.0031064-7406/12/$ – see front matter � 2012 Elsevier Inc. All

c

estimated number of patients with NMSCs was374,000.3 In addition, the economic burden spenton the care settings and treatment modalities ofNMSCs was more than $264 million.6 Meanwhile,the incidence for NMSCs in the United Statescannot be regarded as too low to overlook. In theUnited States, the estimated total number of newNMSCs was 3,507,693 in 2006, and approximately3.69 million in 2008.7,8 The estimated total cost ofNMSCs was approximately $426 million per yearin the Medicare population.9 In addition, Guy andEkwueme10 reported the years of potential lifelost and indirect expenditures of skin cancers(including melanoma and NMSCs), which rangedfrom $28.9 to $39.2 million for morbidity, and $1.0to $3.3 billion for mortality. Epidemiologic studiesand health economic analysis highlight that the

Celal Bayar University, Uncubozkoy yerles‚kesi, 45030,ead & Neck Surgery, Eskisehir Osmangazi University,

rights reserved. facialplastic.theclinics.

Eskiizmir & Cingi416

incidence of NMSCs is increasing and it isbecoming an important public health problemworldwide with an increasing economic impact.Therefore, several countries and the World HealthOrganization (INTERSUN program) recommendand encourage preventive strategies (eg, sun-protective behaviors and attitudes, topical sun-screens) against skin cancers. In addition, skincancer screening programs have been imple-mented recently with promising results in certaincountries, such as Germany.11

COMMON TYPES OF NONMELANOMA SKINCANCERS

The most common types of NMSCs are basal cellcarcinoma (BCC) and squamous cell carcinoma(SCC), although several other rare types, such asMerkel cell carcinoma and sebaceous gland carci-noma are also present.Themajor etiologic factor for the development of

NMSCs is overexposure to solar ultraviolet (UV)radiation, especially UVB (ranging 320 to 290 nm).Therefore, the sun-exposed skin regions, such asthe head, neck, and extremities, are at higher riskfor the development of NMSCs. The developmentof BCC is associated with intermittent exposureto the sun. The development of actinic keratosis(precancerous progenitor of SCC) and/or invasiveSCC is associated with continual, chronic sunexposure. UV radiation-induced carcinogenesis inNMSCs is basically related to a defect in the repairof UV radiation-induced DNA damage. In BCC,mutations in Hedgehog signaling pathway–relatedgenes, and in SCC, mutations in p53 tumorsuppressor genes play a key role.12–14

Basal Cell Carcinoma

Basal cell carcinoma, the most frequent subtype ofNMSCs, originates from the basal cells of theepidermis. It almost always invades the local struc-tures; however, it rarely metastasizes. It has varioussubtypes, which are mainly classified according totheir clinical and histopathological characteristics:noduloulcerative, superficial, morpheaform, infiltra-tive, basosquamous, cystic, and fibroepithelioma ofPinkus. Noduloulcerative and superficial BCC arethe most common subtypes and generally involvethe head and neck regions. Morpheaform, infiltra-tive, and basosquamous subtypes of BCC areless commonly detected; however, they havea more aggressive behavior.

Squamous Cell Carcinoma

Squamous cell carcinoma originates from epidermalkeratinocytes. It is a locally aggressive skin cancer,

which also has the potential to metastasize toregional lymph nodes and distant structures. Theincidence of regional lymph node involvement incutaneous SCC of the head and neck is approxi-mately 5%; and the lymph nodes in the parotidgland are a metastatic basin for cutaneous SCC ofthe head and neck.15 Unfortunately, the survival ofpatients with metastatic cutaneous SCC decreasesdramatically (overall 5-year survival rate of 34.4%).16

HISTORY AND EXAMINATION FORNONMELANOMA SKIN CANCERS

Most patients with NMSCs report a history of non-healing, ulcerative, bleeding lesions. In physicalexamination, typical morphologic appearances ofBCC (a firm, “pearly” papule or nodule with tele-ngiectasis) and SCC (a papule, nodule, or plaquewith or without hyperkeratosis) can be detected.Moreover, dermoscopic examination of the lesionscan be helpful in differential diagnosis.17 Any lesionwith a suspicion of skin cancer should be excisedor biopsied for histopathological examination.

TREATMENT FOR NONMELANOMA SKINCANCERS

The gold standard treatment modality for NMSCsis surgical resection; however, cryotherapy, radio-therapy, curettage and electrodessication, photo-dynamic therapy, or topical immunmodulatorsmay be recommended as an alternative therapyto patients who are not good candidates forsurgery or are unwilling to have a surgical proce-dure. The major goal of a surgical excision is tohave a tumor-free excision area while preservingthe maximal healthy tissue. Surgical margincontrol is of paramount importance in the manage-ment of NMSCs. Tumor recurrence is rare (<2%)when a tumor-free surgical margin is achieved;on the other hand, a high rate of tumor recurrence(25%–41%) has been reported in incompletelyexcised lesions.18–21

SURGICAL INTERVENTIONS FORNONMELANOMA SKIN CANCERS

The surgical interventions for NMSCs are Mohsmicrographic surgery, surgical excision with post-operative margin assessment, and surgical exci-sion with complete circumferential peripheral anddeepmargin assessment with frozen or permanentsections (staged surgery).18,22 Mohs micrographicsurgery is performed successfully for the manage-ment of both BCC (1.4% in primary tumors and4.0% in recurrent tumors) and SCC (2.6% inprimary tumors and 5.9% in recurrent tumors)with a very low recurrence rate.23,24 However,

Nonmelanoma Skin Cancer of the Head and Neck 417

staged surgery with permanent sections may beconsidered in patients with high-risk NMSCs andrecurrent tumor, or after a Mohs micrographicsurgery failure.18,25 A defect is formed after thesurgical excision of the tumor. Therefore, a recon-struction technique is generally required to obtaina functional structure and a esthetically pleasantappearance, unless the defect size is small enoughfor primary closure. A successful facial reconstruc-tionmainly depends on an accurate defect analysisand surgical plan that is tailored according to thesize, depth, and location of the defect, andmeticu-lous application of surgery. In addition, a goodphysician-patient relationship is essential; thereby,patients’ expectations can be realized by thesurgeon and the details (eg, surgical outcome,complications) about the reconstruction techniquecan be discussed with the patient preoperatively.

REFERENCES

1. Gloster HM Jr, Brodland DG. The epidemiology of

skin cancer. Dermatol Surg 1996;22:217–26.

2. Geller AC, Annas GD. Epidemiology of melanoma

and nonmelanoma skin cancer. Semin Oncol Nurs

2003;19:2–11.

3. Staples MP, Elwood M, Burton RC, et al. Non-mela-

noma skin cancer in Australia: the 2002 national

survey and trends since 1985. Med J Aust 2006;

184:6–10.

4. Leiter U, Garbe C. Epidemiology of melanoma and

nonmelanoma skin cancer—the role of sunlight.

Adv Exp Med Biol 2008;624:89–103.

5. LomasA, Leonardi-Bee J, Bath-Hextall F. A systematic

review of worldwide incidence of nonmelanoma skin

cancer. Br J Dermatol 2012;166:1069–80.

6. Australian Institute of Health and Welfare. Health

systemexpenditures on cancer and other neoplasms

in Australia, 2000–01. Health and Welfare Expendi-

ture Series No. 22. Canberra (Australia): AIHW;

2005. AIHW Catalogue No. HWE 29.

7. Rogers HW, Weinstock MA, Harris AR, et al. Incidence

estimate of nonmelanoma skin cancer in the United

States, 2006. Arch Dermatol 2010;146:283–7.

8. Donaldson MR, Coldiron BM. No end in sight: the

skin cancer epidemic continues. Semin Cutan Med

Surg 2011;30:3–5.

9. Chen JG, Fleischer AB Jr, Smith ED, et al. Cost of

nonmelanoma skin cancer treatment in the United

States. Dermatol Surg 2001;27:1035–8.

10. Guy GP, Ekwueme DU. Years of potential life lost and

indirect costs of melanoma and non-melanoma skin

cancer: a systematic review of the literature. Pharma-

coeconomics 2011;29:863–74.

11. Breitbart EW, Waldmann A, Nolte S, et al. Systematic

skin cancer screening in Northern Germany. J Am

Acad Dermatol 2012;66:201–11.

12. Brash DE, Rudolph JA, Simon JA, et al. A role for

sunlight in skin cancer: UV-induced p53 mutations

in squamous cell carcinoma. Proc Natl Acad Sci

U S A 1991;88:10124–8.

13. de Gruijl FR, van Kranen HJ, Mullenders LH. UV-

induced DNA damage, repair, mutations and

oncogenic pathways in skin cancer. J Photochem

Photobiol B 2001;63:19–27.

14. Goppner D, Leverkus M. Basal cell carcinoma: from

the molecular understanding of the pathogenesis to

targeted therapy of progressive disease. J Skin

Cancer 2011;2011:650258.

15. O’Brien CJ. The parotid gland as a metastatic basin

for cutaneous cancer. Arch Otolaryngol Head Neck

Surg 2005;131:551–5.

16. Rowe DE, Carroll RJ, Day CL. Prognostic factors for

local recurrence, metastasis, and survival rates in

squamous cell carcinoma of the skin, ear, and lip.

J Am Acad Dermatol 1992;26:976–90.

17. Zaballos P, Llambrich A, Puig S, et al. Dermoscopy

is useful for the recognition of benign-malignant

compound tumours. Br J Dermatol 2005;153:

653–6.

18. Walker P, Hill D. Surgical treatment of basal cell carci-

nomas using standard postoperative histological

assessment. Australas J Dermatol 2006;47:1–12.

19. Sherry KR, Reid LA, Wilmshurst AD. A five year

review of basal cell carcinoma excisions. J Plast Re-

constr Aesthet Surg 2010;63:1485–9.

20. Sussman LA, Liggins DF. Incompletely excised

basal cell carcinoma: a management dilemma?

Aust N Z J Surg 1996;66:276–8.

21. De Silva SP, Dellon AL. Recurrence rates of positive

margin basal cell carcinoma: results of a five year

prospective study. J Surg Oncol 1985;28:72–4.

22. Cumberland L, Dana A, Liegeois N. Mohs micro-

graphic surgery for the management of nonmelano-

ma skin cancers. Facial Plast Surg Clin North Am

2009;17:325–35.

23. Leibovitch I, Huilgol SC, Selva D, et al. Cutaneous

squamous cell carcinoma treated with Mohs micro-

graphic surgery in Australia. I. Experience over 10

years. J Am Acad Dermatol 2005;53:253–60.

24. Leibovitch I, Huilgol SC, Selva D, et al. Basal cell

carcinoma treated with Mohs surgery in Australia.

II. Outcome at 5-year follow-up. J Am Acad Derma-

tol 2005;53:452–7.

25. Eskiizmir G, Gencoglan G, Temiz P, et al. Staged-

surgery with permanent pathology for the manage-

ment of nonmelanoma skin cancer of the nose. Eur

Arch Otorhinolaryngol 2011;268:117–21.