BASAL CELL | SQUAMOUS CELL | MELANOMA | BLUE LIGHT TREATMENT
The three most common forms of skin cancer are, in order, from most to least frequent, basal cell carcinoma, squamous cell carcinoma, and melanoma. Basal and squamous cell carcinoma do not change into melanoma. Some cancers have features of both basal and squamous cell carcinoma and are called basosquamous cell carcinoma. They are treated like squamous cell carcinoma.
After having one skin cancer, the odds of having another are about 50%. Having had any type of skin cancer increases the risk for development of melanoma. The more skin cancers a person has, the more likely the person will continue to have future skin cancer.
Persons that are immunosuppressed as a result of heart, kidney transplant, etc. are much more prone to develop skin cancer and more often develop squamous cell carcinoma.
Basal cell carcinoma extremely rarely metastasizes (travels to distant sites of the body). Basal cell carcinoma is a destructive cancer and will continue to grow, destroying the area it is located, until it is removed. Certain forms of basal cell carcinoma, the sclerosing, or morpheaform type, are often more extensive than they appear. Small islands of cancer grow out from the original tumor. Sclerosing means scarring and often these tumors appear like a scar. Larger margins of skin, around the tumor, need to be removed to obtain complete removal. In cosmetically or functionally vulnerable areas, the Mohs surgical technique may be used. This is a procedure where smaller margins are removed around the tumor. The specimen is checked, using frozen sections of tissue under the microscope, while the patient is waiting, to see if the tumor is gone. More tissue is taken until the margins are clear. The site is repaired as with any other surgical defect.
Squamous cell carcinoma, in the invasive form, grows rapidly and has the potential to metastasize. Areas more prone to metastasize are the lip and ear. Actinic keratosis is a precursor to squamous cell and is treated to reduce the risk of squamous cell carcinoma. Squamous cell carcinoma also grows in a non-invasive, superficial form know as in-situ or Bowen’s disease. At this stage, metastasis would be extremely rare.
Invasive squamous cell carcinoma is usually rapidly growing, tender or painful and often has a central hard plug or warty center. A red erupting volcano describes this growth. Most people will readily realize this growth is abnormal and will seek help before this cancer has a chance to spread.
Melanoma is the most feared skin cancer because, it is the most likely to metastasize. Yet the non-invasive form of melanoma, melanoma in-situ, has no access to the blood or lymph system and therefore, metastasis is extremely unlikely. The depth, the melanoma cells penetrate into the skin, determines the prognosis. As melanoma penetrates more deeply in the skin, the tumor gains access to larger blood and lymph vessels, increasing the risk of spread.
50% of melanomas occur in pre-existing moles and the other 50% are new growths. Therefore, any change in a mole- itching, color, size, scaling, etc, should be evaluated. Any new mole, in an adult, should be evaluated. The earliest melanomas are flat- do not wait for the changing mole to be raised to seek evaluation. Things are a little trickier in children, as they are just acquiring their moles so, the moles are changing. Follow the ugly duckling rule, if one mole looks very different from the others, have it evaluated. Luckily, prepubertal children are very unlikely to develop melanoma.
Treatment of melanoma is surgical, a 1-2 centimeter margin of normal skin is removed around the growth. Patients at high risk of metastasis, may be referred to a cancer center or surgeon for lymph node mapping. Dye is injected at the site of the melanoma, the first lymph node the dye drains into is called the sentinel node. The sentinel node is harvested, if positive, the remaining nodes are removed.
Persons at high risk of spread should be evaluated at a cancer center for adjunctive treatment. Unfortunately, most adjunctive treatment is experimental, at this time. Interferon is FDA approved for treatment of high risk melanoma and may provide a slight advantage in certain groups of patients.
X-rays, MRI, and CT scans and blood work are not recommended for persons at low risk of metastasis.
Blood relatives of persons with melanoma should be evaluated as, they are at increased risk of melanoma. Persons with melanoma will be seen frequently the first two years after diagnosis. All skin cancer patients should be seen annually for life.
Blue light in combination with the Levulan Kerastick is an F.D.A. approved treatment for actinic keratoses. Upon application of Levulan, a photosensitizer, pre-cancerous cells become sensitized to light. The scientific term is photodynamic therapy or PDT.
After cleansing the skin with acetone, Levulan is applied to the skin, and after a waiting period, the patient is placed under a Blue light which is visible light, for several minutes, usually 12-16 minutes. While under the light, there is an uncomfortable sensation of burning and stinging in the pre-cancerous ares. Discomfort is at its maximum during the first six minutes of treatment. This stops after the procedure is over only to recur, feeling like a very warm sunburn in about 12 hours. Relief will occur in a few hours and the symptoms can be relieved by using a topical anesthetic, taking oral non-steroidals such as Motrin, or Naprosyn and, oral Benadryl as needed. The lesions will look red and inflamed after treatment. If there is a lot of sun damage, you may have some swelling. This should improve greatly within the next few days and be obviously healing within a week. Some areas may remain pink for a few weeks, but this can be camouflaged with make-up for women, and is usually tolerated easily by men. Any dryness, in the first few days, can be alleviated by Vaseline. Moisturizers may be used once the skin is healed even if it is still pink, usually about 5-7 days.
Very important, is absolute sun avoidance for the first 48 hours after Levulan is applied to the skin. Remember, this medicine makes you sensitive to visible light and sunscreen will not give adequate protection. Plan on spending the next 48 hours indoors away from windows. If any errands have to be done, do them very early in the morning or after the sun is down in the evening. If you must run an errand, wear a broad brimmed hat and minimize exposure. If you are getting light to the skin, you will get a recurrence of the stinging sensation experienced underneath the Blue Light.
The original studies with the Blue Light were done by applying the Levulan only to the most obvious pre-cancerous lesions and leaving this on for a period of 14 to 18 hours, prior to applying the Light treatment. This method was very uncomfortable and many patients were not able to tolerate this treatment. More recent treatment protocols involve using the Levulan over entire sun damaged areas to treat subclinical lesions in addition to the visible lesions. The incubation period, time the Levulan is left on the skin, has been shortened to 1-8 hours, depending on the location being treated and severity of damage. Results are more thorough than with the spot treatment and seem to be on the same level of resolution as with comparable therapies such as Efudex. The procedure is much less painful with this short incubation period. Advantages to Blue Light over other treatments are, it is quick, the time ones skin looks abnormal is shortened greatly, and it is effective, is covered by Medicare and requires no prescription purchase.
Disadvantages include: it is uncomfortable, though tolerable, and one must be inside for two days. I have found the vast majority of people who have previously used Efudex or Carac greatly prefer the Blue Light treatment.