Featuring Todd Cartee, MD
Mohs surgeon Dr. Cartee provided a comprehensive overview of cutaneous oncology in one of the afternoon breakout sessions. Incidence of non-melanoma skin cancers is increasing in patients under 40 years of age in the US. High risk basal cell cancers include micronodular, infiltrating and morpheaform subtypes. Morpheaform basal cell carcinomas tend to have significant subclinical spread. While it is incredibly rare for basal cell carcinomas to metastasize, there can be significant local destruction by these tumors. Dr. Cartee revealed histologically aggressive basal cell cancers have a recurrence rate of 27% if treated with ED & C alone at 6.5 years post-treatment. He emphasized that “basal cell cancers can humble you”.
Incidence of non-melanoma skin cancers is increasing in patients under 40 years of age in the US.
Next, Dr. Cartee discussed squamous cell cancer. He recommended review of the evidence based guidelines published in February 2018 of JAAD. High risk factors for nodal disease include size > 2 cm, deep invasion beyond fat and perineural invasion. Metastatic rate of squamous cell cancer is approximately 3%. For high risk tumors, Mohs removal is recommended. Additional options for management may include investigational lymph node biopsy, CT of the head and neck, radiation therapy and close clinical follow up.
The 2012 appropriate use guidelines for Mohs surgery were discussed and Dr. Cartee pointed out there is an app you can download to help make these management decisions. Mohs surgery for the removal of NMSC has a 97-99% cure rate and allows for tissue conservation. The key to Mohs is full margin examination. Use of mohs for rare tumors include extramammary Paget’s disease, dermatofibrosarcoma protuberans, atypical fibroxanthoma and sebaceous carcinomas. He emphasized these are appropriate tumors to treat with Mohs removal but that not all Mohs surgeons have enough experience to treat these tumors. The biggest difficulty for Mohs surgery is it can be time and labor intensive.
Use of Mohs for rare tumors include extramammary Paget’s disease, dermatofibrosarcoma protuberans, atypical fibroxanthoma and sebaceous carcinomas.
Finally, Dr. Cartee reviewed melanoma. He pointed to the new AJCC staging system for management of melanoma with depths of tumors measured to the nearest 0.1 mm. For patients with T1b disease, sentinel node lymph node biopsy should be considered and discussed with a positive rate ranging from 5-12%. Fortunately, survival is improving across all T stages of disease. Adjuvant therapy for stage 3 disease melanoma is in flux and has changed dramatically over the last 3 years. Pd-1 inhibitors are becoming standard of care with interferon becoming obsolete. Unfortunately, Pd-1 inhibitors are still incredibly expensive. Dr. Cartee concluded his lecture examining Mohs, slow Mohs and wide local excisions for the surgical removal of melanoma.