Skin neoplasms: causes, symptoms and treatment at the Yusupov Hospital

Skin neoplasms are usually understood as benign or malignant skin lesions of a tumor nature against the background of abnormal proliferation of dermal cells. It must be said that, as a rule, it is recommended to remove the resulting benign neoplasm, since the slightest injury or exposure to sunlight significantly increases the risk of its malignancy. Malignant neoplasms of the skin include skin cancer.

Skin cancer is one of the few that can be almost completely cured by consulting a doctor in time. Yusupov Hospital provides a wide range of diagnostic and treatment services for all forms of skin cancer. Experience in managing patients with this pathology allows us to demonstrate excellent results. Doctors develop a comprehensive individual program for the management of each patient. It includes both diagnosis and treatment, as well as rehabilitation. At the Yusupov Hospital, a diagnosis is made as quickly as possible and, preventing the progression of the disease, an effective treatment method is selected. The living conditions are comfortable, and all the medical staff are specialists in their field.

Reasons for the development of the disease

Currently, there is no clear answer to the question of what causes skin cancer. Like many other oncological diseases, skin tumors are considered a multi-etiological pathology. There are several predisposing factors, the presence of which increases the risk of developing a tumor focus. These include:

• Excessive exposure to ultraviolet rays on the skin. A similar situation occurs with prolonged and frequent exposure to sunlight, visiting a solarium, or working outside. Residents of the southern regions are at risk of developing skin cancer.
• Having light skin. Lack of melanin production increases the likelihood of skin tumors.
• Skin burn. A high degree of burn is accompanied by scarring of the skin. This process contributes to the emergence of latent carcinogenesis.
• Irradiation. Exposure to radioactive, ionizing rays has a detrimental effect on the skin. The risk of radiation dermatitis increases.
• Presence of skin contact with toxic substances. This group of carcinogens includes arsenic, aluminum, titanium, nickel and other heavy metals.
• Immunodeficiency. Conditions in which the body's protective functions decrease predispose to the formation of a tumor focus.
• Age. Most often, skin tumors affect people over 50 years of age.
• Concomitant systemic diseases. Doctors identify a group of pathologies in which the risk of developing skin cancer increases significantly. These include systemic lupus erythematosus, leukemia, and chronic skin diseases.
• Heredity. The presence of a skin tumor in previous generations of relatives is not a major risk factor. However, family history in combination with other predisposing conditions increases the possibility of developing skin cancer.
• Tattooing. In this case, there are two risk factors. This is a violation of the integrity of the skin and the introduction of paint with carcinogenic substances. Cheap tattoo ink may contain impurities of aluminum, titanium, and arsenic.
• A large number of nevi. Doctors urge you to monitor the condition of moles and contact a specialist if there is the slightest change. Traumatization of nevi increases the possibility of developing skin cancer.
• Excessive alcohol consumption, smoking. Chronic intoxication has a detrimental effect on the body as a whole. Against this background, the risk of tumor formation increases several times.
• Eating foods high in nitrates.

Expert opinion

Author:

Alexey Andreevich Moiseev

Head of the Oncology Department, oncologist, chemotherapist, Ph.D.

Every year, 9,000 cases of newly diagnosed melanoma are registered in Russia. This aggressive malignant tumor is responsible for the death of 40% of patients. Such statistics indicate that the country's population is not sufficiently aware of the symptoms of melanoma. As a result, a visit to a doctor occurs in the later stages, when treatment is considered ineffective.

Doctors at the Yusupov Hospital determine the location of melanoma and prescribe treatment appropriate to the stage of tumor development. An individual approach to the problem of each patient allows us to reduce the number of deaths. A tumor detected in time is characterized by a favorable prognosis for recovery. The later melanoma is detected, the longer the treatment process will be. Its success depends on many factors. The main treatments for melanoma are surgery, radiation and chemotherapy. Depending on the condition, symptomatic therapy is carried out.

You can diagnose the presence of skin cancer yourself at home. Doctors recommend regularly examining the skin, especially nevi, for the appearance of pathological formations.

Reviews about the treatment of basal cell carcinoma

Maria Alexandrovna, 57 years old “ Around the end of the summer of 2021, a reddish spot the size of a pea, with jagged edges, appeared on my right cheek. Over time, the spot began to increase in size and peel off. This alarmed me and I went to the clinic to see a surgeon, who examined me and did not give me a clear answer that it was he who did not give me. He prescribed me ointments, but they had no effect. As time passed, the spot became inflamed and turned into a weeping wound, which began to get worse. I was tired of all this and on the Internet I came across the LazerVita clinic and made an appointment with a surgeon. On the day of the appointment, the surgeon Gafarov Sarkhan Vidadievich saw me, examined the wound, he immediately did not like it and took cytology. After explaining everything to me and reassuring me, he made an appointment with oncologist Violetta Aleksandrovna Purtskhvanidze in 3 days, by which time the cytology will be ready. He prescribed me to treat with antiseptic solutions and antibiotics for now. Three days later, I came to see Violetta Alexandrovna. After examining the wound, she diagnosed Basal cell carcinoma, which was confirmed cytologically. She explained my diagnosis to me in detail, reassured me, and explained to me all the treatment options. Then, on the same day, Dr. Sarkhan Vidadievich performed an operation on me: laser removal. The operation went without complications, everything healed perfectly. I want to express my gratitude to the entire LazerVit team, and especially to doctor oncologist V.A. Purtskhvanidze. and doctor surgeon S.V. Gafarov Thank you very much!

» All reviews about the treatment of basal cell carcinoma and other diseases.

Kinds

Skin tumors are divided into three types: benign, borderline or precancerous tumors, and malignant. All of them differ in their ability to metastasize to other organs, complications, and the ability to lead to death. It should be added that a large number of moles on the skin or other neoplasms of a benign nature (papillomas, warts) is evidence of a given person’s predisposition to cancer. Benign neoplasms are considered:

• moles or nevi;
• atheromas;
• adenomas;
• lymphangiomas;
• hemangiomas;
• fibroids;
• neurofibromas;
• lipomas;
• papillomas.

Borderline tumors include:

• keratoacanthoma;
• senile keratoma;
• cutaneous horn;
• xeroderma pigmentosum and other not very common neoplasms.

Malignant neoplasms are represented by melanoma, sarcoma, epithelioma, basal cell carcinoma.

During a general examination of the patient, an oncodermatologist

EVERYONE is watching! Skin on the torso, face, neck, limbs, mucous membranes, scalp.

• Dermatoscope.
• SIAscopically.
• Cytologically.
• Histologically!!

Biopsy of a skin tumor
A mandatory diagnostic step for skin tumors is morphological verification of the process; for this, a biopsy

. The oncologist takes cells or tissues from the site of the tumor and submits them for examination to pathologists, who form their conclusion.

The morphological report contains information about the tumor:

• localization of the process (where the tumor is located);
• diameter (what size is the tumor);
• growth type;
• characteristics of the resection margin (the tumor was completely removed or not).

The oncologist makes a final diagnosis and forms a treatment plan only after receiving the results of the biopsy.

Benign skin tumors

Benign neoplasms have a slow growth rate; during development, they put pressure on nearby tissues, but do not penetrate them. Benign neoplasms are as follows:

• Lipoma is a neoplasm from the fatty layer;
• papillomas and warts. Externally they look like growths on a leg (if injured they often turn into cancer) or bulges, the origin is viral;
• Dermatofibroma develops from connective tissue. Most often it is detected in representatives of the fair sex at a young and mature age. Distinctive features are small size (0.3-3 cm), slow growth, and insignificant subjective sensations. Mainly affects the lower extremities. Dermatofibroma should be distinguished from nevus, basal cell carcinoma and dermatofibrosarcoma;
• Nevi are various sharply limited hyperpigmented areas of skin that have different shapes and colors. The surface is both striped and smooth. Warty nevus growths up to two centimeters in diameter may be observed. They can be distinguished from soft fibromas by the hyperkeratotic layers present on the surface (dense crusts resembling peeling). The most dangerous representative is considered to be a pigmented borderline nevus, in which melanin is present and which can degenerate into melanoma;
• Lentigo usually occurs in adolescence on any part of the body. Outwardly it looks like a smooth oval spot, the diameter of which can reach up to one and a half centimeters. If this neoplasm occurs in old age, it is called senile lentigo;
• Atheromas develop from the sebaceous gland. Atheroma or epithelial cyst has a high potential for malignancy into liposarcoma. Most often it occurs in areas of the skin where many sebaceous glands are concentrated (scalp, face, forehead). This is a single, painless formation that rises above the surface. In case of inflammation and the beginning of the process of suppuration, the skin becomes red, and pain occurs;
• Hemangioma. There are capillary and cavernous hemangioma. The capillary can reach significant sizes, but the cavernous, despite its deeper location, does not reach large sizes. The color of the tumor depends on the structure and can vary from red to bluish-black. Surgical treatment with excision of the tumor and underlying layers is indicated.

At the moment, there are two most common forms: superficial and nodular

Superficial (newly identified) BCC:

• most often develops on the skin of the trunk and limbs;
• less common: head and neck;
• in younger patients, with a predominance of women.

Important!

The main development factor is genetic - this is a hereditary mutation that is transmitted to descendants or arises in connection with environmental or other adverse effects of the external environment. Nodular form (first identified) of BCC:

• most often develops on the scalp
• in elderly and senile patients

Removal of benign skin tumors

Removal of benign skin tumors must be carried out to eliminate a cosmetic defect, prevent compression of adjacent structures and permanent damage.

Surgical removal is carried out in different ways:

• Classic method (scalpel);
• Electrocoagulation;
• Radio wave method;
• Laser method, etc.

As a rule, preference is given to laser and radio wave methods, since they are the least traumatic and have the lowest relapse rate.

The choice of treatment method should be made only after a thorough examination and taking into account all the individual characteristics of the patient.

The Yusupov Hospital provides diagnostic and treatment services for all benign skin tumors. Our specialists will help you eliminate both a cosmetic defect and prevent the consequences of incorrect treatment tactics in a short time.

Complications and prognosis of basal cell carcinoma

We have already said that basal cell carcinoma is a semi-malignant tumor. It grows slowly and rarely metastasizes. With timely treatment, the prognosis is favorable. Relapses develop in less than 10% of patients. The situation is worse in patients with large basal cell carcinomas or with an infiltrative form of the disease. They have a high risk of relapse and distant metastases. Moreover, such forms of basal cell carcinoma can destroy the underlying tissues, leading to disfigurement of appearance, the development of bleeding, chronic inflammation and dysfunction of the affected segment.

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Precancerous skin growths

Precancerous skin conditions are divided into two main groups: facultative, the risk of malignancy of which is minimal, and obligate - precancerous conditions, which will ultimately become cancerous.

Precancerous skin conditions include:

• Xeroderma pigmentosum. This tumor develops due to excessive sensitivity of the skin to solar energy, as a result of which the skin loses its ability to regenerate. The disease is congenital in nature, it is easy to diagnose it in children of the first year of life by the abundance of freckles on the surface of the skin, which is most often exposed to solar radiation. In almost every case of this disease, cellular and squamous cell carcinoma occurs. There is a very high mortality rate in people under twenty years of age with this disease;
• Buschke-Levenshtein condyloma, the causative agent of which is considered to be the human papillomavirus. This neoplasm has rapid growth, enormous size, and also secretes a cloudy liquid with an unpleasant odor. This disease is characterized by a progressive course, tends to grow into nearby tissues and can recur even after complete surgical removal. Additionally, the condition quickly progresses to squamous cell skin cancer;
• Actinic keratoma or actinic keratosis (or solar). Typically occurs in older people. Externally, this condition appears as orange or yellow rashes on the skin no more than one centimeter in diameter. Subsequently, scales and dry crusts form at the site of the rash, and when mechanically peeled off, slight bleeding is observed. If a compaction appears at the base of the tumor, it is considered that this is the beginning of malignancy of the tumor. But this phenomenon is observed quite rarely;
• Paget's disease. After 42 years, women may experience areas of redness around and on the nipple with accumulation of biological fluid, signs of peeling, and weeping. Then crusts form in this area, and nipple retraction is observed. The development of this disease can take years. According to some oncologists, this condition is a development of early stage cancer;
• Cutaneous (senile) horn. This disease is usually observed in very old age. It also occurs on open areas of the skin that are constantly squeezed or subject to friction. Primary cutaneous horn occurs on healthy skin, while secondary horn occurs after certain diseases (for example, lupus erythematosus, solar keratosis). At the end of its formation, the tumor has the appearance of a cone-shaped horny formation, the length of which is significantly greater than the diameter of its base. This disease is characterized by a long course and has a tendency to become malignant.

4.Prevention of basal cell carcinoma

Methods for preventing basal cell skin cancer are well known to everyone. They are often talked about simply as ways to avoid skin cancer during the hot season:

• Try not to be in the sun during the hottest hours - from 10 am to 2 pm;
• Wear hats (hats with brims) and thick clothing when in the open sun;
• Use sunscreen;
• Be regularly examined by an oncodermatologist and tell your doctor about any suspicious or changing appearance of skin lesions (moles, spots, etc.).

Malignant neoplasms of the skin

Tissue cells of such tumors are difficult to differentiate at the initial stage of development. They have lost the ability to perform their own functions, can penetrate into nearby tissues and organs, and often metastasize into the blood and lymph vessels, forming tumors throughout the body. The main signs that may indicate the degeneration of benign neoplasms (nevus, pigment spots, etc.) into malignant ones are changing pigmentation of the mole, spontaneous and rapid increase in size of the neoplasm, its spread to other areas, bleeding, ulceration, that is, those manifestations that were not there before.

Malignant skin neoplasms are divided into several groups, according to their cellular structure and clinical manifestations:

• Melanoma is the most common malignant tumor. Localized in the skin. In most cases, melanoma is a consequence of the degeneration of a nevus against the background of a severe burn or injury. Therefore, trauma to the nevus is the main risk factor for malignancy of the neoplasm. Formations are especially dangerous in areas that are constantly exposed to friction. Treatment is surgical, sometimes with the use of radiation and chemotherapy. The prognosis of the disease is directly dependent on the time of detection of the tumor and its treatment;
• Basalioma. Occurs in areas of the skin that are often exposed to excessive sun exposure. Heredity contributes to the development of the disease. Over the course of several years, it degenerates into squamous cell skin cancer. At the initial stage, the formation has the appearance of a whitish nodule, on the surface of which a dry crust forms;
• Squamous cell carcinoma or epithelioma is observed less frequently and has a severe course. The focus of localization is most often the perianal region, the external genitalia. It is almost impossible to distinguish it from another type of cancer visually; it metastasizes quickly. At the initial stage, the tumor looks like a ball in the thickness of the skin with a diameter of no more than a centimeter. As they grow, warts and ulcerations form, after which the edges become dense and uneven, and severe pain appears. As soon as the formation metastasizes to the lymph nodes, the patient's condition quickly deteriorates. Death can occur due to bleeding due to tumor disintegration and vascular damage, as well as as a result of rapid exhaustion of the body. For treatment purposes, surgical removal of the tumor and lymph nodes is indicated, often in combination with radiation and chemotherapy;
• Kaposi's sarcoma or angioreticulosis. The disease in most cases develops in patients with AIDS, but the usual form of the disease clinically has an identical clinical and histological manifestation. The risk group includes men. The site of the disease is the lower extremities. First, violet, sometimes lilac-colored spots are formed that do not have clear boundaries. Gradually, dense, rounded nodules of a bluish-brown color appear, reaching a diameter of up to two centimeters. These nodules often aggregate and ulcerate. In patients with AIDS, the disease has an aggressive course, often with severe damage to the lymph nodes and metastases throughout the body.

As the most common neoplasm in the population, basal cell skin cancer is associated with significant morbidity and health care costs. Ongoing research has made it possible to refresh our understanding of the course of the disease and reconsider approaches to the diagnosis and treatment of BCC. This two-part review summarizes current evidence on various aspects of basal cell carcinoma. The second part of this review discusses issues of diagnosis, treatment and prevention of the disease.

Key Points

1. The gold standard for diagnosing basal cell carcinoma is performing a biopsy of a suspicious tumor.
2. Dermatoscopy is a new non-invasive diagnostic method that makes it possible to recognize BCC before performing a biopsy.
3. The gold standard for diagnosing basal cell carcinoma is a skin biopsy. Treatment tactics are largely determined by the histological variant of the tumor. The main advantages of shave biopsy include the speed of the procedure, low cost, and minimal bleeding. However, after a shave biopsy, secondary erythema may form in the circumference of the formation, and the edges of the tumor may be clinically questionable. Punch biopsy is also an acceptable method of confirming the diagnosis, which does not have the disadvantages listed above. Also, when obtaining material by performing a punch biopsy, the pathologist has the opportunity to evaluate the histological structures located deep in the tissues.
4. Performing a shave biopsy allows you to obtain a larger area of ​​tissue for examination, which reduces the likelihood of error.

According to various studies, the probability of correctly recognizing the histological variant of the tumor is about 80%. One study assessed the accuracy of histological diagnosis of 174 basal cell carcinomas removed from the periorbital region. The results of diagnostic biopsy and subsequent excisional biopsy were compared. At the same time, coincidence of diagnoses was observed in 54% of cases. The greatest accuracy in making a diagnosis was observed for the nodular form of basal cell carcinoma. For aggressive BCC, the accuracy of histological diagnosis did not exceed 48%. Another retrospective analysis of 243 primary basal cell carcinomas found a 60.9% agreement between diagnoses (primary when performing a diagnostic biopsy, secondary when performing surgical removal of the tumor). Punch biopsy can determine the aggressive type of BCC in up to 84.4% of cases.

Dermatoscopy increases the accuracy of diagnosing BCC; in some cases, it allows one to differentiate basal cell carcinoma from other neoplasias and inflammatory dermatoses, as well as distinguish between forms of BCC before performing histological examination.

The accuracy of the method varies from 95 to 99%. It is especially important to evaluate vascular structures and the presence of fibrosis (Figure 1, A-D). Dermatoscopy makes it possible to differentiate BCC from other pigmented skin tumors (Fig. 2). The presence of “maple leaf” structures (Figure 3A), short thin telangiectasia (Figure 1C), absence of tree-like branching vessels (Figure 1A), gray-blue ovoid structures (Figure 3B), ulceration speaks in favor of a superficial form of BCC with sensitivity 81.9% and specificity 81.8%. The pigmented form of BCC in some cases is difficult to distinguish from melanocytic neoplasms; it can be accompanied by brown, black globules, dots, the presence of structures such as a blue-white veil, and the absence of tree-like branching vessels.

New non-invasive diagnostic methods

Key Points

• Confocal reflectance microscopy and optical coherence microscopy are non-invasive methods for diagnosing BCC.

New non-invasive techniques are used to diagnose BCC. Confocal reflectance microscopy allows in vivo imaging of thin sections of human skin. Laser radiation close to the infrared range is reflected from a certain area within the study area and is captured by the detector. A number of articles present the most characteristic signs of BCC detected by confocal microscopy (Figure 4 A-C)

When tested on 800 clinical cases of BCC, the sensitivity of confocal microscopy was 100%, specificity - 88.5%. In a meta-analysis evaluating the performance of confocal microscopy on 3602 tumors, the sensitivity and specificity were 91.7% and 91.3%, respectively. It is assumed that the combined use of confocal microscopy and dermatoscopy will make it possible to diagnose basal cell carcinoma without performing a biopsy.

The limitations of the method include limited visualization depth and the possibility of incorrect interpretation of the resulting image. Optical coherence microscopy provides non-invasive, real-time skin diagnosis by penetrating infrared radiation reflected from skin structures with different optical characteristics. In a cohort study, the sensitivity and specificity of the method were 87% and 80%, respectively. The accuracy of optical coherence microscopy increased (87.4%) when combined with dermatoscopy.

Optimization of confocal microscopy and optical coherence microscopy techniques continues to improve visualization and simplify instrument use. The main barriers to the widespread introduction of these diagnostic methods into practice are the need for additional training of specialists, as well as the high cost of devices. The commercially available VivaScope 1500 and 3000 systems (Caliber ID, Rochester, NY), approved by the US Food and Drug Administration, range in price from £62,300 to £90,224. The strengths of confocal microscopy include high image resolution and newly developed terms for image description and interpretation.

Disadvantages of the method include limited radiation penetration depth, as well as limited ability to assess tumor invasion and margin depth. The advantages of optical coherence microscopy include the ability to obtain images of cross sections and the surface of the skin, and the ability to penetrate deeper into the layers of the skin. Limitations of the method include the lack of generally accepted terminology and limited use in the diagnosis of pigmented neoplasms. Other non-invasive methods that require further research include Raman spectroscopy, high-resolution ultrasonography, and THz radiation.

Standards for the treatment of primary skin tumors

Key Points

• Depending on the individual clinical picture, for low-risk BCC, radiofrequency surgery and curettage, as well as standard surgical excision with postoperative examination of the tumor margins, are recommended. The lowest risk of recurrence in high-risk BCC is associated with the use of Mohs micrographic surgery.

Depending on the individual clinical presentation, the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines) considers 2 possible methods of tumor removal for low-risk BCC: electrodissection and curettage, as well as standard surgical removal with postoperative examination of the tumor margins. For high-risk neoplasms, Mohs micrographic surgery is recommended. Additional methods of therapy include topical medications, intralesional chemotherapy, cryotherapy, photodynamic therapy, laser therapy, and radiotherapy.

Determination of neoplasm risk. There are a sufficient number of methods for the treatment of BCC, and the recommended treatment options are selected based on the classification of the tumor into a certain risk group - low or high, according to the NCCN recommendations. The risk of a tumor depends on factors influencing the possibility of tumor recurrence - tumor localization, size, borders, primary tumor or relapse, histological structure, individual characteristics of the patient.

Clinical factors. Anatomical location is a well-known risk factor for BCC recurrence. According to the NCCN recommendations, the three most important areas of the skin are identified for risk assessment based on the primary location of the tumor. Area H (facial skin) is considered to be at highest risk (Figure 5). The size of the tumor and blurred margins are independent risk factors for recurrence. Critical size indicators vary for certain anatomical locations.

Individual characteristics of the patient. A significant risk factor is immunosuppression due to organ transplantation, chemotherapy, prolonged use of PUVA therapy, and local radiotherapy. However, the risk of recurrence of BCC in organ and tissue transplant recipients and patients receiving PUVA therapy is no greater than the risk of recurrence in the control group. However, according to NCCN guidelines, immunosuppressed patients are still at high risk based on anecdotal clinical observations of BCC recurrence.

Histological risk factors. The risk of recurrence increases in the presence of perineural invasion, as well as in patients with aggressive histological subtypes, for example, micronodular, infiltrative, morphea-like. An important limitation of diagnosis based on the histological structure of BCC is the possibility of incomplete excision and formation, as well as incomplete assessment of the tumor. One retrospective study found that up to 18% of all BCC cases reviewed were misidentified, with difficulty determining the aggressive histologic subtype. Up to 24% of basal cell carcinomas turn out to be more aggressive when the specimens are reviewed than during the initial assessment by the pathologist. When reviewing specimens, up to 50% of basal cell carcinomas are diagnosed as a mixed histological variant, characterized by a more aggressive course, which is associated with insufficient treatment effectiveness.

Perineural invasion in BCC is rare, the frequency varies from 0.18% to 10% of cases. Fibrosis surrounding the tumor, perineural inflammation, and artifacts formed during the preparation of the drug have a similar pathomorphological picture. Neoplasms accompanied by perineural invasion require more stages of Mohs micrographic surgery and are more likely to recur. Perineural invasion can extend from the middle of the face to the base of the skull. If perineural invasion occurs, the central nervous system may be affected. To assess the extent of the process, MRI is required. Warning regarding perineural invasion should be caused by symptoms such as pain, numbness, and dysfunction of facial muscles.

For patients who have clinical symptoms of perineural invasion with a known cutaneous neoplasm and evidence of perineural invasion on MRI, the 5-year survival rate is 50% to 60%, while those with no changes on MRI have a 5-year survival rate of 86% to 100 %. The occurrence of perineural invasion is more likely when the diameter of the neoplasm is more than 2 cm, the presence of aggressive histological subtypes, localization on the skin of the lips, ears, forehead, scalp, dorsum of the hands.

Treatment tactics. Standard excision

Standard surgical excision followed by histological examination of the tumor margins is the method of choice in the treatment of low-risk BCC with level of evidence I according to the recommendations of the Oxford Center for Evidence Based Medicine (OEBM). For neoplasms with a diameter of up to 2 cm, a sufficient distance is considered to be 3-4 mm from the edge of the neoplasm.

According to NCCN guidelines, the margin should be 4 mm for low-risk lesions. The likelihood of recurrence after standard surgical removal is generally low. According to the literature, relapses occur in 0.7%-5% of cases. Tissue reconstruction should be performed in the form of a linear connection of the wound edges or heal by secondary intention. When tissue is repositioned, the normal anatomical structure of the affected area is disrupted, which can cause difficulties in diagnosis and treatment if a relapse occurs.

If tissue reposition is necessary, it is necessary to perform an intraoperative histological examination of the edges of the tumor in order to ensure complete eradication of the tumor. In selected patients with low-risk tumors, non-surgical techniques may be used. Radiotherapy may be recommended in patients who are not candidates for surgery, but should be used with caution in patients over 60 years of age. Other non-surgical methods are recommended only if there are contraindications to surgery or radiotherapy.

Mohs micrographic surgery. The most optimal method for removing high-risk tumors is surgical removal with intraoperative histological examination of the edges of the tumor. The risk of BCC recurrence with Mohs removal of the tumor ranges from 1% to 5.6%, while with standard surgical removal the risk ranges from 10.1% to 17.4%. According to a retrospective controlled study, the five-year risk of recurrence of facial BCC (408 cases assessed) was 4.1% with standard surgical removal and 2.5% with Mohs removal.

Mosterd et al, with a 10-year follow-up of patients, found that the risk of recurrence after standard surgical removal was 12.2%, while with removal using the Mohs method it was 4.4%. In 2012, criteria were developed for selecting patients who require tumor removal using micrographic surgery. According to NCCN guidelines, surgical excision with intraoperative frozen section examination is the treatment of choice for high-risk BCC. An alternative is standard surgical removal with a wider excision.

Radio wave surgery and curettage. Radio wave surgery is a cost-effective and convenient treatment method for BCC. The main disadvantages of the method include the inability to conduct a pathomorphological examination of the edge of the removed tumor, the impossibility of application in areas with terminal hair, since the method does not allow the removal of tumor cells spreading into the depths of the follicular unit.

When reaching the subcutaneous fatty tissue, a transition to standard surgical removal of the tumor is required, followed by a pathomorphological examination of the boundaries of the tumor to exclude the possibility of deep germination of the tumor. According to the literature, the five-year relapse-free period in low-risk patients with this method of tumor removal ranges from 91 to 97%. There is evidence of a higher risk of relapse - from 19 to 27%, which depends on the initial condition of the patient.

Topical therapy. US Food and Drug Administration-approved topical medications for the treatment of BCC are 5-fluorouracil 5% and imiquimod cream 5%. Randomized controlled trials of 12 weeks of imiquimod showed 100% histological recovery at 6 weeks of therapy. According to other studies, the five-year disease-free period for the superficial form of BCC ranged from 77.9% to 80.4%. The nodular form of BCC has similar results, with recovery by week 12 observed in 76% of patients.

According to a randomized controlled trial, the five-year disease-free survival rate during treatment with imiquimod for superficial and nodular forms of BCC was 82.5%, while with standard surgical removal it was 97.7%. The cosmetic results of imiquimod are more acceptable. The drug can be used for basal cell nevus syndrome.

An additional treatment for BCC is the use of topical 5-fluorouracil. According to the literature, the effectiveness of topical 5-fluorouracil in the treatment of superficial forms of BCC is comparable to imiquimod. According to other studies, the three-year disease-free survival rate with imiquimod is 79.7%, and with topical fluorouracil it is only 68.2%. Thus, data on the effectiveness of topical 5-fluorouracil are limited to clinical observations described in the literature. There are currently no substantiated recommendations for prescribing the drug for the treatment of BCC. The use of a number of other topical drugs is described in the literature, however, the evidence base for them is insufficient.

Intralesional therapy. The penetration of topical drugs is limited by the permeability of the epidermal barrier. An alternative is to deliver the drug through intralesional injections. A number of studies have examined the effectiveness of various chemotherapeutic agents when injected into the site of BCC. Side effects with this treatment method are rare and are usually dose-dependent. The most common manifestations include local reactions at the injection site, as well as flu-like symptoms.

Cryotherapy. Another alternative method is cryotherapy. According to prospective studies, the frequency of relapses varies within a fairly wide range (1-39%), which is explained by differences in the studied groups of patients (the somatic status of the patient, the severity of BCC, observation time, and the method of tumor removal). According to various studies, the five-year relapse-free period after cryotherapy of a tumor is up to 99%.

Cryotherapy has less acceptable cosmetic results than standard surgery. The use of this technique is contraindicated on the scalp due to the risk of cicatricial alopecia, as well as on the skin of the legs due to the risk of ulceration. Also, cryotherapy is not recommended for large tumors, aggressive histological forms of the tumor, in case of relapse, fixation to the underlying bone tissue, or deep invasion.

Photodynamic therapy. PDT is another alternative treatment for BCC. Photosensitizers such as methyl aminolevulinate and aminolevulenic acid have been shown to be equally effective. Both drugs are approved by the US Food and Drug Administration for the treatment of actinic keratosis of the face and scalp. It is noted that methyl aminolevulinate works better with the rays of the red spectrum, while aminolevulenic acid works better with the rays of the blue spectrum. According to a meta-analysis involving 1583 patients, the use of photodynamic therapy can cure the disease in 86.4% of patients, while the effectiveness of surgical techniques is 98.2%.

Despite its lower effectiveness compared to surgical techniques, photodynamic therapy is characterized by more acceptable cosmetic results. Photodynamic therapy can be used as a neoadjuvant therapy to reduce the tumor mass, as well as to reduce the risk of tumor recurrence.

Laser therapy. Laser therapy has been studied as monotherapy and also as an adjunct to primary therapy for BCC. According to a retrospective study, the use of a CO2 laser for the treatment of superficial and nodular forms of BCC led to 100% histological cure, as well as the absence of relapses during a three-year observation period. According to a retrospective study of 2719 basal cell carcinomas removed in the facial area using a neodymium laser, the recurrence rate is about 1.8% (in the period from 3 months to 5 years). Side effects include reactive hyperemia, swelling, risk of scarring, and pain. A new treatment option for BCC is photodynamic therapy using laser radiation.

According to two randomized controlled trials, there is a lower incidence of relapse of BCC when using a combination of photodynamic therapy (aminolevulenic acid) with yttrium aluminum garnet doped with erbium ions compared with monotherapy (PDT or laser).

Radiotherapy. The goal of radiation therapy is total eradication of the tumor with maximum preservation of intact tissue. There are two types of radiation therapy used to treat BCC: external beam therapy and brachytherapy. The choice of irradiation method is determined by the characteristics of the tumor, size, depth of invasion, and anatomical location.

Prospective randomized controlled trials have assessed the effectiveness of radiotherapy compared with other treatments for BCC. When comparing cryotherapy with superficial radiation therapy, it was found that the relapse rate with radiation therapy was 4%, while with cryotherapy this figure reached 39% (93 patients were included in the study). Necrosis of the tumor and serious discomfort were recorded in only 2% of cases. Cosmetic effect for both cryotherapy and radiation therapy was “moderate.” Another randomized controlled trial compared the effectiveness of topical imiquimod 5% with superficial radiation therapy in the treatment of eyelid basal cell carcinoma. The response to therapy in all groups of patients (27 patients) was 100% after 6 weeks from the start of treatment; no relapse was observed during 24 months of observation.

Also, a number of randomized controlled studies compared the effectiveness of radiation therapy with surgical removal of basal cell carcinomas localized on the facial skin. The majority of patients (55%) received local low-dose radiotherapy, while only 12% of patients received external beam radiotherapy. A total of 173 patients took part in the study. The relapse rate 4 years after treatment was minimal in the case of surgical removal of the tumor (0.7%), in the radiation therapy group - 7.5%.

Approaches to the treatment of “complex” clinical cases

Key Points

1. In case of deep tumor invasion, adjuvant radiation therapy is required (in the presence of tumor cells at the edges of the tumor during histological examination of the surgical material, clinically significant perineural invasion).
2. If there is resistance to other treatment methods, radiation therapy may be performed.
3. In the absence of a response to radiation therapy or the presence of metastases, chemotherapy may be performed.

Basalioma is not always amenable to surgical removal. If tumor cells are detected at the edges of the tumor during histological examination of the surgical material, radiation therapy may be required to reduce the risk of tumor recurrence. The five-year risk of relapse with incomplete tumor removal is up to 39%, however, adjuvant radiation therapy reduces the risk to 9%. Not all patients with incomplete tumor resection develop clinically significant recurrences of BCC. Adjuvant radiation therapy is prescribed on an individual basis and is not indicated for all patients. Also, radiation therapy can be an effective treatment for unresectable tumors (stage T3/T4)

Thus, treatment of advanced stage tumors does not always require radical surgery. In the presence of distant metastases, the impossibility of surgical removal of the tumor or radiation therapy, systemic chemotherapy is necessary. The Hedgehog pathway inhibitors vismodegib and sonidegib are approved by the US Food and Drug Administration for the treatment of advanced stage BCC, as well as BCC accompanied by metastases.

These drugs lead to significant improvements in localized and systemic disease. (Figure 6 AD) Vismodegib was approved following a non-randomized trial in two cohorts of patients receiving the drug at a dose of 150 mg daily for metastatic BCC (33 patients) or unresectable BCC (63 patients). The response to therapy was 33.3% and 47.6%, the median duration of response was 9.5 and 7.6 months, respectively. Data from other studies have shown similar results. Most patients experience side effects such as muscle spasms, alopecia, loss of taste, decreased appetite, weakness, nausea, and diarrhea.

Serious side effects were reported in 30%-50% of cases. One study found that patients treated with vismodegib for BCC had a subsequent increased risk of developing squamous cell skin cancer. Primary refractoriness to the drug occurs in approximately half of the cases. About 20% of patients who respond to therapy subsequently become refractory—a relapse or progression of the disease is noted.

For sonidegib, a randomized trial was also conducted (number of patients 381) in which the effectiveness of two different doses was compared in patients with treatment-resistant metastatic BCC or late-stage BCC (inoperable basal cell carcinoma, patients with contraindications to radiation therapy). The response to therapy was similar (dose 200 mg/day and 800 mg/day) - 32% and 34%, while the higher dose was associated with severe side effects.

The most common increases in creatine kinase and lipase levels were observed to be grades 3 and 4. Hedgehog signaling pathway inhibitors may also be used as adjuvant therapy. In a clinical study of 15 patients with large basal cell carcinomas treated with vismodegib for 4 ± 2 months, a 27% reduction in tumor size was found. Four patients did not complete the course of therapy due to side effects of therapy. In a phase 2 clinical trial comparing different vismodegib regimens for resectable BCC, the best response to therapy with complete histological recovery (44% of patients) was observed with multiple courses of 8 weeks on/4 weeks off. A phase 1 trial of saridegib, a novel inhibitor of the Hedgehog signaling pathway, was also conducted.

Unfortunately, patients previously treated with vismodegib did not respond to the drug.

Itraconazole is also known to inhibit the Hedgehog signaling pathway. A study of 19 patients treated with itraconazole for BCC found reductions in cell proliferation, Hedgehog signaling pathway activity, and tumor area by 45%, 65%, and 25%, respectively. Side effects included weakness and heart failure.

Stabilization of the tumor process was observed when using a combination of itraconazole and parenteral arsenic trioxide in the case of metastatic BCC resistant to vismodegib in 3 out of 5 patients; however, tumor regression was not observed. Cases of successful treatment of BCC with chemotherapy have been described - carboplatin/paclitaxel, cisplatin/paclitaxel, doxorubicin.

The quality of life. Treatment tactics in elderly patients. Monitoring patients. Prevention.

Key Points

1. Important issues related to the quality of life of patients with skin tumors include anxiety about the diagnosis, scarring after removal of the tumor, fear of recurrence and the emergence of new tumors.
2. The incidence of BD in the United States is increasing as the population ages.
3. For prophylactic purposes, patients can be prescribed nicotinamide, retinoids - drugs with varying degrees of clinical effectiveness.

Factors affecting the quality of life of patients with skin tumors include anxiety, fear of tumor relapse and the appearance of new tumors, scars and tissue deformations after tumor removal. Traditionally, the goal of therapy for skin tumors is to minimize the risk of recurrence and complications. When carrying out treatment, it is necessary to take into account the patient's opinion. The most pressing issues in the treatment of skin tumors, according to quality of life studies, include patients’ fear of the formation of scars and disfiguring tissue deformations, which is often not taken into account by doctors.

It is important to note the gradual aging trend of the US population. The proportion of residents over the age of 85 is expected to increase significantly by 2050. The frequency of diagnosis of skin tumors in this age group is significantly higher. There is a need to review the treatment tactics for patients in this age group, which is associated with a large number of comorbidities and limited life expectancy. When choosing treatment tactics, it is important to take into account the patient’s general condition, the presence of concomitant diseases, the patient’s functional status, and the possibility of social support.

The three-year cumulative risk of developing BCC in patients with a history of basal cell carcinoma is 44%, and the incidence of de novo BCC is 10 times higher compared to the general population. As a rule, the second tumor appears soon after the first one is removed. In addition, patients with a history of BCC are at high risk for developing other skin tumors, including melanoma.

According to WHO research, the main factor determining treatment tactics is the size of the tumor, therefore early diagnosis of basal cell carcinoma is most preferable. NCCN clinical guidelines suggest performing a complete examination of the patient's skin every 6 to 12 months for the first five years of follow-up after BCC removal, and annually thereafter. It is important to explain to the patient the need to use photoprotection, regular skin examination, including self-examination, and also provide links to information resources about skin tumors.

In patients with an increased risk of skin tumors, the use of nicotinamide for prophylactic purposes is noted to be effective. The mechanism of action of the drug is based on the prevention of ATP depletion, glycolytic blockade and immunosuppression induced by ultraviolet radiation.

In a phase 3 randomized controlled trial of nicotinamide 500 mg twice daily for 12 months, there was a 23% reduction in the incidence of non-melonoma skin cancer. Systemic retinoids are used in patients with immunosuppression, as well as in genetically predisposed individuals as prophylaxis. According to research, the drug is effective against RCC, however, for the prevention of RCC, the data are ambiguous.

Symptoms and signs

The clinical picture of skin cancer development depends on its type. Often the first signs of a tumor are mistaken for other skin diseases. This results in untimely consultation with a doctor and the spread of the malignant process. Common signs for all types of skin cancer are:

• The appearance of a small spot or lump on the skin. The color of the formation can be pinkish, gray-yellow. It is noteworthy that the color of the neoplasm differs from moles and freckles.
• Uneven shape and asymmetric contours of the pathological focus.
• The appearance of itching and slight discomfort in the area of ​​the tumor process. This symptom appears some time after the formation of cancer.
• Progressive growth of the tumor.
• Fatigue, weakness, sudden loss of strength.
• Decreased appetite, resulting in sudden weight loss.
• As cancer develops, regional lymph nodes are affected.

If any of the above symptoms appear, it is recommended to seek medical help. Depending on the type of skin cancer, the following symptoms are distinguished:

1. Basalioma. It is the most common form of skin tumor. It is characterized by a favorable prognosis when detected at the initial stage. Appears in the form of a nodule, painless on palpation. It has a grayish-pink color. The surface of the nodule is usually smooth. Scale formation is possible. As the tumor process spreads, the affected area increases. The neoplasm is covered with a bloody film. The predominant localization of basal cell carcinoma is the face, neck, and arm area. Basalioma does not cause a significant change in condition. This is the reason for late seeking medical help.
2. Squamous cell carcinoma. At an early stage, it looks like a dense red or brown nodule. A tumor of this type is prone to rapid decay, and therefore, as the process progresses, an ulcer forms. It often bleeds, its edges are heterogeneous. Squamous cell carcinoma quickly grows into nearby tissues. If detected at a late stage, metastasis to regional lymph nodes or organs is possible.
3. Melanoma. Refers to an aggressive type of tumor. Most often, melanoma occurs at the site of an injured nevus, which increases in size, changes color and acquires uneven contours. A characteristic feature of this type of cancer is the asymmetric form of formation, as well as a tendency to bleed. The malignant neoplasm itches and increases in size. As the process progresses, the tumor turns into an ulcer. Melanoma progresses rapidly and often metastasizes.
4. Adenocarcinoma. At the initial stage of development, it looks like a dense nodule. It is most often localized in the armpit area, under the breast. With the development of the tumor process, adenocarcinoma grows into nearby tissues. This type of tumor is detected extremely rarely and is characterized by slow growth.

Clinical signs of basal cell skin cancer

Surface form

- the least aggressive of all “carcinoma” forces the patient to consult a doctor when the tumor is already a fairly significant cosmetic defect or begins to cause inconvenience due to the addition of ulceration. The superficial form of BCC is also called basal cell carcinoma of the trunk and extremities. On the body, most often, it has a multiple character. Radial, extremely slow tumor growth predominates, occupying an area of ​​several centimeters before the onset of invasion and confirmation of the diagnosis. This form is often considered by a specialist as a superficial keratoma and is ignored in senile and elderly people. Visually, it is defined as a flat, pinkish-brownish, slightly scaly formation, with a barely detectable ridge-like edge on palpation, thread-like nodules like a “pearl necklace” along the perimeter of the tumor, pearlescent color and, sometimes, visualized telangiectasia.

With nodular form

basal cell skin cancer, the patient consults a specialist if the tumor size is quite small, since the exophytic component is often subject to constant trauma and, as a consequence, contact bleeding. The process begins with a pearly-light or pink papule, on a wide base, a glossy surface with the absence of a skin pattern and the presence of telangiectasia.

The center of the node often ulcerates, followed by the formation of an eschar and hyperkeratosis. The perimeter roller is also often defined by the classic “pearl necklace”.

Scleroderma-like/sclerosing form of BCC

. The least common but most aggressive form. The skin formation resembles a scar, pale yellow in color, waxy to palpation, glossy. At the same time, the “string of pearls” characteristic of basaliomas in general and telangiectasia are most often absent. It recurs extremely often, due to the spread of the tumor both in area and in depth (the “iceberg” phenomenon). Very often the disease is not diagnosed for a long time due to its atypical picture.

For ulcerated basal cell carcinoma

patients complain of weeping and bleeding in the earliest stages of the tumor, lack of pain, which increases in proportion to the enlargement of the lesion. Subsequently, a secondary infection occurs, which can visually increase the area of ​​the lesion. When this form of tumor occurs on the extremities, it is most often considered by primary care physicians for a long time as trophic ulcers in elderly people, even in the absence of other clinical signs of chronic venous insufficiency.

Complaints of pain appear with locally widespread tumors and are associated with involvement of nerve trunks or bones in the process. Arrosive bleeding is also characteristic of advanced forms of basal cell carcinoma.

Diagnostics

Diagnosis of malignant skin tumors is in most cases simple. The examination of the patient should begin with a history and medical examination, with special attention paid to a complete examination of the skin and regional lymph nodes. The Yusupov Hospital diagnoses and treats benign, precancerous and malignant skin tumors. The Yusupov Hospital has all the necessary equipment for an accurate diagnosis and the most effective therapy.

The main diagnostic measures to confirm skin cancer include:

• Dermatoscopy is a visual assessment of the tumor, zoomed in using special magnifying glasses;
• Thermography - measuring the temperature of a tumor;
• A smear is an imprint. A method in which a glass slide is applied to a crusted ulcer with gentle pressure. Several pieces of glass and different areas of the suspected tumor are used. The collected prints are then examined using microscopy;
• Scraping Using a special wooden spatula, scrape off a certain amount of content from the bottom of the ulcerated surface and transfer the material to a glass slide for subsequent study;
• Biopsy. In the puncture form, using a needle and syringe, cellular material is taken from the depth of the formation. In the excision option, which is possible when the size of the formation is tiny, it is excised within tissues not affected by the process, followed by examination of the removed area. With the incisional option, a large tumor is removed in a wedge shape, capturing healthy tissue structures;
• Imaging methods necessary to clarify and verify the spread of the oncological process. These include: ultrasound screening, computed tomography examination.

2.What does basal cell carcinoma look like?

Basal cell carcinoma usually begins as a small, dome-shaped lump, often with small superficial blood vessels. The skin in this area may look shiny and translucent, as if pearlescent. Some basal carcinomas contain the pigment melanin, and because of this they appear dark rather than shiny. Because of these variations, it can be difficult to distinguish basal cell carcinoma from benign skin lesions without a biopsy.

Basal cell skin cancer grows slowly. It may take months or even years before it reaches a serious stage. Although basal cell carcinoma metastasizes to other organs and tissues very rarely, skin changes can damage or disfigure the eye, ear, or nose if the tumor grows nearby.

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Treatment at the Yusupov Hospital

The Yusupov Hospital provides 24-hour diagnostic and treatment services for all benign skin tumors. Specialists of the highest level will help in a short time to eliminate both a cosmetic defect and prevent the consequences of incorrect treatment tactics. Most often, a surgical technique is used to treat skin tumors, in which the affected tissue is completely removed with a small inclusion of healthy tissue. The choice of surgical procedures is quite wide, their use depends on the stage and type of tumor:

• Cryotherapy is the removal of neoplasia using liquid nitrogen. An effective and safe method, used in the initial phases.
• Electroexcision - excision of a tumor using an electric knife;
• Laser destruction - removal of pathology using a special laser, without affecting surrounding, undamaged tissue;
• Excision is a method in which neoplasia is excised with a scalpel to the extent necessary for a given case, possibly including healthy tissue and even subcutaneous tissue, as well as fascia with regional lymph nodes. A radical method can help in late stages of the disease.

The prognosis can be very varied, it all depends on the type and stage of the disease. In the absence of metastases and adequate treatment, the chances of a favorable outcome reach 80-90%. The more widespread the cancer process, the lower the chances of a good outcome.

At the Yusupov Hospital, patients are diagnosed and treated in the most productive and comfortable conditions. Specialists work on modern technology, follow innovations in the medical industries, and conduct their own research and dynamic observations. The wards are equipped for maximum comfort, and attention is paid to the leisure of patients. All staff are friendly, responsive and competent.

Risk factors for basal cell carcinoma

• Light skin type.
• Red or blond hair.
• Prolonged exposure to ultraviolet radiation.
• Exposure of skin to radiation.
• Chronic trauma to the skin, for example, rubbing with uncomfortable clothing or shoes.
• Exposure of the skin to chemical carcinogens, including household chemicals.

The development of basal cell carcinoma may be due to genetic predisposition. This pathology is called Gorlin syndrome. It is characterized by the following symptoms: multiple foci of basal cell carcinoma, endocrine pathology, skeletal and mental disorders. Pathology begins to manifest itself at a young age.