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Skin Cancer

Clinical Description 
Skin cancer is the most common cancer in both men and women. More skin cancers are diagnosed each year than all other cancers of all anatomic sites combined. Most skin cancers are either basal cell or squamous cell carcinoma. Basal cell carcinoma (BCC) develops from the basal layer of the epidermis while squamous cell carcinoma (SCC) develops from the keratinocytes in the epidermis. The epidermis is the layer of tissue just below the surface of the skin.

More than two million new cases of skin cancer (BCC and SCC) are diagnosed each year, and this number continues to rise. Seventy-five percent of these will be BCC. SCC and BCC are usually slow-growing tumors that are easily treated. While these types of skin cancer tend to spread locally, rarely SCC can be aggressive and spread to surrounding lymph nodes. Melanoma is another type of skin cancer that is more serious and is discussed in a different section.

Symptoms of Basal Cell and Squamous Cell Skin Cancer
Most skin cancers are detected based on the appearance of a skin lesion. BCC and SCC can occur anywhere on the skin surface, although most occur on the sun-exposed areas of the skin such as the head, face, hands, forearms and legs. BCC and SCC can appear as skin changes that include pink discoloration, peeling, swelling, ulceration, bleeding, thickening, or crusting. These signs/symptoms can mimic benign skin conditions such as eczema or acne. Typically the lesions will not heal and may continue to worsen despite good skin care. Evaluation by a healthcare provider is warranted.

Risk Factors of Basal Cell and Squamous Cell Skin Cancer 
Both environmental and genetic factors can increase a person’s risk for developing skin cancer. Sun exposure is the most important cause of both BCC and SCC. Those with fair skin, light-colored eyes, red hair and/or northern European ancestry are at increased risk of developing skin cancer due to UV damage from the sun. There is also an association with both the number and severity of past sunburns with the risk of skin cancer.

Chronic sun exposure is the most common cause of SCC, while intense intermittent sun exposure is a risk factor for BCC. Tanning beds cause skin changes similar to chronic sun damage and increase the risk for both BCC and SCC.

A weakened immune system is also a significant risk factor for BCC and SCC. Examples of people with weakened immune systems include those who have undergone organ transplantation, have required long-term immunosuppressive medications such as steroids, or have HIV. Other less common risk factors include chronic exposure to arsenic (in drinking water or contaminated seafood) and radiation therapy (used to treat some types of cancer).

How Basal Cell and Squamous Cell Skin Cancer is Diagnosed
Squamous cell and basal cell carcinomas have characteristic features that aid doctors in identifying suspicious skin lesions. However, biopsy is the preferred method for differentiating skin cancer from benign skin lesions. A piece of tissue is removed (biopsied), usually under local anesthesia, and examined under a microscope. If the cancer is small, the entire lesion may be removed during the biopsy. If it is larger, only a piece of the cancer will be removed.

Treatment Options for Basal Cell and Squamous Cell Skin Cancer at Tufts Medical Center
Treatment depends on several factors, including:
• The size, type and location of the cancer
• The chances that the cancer is aggressive or likely to recur
• The person’s preferences regarding the appearance of the area after treatment

Certain features are associated with an increased risk that BCC or SCC will recur. Treatment requires a balance between the risk of recurrence and the result of treatment.

Low-risk skin cancers can be treated with cryosurgery, curettage and electrodessication (scraping and burning), topical therapy, or surgical treatment. Low-risk SCC may also be treated by radiation therapy.

• Cryosurgery uses liquid nitrogen to freeze the cancer. After treatment the area may become painful, swollen, and may form a blister. The treated area subsequently peels off, leaving a layer of healthy skin underneath which will heal and may leave a round, flat, whitened scar.

• Curettage and electrodessication is a form of electrosurgery that is performed in the office under local anesthesia. This procedure typically leaves a circular pink to white raised scar. It is not typically recommended for skin cancer on the face or head.

• Topical treatments include 5-FU (5-fluorouracil) and Imiquimod (Aldara). 5-FU works by inhibiting growth of the cancer cells. It is available as a cream or solution that is applied to the skin twice a day for several weeks. Side effects of 5-FU include irritation at the site, such as stinging, burning, pain, redness, swelling and ulceration or infection. Use of an emollient such as petroleum jelly or a steroid ointment can help soothe the irritation. Imiquimod works by activating the immune system. The cream is applied once or twice daily for several weeks. Imiquimod’s main side effect is skin irritation, but also can cause lightening of the skin color. Rarely patient’s can develop fatigue and/or body aches, which may limit treatment. The main advantage of topical skin cancer treatment is that it provides a favorable cosmetic outcome. After treatment the skin color may change, but this usually fades with time.

• High-risk skin cancers are usually treated by complete surgical removal of the growth. The surgical treatment is typically performed in the physician’s office or a surgery center under local anesthesia. The treated area is usually sutured closed, but large cancers may require a more extensive procedure that may include skin grafting or flaps. Mohs surgery is a specialized surgical technique performed by a specially trained dermatologic surgeon. This procedure also known as Mohs Micrographic surgery, entails ultra-conservative removal of the cancer to minimize the size of the wound. The excised tissue is immediately examined under a microscope to ensure all of the cancer is removed. If residual cancer is present (roots of cancer spreading beyond what was initially removed) the Mohs surgeon can go back, usually in less than one hour, and remove more tissue – specifically and precisely in the location of the root, without sacrificing normal tissue. Once the tumor is completely removed the wound is closed with sutures (stitches). The entire procedure, Mohs surgery and the cosmetic reconstruction is performed in one day. Cure rates with Mohs surgery approaches 95-99%. The Dermatologic Surgery Program at Tufts Medical Center is unique in that the Mohs surgery can be coordinated with specialized reconstructive surgeons, eye plastic surgery, facial plastic surgery or hand surgery, such that the patient can have the expertise of the Mohs surgeon and cosmetic surgeon in one visit to the Center.

• Radiation therapy (RT) is another option for high-risk skin cancers that cannot be removed surgically. It is typically reserved for patients who are unable to tolerate surgery or to elderly patients with large tumors. RT involves the use of focused; high energy x-rays to destroy cancer cells. Treatments are brief and are not painful. The treatment is administered as small doses of radiation given daily over a few seconds each day, five days per week, for several weeks.

Rarely squamous cell carcinoma can spread (metastasize) to nearby lymph nodes. If any lymph nodes feel enlarged or abnormal, further examination with imaging (CT scan or MRI) or biopsy may be warranted. If any cancer cells are found in the lymph nodes, treatment usually includes surgical removal of the lymph nodes as well as radiation therapy.

Programs + Services


Skin Cancer Program

Discover the Skin Cancer Treatment Program and learn more about treatments for melanoma and other skin abnormalities at Tufts Medical Center in Boston.
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Dermatologic Surgery Clinic

The Dermatologic Surgery Clinic at Tufts Medical Center in downtown Boston provides advanced surgical treatment for both common and rare skin cancers.
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Doctors + Care Team

Roger Graham, MD

Roger Graham, MD

Title(s): Chief, Division of General Surgery; Chief, Surgical Oncology; Director, Breast Health Center; Surgeon; Associate Professor, Tufts University School of Medicine
Department(s): Surgery, General Surgery, Surgical Oncology
Appt. Phone: 617-636-8270
Fax #: 617-636-9095

General surgery, surgical oncology, thyroid surgery, breast cancer

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Arnold S. Lee, MD
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Arnold S. Lee, MD

Title(s): Director, Facial Plastic and Reconstructive Surgery; Otolaryngologist; Assistant Professor, Tufts University School of Medicine
Department(s): Otolaryngology
Appt. Phone: 617-636-7702
Fax #: 617-636-1479

Facial cosmetic and reconstructive surgery, aesthetic facial plastic surgery, aging face rejuvenation, face lifts, brow lifts, blepharoplasty, septal deviation, rhinoplasty/revision rhinoplasty, cosmetic filler, lipodystrophy & lipatrophy of the head, face and neck, Mohs reconstruction, cleft lip and palate, trauma and craniofacial surgery, mandible and facial fractures, nasal obstruction, head and neck reconstruction following cancer resection

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Bichchau Michelle Nguyen, MD, MPH

Bichchau Michelle Nguyen, MD, MPH

Title(s): Director, Mohs Micrographic Surgery; Dermatologist; Assistant Professor, Tufts University School of Medicine
Department(s): Dermatology
Appt. Phone: 617-636-0156
Fax #: 617-636-8316

Mohs micrographic surgery, dermatology surgery, high-risk squamous cell carcinoma, high-risk basal cell carcinoma, stage 0/I melanoma, skin cancers in organ transplant recipients, patients with history of lymphoma/leukemia or other type of immunosuppression, non-surgical management of basal cell and squamous cell carcinoma including topical and intra-lesional chemotherapy, basal cell nevus syndrome and other genetic predisposition to skin cancers, patients with history of multiple skin cancers, recurrent skin cancers or difficult to manage skin cancers

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David E. Wazer, MD

David E. Wazer, MD

Title(s): Radiation Oncologist-in-Chief; Chairman, Department of Radiation Oncology; Chairman and Professor, Tufts University School of Medicine
Department(s): Radiation Oncology
Appt. Phone: 617-636-6161
Fax #: 617-636-4513

Oncologic consultation for general radiotherapy, breast cancer, including postlumpectomy radiotherapy for breast preservation, melanomas, including ocular melanoma, gastrointestinal carcinoma, brachytherapy, stereotactic radiotherapy and radiosurgery

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Gary M. Strauss, MD, MPH

Gary M. Strauss, MD, MPH

Title(s): Medical Director, Lung Cancer Program; Professor, Tufts University School of Medicine
Department(s): Medicine, Hematology/Oncology
Appt. Phone: 617-636-6227
Fax #: 617-636-8538

Lung cancer, melanoma, breast cancer, genitourinary cancer, solid tumors

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John E. Mignano, MD, PhD

John E. Mignano, MD, PhD

Title(s): Radiation Oncologist; Clinic Director; Associate Professor, Tufts University School of Medicine
Department(s): Radiation Oncology, Pediatric Radiation Oncology
Appt. Phone: 617-636-6161
Fax #: 617-636-4513

Oncologic consultation for general radiotherapy and Gamma Knife, pediatric radiation oncology

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Katrinka L. Heher, MD

Katrinka L. Heher, MD

Title(s): Director, Oculoplastic and Orbital Surgery Service; Director, Aesthetic Eyelid and Facial Surgery; Director, Ophthalmic Plastics and Reconstructive Surgery Fellowship Program; Assistant Professor, Tufts University School of Medicine
Department(s): Ophthalmology
Appt. Phone: 617-636-7770
Fax #: 617-636-0759

Oculoplastic, orbital and reconstructive surgery, aesthetic and cosmetic surgery

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Miriam O'Leary, MD, FACS
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Miriam O'Leary, MD, FACS

Title(s): Otolaryngologist; Assistant Professor, Tufts University School of Medicine; Director, Otolaryngology Residency Program
Department(s): Otolaryngology
Appt. Phone: 617-636-3030
Fax #: 617-636-1479

Head and neck cancer, management of thyroid cancer and hyperparathyroidism, head and neck reconstruction including microvascular techniques, management of radiation-related complications

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Mitesh Kapadia, MD, PhD

Mitesh Kapadia, MD, PhD

Title(s): Ophthalmologist; Oculoplastics Specialist; Assistant Professor, Tufts University School of Medicine
Department(s): Ophthalmology
Appt. Phone: 617-636-7770
Fax #: 617-636-0759

Oculoplastics, orbital and aesthetic surgery

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Richard O. Wein, MD, FACS
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Richard O. Wein, MD, FACS

Title(s): Chief, Division of Head and Neck Surgery; Associate Professor, Tufts University School of Medicine
Department(s): Otolaryngology
Appt. Phone: 617-636-8711
Fax #: 617-636-1479

Head and neck surgical oncology, head and neck reconstruction including microvascular techniques, management of salivary and thyroid disorders, management of radiation-related complications, maxillofacial trauma

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Robert Martell, MD, PhD

Robert Martell, MD, PhD

Title(s): Medical Oncologist; Associate Professor, Tufts University School of Medicine
Department(s): Medicine, Hematology/Oncology
Appt. Phone: 617-636-6227
Fax #: 617-636-8538

Phase I clinical trials, GI oncology, breast cancer, head and neck malignancies, liver tumors

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