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Skin Cancer

Diagnosing Skin Cancer

Getting to a diagnosis begins with a history and physical examination. For skin cancer, if there is a suspicious lesion, most doctors will go for a biopsy early because it can be done in the office with very little risk.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion on your skin (or a mass in your neck).

Biopsies of the skin are more straightforward than for other sites, mainly because they are easier to get to. Typically, you will get a tiny injection of numbing medicine before the procedure. Your biopsy needs to be interpreted by a good pathology doctor.

  • Incisional biopsy: In this technique, a piece of a suspicious lesion is removed. The goal is NOT to remove it all but to get a good enough piece that a pathology doctor can make a diagnosis. The second step will be removing it all and treating it. One or two sutures (stitches) might be required to close up the skin.
    • Punch biopsy: This is a type of incisional biopsy in which a special circular forcep penetrates into the skin, then a quick little snip releases a cylinder of tissue. This is usually done at the edge of normal skin and an abnormal-looking lesion on your skin. The advantage of this method is that it can determine the depth of an invasive cancer.
  • Excisional biopsy: In this technique, the entire lesion is removed and then analyzed under a microscope later to find out what it is. A rim of normal tissue is removed along with the lesion. The problem with this technique is that if additional treatment is required (for example, the need to take even more normal tissue), it can sometimes be difficult for your surgeon to see exactly where the lesion was. A few sutures might be required to close up the skin, and you will have a scar.
  • Shave biopsy: In this procedure, usually performed by a dermatologist who has a low suspicion for cancer, a very thin layer of cells is removed using a sharp blade. A shave biopsy should typically not be used if there is suspicion for cancer because it does not give good information about how deep the cancer goes into the skin. Knowing the depth of the cancer can determine the best type of treatment.

If you came to a specialist after having something small removed from your skin, and you found it was cancer only afterwards, your doctor might skip some of the tests and jump to recommending the need for close follow-up or additional treatment. Make sure to bring all the reports and images from any prior treatment with you to your cancer specialist appointment.

In some cases, your doctor might want to assess lymph nodes in your face or the neck. This can be done by fine needle aspiration, core biopsy, open biopsy (rarely) or by sentinel lymph node biopsy in the operating room. Sentinel lymph node biopsies for skin cancers are used mainly for melanoma and Merkel cell cancers.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, imaging might not be necessary for small tumors easily evaluated on physical examination. For larger tumors, or tumors in locations difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes.

Your doctor will probably be a little more aggressive on imaging tests for melanoma than for other types of skin cancers. At the very least, for anything more than a melanoma in situ (which is an extremely thin melanoma that has not invaded into deeper layers of the skin), you will probably get a chest X-ray and blood work.

If imaging is required, your doctor will most likely start with a computed tomography (CT) scan with contrast. Other tests might include magnetic resonance imaging (MRI) and/or a positron emission tomography (PET) scan.

Some tests that might be ordered include:

CT scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumor mass and what structures it has invaded. It can also help pick up spread into the neck.

  • Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
  • Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
  • Important points: A CT scan looking for throat tumors should be done with contrast injected into your veins, unless there is some reason that you cannot receive contrast.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should take only one or two minutes. Try not to swallow, speak or move during this quick test.

MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumor mass is. It can also help pick up spread of cancer to lymph nodes in the neck.

  • Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
  • Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine.
  • Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. You will then enter the scanner, and the MRI machine will start moving and taking pictures. This can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test.

Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumor when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.

Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area he or she is examining and rub a plastic probe over the area to take pictures. The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. At the same time as he or she is performing an ultrasound, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).

Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every few months or every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

References

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5 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

7 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

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