The role of plastic surgery in treating skin cancer

There are two main types of skin cancer; melanoma and non-melanoma skin cancer. Both are increasingly rapidly. Melanoma incidence rates have quadrupled over the past 30 years, with death rates tripling over the same period. It is now the second most common cancer in the 15-34 yr old age group and in 2008 approximately 11,700 new cases of melanoma were diagnosed in all age groups. The data on non-melanoma skin cancers is not as complete but it is estimated that in 2008, 100,000 people had a non-melanoma skin cancer diagnosed.

NICE have produced guidelines for managing skin cancer, which defined how skin cancers in the UK should be treated. They aim to ensure a uniformity of treatment within every cancer network across the UK in the form of local and specialist multidisciplinary teams (MDT). NICE recognises that Plastic surgeons are one of  the vital elements in treating patients with skin cancer and so in their guidelines states that there must be at least one plastic surgeon as a core member of a specialist MDT.

The specialist MDT service in Leeds is uniquely split into a melanoma and non-melanoma service, but generally within the cancer networks there is a single specialist skin cancer. The specialist melanoma MDT in Leeds is a fully integrated melanoma service.

Patients referred to the service have their pathology and radiology discussed. The MDT considers the most appropriate treatment and their suitability for clinical trials. Following this in clinic a patient will be seen by their consultant but as part of a large joint clinic with dermatologists, medical and clinical oncologists and plastic surgeons attending. This ensures a ‘one stop clinic’ approach, where patients with new problems can be immediately seen by consultants with the relevant expertise.  A similar process is in place for the specialist non-melanoma clinic in Leeds and also for other centres in England.

Diagnosing some types of skin cancer can be difficult, however recognising a skin cancer or concerning skin lesion is part of a plastic surgeon’s training. Melanoma in particular requires pathological examination of the whole lesion rather than part of it and consequently pigmented lesions, those containing a brown/black/blue colour, should only be removed by a skin cancer specialist. Commonly skin lesions are removed but then often need a wider excision to try and ensure no single cancer cells remain.  The defect left after the wider excision will need to be closed and there are a variety of ways of achieving this eg. skin graft or moving tissue, known as a flap.  A plastic surgeon can discuss all of these with you and with the option of having surgery performed under either local or general anesthetic. The training of a plastic surgeon to reconstruct any size defect should ensure that the margins planned for your skin cancer are based on the skin cancer itself and not the surgeon’s limitations in reconstructing defects. The expertise of a plastic surgeon in assessing skin from an aesthetic perspective ensures that the scars from any surgery can be orientated to minimise their cosmetic impact.   

The wide excision of a melanoma is frequently accompanied by a procedure called a sentinel node biopsy.  In the UK this is generally performed by a plastic surgeon and is the single most accurate method of assessing whether the melanoma has spread. If any skin cancer has been found to have spread or it subsequently recurs then it is likely that a plastic surgeon will be the surgeon responsible for removing it. On rare occasions surgical removal will not be possible other treatment options are available. Isolated Limb Infusion and Electrochemotherapy are two other treatments which are available in a few centres in the UK, where again a plastic surgeon is likely to be the clinician responsible for discussing the alternatives and carrying out these operations.

It is not only the use of current treatments that plastic surgeons are involved with, development of new treatments for future patients are equally important. Plastic surgeons as part of the MDT can advise about clinical trials patients may be eligible for and refer to the appropriate clinician. Generally this will be to a consultant within the local cancer network, as the networks will provide core trials and treatments. However for specific patient situations a referral outside of the local cancer network may be necessary. This explains the variation in trials available between cancer networks. Trials currently open in Leeds include examining the potential benefits of vitamin D, enrolling patients into a national gene profiling study and epidemiology studies. 

Howard Peach
Consultant Plastic Surgeon
Chairman BAPRAS Skin Cancer Specialist Interest Group