May 14, 2019
Skin cancer is common in the head and neck area because of exposure to ultraviolet (UV) radiation from the sun. Dr. Jonathan Giurintano discusses the most common types of skin cancers and how we treat them.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Jonathan Giurintano, a head and neck cancer surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Giurintano.
Dr. Giurintano: Thank you so much for having me today.
Host: Today we’re discussing treatment options for skin cancers of the head and neck. Dr. Giurintano, how common are skin cancers of the head and neck compared to skin cancers that affect other areas of the body?
Dr. Giurintano: Skin cancers in the head and neck region are extremely, extremely common. The most common types of skin cancers (these are basal cell carcinomas, squamous cell carcinomas and melanomas), are found in areas of the body that receive exposure to the UV radiation from the sun. As the head and neck are the most frequently sun-exposed areas of the body, it follows that these are also extremely common areas that we see skin cancers, often occurring on the scalp, the face, the ears, nose, cheeks or on the neck.
Host: In less visible areas of the body, cancerous moles, spots and other tissues often are removed. How do you approach treatment of the very visible tissue of the head and neck?
Dr. Giurintano: So, it’s similar to other areas of the body, especially for larger skin cancers. The best treatment is typically surgical excision. Our colleagues, the dermatologists, are often times specially trained to perform a procedure called Mohs micrographic surgery. So, this is actually a very special type of surgery in which the skin cancer is removed and normal appearing skin around the periphery of the skin cancer, and this is sectioned by the dermatopathologist and looked at under the microscope at the time of the surgery to confirm that there is no further cancer cell present. By doing this, the dermatologists are able to not only completely excise all cancerous cells from the region of the skin cancer, but oftentimes are able to limit the amount of normal skin that must be sacrificed in order to completely resect the skin cancer. In areas such as the nose, the ears or the cheeks, there oftentimes is not much elasticity to the skin that allows for the defect in the skin to be closed simply. Other times, the defect might be closed simply, however the resultant scar might result in an unattractive cosmetic appearance. So, for these types of patients, we do have special ways that we can rearrange the tissue on the face in order to not only reconstruct the defect left behind by the resection of the skin cancer, but also do so in a way that the scar is camouflaged and has the most cosmetically appealing appearance.
Dr. Giurintano: Well, basal cell and squamous cell carcinoma are the most common types of skin cancers that we treat. Other skin cancers such as melanoma require different types of treatment.
Host: What makes treatment different for melanoma?
Dr. Giurintano: So, one of the concerning features of melanoma is that we really cannot do Mohs micrographic surgery for melanomas. Whereas Mohs surgery relies on freezing the samples of normal skin from around the periphery of the tumor and looking at that sample under the microscope with very good success rates for ruling out the presence of cancerous cells, we know that that technology does not work quite as well for melanoma cells. As a result, most melanomas require pretty large resections. So, not only do you excise the melanoma itself, but oftentimes we excise at least one centimeter of normal appearing tissue around the periphery of the melanoma up to two centimeters of normal appearing tissue, dependent on how deep the melanoma is traveling underneath the skin. So, what initially starts out as a very small defect in the face, might soon become a defect that measures 4 or 5 centimeters and needs a major reconstruction. Another facet of melanoma is that it tends to spread very easily to lymph nodes in the neck. So, anytime patients have a melanoma in the head and neck region, very commonly we want to know what is the status of the lymph nodes in the neck. One of the special tools we have for helping determine the lymph node status in the neck is something called sentinel lymph node biopsy. So, this is a special procedure where, on the day of the surgery, before the melanoma is removed, the area around the melanoma is actually injected with a dye that has kind of a radioactive uptake. And then after the melanoma is excised, we can then actually go down to the neck and determine where the lymph nodes are that that melanoma was draining to. So, instead of having to do a large incision to take out all the lymph nodes in the neck without knowing if any of the lymph nodes are positive, we can actually pinpoint only one or two lymph nodes that we know the melanoma would have most likely been draining to and we can go take those lymph nodes out and then look at those lymph nodes under the microscope. And if those lymph nodes do not have any evidence of melanoma, then we know that it’s generally safe to watch the neck and not perform any major surgery or give any other therapeutic treatments. So, if that lymph node is involved with tumor, then we could go into the neck, make the incision larger and do a complete neck dissection or complete removal of the lymph nodes in the neck to help prevent recurrence of the melanoma in the future.
Host: Can these cancers spread to other parts of the body?
Dr. Giurintano: Yes. So, that is where my job as a head and neck cancer surgeon often takes the most importance in treating patients with skin cancers. For some people, they might have a small skin cancer on the scalp or on the ear. This is removed by a Mohs surgeon, with negative margins. The area is closed, the patient’s happy, and then 5 or 6 months down the road, that patient might develop a small lump in the parotid gland or in the neck. In short, yes, these skin cancers can also send metastasis to the lymph nodes in the face and lymph nodes in the neck. And whenever these lymph nodes do occur, they can often become very aggressive and distort the tissue surrounding them. So, my job as a head and neck surgeon in dealing with skin cancers, often occurs once the skin cancer has spread or metastasized to lymph nodes. And my job is to go into the neck or into the parotid gland and to remove these lymph nodes to remove all the cancer that has spread.
Host: How do you recommend that patients prepare for treatment?
Dr. Giurintano: A large part of the preparation for these patients is mental and emotional. Oftentimes, when the Mohs surgeon performs their portion of the procedure, which is the removal of the skin cancer, the resultant defect might be left in place with a bandage over it so that they can then be reconstructed secondarily by an otolaryngologist or by a facial plastic surgeon. It can be very distressing for patients to see a large hole in their face immediately after surgery, but they must be assured that this will be reconstructed in a manner that is both cosmetically appealing and functional. Occasionally, in order to repair defects in the skin on some parts of the nose, we have to take tissue from adjacent sites on the face, such as the skin on the forehead, and use that skin to resurface the lining of the nose. In order to do that sort of procedure, what’s called a local tissue flap, the patient has a very odd appearance immediately after surgery as the piece of skin still has a bridge connecting it where the artery, that is supplying the skin flap, is running. This can result in a very strange physical appearance for the 3 to 4 weeks immediately after reconstructive surgery while the skin is healing in to place on the nose. However, we have to encourage the patient that within 6 weeks, a second procedure is performed where that skin bridge is removed, and the remaining tissue is reoriented so that there is a normal cosmetic appearance with only a minor scar present on the forehead.
Host: What does recovery from head and neck skin cancer treatment entail?
Dr. Giurintano: So, aside from the actual recovery from surgery, which is often performed either on an outpatient basis or maybe with a 1 to 2 day hospital stay, if the lymph nodes in the neck need to be removed, recovery from head and neck skin cancer treatment, most importantly, requires a very close follow-up, with either an otolaryngologist or a dermatologist, in the future to ensure that no other areas of skin cancer arise within the head and neck. While it is impossible to completely reverse the many decades of damage the UV radiation from the sun has often done to patients’ skin, it is never too late to begin applying sunscreen and to do precautionary measures to help limit the amount of damage to the remaining skin and to help prevent further skin cancers from occurring in the future.
Host: You mentioned sunscreen. Are there any other prevention tips that you can offer to people in the community?
Dr. Giurintano: So, aside from wearing sunscreen daily, which should be part of all of our daily routines anytime we go out - the face, the ears, and, especially for men who might be balding, application of sunscreen on the scalp, a few other very good preventative measures are to wear a wide brimmed hat if you are going to be out in regular sun exposure and to not only apply sunscreen whenever it’s sunny outside. Even if it’s cloudy outside, the UV radiation from the sun can still cause damage to the skin, so sunscreen in encouraged and recommended anytime patients are going to be outside.
Host: Could you share a story about a patient who had a particularly successful outcome after skin cancer treatment?
Dr. Giurintano: So, I previously had a patient who was actually a transplant patient - previously had a kidney transplant - and, as part of his transplant protocol, he was required to take immunosuppressive drugs to ensure that the body did not reject the transplanted kidney. The unfortunate thing about immunosuppressive drugs is that if a cancer does develop in the body, the immune system is not present to help fight that cancer and it can spread very rapidly. So, I previously had a patient who was a transplant recipient, who developed what was initially a very small skin cancer present on his left face that very rapidly increased in size, to the point where nearly the entirety of his left face was involved with the skin cancer within only a few weeks. This patient required a large radical resection of the tumor as well as the underlying parotid gland and the lymph nodes in the neck. In this patient, we actually used a free flap (so, that’s a piece of tissue from the thigh that we connected with an artery and a vein in the neck), and we used that tissue from the leg to resurface the skin, fat and parotid gland that was resected during the cancer resection. And, the patient had an excellent cosmetic appearance afterwards and was able to complete radiation therapy and chemotherapy, and since that time, has not had any further skin cancers develop.
Host: Why is MedStar Washington Hospital Center the best place for patients to come to receive treatment for skin cancers of the head and neck?
Dr. Giurintano: MedStar Washington Hospital Center is an excellent place to come for head and neck skin cancer treatment as we have all the tools necessary to handle the most minor skin cancers up to the most complicated of skin cancers. While many small skin cancers can be handled in the community setting, for those type skin cancers which become very aggressive and which might invade locally into structures of the face - this includes the muscles of the face, the parotid gland or the large saliva glands on the side of the face and even the facial nerve, the nerve that controls all facial movements on one side of the face - for all these patients, even if the tumor is involving these structures, we have the surgical capability as well as the capability to provide adjuvant radiation therapy and chemotherapy, for even the most aggressive skin cancers to help patients have not only the best oncologic outcome possible but also the best cosmetic and physical outcome possible.
Host: Thanks for joining us today, Dr. Giurintano.
Dr. Giurintano: It was a pleasure. Thank you so much for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.