Skin cancer encompasses numerous tumors: basal cell carcinoma, squamous cell carcinoma and melanoma. This is how he explained it Gaston Galimbertidermatologist, director of international dermatology and head of the Argentine Society of Dermatology in dialogue with THE NATIONwith just a few days left until June 13, the date on which World Skin Cancer Day is commemorated.
The latest data from the World Health Organization (WHO) indicates that among the most common cancers in 2020 is skin cancer with 1.20 million cases. “There are no statistics [en la Argentina], if I show you the statistics they are totally wrong. The problem with cancer staging in Argentina lies in the fact that skin cancer can be treated on an outpatient basis, sometimes with topical treatment, and does not always require admission to a hospital. For this reason, many times it is not possible to have complete real statistics, added to the failure of the tumor detection system,” Galimberti explained.
The doctor explained that although there are advances in the treatment of these tumors, with some oral or systemic medications, normally both basal cell and squamous cell carcinoma, when the tumor is considered high risk, have an indication for MOHS micrographic surgery. Although this technique was devised in the 1930s mainly in the United States, and in the rest of the world in the 1970s, it arrived in Argentina 30 years ago, and despite having a 99% cure rate, it is performed in few places. This was stated by the specialists consulted by THE NATION.
“Basal cell carcinoma is the most common type that affects humans, accounting for almost 70% of skin tumors. It is followed by squamous cell carcinoma, which occupies 20%, and then melanoma. “Everyone talks and knows about melanoma or has more reference to it, because from a lesion on the skin, a spot, that tumor can spread and generate problems in other organs with other complications that can be serious,” Galimberti explained. .
And he explained: “Squamous cell carcinoma is an intermediate tumor between melanoma and basal cell carcinoma that is very important because in immunosuppressed patients it is more aggressive. and also in a low proportion it can cause systemic problems in other organs.”
Returning to basal cell carcinoma, which the doctor described as the most common tumor, Galimberti pointed out: “It is a tumor that almost never has the possibility of spreading, but it does invade locoregionally advanced tissues: It begins in the skin, it can go deeper and if it is not treated in time it can deeply invade muscles, invade nerves, invade bones. Then it must be treated. The sooner the three tumors are treated, the better.”
“High-risk tumors are according to their location: when it is on the face, periorificial, in the hands, in the legs; when the tumors are of a certain size, more than one centimeter on the face, more than two centimeters on the body; when we do a biopsy to determine what histology they have and it is found that they have a more aggressive one; when tumors occur in patients with immunosuppression, whether due to transplant or another type of disease and also when a tumor was previously treated and returns, which is a recurrence. In these cases, the indication for MOHS surgery takes on much more value,” highlighted the specialist, who in the last 20 years directed the MOHS skin cancer and micrographic surgery training school.
“In Argentina, MOHS surgery began to be performed in 1990, with Dr. Abel González, who is the pioneer in this technique in the country. Many doctors have trained with him at the Ángel H. Roffo Oncology Institute,” he said, in dialogue with this medium. María Fernanda Romero Gaunaplastic surgeon and head of the plastic surgery service at the Rodolfo Rossi Hospital, who began performing this type of surgery in 2001.
Romero Gauna is also the medical director of the Well Beauty clinic in La Plata, a beauty center that opened two years ago and where the doctor, along with a team of specialists, also performs the surgery.
As he explained, MOHS surgery is a technique that is done “in few places in our country” because there are not many doctors who have been trained in it: “Not all plastic surgeons do oncological surgery and within those of us who work in oncological surgery, not all of us do MOHS surgery.”
In this sense, he indicated: “As all surgeries have their learning curve, it is a technique that takes a few hours, you work as a team, necessarily You have to work with the pathologist in the operating room, who is the one who will be seeing the cuts, the surgical pieces that we are resecting, and you need equipment, which is also quite expensive.“It is an important investment that must be made in devices.”
And he explained: “Operating on the patient takes several hours of surgery, all depending on the training of each one, if you already have important experience out there it is done a little faster, but in general it takes you, between the resection of the tumor, the study and the subsequent reconstruction, about two hours at least.”
Regarding the decision to perform the technique at Wall Beauty, he explained: “As I mentioned before, there are not many places here in La Plata: it is practiced in Español and in Rossi, where he worked together with the pathologist Cosi, with whom we worked privately in the clinic”.
“This technique is different from conventional skin cancer treatment surgery because the patient is cured.: He enters the operating room and leaves knowing that he is healed and rebuilt. For the plastic surgeon, reconstructing an area that is resected and reconstructed at the moment is not the same as resecting the patient, removing the tumor, letting the patient leave, and if it comes back and they have to be operated on again, that’s it. There is fibrosis, a whole scarring that if we have to go to operate there again, the tissues are not the same and it is much more difficult to do a plastic reconstruction on that ground,” explained Romero Gauna.
In this line he exemplified: “So, To save tissue, especially when it comes to tumors on the face, removing two centimeters from the eyelid is not the same as removing five millimeters. “In this way we can ensure that with those five millimeters it is healed, the reconstruction and the function of that eyelid will have a normal function after the reconstruction.” And he distinguished: “If we have to remove the entire eyelid, the reconstruction has to be much larger to be able to maintain the function of the eyelid. So, these are all benefits that MOHS surgery brings.”
“By analyzing 100% of the margins you can determine if there is persistence of the tumor and the patient re-enters the operating room and we only take out where it is positive, not everything around the defect just in case. In other words, it has the possibility of following the tumor invasion, what people know as the root, whether on the surface or in depth, and preserves healthy tissue, something very significant in certain areas,” noted Galimberti.
Both Romero Gauna and Galimberti assured that it is the technique with the highest cure rate for the treatment of skin cancer, close to 99%.
“With conventional resection, the cure rate is also high, but it is 92%, 93% and has the caveat that the patient has to wait a month for the pathologist’s report that everything is resected,” compared Romero Gauna.
At this point, the doctor Luis Daniel Mazzuoccolohead of the Dermatology Service of the Italian Hospital, added in dialogue with THE NATION: “It is a procedure that, unlike other techniques, studies all the margins and depth of the tumor at the time in order to avoid leaving tumor remains in the patient. The final objective is to avoid removing excessive healthy tissue since this makes wound closure, functionality and aesthetics of the affected area difficult.”
Regarding the small number of offers to perform the technique, he specified: “There are few places because it requires an interdisciplinary team with pathologists, dermatological, head and neck, or reconstructive surgeons, personnel trained in sample processing and specific equipment.” . And he added: “At the Italian Hospital around 22,500 Mohs surgeries have been performed so far.”
However, Galimberti assured that there are more and more MOHS micrographic surgery centers because “the increase in the incidence of skin cancer in our population is high” and stressed that a few years ago it was done in one place.
And regarding the cost of the surgery he indicated: “The value of the surgery is a value that includes everything that is the surgical procedure, it includes all the management of the laboratory, you have to calculate that there are five people because there is an instrument operator, a technician, two surgeons and a pathologist, so it is not more expensive than the conventional procedure because in addition to having fewer recurrences the final cost when one adds all this, this has already been studied in the United States and also valued, the final cost is lower. Today the cost of surgery varies greatly depending on the place and there are agreements with many social works to be able to perform this”.
“Conventional surgery with clinical safety margins is appropriate for primary tumors located in the trunk, for example. There is also surgery with intraoperative margin control, but it does not control 100% of the margins unlike MOHS surgery.
Additionally, there are non-surgical procedures that are appropriate for certain stages of the disease and certain patients,” Mazzuoccolo said.
Finally, Galimberti recalled: “All patients who have a history of skin cancer have a greater chance of developing another basal cell carcinoma. For that reason, The important thing is to check with a dermatologist once a year. and sometimes depending on the tumor, that can be a little more limited depending on the type of tumor the patient has.”