Skin cancer surgery on referral

23 Golden Rules

23 Golden Rules for Skin Cancer

Anthony Joseph Dixon, MBBS, FACRRM, FACSCM - Geelong, Victoria, Australia

Richard Scott Hall, MD, Fellow ASMS - Dermatologist,  Cookeville, Tennessee, USA.

From their collective experience in Australia and the USA, Anthony Dixon and Scott Hall have compiled a list of ‘golden rules’ for general practitioners to help reduce errors and problems with skin cancer management. It is anticipated that these tips will provide a brief yet informative reference when faced with skin cancer management concerns in general practice. These rules were first published in Australian Family Physician in August 2005.

These ‘golden rules’ have proved immensely valuable in minimizing mistakes managing melanoma and other skin cancers. In 2008, Scott and Anthony now present a much expanded and updated version for the information of GPs and for better outcomes for their patients.


1. Suture rule – if histology indicates further treatment is needed, leave sutures in

If histology reveals that more surgery is needed, don’t remove sutures. They are a marker of the location and direction of the initial surgery. One does not need to worry that sutures left a long time might cause a reaction – the skin is set to go in subsequent surgery. Early suture removing can lead to later head scratching!

Some doctors have questioned this rule since 2005. But won’t the scar get worse with sutures left in? – The whole lot is going with the next stage in treatment anyway. But what if the final surgery can’t be scheduled for months? – In fact this actually increases the importance of leaving sutures in. The longer the time lag to final surgery, the harder it can be to be certain of the biopsy site.


2. Melanoma rule – cut it out early and cut it out widely

Only two things have been demonstrated to improve outcome/survival for melanoma patients: cut it out early and cut it out widely. In short, chemotherapy, radiotherapy, lymph node dissection, sentinel node biopsy, immune therapy, BCG therapy and anything else tried has not been demonstrated to improve patient outcome/survival.

Since 2005 little has changed. Sentinel node biopsy is now recognized as having even less of a feature in the management of melanoma since a large randomized control trial demonstrated no difference in 5 year survival on an intention to treat basis. See what we advise patients about melanoma in the fact sheet section of College web site.


3. Basal cell carcinoma rule – BCCs ain’t BCCs

There are three broad groups of basal cell carcinoma (BCC):

• superficial BCCs (SBCCs)

• simple nodular BCCs, and

• tough BCCs

The latter include morphoeic, desmoplastic, recurrent, and micronodular BCCs, as well as those previously partly treated with cryotherapy many times or photodynamic therapy (PDT). Other than surgery, options for SBCCs include imiquimod ointment, curette, cryotherapy and PDT. We would never consider these options for tough BCCs. In contrast, Mohs surgery is benchmark management for tough BCCS, but elaborate overkill for SBCCs.

We provide a fact sheet for patients regarding the different sorts of BCCs here. We also explain to patients what is meant by managing skin cancers with creams, curette, cryotherapy, Mohs surgery and PDT. Since 2005 Diclofenac topical has come on the Australian market. This is used for actinic keratoses only. It has no place managing BCCs.


4. Squamous cell carcinoma rule – SCCs can spread

Invasive SCCs can go to nodes and further. Squamous cell carcinomas at greater risk of spread include:

       recurrent SCCs – This is the most important risk factor

       tumours on lip, ear, scalp, eyelids and genitals

       large tumours, over 2 cm in radial diameter

       aggressive poorly differentiated or spindle malignancies

       Immuno-compromised patients, including HIV patients or those on chemotherapy

       Transplant patients, - especially renal transplants


Think beyond 'cut it out early and cut it out widely' with these tumours. We are more likely to consider scanning patents with SCCs than patients with other skin cancers. We can aggressively treat metastatic SCC and in so doing save lives. We consider scans when a patient’s SCC has two or more of these risk factors. Information for patients regarding SCCs is available here.


5. Dysplasia rule – dysplastic naevi need to be diagnosed (not necessarily excised)

A patient with multiple dysplastic naevi is at high risk of developing malignant melanoma. However, removing the dysplastic naevi does not remove the risk. The melanoma is more likely to develop elsewhere on skin that now looks ‘normal’. The emphasis of treatment is photography, surveillance and dermoscopy, not excising everything looking dysplastic.

Since 2005 we have developed the role of dermoscopic imaging as a follow up tool when managing dysplastic naevi. Naevi with mild changes can be imaged and the patient reviewed several months later. If it has changed, it goes.


6. Hole rule – think first of the mole, next of the hole

Recurrence rates are the key outcome indicator in cutaneous oncology. The biggest factor leading to high recurrence rates is surgery with inadequate margins. First work out what margin each tumour needs. Then work out whether you will be able to close that defect, or refer the patient.

Since 2005 it has become increasingly frequent for doctors to clear tumours and refer the subsequent defect if they then find this hole to big for them. This is a good thing. Such an approach indicates the doctor is correctly putting the cancer clearance foremost and the reconstruction second. There are three main goals in skin cancer surgery; cure the patient of the tumour, restore function if it is at all impaired and then achieve the best aesthetic result possible having effected the first two goals. They are all important, but they have this priority order. If the scar is sub-optimal, it can always be revised. This an important step sometimes required in skin cancer management.


7. Examination rule – with bright light and magnification, less tumours will be missed

The jeweller's loupe, natural light and good artificial lighting, all help the close examination of suspicious skin lesions. A digital camera and a dermoscope are also vital tools. Patients often ask you to glance at a lesion at the end of a consultation on another matter. Avoid the temptation to have a quick glance with poor lighting and no equipment. A melanoma will not be found if it is not carefully looked for. You don’t have to treat lesions and effect skin checks at the same time. Indeed it is better for the patient if they have a consultation dedicated to skin checks and other attendances dedicated to management of identified lesions or other medical matters.


8. Dermoscopy rule – dermoscopy diagnoses dark dudes

Accuracy in diagnosing melanoma and other dark skin lesions improves dramatically with dermoscopic skills (Figure 2). This means having a dermoscope at the ready, and using it repeatedly to build familiarity. Education on what to look for will enhance skills and accuracy. Further, even when the dermoscope does not provide the answer, it often helps to decide whether a punch biopsy, shave biopsy, curette or excision is appropriate. Large brown macules on the face are often best shaved; this way you sample widely without a full thickness scar. Don’t simply freeze undiagnosed pigmented lesions. Remember ‘ABCD’ with pigmented lesions: Asymmetry, Border, Colour, Diameter.

Since 2005 we have seen a significant improvement in our ability to use dermoscopy for lesions that are not dark. We now use dermoscopy to evaluate the blood vessel features of a skin lesion. This can be immensely helpful in diagnosis and management. Indeed just about all lesions that are suspicious are now examined with a dermoscope.


9. Histology rule – send it to the lab, not the bin

Among others, medical defence organisations warn us against treating skin cancer without histology. Surprises happen. Some malignant melanomata look nothing like melanoma. If every specimen goes to histology, many surprises can be discovered. If the pathology report seems odd, consider another biopsy. A commonwealth agreement means extra histology does not increase government spending on histology. If in doubt, have little hesitation in sending specimens for histology.

Since this rule was first published we have been astounded by the feedback. Countless doctors have detailed accounts of lesions such as cysts that would have been thrown away in the past, but they now send them all to the lab. We have heard of all sorts of tumours diagnosed and lives saved as a consequence.


10. Nerve rule – perineural invasion on histology means radiotherapy consult

Perineural invasion is an important warning sign on histology reports. Tumour can ‘skip’ down the nerve. This means that a tumour may have continued well beyond histologically clear margins. Options include further surgery and radiotherapy. Where a radiotherapy service is available, offer it to the patient. Head and neck units are often required for these patients.

This rule predominantly refers to cancers on the face, especially SCCs and BCCS on the medial cheek or near the eyelids, nose, ears and lips. Here the cancer risks travelling with the facial nerve or trigeminal nerve into deeper bones and compartments of the head. This can be very dangerous. Also, since 2005 we have come to learn that larger nerves under the microscope (>0.1mm in diameter) pose the greater risk. We rarely order MRI scans for any skin cancers. This is one circumstance when such a scan might be valuable.


11. Follow up rule – examine rest of skin

In following up a skin cancer patient, the most important aspect of the consultation is examination of the remaining skin. Melanoma patients have a high risk of a second tumour. A patient who has had one non melanoma skin cancer has a two out of 3 chance of developing another. A patient who has had three skin cancers nearly always grows more skin cancers – and the next might be malignant melanoma.

We still see this rule being neglected. A large study showed that less than 10% of doctors effect a skin check as part of ongoing management of patients with melanoma. This is very concerning. A patient with a thin melanoma has a greater chance of developing a 2nd melanoma than they have of developing metastases from the first tumour.In general a patient who has had one melanoma has a 13% chance of another melanoma each 10 years they continue to live.


12. Research rule – we are supposed to be scientists

While adjuvant therapy for melanoma is limited thus far, we can’t find that breakthrough unless current and future ideas are trialled. Many tertiary centres in Australia are trialling future melanoma treatments. In the meantime, as scientists, we must be prepared to cease techniques that were once popular and have been found wanting in more recent larger long term trials. We now provide a fact sheet for patients on the role and function of a melanoma unit. Read it here.


13. GP rule – GPs rule!

Most skin cancers in Australia and New Zealand are managed by GPs. These GPs are among the best doctors in the world at recognising skin cancer. Further, GPs know when lesions are beyond their expertise and other doctors need to be involved. Patients need to have the advice and confidence that their own GP is the doctor they should see to have their skin checked and skin cancers treated, and that their GP knows exactly who is best to treat them if their skin cancer is too difficult.

Since 2005 we have seen more skin cancer education in Australia and New Zealand than ever before. The ACSCM has been an integral part of this expansion and role out of education for doctors on skin cancer diagnosis and management. GPs are better than ever. College has also introduced a certification system so that patients can recognize doctors with dedicated post graduate skills in skin cancer management.


14. Photography rule – two or more: number and photograph them

Photography is increasingly useful in cutaneous oncology. Quality digital photography is affordable and images can be easily downloaded into clinical software. When removing or sampling many lesions, photography becomes invaluable. Mark the skin and photograph each lesion in advance (Figure 4). Remove them in order as numbered. When histology returns, it becomes easy to determine which report relates to which anatomical site.

Quality digital cameras are now cheaper than ever. High grade digital SLRs with fancy macroscopic lenses are now within the financial reach of any doctor managing skin cancer. It is best to have the camera near you and ready to go the whole time. This reduces the risk that the photo might be forgotten.


15. Computer rule – an Australian GP beats any machine at diagnosing skin cancer

There are numerous computer programs claiming to diagnose skin cancer by linking software to a scanner. They are heavily marketed to the public, especially in Queensland and New South Wales. Advertising suggesting scanning machine are necessary or foolproof are grossly misleading. Patients are better off seeing their a doctor certified with skills in skin cancer diagnosis and treatment. (see Rule 13).

Some doctors use expensive dermoscopic imaging computers as an efficient means of taking and storing patient images. That is fine. We get concerned when other doctors use a machine to diagnose skin cancers because of a paucity of clinical skills. We have a patient fact sheet here.


16. Experience rule – the more we see and treat, the better we get

Accuracy in skin cancer management comes with experience. The best are those who see and manage the most. Unlike most areas in medicine, we have a constant ‘supervisor’ continually checking and rechecking our skill and accuracy on everything we do in cutaneous oncology. It is called histology. Take a stab at the diagnosis every time and write it down in the notes. The learning never stops.


17. Dressing rule – wounds heal better occluded

Sutured wounds have better cosmetic outcomes if covered with an occlusive dressing for at least 4 days. Uncovered wounds have more scab formation, more infection and worse scarring. Cover every wound and urge the patient to keep the dressing on as long as possible. The wound may ‘smell’ when the dressing is removed. Smell is not infection. Ointment should not be placed on a wound after suturing. This has been shown not to aid the patient. Indeed antibiotic ointment only raises bacterial resistance problems. This research was undertaken by Dr. Anthony Dixon.

There is greater uncertainty about dressings now than there has ever been. A quality clinical trial by an Australian GP, Dr. Clare Heal has shown that dressings left on for a few days is no better than no dressing at all. Clare’s work has been presented at College conference in 2007. 


18. Time rule – if you only ask one question, make it: ‘How long has it been there?’

‘Months’ is the key. Changes or growth over days or weeks are often due to inflammation. It may soon change back or disappear. If it has not changed for years then it probably won’t change any time soon. If the patient says the lesion is changing or growing and staying changed for months, be quick to biopsy.


19. Orientate rule – mark or stitch one edge of tumour for orientation purposes

It is unfortunate when histology says, ‘incompletely excised at one lateral margin’. It helps when that margin can be identified. A ‘nick’ or stitch at one point can be denoted 12 o’clock for pathology. The report back from histology might then say, ‘incompletely excised at ## o’clock’. The result is the affected margin can be identified and addressed without having to excise further in every direction.

Pathologists prefer the marking to be done with a suture. It is easier not to be missed in the lab. Also, when a nick is made, it sometimes cuts into the tumour and this may then be misreported as a positive margin.

Whenever we send a specimen to the lab, we are esentially asking one of two questions of the pathologist; "What is it?" or "Is it all out?". Think about the heart of the question you are asking the pathologist. If your main question is "Is it all out?" then orientation is essential.


20. Pink rule – persisting pink ‘pimple’ might be nodular melanoma

Nodular melanoma accounts for 15% of malignant melanoma, but 50% of melanoma deaths. They are often amelanotic and difficult to diagnose. Many are described as a pink pimple that grew and didn’t go away. Nodular melanomas do not have classic dermoscopic features. A short fuse to histology is essential.

We feel the best way for doctors and patients to learn what nodular (and other) melanomas look like is by photo recognition. For this reason, ACSCM has a specific page on this web site showing a variety of melanomas including nodular melanomas.


21. Topical rule – GPs pick lesions for creams, not patients

5-fluorouracil (Efudix) is used for benign actinic lesions, not skin cancer. Never prescribe 5-fluorouracil for self administration by the patient. This can lead to nightmare malignancies. It should only be prescribed after careful examination by a physician to rule out existing cancers. Treat only for a specified period under close medical supervision.

Since 2005 imiquimod (Aldara®) has emerged as a major pharmaceutical agent in the management of superficial BCCs and actinic keratoses. Diclofenac topical is also now available for actinic keratoses. Hence this rule has now been changed to the “topical rule” rather than the Efudix rule. The principle of the doctor identifying the lesions to treat and ensuring there is follow up is equally important with all three creams.

Just as we saw nightmares when Efudix was used poorly, now we are seeing disasters when imiquimod  (Aldara®) is used by doctors outside of the strict recommendations.

Remember the only BCCs that Aldara works on are superficial BCCs. It is never to be used on nodular or tough BCCs.

Don’t ever use Aldara for any BCC anywhere on the “H” zone; near the eye, nose, ears, lips or medial cheek. The Aldara disasters have a very common theme. A doctor incorrectly uses the topical to treat nodular or tough BCCs or uses it in this “H” zone of the face. Frquently large and difficult surgery is required instead of a much simpler surgical procedure 6 months to two years earlier.

We provide information for patients about creams for skin cancer here. We also advise patients about types of BCC here.


22. Location rule – tumours on eyelids, nose and ear require considerable expertise

Banal looking tumours in bad locations can require aggressive and disfiguring treatment to save vital structures and/or life. Consider referring BCCs located near the nose, ears, lips and eyes. Even small BCCs can invade the nasal vault or the orbital rim. Orbital rim involvement is very dangerous and difficult to treat. Basal cell carcinomas on the ear can be much larger than apparent. For SCCs be aware of the temples, around nerve foramens such as the infra-orbital nerve and pre-auricular areas. They can be much larger or deeper than clinically suspected.

We have seen an enormous expansion in the variety and subtlety of reconstructions for defects on or near the ear, eyelid, lips and nose. A great deal of training and expertise is required by doctors. This has been a focus of attention for Dr. Dixon in his doctor education program. 


23. Curette rule – careful technique produces best results when curetting SBCCs or Bowen tumours

When treating a skin malignancy with curette, scrape from multiple angles, otherwise some edges will get less pressure. Curetting a BCC needs a sharp curette that you ‘trust’ as it lifts off the tumour. Continue until normal tissue is ‘felt’, even if the naked eye suggests otherwise. Consider cryotherapy to help destroy residual tumour cells following curettage. The curette should not be razor sharp. This sort of curette will lift off any cells, not just haphazard malignant cells.

Curettage remains an underused modality in Australia and New Zealand. It requires skill to learn but these skills can be acquired. Dr. Dixon actively teaches doctors to learn and adopt this important technique. Training starts at our 2 day workshops. We also provide a fact sheet for patients on usage of the dermal curette.


We hope you find these rules as useful in the future as they have been since 2005. If anything they are now even more important. Just following these simple 23 steps will keep most doctors out of hot water when managing skin cancers. We hope you enjoy this expanded update.

Scott and Anthony