Advancing Care for Complex Skin Cancers

Kishwer S. Nehal

Unlike the clinical management of other types of cancer, a multidisciplinary approach is not the established norm for treating skin cancer, resulting in significantly limited opportunities to individualize patient care.

A recent study by our group, and set to be published in the Journal of the National Comprehensive Cancer Network, confirmed that even at some elite cancer centers, multidisciplinary conferences about complex skin cancer cases are not held.

At Memorial Sloan Kettering, experts in our Multidisciplinary Skin Cancer Management Program collaborate on the diagnosis and treatment of advanced skin cancers. We are focusing our efforts on improving outcomes and quality of life for patients with complex skin cancers in four exciting areas:

  1. integrating novel noninvasive imaging modalities
  2. incorporating patient-reported outcomes
  3. improving the management of lentigo maligna melanoma, and complicated skin cancers
  4. investigating new treatment approaches in clinical trials

Cutaneous malignancies are the most common cancers worldwide, outnumbering all other types of cancers combined. Approximately 5.4 million Americans are diagnosed with basal cell carcinoma, squamous cell carcinoma, melanoma, and other skin cancers every year. (1) Most cases are highly treatable if they are diagnosed early. However, a significant number are more complicated.

At MSK, personalized treatment plans are developed for each patient to ensure the best possible oncologic, functional, and cosmetic outcomes. Care teams also collaborate on basic and clinical research programs aimed at advancing the field.

Novel Noninvasive Imaging Modalities for Cancer Detection

New imaging tools are enabling Memorial Sloan Kettering dermatologists to evaluate skin cancers noninvasively, leading to new treatment paradigms. An approach called reflectance confocal microscopy (RCM) uses near infrared light to produce images and videos of thin sections of human skin in vivo at the cellular level with high resolution. (2) These digital images with microscopic detail can help reduce unnecessary biopsies, guide management, and monitor treatment response over time. (3)

Optical coherence tomography (OCT) is another noninvasive, real-time diagnostic tool that assesses skin lesions with a greater depth of imaging. Scientists at MSK are currently exploring ways to combine OCT, which allows dermatologists to see cellular structures up to 1.5 millimeters deep, with RCM that provides superior clarity. The combination may allow a fuller view of lesions and margins before surgical procedures, limiting unnecessary biopsies and streamlining treatment compared with waiting for tissue pathology results.

Memorial Sloan Kettering is one of a few centers worldwide that offers 3-D total-body photography. The technology can help track changes in the appearance of moles or lesions in people with a high risk of melanoma. Digital cameras take 46 photos of a patient at the same time. Computer software assembles the photos into a digital avatar, showing all of the patient’s skin surfaces. Dermatologists can refer to the images during patient exams and zoom in on specific areas for closer inspection.

Patient-Reported Outcomes Inform Care

Recognizing that a patient’s satisfaction with their appearance and their quality of life are impacted by scarring from facial surgery, MSK developed the FACE-Q Skin Cancer Module. It is a multimodule instrument that measures patient-reported outcomes for patients undergoing skin cancer surgery. (4)

New imaging tools are enabling Memorial Sloan Kettering dermatologists to evaluate skin cancers noninvasively… reflectance confocal microscopy (RCM) uses near infrared light to produce images and videos of thin sections of human skin in vivo at the cellular level with high resolution.
Kishwer S. Nehal Director, Mohs and Dermatologic Surgery

In a recent study published in the British Journal of Dermatology to validate the FACE-Q Skin Cancer Module, we evaluated its comprehensive set of metrics in a group of more than 200 patients who underwent Mohs surgery for facial basal or squamous cell carcinoma or excision of early facial melanoma. (5)Together with our colleagues, we evaluated patient responses on novel scales for facial appearance, scar appraisal, and quality of life, and other metrics, including appearance-related psychosocial distress, cancer worry, and patient experience. Results showed that all scale items had ordered thresholds, good psychometric fit, and high reliability. (5)

Dermatologic and plastic surgeons can use the FACE-Q Skin Cancer Module to evaluate outcomes in individual patients and across a whole practice. The tool can also be used in clinical research and quality improvement initiatives.

Lentigo Maligna Melanoma

Management of lentigo maligna melanoma poses multiple challenges given its very visible facial location and potential for significant subclinical extension. There is a frequent misunderstanding when diagnosing and managing this type of melanoma due to the clinical, pathologic, and surgical complexities involved, especially as educational resources have been lacking. MSK’s experts approach the disease in a comprehensive multidisciplinary manner, as outlined in the recently published book, Lentigo Maligna Melanoma: Challenges in Diagnosis and Management. Drawing from multiple disciplines, it provides insights on clinical presentation, clinical and pathological diagnosis, surgical management, nonsurgical options, and follow-up. (6)

In a prospective study, published recently in JAMA Dermatology, we mapped the margins of 23 lentigo maligna melanoma lesions using handheld RCM with radial video mosaicking. This noninvasive imaging modality allowed us to accurately estimate and map ill-defined surgical margins, reducing the risk of re-excision. Estimated surgical defects correlated well with final surgical defect size. This multimodality approach guides surgical planning and reconstruction, and ultimately allows improved patient counseling. (7)A comprehensive approach is necessary as patient-reported outcomes demonstrate that patients have multiple functional and aesthetic concerns.

Skin Cancer Clinical Trials

We are currently conducting several clinical trials investigating new ways to improve outcomes and clinical care for patients with advanced skin cancers:

  • A Phase III Study of Surgery Followed by Radiation Therapy or Observation in Patients with Neurotropic Melanoma of the Head and Neck. Neurotropic melanoma develops in or around nerves and has a high risk of recurrence. In this international, multisite study, researchers are comparing immediate radiation after surgery with surgery alone to compare cancer recurrence rates and determine if the benefits of immediate radiation after surgery outweigh the risks. Status: Currently recruiting.
  • A Pilot Study of Electronic Skin Surface Brachytherapy for Treating Basal Cell and Squamous Cell Skin Cancers. Our researchers are evaluating a new form of radiation called electronic skin surface brachytherapy in older patients with early-stage basal cell or squamous cell skin cancers. The study is assessing safety, cosmetic results, and quality of life. Status: Currently recruiting.
  • A Phase II Study of Vismodegib plus Radiation Therapy for Locally Advanced Basal Cell Cancers of the Head and Neck. Vismodegib (Erivedge®) is an oral capsule, already approved for treating basal cell cancers of the skin that cannot be treated with surgery or radiation or have metastasized. The objective of this study is to see if treating patients with vismodegib plus radiation therapy can eliminate locally advanced basal cell cancer of the head and neck that cannot be surgically removed. It will also determine whether this treatment can prevent metastases to other parts of the body. Status: Currently recruiting.
  • A Phase II Study of T-VEC Immunotherapy plus Radiation Therapy in Patients with Melanoma, Merkel Cell Cancer, and Other Solid Tumors with Skin Metastases. Talimogene laherparepvec (Imlygic®), which is called T-VEC for short, is an oncolytic immunotherapy that is injected directly into tumors and causes cancer cells to rupture and die. In some patients, this therapy triggers an immune response throughout the body. This study is investigating the safety and effectiveness of T-VEC with or without radiation therapy in patients with melanoma, Merkel cell cancer, and other solid tumors that have spread to the skin. Status: Currently recruiting.
  • A Phase II Study of Proton versus Photon Beam Radiotherapy to Treat Head and Neck Cancer. This study is evaluating the side effects of two different technologies currently used to treat head and neck cancers, including skin cancers. Adult patients with skin cancer or melanoma on one side of the head or neck and who are candidates for radiation therapy are eligible. Status: Currently recruiting.

Find more clinical trials for new approaches to treating complex skin cancers.

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  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66(1):7-30.
  2. Cameron MC, Lee E, Hibler B, et al. Basal cell carcinoma, part II: contemporary approaches to diagnosis, treatment, and prevention. J Am Acad Dermatol. Epub ahead of print: May 2018.  
  3. Rajadhyaksha M, Marghoob A, Rossi A, Halpern AC, Nehal KS. Reflectance confocal microscopy of skin in vivo: from bench to bedside. Lasers Surg Med. 2017;49(1):7-19. doi:10.1002/lsm.22600.
  4. Pusic AL, Klassen AF, Scott AM, Cano SJ. Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale: a new patient-reported outcome instrument for facial aesthetics patients. Clin Plast Surg. 2013;40(2):249-60.
  5. Lee EH, Klassen AF, Cano SJ, et al. FACE-Q Skin Cancer Module for measuring patient-reported outcomes following facial skin cancer surgery. Br J Dermatol. April 14, 2018 (Epub ahead of print).
  6. Nehal KS, Busam K, et al. Lentigo Maligna Melanoma: Challenges in Diagnosis and Management. Springer International Publishing. 2017.
  7. Yélamos O, Cordova M, Blank N, et al. Correlation of handheld reflectance confocal microscopy with radial video mosaicing for margin mapping of lentigo maligna and lentigo maligna melanoma. JAMA Dermatol. 2017;153(12):1278–1284.