Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Patient Choices And Skin Cancer: 

Are you worried that you might have a skin cancer? Treatment follows a correct diagnosis, and here are options for non-melanoma skin cancer.

It is difficult for patients and physicians to be absolutely sure whether a skin growth/lesion is cancerous or benign, unless it is biopsied and then processed and interpreted by a qualified pathologist. Sometimes, however, the experienced clinical physician can be sure enough of the diagnosis so as to consider institution of one of several types of treatment without preliminary biopsy…based on a "presumptive diagnosis"

Malignant melanoma (cancerous skin mole) is a particular type of skin cancer which is very dangerous and is virtually always treated with surgical removal. This can be an especially difficult surgical pathology diagnosis, some of the poorest published performances being by nationally-recognized pathologist melanoma experts ("board-certified in dermatopathology...Human Pathology 27:528-531,1996)!

We will concern ourselves now with premalignant keratoses (PMK), basal cell carcinomas (BCC), and squamous cell carcinomas (SCC). These are by far the most common premalignant and malignant skin lesions. There are additional rare types of skin non-melanoma malignancies (adnexal, neuroendocrine, soft-tissue, sarcoma, & lymhoma) which have special issues.

The careful and conscientious, properly motivated, and properly trained clinical physician (most commonly in the specialty of dermatology) can usually be at least mildly "presumptively" certain of the diagnosis, among these three conditions, without biopsy. The PMK can often be treated with superficial freezing, superficial laser, or topical chemotherapy. They can also be removed surgically by curetting, shave excision, or thick excision.

Basal cell cancers and squamous cell cancers can be treated by either of surgical treatment or radiation treatment. Our experience is that one never sees unbiopsied skin cancer first treated by radiation therapy, even though so-called superficial therapy treatments are said to be equally as effective as surgery.

Our pathology group offers "point of service pathology" services which are specifically coordinated with some of our local dermatologists and surgeons and our radiation oncologist. We have been involved since 1976 with the above clinical doctors (and since early 1996 with our radiation oncologist) in a highly coordinated program of skin cancer treatment, particularly when it occurs on the head and the face. In this location, our coordinated program makes the most maximal effort possible/devised to conserve uninvolved skin. We are a group which has taken special interest in skin pathology since 1975 and maintains both a system of intra-departmental consultations between us 7 pathologists and a network of expert dermatopathologists who are 24 hours away by Federal-Express-type mail.

Our personal experience is that the classical frozen section Mohs technique has deficiencies in dealing with certain skin cancers which are not rich in cancer cells. In most situations, this expensive and highly patient-time-consuming technique can be avoided with co-ordinated, rapid over-nite processing in a two-stage procedure. Stage (1): the cancer is excised with presumptively very conservatively-clear surgical margins. That excision tissue is processed by pathology and interpreted the next day & completeness or incompleteness of the removal reported to the doctor. If the removal turns out to be incomplete, (stage 2) more tissue is removed in the second stage to get clear margins.

So, in our own hospital system, the skin cancer is surgically conservatively removed with what is hoped to be a very small surrounding margin of uninvolved normal tissue (as in the paragraph above). The specimen is submitted to our laboratory with an exacting orientation (by the doctor) which we are able to maintain through overnight permanent-section processing, all orientation being maintained into slide production by use of marker dyes and agar pre-embedding. By the next morning after quick and comfortable surgery, we are able to FAX information to our doctors with a very exacting report on whether the surgical margins were actually clear or not (additional discussion…when needed…is done by telephone).  If the margins were not clear, our report can detail exactly where the margin is positive. Depending on the type of margin positivity, the skin surgeon makes a determination as to whether to remove the bandage and cut more tissue or to send the patient for margin “sterilization” by superficial x-ray therapy following plastic-surgery style final surgical closure.

In other words, while skin cancer can be treated alone by radiation therapy, our coordinated approach is most commonly tailored toward the very exacting and skin-conserving cancer surgery performed in the doctor’s office, followed by the exacting skin cancer pathology diagnosis and pathology specimen mapping as performed by Pathology Associates of Lexington, P.A. at Lexington Medical Center here in West Columbia, S.C.

Because of the special surgical and pathology procedures to enhance the conservation of skin (again, particularly around the face) and the resulting plastic surgery repair (almost always by the dermatologist, but also by surgical plastic-surgeon procedures), our ability to vary both the dose and size of the site radiated becomes an additional exceptional advantage. A skin cancer found to be very superficial requires less radiation than a deeper one.

SUPERFICIAL RADIATION THERAPY is almost a lost art, and our capability at Lexington Medical Center is one of only a few sites in South Carolina (the only source in central South Carolina) providing this expertise. In addition, there are occasional rare cases where radiation by linear accelerator is required. But, radiation delivery by linear accelerator cannot be focused down any smaller than the size of the opening in a coffee cup. With superficial therapy, the focus can be brought down to a size smaller than a dime, thereby sparing surrounding tissue from radiation effect/injury.

When superficial radiation is required to a skin site over either bone or cartilage (such as nose or face), a larger number of less-intense doses is required (a larger number of visits scheduled) in order to keep from damaging the underlying bone or cartilage. In delicate skin or skin more likely to show the scarring effects of radiation, such effects are lessened by utilizing a larger number of less intense doses, provided that the skin cancer was not too thick.

Because of the exacting method of processing and diagnosis of your skin cancer by our pathology department, measurements of the cancer are available and can be used in optimizing the radiation dosage and number of treatments (number of separate treatment days) when treated in the Radiation Oncology Department of Lexington Medical Center. Treatment visits could be as few as 2 or as many as 21.

In order to be in a position to take advantage of this highly coordinated program, a suspicious skin lesion must be evaluated and biopsied or removed by one of our participating physicians. These physician groups are:

  • Palmetto Dermatology: 803-796-2500 or 800-432-7546
    With office hours in West Columbia, S.C. Lexington, & Newberry, S.C.
  • Rebecca Clemenz, M.D. 803-749-0092 Irmo, S.C.
  • Lexington Surgical Assoc. 803-359-4133 Lexington, S.C.
  • Southern Surgical, West Columbia, S.C.
  • Brett Carlin, West Columbia, S. C.
  • Peter haines, Irmo, S. C.
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