Hey everybody. this is So It's Cancer. Welcome back. And it's a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and a prognosis, its impact on a person's quality of life, and and how to move forward after a cancer diagnosis. today we are very excited to have Mirnaz Mirzad and

Zajanta Zahearsha, both with us from dermatology at Loyola University. And we're talking about skin cancer, not the melanoma type, just the non-melanoma skin cancer. so welcome aboard, you guys. Thanks for joining us. And and and Renaz, would you mind just introducing yourself for a moment?

Sure, thank you so much for having me. I'm really happy to be here. I'm Mur Naz, I'm a dermatology second year at Loyola Dermatology Resident. before dermatology, I did a prelim year in general surgery. And I always really liked the overlap of dermatology, overlap of medicine and surgery together. So I think Derm was the perfect.

fit for that where you can get the patient interaction and also hands-on procedures and surgery. So

Fantastic. Do you think you'll be a Moes surgeon someday or you wanna stick with

It's it's hard to I I can't tell that right now. It's it's hard to tell, but it's definitely it's definitely in in the back of my heart.

Yeah.

Great, great. And Dr. Z?

Well, and I'm grateful 'cause you treated one of my skin cancers. So not to get too personal, but hey, it it had to be done. all right, all right. So today we're gonna talk about skin cancers. We've already spoken about melanoma on this show about a year or more or two ago. And and today we're gonna talk about other types of skin cancer. the the basic types are basal cell and squamous cell. That's the vast majority of them.

maybe five percent are a type called Merkel. there's three that are very rare. DMFSP, which is what, dermato myofibrosarcoma protuberans. Yeah

Yeah, der Matopi.

Okay, time out right there.

Well so I mean, help me out here as the sole layman in the group. What?

Yeah.

I would just describe that as a rather rare type of skin cancer that can be extensive. I mean, I think if you do end up coming across that term, that's probably a more extensive discussion you need to have with like the dermatologist. Quite frankly, you know, it's not a common one you're gonna see by any means. So

Yeah, that's a

And then there's a lymphoma that can start in the skin, oddly enough, of all places, called primary B cell lymphoma, and then a very rare one called Kaposi sarcoma, which is almost never seen except in the context of HIV AIDS, if I'm not mistaken.

Yeah, pretty much HIV or immunos.

Well, would you guys like to talk about, you know, we'll talk about these non-melanoma skin cancers in general as a as a group, perhaps, and and about what would you say would be the predisposing factors to these types of problems? Who who gets them?

Go ahead.

Okay, thank you. so I think any anyone can essentially get skin cancers, but there are some risk factors that predisposes you to getting skin cancers. One of them is having fair skin, UV radiation, meaning being out in the sun, and that can be accumulative damage throughout many years, or it could be even intense episodes. For example, as a child getting multiple sunburns.

That can also be another risk factor. Other risk factors are immunosuppression. So patients who are either through surgery, through multiple other reasons, immunosuppressed through medication or organ transplant patients or any other reasons for them to be immunosuppressed, that can also be a risk factor. Other things are genetics as well.

sorry, go ahead.

No, no, I I was just gonna ask, on when you said an an intense episode like a as a child getting a sunburn, is that something that shows itself decades later or is that something that you're seeing right away?

Yes, exactly. It will it will be decades later. it would it that by itself is also precursor for especially specific types of skin cancers, like for example, basal cell carcinomas, will present that way. yes. The

What is a basal cell carcinoma?

That's a great question.

exactly, yes. So that's the actually the most common type of skin cancer. it's the least aggressive type. it's very locally destructive, but it doesn't really metastasize. So by itself, we're not really worried about any systemic involvement, any nodal involvement. But if if it happens, for example, on areas or anywhere, it like for example the nose, it can get very locally destructive. So that's why.

And this is primarily from like a sunburn or or exposure?

It can be from sunburn or any of the other risk factors that we discuss. And even tanning beds. I I forgot to mention tanning beds, those are the the the worst ones.

okay.

Well like Michael, I mean probably like I spent my entire childhood sunburned. There wasn't a photon there wasn't there wasn't a photon I ever met that I didn't like. And and and P

Yeah, I know.

Mm-hmm.

I I was just thinking, like, my God, I gotta worry about the like terrible sunburns that I had as a kid.

Yeah. Yeah. And as we get older it's gonna be even worse. But yeah w

It's a good shit.

Ha ha

Is there something that to my doctors, is there something that like I know I've had severe sunburns as a kid. How would how would that manifest itself and what would I be looking for? Like do I have to remember exactly which shoulder was worse or or what?

No, I mean usually when I hear of a patient having like a history of blistering sunburns, we just know that you're at a higher risk for skin cancers. So the the same goes for any location. The biggest things you're looking for are bumps or new growths that are like bleeding, itching, painful, the sore that isn't going away. Those are kind of the stories, especially for these non melanoma skin cancers of

Something to be concerned about. So just being on a close, keeping out a close eye for any new or strange growth or something that's not going away is probably enough reason to go have it checked out.

And you'll think, like, this is just a let's say, all right, my first skin cancer was I was in my mid-20s, and there was this thing on my face, and it wouldn't heal. And it would heal and it get and then it would open up again and heal and up get up again. And I was newly wed, and my wife was like, You need to get this checked. It could be a skin cancer. And of course, I was a little know it all. And I was like, No, I'm too young, you know? and I was also

Yeah.

Heading off to Okinawa for a year and a half with the Marine Corps. And so I finally go and check it the last moment I possibly could. And wouldn't you know it's a it's a basal cell and it's a morphia form. And we'll talk about that in a second. And I needed Moe's surgery. We'll talk about that in a second. So I I had this huge scar. And she was right. So that was probably the last time I ever you know, dare she was right. She was like, that was a skin cancer. And

Yeah.

Yeah.

I I was too young, but all those sunburns as a kid, you know?

Yeah, even then I guess I I've learned through practice there is no such thing as too young. You know, I depending on the type of skin cancer or your genetics or your risk factors, it can ha you know, it can happen in kids. Obviously, the older you are, the higher risk you eventually become with all the sun damage. But there are other reasons people can get a lot younger.

And also it sounds like doctors are the worst patients. But that's for another discussion on another day.

It's true.

Yeah.

yeah. Without a doubt. Without a doubt. Do everything wrong. All right, Mernesse. would you want to talk a little bit about precursor lesions?

Yeah, for sure. so we have multiple different precursor lesions. for example, actinic keratoses. These are called we just call them for short AKs. these are these kind of gritty pimple looking areas. I w I would say like hyperkeratotic papules, that can happen on sun exposed areas. Okay, that's exactly so so here we go. Sorry, okay.

All right.

Yeah.

There are these gritty textured unevenness of the skin. and please Doctor Z interrupt me if you have a better way of describing them.

I usually tell patients it's like when you feel sandpaper on your skin, you might be dealing with an AK. They're sometimes a lot easier to be felt than seen. so that yeah, I think of it as like sandpaper.

Yes.

And this can it be on any part of your skin, in any part of your body? Okay. So not just sun exposed, but like anywhere.

Technically, yes.

I would say technically, yes. Most commonly it would be a sun exposed area, for sure.

Yes.

And so yeah, so those would be precursors, for example, to squamous cell carcinoma. However, not all of them would turn into squamous cell carcinoma. The rate of them turning in is probably one out of one hundred. however, we still will treat them because they do have that potential. And we can talk about treatments maybe later on.

Yeah, so that's one of the precursors.

Yeah, I mean the transformation from an AK, which we call a pre cancer, to a squamous cell carcinoma, a true cancer. I mean, you can look all over the internet. It I usually I tell people like if you let a hundred go for like ten years, one of them would turn into a skin cancer. So yeah, it's like point one percent per year. So like by itself it's not super scary, but they easily rack up th over the years, which is why we recommend treatments.

I didn't realize it was that low, yeah.

Yeah.

Okay.

For him.

if you have half a dozen of and you have for thirty years, the numbers add up.

Exactly. Exactly.

I think something

Half a dozen sandpapery areas on your body? This is a common thing? Jesus. All right.

yeah.

Yes. Especially on the forehead, temples, back of the hands.

Yeah, wait till you get

Yeah.

Yeah.

And you know, I think that is an important thing is

if if your skin is from like let's say a very northern latitude, but you're living closer to the equator than nature had intended for you, you know? like the the most dramatic is is people from Scotland that go to Australia. You know, they're they're built for clouds and rain and now they're they're baking in the sun.

No,

Yeah.

Red, yeah.

Exactly. Yeah.

Exposures, like how do you all right? You say, okay, well, I live down here. I'm living in Florida, or I'm I'm living, you know, in Mexico City or whatever. What do you do? You have to be careful. You have to avoid, you know, in the middle of the summer and the middle of the day is like the worst time for you, you know. The the sun's just gonna cook you. So you have to be sensible about those issues. Anyway, back to the precursors.

I guess like there's Bowen's disease and keratoic anthomas, KA's. Do you want to touch base on those?

Yes. Yeah, absolutely. So for Bowen's disease, Bowens is essentially the squamous cell carcinoma that is contained within the within the first layer of the skin. So it still has not fully developed into a full on squamous cell carcinoma because it hasn't broken that barrier of metastasis down to the deeper tissue. So it's essentially we call it squamous cell carcinoma in situ.

meaning that it had it it's it's still within the first layer of the skin. so those are the the characteristic is exactly the squamous cell carcinoma it's not anymore the AK where it can potentially turn into squamous cell this is an actual squamous cell carcinoma that has not full on turned into going deeper for

The other one, the keratoacantoma that you mentioned, these are also very rapidly evolving squamous cell carcinoma-like lesions. There is a lot of I guess debate whether or not they are actually squamous cell carcinomas and whether they will involute by themselves if you leave them. but we in practice,

Wait, what's an involute?

Yeah. It's like an invalid, but he plays a lute. Yeah.

Yeah.

Yeah.

Invoid just means to go away.

Just like going away. Just just going away. Yes. Yes. there are yes, but we still we still treat them as squamous cell carcinomas.

Okay. It's not gonna heal itself.

Yeah, I agree.

So it sounds like this is surface. Like it's it is cancerous, but it's so shallow on the surface. I mean we've talked about this on on some of the previous podcasts about the depth matters. and so so you're catching it early. It it one of the things that we always talk about is getting into your doctor early and and usually it's your GP and getting things checked. So this sounds like one of those like go get it checked right away, unlike you know what Paul was saying about in his past. If it's a surface thing, that's a good time to catch it, right?

So

Exactly. Yes.

Exactly.

Because otherwise it will go deeper probably.

In exactly. So the Bowens disease or squamous cell carcinoma inside two, how I try to explain is inside two actually is Latin for in place. So it just means the cancer is in place in the top layer of the skin. So they have a five percent risk of diving deeper and becoming a full blown cancer. So you're right, like you know, you have the opportunity to catch it earlier, you have no risk of spreading to other parts of the body, you have as we'll discuss

more variety in or more options in terms of treatment to reliably cure yourself of it. And then as Dr. Mirzad mentioned, you know, caratoacanthoma is an elusive term. I would say the majority of dermatologists kind of treat that as a squamous cell carcinoma. Most of the treatments for it are tend to be the same. The unique aspects are that like a KA is what it's called a caratoacanthoma can tend to happen with trauma.

And can be really fast growing. So, you know, we see people all the time, they kind of bump their hand, and literally a week later they have a, you know, a golf ball sized nodule on their hand. And you're like, how how did that happen? So that that tells us it's a little more of that KA type. But the good news is those actually tend to be the less aggressive kind of squamous cell carcinopas for even though they like grow very quickly. So

Wow. Yeah.

Z sorry, 'cause we were talking about if it grows deep it it's starting to be serious, but then you set up a golf ball sized lesion. It sounds like it's growing up and out rather than down and in. Okay.

Exactly. Exactly. The KAs are kinda like almost like a volcano phenomenon rather than like the scarier squamous cell carcinomas we see. It's still one we treat as a squamous cell carcinoma, but I would say it's not a high risk feature.

Exactly.

The the two most problematic characteristic behaviors of any cancer are invasion and metastasis. So invasion is it it's moving from where it began into the stuff around it. And and that's it it goes deep and then it can go, you know, whatever cancer we're talking about and to go into whatever's next door to it. And then metastasis means the cancer.

it breaks away from the mothership and it sends out into other places in the body. And, you know, that could be the lymph nodes and then it it could be other organs. So with the in situ lesions, the you know, Bowen's disease, the squamous cell in situ, AK is not a cancer yet. It doesn't have the features under the microscope that would make it

anyone looking at it say this is a cancer. Bowens does, but it just hasn't invaded yet. And then a and then KAs are just this bizarre phenomenon that kind of breaks some of the rules but turn out to be not that likely.

So

Okay, wait a minute. I need to reset here for just a second because I I didn't realize we were talking about AKs and KAs. So so just a so just a quick give me a quick reminder, an AK is the sandpaper one and the KA is the golf ball one. Okay.

Raj.

Yeah, sorry about that.

Mm-hmm.

Yeah.

Exactly. Yes.

Yeah.

Yes. Beautiful.

Yeah.

Protruding exactly, there you go.

Looking for sandpaper and golf balls. All right.

All right.

All right. And with that, I guess we could move on into just overall levels of of risk. And again, we're primarily talking about basals and squamous, which is let's say 95% of the whole group of non-melanoma skin cancers. and the risks, if if Renaz, do wanna jump into the different categories and kind of explain them? thanks.

Sure, yeah. so for risks, for basal cells, basal cell by itself as a category, it's lower risk. So it means that it's not aggressive type of cancer. We don't worry about it going to the nodes or metastasizing anywhere. But by itself, it does have some subcategories that can determine the treatment options available. So for example,

There are some subcategories to basal cell, it's the superficial type. That one is the least aggressive type. Then there's infiltrative, nodular, micronodular, morphiform. these are more aggressive, means more local destruction, and more kind of like especially in specific places, they can really go deep.

so for those ones the treatment options changes. So for example, for the very superficial ones, we can use topical therapy, but for the very deep ones, like the infiltrative type, the standard of care kind of changes.

Yeah, I mean if I had to like classify when you're thinking like, is this low risk, high risk, what do you do with this? There are two components to everything. One is the patient, which we kind of discussed, you know, there are some predisposing factors, but there are aspects of the patient that could make them more high risk. most commonly tends to be like immunosuppression or some way to decrease the immune system. Like we discussed, like

organ transplant or you're on some intense medications or chemotherapy or something like that that lets a cancer whatever it is be easier to spread in your body and then there are their aspects of the cancer itself and as Dr. Mirzad mentioned the biggest ones I would say are size you know something that's a little pea size is just gonna operate a little differently than the one that's a golf size, a golf ball size overall.

Two is location. you know, head and neck tend to be the higher risk locations. There are other high-risk ones, such as like special sites like the genitals or like the hands and the feet, things like that. and then three would be what you see under the microscope. You know, there can be aggressive features under the microscope that would come in like a pathology report you would see as a patient that would point you towards one treatment option over it.

Excellent. So for for both basal and squamous, they have categories of low risk, and most of the tumors that we ever see are gonna fall into that category.

yeah, I I would say the majority would be low risk if they're like below the neck. But the irony is, you know, I would say a a strong percentage of the skin cancers we deal with tend to be head and neck cancers, right? That's where you get most of your sun exposure. That so by default those are technically higher risk skin cancer, which is

High risk. Yeah. And actually, you know, the I I I don't do with those, I don't do head and neck. So so I sort of was a little self-obsessed when I said that, that most that we see, most that I see are are low risk, but I I see a lot of high risk that come my way. And then so what sorts of features, Mernaz, make something high risk or very high risk?

Yeah.

Yeah.

Okay.

Yeah, so for example for squamous cell carcinoma, there are some categories. So if it's more than two centimeters, that's gonna be a higher risk for squamous cell carcinoma. There's if if the patient is immunocompromised, that's another higher risk. If the in if the thickness is more than six millimeters, so meaning that it's going down to the fat layer. if when they look at it under the microscope they see that it's around a nerve, so we call

per neural invasion. these are all features of it being high risk. Other things is if you look at it under the mic microscope and not be able to really distinguish where the where the cell was originated. So like it's if it's poorly differentiated type of skin cancer, I mean type of SCC, that would also be another high risk features. anything else that I'm missing out, Dr. Z?

No, that that about sums it up. other things that may not be listed that can make something a little more high risk, specifically with like squamous cell carcinomas, is that it can as I mentioned before with those KA or golf ball size things, it can happen in trauma. So you can actually develop in chronic scars or ulcers. You know, if someone has a leg wound that's been there for years.

you can develop a skin cancer within it. And it can be very hard one to even recognize there is a skin cancer there because you've just already been dealing with this non-healing wound. But you can develop due to that trauma and you know all that activity happening, a skin cancer. And those can be even higher risk. They're harder to identify, they're harder to cure because they're all messed in with all the ulcer and scar that's going on. So those can be other things to like consider.

And they're they're much yeah, they're much more aggressive, more likely to to jump from the site to the lymph nodes and and also to the organs after that.

So low risk means you it's a local problem and maybe even a big problem if it's near your eyelid or on your nose or near your lip or and then but it's something that you can manage with with treatments and it's not likely to jump to either the regional lymph nodes or the distant places. High risk has a bit of a chance of this, and very high risk, you're really concerned.

You know, and if you've got a squamous cell that's already moved to the lymph nodes, then you've got a very dangerous situation. you know, it's a full on cancer like like every other one that you treat.

Yeah.

Yeah, exactly. You know, squamous cell usually we I tell patients, like the average squamous cell has maybe like a four percent chance of spreading to other parts of the body. So but if it does do that, that's a big deal. So

So to get to the treatments, let's talk about treating the primary lesion. you know, what are the array of treatments you guys might propose to a person if they come in? They've got a lesion, they they saw something unusual on their skin or it felt weird and they brought it to their GP, their GP said, Yeah, I'm concerned. and they sent to you.

Yeah, I mean there's this is one thing I enjoy about dermatology, you know, there's a lot of different treatment options and we're very blessed that a lot of the cancers we talked about are curable. You know, when I talk about treatment rates, I'm talking about like cure rates. when I'm sure you know many cancers and talks are like discovering treatments to just extend survival by, you know, X, Y, and Z percentage.

Yeah, extra couple of months. Yeah.

so we are very blessed that most of the things we deal with can be full-on cured. And I'd say the majority of skin cancers I deal with are in that case. So the first category would be like topical creams. So there are new there are a couple different creams that can be used for skin cancers. One is called a Miquamod. this is like on label, so you know it's approved for use of superficial basal cell carcinomas.

Superficial BCCs. This is the least aggressive type of basal cell carcinoma, and it's typically used for ones that are in low risk locations, like the trunk or extremities. it's a cream that like essentially just gets your immune system to ramp up and target the skin cancer when you put it on and attack it. The cure rates, you know, they can vary. We're talking probably somewhere in the like

I don't know, seventy to eighty percent range, I would say. And you do have to use it for a decent amount of time. typically like at least six weeks.

The one you gave me seemed to work. I showed up to Dr. Z with the skin cancer on my leg and he gave me that and you know I I followed the rules and it seems to be good. Now does this teach the body how to prevent future ones or

Yeah. So

Nice.

I wish.

yeah, not that I know not that I've ever seen that it really teaches you to do it. It just gets your body to identify that area you're putting on the cream. But you will have to deal with a can be a gnarly rash during that time when you're treating it. the reaction can really vary patient to patient. It could be anything from like just a meh kind of annoying little itchy rash to like, you know, essentially almost like an ulcer. Yeah. Yeah.

Yeah.

Yeah, mine wasn't too bad.

Yeah.

All Murnaz, what else do we have?

so also something about that, like that's the discussion comes into like is the patient going to actually be able to apply the topical treatment all the time? So that's what the that's one of the other things that we also take into account is like patient specific treatment, other ways of treating it if if they're not a really good topical treatment,

therapy candidate for example it's just difficulties at a location that it's like on their back they cannot reach it every day and they don't have anyone to help them with it then we have other options. we have other options like what we call EDNC electrodesiccation and curatage bear with me it's just a scrape and burn essentially it's exactly

Yeah. Mike was ready.

Nicely done.

It's it's it's essentially a a procedure that can be done in the clinic. it takes about 10 minutes. you numb up the area because you already see the outline of the cancer outside, and then you can just use a sharp tool to scrape the area first. the cancer cells don't really have that adhesion that normal cells have, so you really easily can feel them sloth off.

Yeah.

so you scrape the cancer out, and then you br burn the you can burn the area. So you do that three times. It's scrape and burn method to make sure you get all the cancer out. then the patient will be left with a little kind of like a scar, essentially that they should take care of it for the next couple of days until it fully heals. that's another method. yeah.

So that that sounds scary. So I'm I'm thinking as a listener, might be hearing this like, wait, wait, like I'm almost imagining you're gonna that's gonna hurt and then you're gonna burn me. What's the what would you recommend to people who might hear that treatment and like now not want to go to the doctor 'cause they're afraid of that? Like is it is it that bad? Is it

okay.

it's it's so it's all going to be under local anesthetic. You will not feel any of this. And that's what I always say. The worst part of the procedure is just that numbing, and everyone who is a candidate for this procedure has already gone through that during their biopsy. So I say it's exactly the same injection that you we use during your biopsy. It's just a tiny little pinch and a burn, and then after that you're not gonna feel anything.

Mm-hmm.

The the good thing about this procedure is that you you do not have any restrictions. You don't have to take it easy for a couple days because your stitches might come off. you after after we're done, after ten minutes, you're completely done. and so there's no really downside to to your recovery essentially.

Okay. Makes me feel better, thank you.

Yeah. I would say probably, you know, every everyone who might be listening to this is why would I not do that scrape and burn over any like excision or massive surgery? you know, there

Yeah.

Yeah, but we're thinking, you know, w we don't know yet, right? We just think I got this little thing. I'm afraid of going to the doctor. I d it sounds bad, but yeah, to your point. For those of us who don't go to the doctor regularly, any excuse it seems, and and that fear of going. But to your point, but if you go and you take care of this small thing, you're avoiding I'm sure what you're gonna tell me in a few minutes.

Yeah.

Exactly. Yeah.

Yeah, a bigger surgery, which is what the other treatment option, which would be like a wide local excision. so this is where you numb up the area just as you did for your biopsy, this frape and burn with the lidocaine, it's kind of like a pinch and a burn. And then here you take safety margins around where you identify the skin cancer. So you know, you take a little margin around.

Hm.

The area and then you kind of cut it out. Usually it tends to be kind of cut out in a football shape almost to kind of stitch it up in a line. So the benefits of this is obviously you're surgically removing the cancer and you're sending it to the lab so that the pathologist under the microscope can look at the margins and say, okay, we don't see anything on the slides we saw.

so you get that report back saying that they didn't see any skin cancer left. And then you're left with stitches usually, and then a typically a line scar that tends to be, you know, two to three times longer than what the skin cancer was. but this requires a little more recovery. You know, usually you're left with like a big bandage you have to keep dry for a couple days, you have to.

take it easy for a couple weeks where depending on where the location of the procedure was done. and then there are higher risks of like bleeding infection, numbness in the area and you trade it for that scar. But the cure rate go ahead. Sorry.

There right is there?

I was just wondering if there's a is there a time sort of like if again if I'm squeamish and I'm like I see the thing, I feel the feel something, or I see it and I think it I I should go to the doctor, but I'm not going to the doctor and I know it's gonna hurt and blah. But is there like a time frame of when it goes from something that's scrapable and burnable to something that's gotta be excised and stitched over? Or is it don't know.

So that's a that's a good question. You know, I'd say there are a lot of skin cancers that could be treated with either option, depending on patient preference, as well as you know, the pros and cons, I would say. You know, the pros of the wide local excision tend to be the slightly higher curate. So that scrape and burn can be somewhere between like

89 to like 92% cure rate. A wide local excision is closer to like 95 to 97% cure rate. So it's slightly higher. And two is with that scrape and burn, you're not sending anything back to the lab to say, okay, the skin cancer is all gone. Versus an excision, I take that skin and then they look at it again. So then you get a second report saying the skin cancer is gone.

So depending on the patient, they may feel really strongly about having a second report, or especially the scars look a little different. You know, this scrape and burn has a little circle scar because you just kind of scrape the area. But if depending on the area, you want like a cleaner line scar, then yeah, you're probably gonna have to cut it out and stitch it. So, but I would say, yeah, if something is becoming larger and you let it go for longer, then it's

not going to be as easy to confidently cure it with a scrape and burn, and you may be more inclined to say, yeah, we should probably be cutting this out. And then the other reason would be those higher risk features we talked about. You know, if something's under the microscope says this is a higher risk skin cancer, the scrape and burn may not be as good of an option because it's not going to get as much down there. and so that would

lead to a higher recurrence rate, so you're gonna be more likely to cut it out.

This might be a good moment to talk about the difference between a standard excision and Mo's. We introduced Mo's earlier, O H apostrophe S, not like Larry Curley and Mo. I don't know who Dr. Moe was originally, but I'm guessing Dr. Mo invented this technique.

Mm-hmm.

Yep, correct. Dr. Frederick Moose invented this. I think he was from Wisconsin. And so Moose surgery or Moose micrographic surgery is there's other terms you might hear. One other term you might hear is PDEMA or peripheral and deep and foster margin assessment. I would conta consider them the same if you're like in the United States. Essentially, all it is is you have the benefit of looking at

All margins of a skin cancer 100%. So when you do an excision, you cut it out, you send it to a lab, and those people look under the microscope. But based on how they process it, you actually only look at less than five percent of the entire block of skin I gave them to make their you know report that the margins are clear.

MOSE surgery is a little more involved because you actually process that tissue in-house. So you have to have in a lab in your clinic. And what happens is you take a little chunk of skin where that skin cancer was, and you, as you know, as the patient, you actually hang out with a bandage and like an open wound, and we process that tissue under a frozen section.

is what it's called and it takes you know it could take anywhere from like twenty minutes to like forty-five minutes to an hour. and the Mo's surgeon will actually look under the microscope themselves and see if there's any skin cancer left. If they see anything there, they go they come back and they take a little more exactly where they saw it and they do the whole process again. You hang out again, we process another slide, we see if there's any skin cancer and do it again.

So you keep doing that until the skin cancer is all clear. Naturally, because you're doing this in such, I would argue, like a more methodical way with high looking at the entire margin, the cure rate is higher. You know, for a standard basal cell, it can be as high as 99%. so, but it is a little more involved, both time-intensive, resource intensive. So it's not necessarily used for every kind of skin cancer based on.

how high risk the skin cancer is.

Translation on that is insurance companies won't pay for it as readily? Okay.

Exactly.

Yeah. But you know, like if you think about it, what we were talking earlier, so many of these cancers happen in your head and neck. So if it's near your eyes, your nose, your mouth, your ears, this is really high rent territory. And so you don't want just you you want to save every little bit you can. You know, I mean, imagine one right underneath your eyelid here. Like it's very it's a big deal to remove even a little bit of that tissue.

And so with Mo's, you can remove the least amount of tissue and have the most confidence that it's not coming back. Because when it does come back locally, it's a problem. It's first of all, it breaks people's spirits. They're like, it's back. And second of all, you have to do the whole thing all over again and take more tissue. And third of all, when it comes back, it can come back more aggressive than it.

Exactly.

began. It sort of learned something through this whole process the first time and it comes back meaner. So it's in everyone's best interest to get it out completely the first time. So if it's on your face or maybe would you say your hands or e if you have it one on your feet, a lot of times that'll be you'll you'll do MO's and insurance will pay for it.

Yeah, so there's actually like a criteria. It's called the appropriate use criteria. that guides providers in understanding like what skin cancers could be appropriate for MOES. It doesn't necessarily mean that how do I put it? If a skin cancer is appropriate for MOE's, it doesn't mean MOS is the right answer for that patient. It just means it would be a an option for that skin cancer.

So it's still always a discussion with a patient because depending on their life circumstances, their age, it might not be the right treatment choice. But yes, if it it tends to be if it's on a high risk area, which is neck up, you know, hands, feet, genitals, if it has high risk features, if it's greater than a certain size, definitely if it's greater than two centimeters anywhere, or if then the patient is like immunosuppressed or at a higher risk, then

those are all factors that can contribute to a score that would lead to you doing those and saying it's appropriate.

Awesome. Manaz, would would there ever be any circumstances where radiation is a good idea to send them to the radiation therapy?

I th I think so. I think there will be if if someone is not a good candidate for any of the things that we already do talked about, and like for example they're they're very frail and fragile and they're already immunosu suppressed or th there's plenty of ways why someone is not a good surgical candidate or like a topical therapy candidate, definitely radiation can play a role in that.

And we can refer them for radiation. But I believe that the standard of care for these cancers still would be excision and everything that we already discussed.

Mm-hmm.

How about when are systemic therapies appropriate for skin cancers, non melanoma skin cancers, whether it's immunotherapy or chemo or small molecules or oddly enough, antifungal?

I think a lot of times when people have for example, in genetic disorders, like there's this genetic disorder with basal cell carcinoma that patients make a lot of basal cell carcinomas, and this is a lifelong thing. that is one of the areas where this can become useful on very highly aggressive types of skin cancers, where things have, for example, esquamous cell carcinoma has metastasized to the nodes.

And it's already very aggressive, those will be a good time to use the systemic therapies. other events, it's usually for more aggressive types of skin cancers.

Or yeah, and my sense like when they show up to me, it's because it's jumped into the lymph nodes. And when it's in the lymph nodes, or if it's like let's say it's a huge cancer, like I now and then we'll see one that's ten centimeters or something and and and and some of these newer medicines are pretty incredible, aren't they? Like you know, the checkpoint inhibitors, like semiplomab or or any of these others are

Exactly.

They're pretty pretty good. They're brand new and and they work well.

Yeah. Yeah, I mean I think it's completely revolutionized how honestly all cancers are being treated. You know, these checkpoint inhibitors are being used for pretty much all like solid organ cancers. So in skin cancer specifically, I would say semiplomab, pembolismab, things like that, especially for squamous cell carcinomas is being

more often used and for basal cells that do not do well with those small molecule and inhibitors you were alluding to. And yeah, I mean it really just gets your immune system to like fight the cancer and you know it revs it up. And I would say there's even new research into potentially like injecting this into like local skin cancers. and all of this is with a goal that

your immune system can now attack this and shrink it and fight it that way. So it can be used in combination with surgeries. It could be used instead of surgeries potentially. it really just depends on the case. And this is kind of where working together as a team across like specialties for a patient is crucial.

it's cool. It's an exciting time to be practicing.

Is this something that that a a patient might ask for? Like it you know, oc occasionally you might b have some information doing your own research or something and are are there therapies that aren't usually presented to a patient and they might kind of self advocate for something?

That's a good question. I would I would imagine semiplomat is probably not something that a patient is coming to me specifically asking for, 'cause it's usually heavily discussed with like a hemonchysian as well, or you know, it 'cause it can be like an intense infusion. So usually patients aren't coming to me demanding chemotherapy or immunotherapy, quite frankly. but

Yeah.

Mm-hmm.

it as it becomes more common, I think you know, it's just there'll be more and more articles about it that people will see. but yeah, I would say it's something that is probably more likely to be discussed by the physician because we're now kind of moving away from the older times of it no matter how bad it is, we just gotta try and cut this thing out. Now we're more far more often to

Try a multi pronged approach, so to speak. So

I think, Michael, for the vast majority of these which are low risk, the systemic treatments are probably too much because they come with side effects. They come with some serious side effects, for the most part. But if it's a high risk or very high risk situation where maybe it's already jumped to a lymph node, that's a small percentage of the overall group, but for those people, these medicines that are brand new and coming coming out all the time.

That's when these really are effective. Or if like Dr. Z was saying, let's say it's a huge tumor and this happens, you'll see big tumors, you know, people don't always have the same access to care as as others and or that they just grow to a huge size before they're they're dealt with. in that circumstance you can the nowadays, never before you could consider shrinking them with some of these medicines first.

for our for our next topic, it's just anything that's specific to either basil or squamous that's worth mentioning. We've sort of talked about them independently and both as a group. for anyone listening, is there I mean, are they f essentially the same or are there a few important differences?

I think one easy way to think about it is basal cell carcinoma, don't get too worried about it. It definitely still needs to get dealt with because of the local destructions, but it won't kill you. Squamous cell carcinoma, it is a little bit more it can be a little bit more aggressive. It does have the potential to metastasize and go to different parts of your body. So be a little bit more worried about.

Wait, I just wanna say I would not know the difference, right? Like if I'm a if if I've got something on me, go to the doctor. Let them worry about it until you tell me not to, right? Like I'm gonna worry until you say, don't worry about it. This one's not gonna kill you. Okay.

Yes, that's right. If it's not healing, yes, yes, that's right, exactly. If it's not healing, if it's if it crusting, if it's painful, if it's not going away, definitely get it evaluated. but yes

Yeah, that's

Yeah, yeah. That's a good point.

Great point. would you guys like to spend a few moments on Merkel cell?

Sure. so I I mean Merkel Merkel cell, as you mentioned earlier, you know, it's much rarer compared to like our basal cell carcinoma or squamous cell carcinoma, but much scarier I would say. You know, the mortality rates are or you know the risks of spread and death are just a lot higher with it, quite frankly. you know, there's there's a few different like risk factors.

All right. Go for it.

to consider. I like to think of like the AEIOU which is like age or you know like age elderly immunosuppression older than 50 years and then ultraviolet exposure so like it's age and asymptomatic as well so it it's not painful it's and then E could be like

also expanding as well. So a non-painful bump that's really growing rapidly in people who are higher risk immunosuppression older than 50 years old and then tend to be in fair skinned individuals on areas exposed to the sun. So all of those can be like the signs of a Merkle cell. and like I said, these just spread quickly. the treatments for them are just

need to be more aggressive, you know, it usually involves a pretty aggressive excision of it as well as checking all the lymph nodes, as well as radiation. and so it's definitely something that if you've identified you you want to take real seriously.

Mm-hmm.

And it's a it it can start off like a little red spot, is that right?

It's I it's so weird. I haven't seen him for years. And then I had a couple in one year patients come in with it and is very aggressive, took a lot of surgery, and radiation and immunotherapy and it was it's different from basal and squamous. This is one that's far more likely to gallop away.

Exactly.

Well guys, a any any final

And yeah.

wait, wait. I gotta get some free medical advice. I got three doctors. So I was born with a bunch of moles on my back, which I can't see, but doctors all my life said keep an eye on those.

All right, all right, Michael. Yeah.

Thank you.

Mm-hmm.

Yeah.

Yeah.

Thanks, Doc. what what are they worried about and and what kind of things can happen? And are are we talking about basal cell? Are we talking what what what's happening to the potentially to the moles that I have?

Yeah.

Yeah, so for I I can attempt to this. so for the moles what what I would assume they're worried about melanestytic lesions for like them becoming cancerous. and depending on genetics, if you ever had well not you or anyone, with a family history of any type of atypical moles or any type of melanomas in the family.

Those would be the concerning ones. to and then you want to keep an eye out for the ABCDEs of melnomas, which I'm sure you've all already re covered in another episode another podcast. but those are the things that you want to look out for for asymmetry, the borders, if they're changing at all, if the color is changing at all, those will be the red flags for possible something going.

So I I jumped from non

Yeah.

Melanoma to melanoma.

Yeah, non medical but see, that's what you get for having a non medical person hanging out with you.

No, it's all right. It's important. And and like patients don't care. Is it melanoma, is it non-melanoma? Just take care of it. But the thing is that's tricky about those moles, first of all, you can't see them. So you should photograph them. and have a photograph so that in six or twelve months you can photo it again and compare the two photos, you know. if there's ever any concern, you should just have it removed, you know.

Yeah.

Yeah.

Yeah.

Get it out.

Exactly.

ready shoot aim, I like to say. if I if these things worry me at all, I take them off. melanomas can ex happen in a mole that's already there or they can happen in a spot that had no mole and now you've got one. so it could it could be a mole that changes or it could be just a brand new spot. So either of those circumstances, you deal with it. But I think the

underlying theme, whether it's melanoma, non-melanoma, is your skin is it's the largest organ in your body. so there's tons of cells. Any of them can decide to go rogue and become cancerous. And so if you are, you know, concerned about skin cancer, as we all should be, you should keep an eye on your skin. And if there's any changes or any abnormalities, bring them to someone's attention.

And again, I think every episode we come back to the how important primary care is for a system. And a lot of our listeners and watchers are not in the USA. And so we try to speak to everybody in in various states of access to care. But not to make you too paranoid, but you know, I think there is these days with the internet, there's a lot on that.

Yeah.

So

video that you can see, you know, you can probably even photo it and ask Google what it thinks. It's gonna put us all out of work, Mernaz. Yeah. Anything, Dr. Z? Anything to add?

Yeah.

Yeah.

Yeah. Doctor Google.

No, I mean I would say yeah, if you'll when in doubt, get it checked out. It's it's pretty simple.

There you go.

Yeah.

All right. Well everybody, thank you very much for for participating and thank all of our audience for for paying attention. And any suggestions, please let us know what topics you would like us to cover.

Absolutely. Thank you for having us.

Thank you. Thank you so much for having us. This was lovely. Thank you.

Thanks, thanks.

Bye.