Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our health archives for her posts—calling on the expertise of medical specialists—on topics from angiography to vulvar melanoma.)

This week, she returns to the expertise of Anetta Reszko, a dermatologist in New York City who is affiliated with New York–Presbyterian Hospital/Weill Cornell Medical Center—and is a member of our Medical Advisory Board—for answers to a subject of on-going investigations:  the use of laser treatment for skin cancer.  Last month, Dr. Reszko responded to questions about detecting early signs of skin cancer.

Dear Dr. Pat:

I have had so much sun damage over the years and it has really aged my hands, arms, anterior chest and face with brown spots. I started having these spots removed with laser about two years ago and was very pleased with the cosmetic results. I then developed two small, red, raised lesions on my forearm last spring in an area where I had undergone extensive laser removal of individual lesions. I just saw my dermatologist after the summer was over and he insisted on doing a biopsy of these lesions. Both were squamous cell cancers that were early and superficial without any deeper invasive component. The dermatologist then sent me for MOHS surgery for removal of these lesions. I don’t understand why these could not have been removed by laser as well.

Karen

Dr. Reszko Responds:

Skin Lesion

Dear Karen,

Sun causes cosmetic skin damage with the development of excessive lines and wrinkles, skin discolorations (brown, flat sun spots and raised “stuck on” keratoses), increase in the number of capillaries. It is an important factor in the development of skin cancer. When treating skin lesions, whether benign or malignant,  it is crucial to understand what laser is approved to be used for and when it is not the right treatment option, even if laser seems to be easier, less expensive and promised to produce a superior cosmetic outcome.  Lasers used to target melanin within brown spots are totally ineffective in treating pre-cancers and superficial squamous cell carcinomas. Your dermatologist made good decisions.  First he did biopsies of lesions that did appear and/or persisted after prior laser treatments, and when biopsies confirmed his clinical impression of malignancies he referred you to a specialist specializing in MOHS surgery.  That type of skin surgery minimizes scarring and offers the highest cure rate to prevent local recurrence of this highly treatable form of early skin cancer.

To laser or not to laser. The simple answer is—it depends.

When considering treatment options for any cancer, including skin cancer, one must take into account numerous factors.  Consideration should be given to the biological character of the cancer along with the risk of metastasis, cancer location, the risk of local tissue destruction and recurrence, characteristics of the patient (age, overall health, cosmetic preferences), and available treatment modalities.

From the management aspect, skin cancers can be divided into two broad categories: (i) non-melanoma skin cancers (basal cell carcinomas and squamous cell carcinomas) and (ii) melanocytic lesions that include nevi (moles), lentiginies (sun spots), lentigo maligna, and malignant melanoma.

Non-melanoma skin cancers are highly curable with both surgical and nonsurgical therapy, especially if treated early. Biological aggressiveness of these skin cancers and the risk of recurrence vary. Cancers of the central part of the face—including the eyelids, nose, ears, and lips—are considered high-risk. Recurrent cancers and those greater than two centimeters in diameter on the trunk or extremities of the body are categorized similarly. Non-melanoma cell carcinomas that are small, superficial (limited to the upper levels of the skin), localized on extremities, with a well-defined edge, and have not been treated before, are low-risk cancers and have a low-risk of recurring.

The use of lasers for non-surgical treatment of skin cancers remains a subject of intense research.  It is important to note, however, that currently lasers are not FDA-approved for the treatment of either basal or squamous cell carcinomas.

Lasers used for the “off label” treatment of non-melanoma skin cancers can be classified into two broad categories (i) vascular lasers (pulsed dye laser (PDL), intense pulsed light (IPL)) that target blood vessels within tumors decreasing their rate of growth and proliferation (ii) ablative lasers (carbon dioxide (CO2), erbium YAG) that remove outer skin’s layer epidermis and variable amounts of deeper skin by vaporizing the tissue with highly focused beams of light.

Because laser light penetrates to only a certain depth within the skin, laser surgery kills only tumor cells on the surface of the skin.  As a result, the laser treatment should be considered for biopsy proven superficial low-risk tumors when other techniques were unsuccessful or are poor surgical candidates.  Reported cure rates with laser treatments varies considerably, ranging from 50 to 90 percent. Close post-procedure follow-up is essential.

Melanin (pigment) targeting lasers (IPL, Q switches Nd-YAG) and ablative lasers are utilized in the treatment of pigmented skin spots and are ineffective in the treatment of basal and squamous cell carcinomas.  Prior to laser treatment of any pigmented lesion, careful dermatologic evaluation and biopsies of any suspicious or concerning lesion is essential.  When biopsying a worrisome sun freckle or atypical mole, a large portion of the lesion should be biopsied to give the most accurate histologic microstaging information. Significant number of lesions might also have an invasive component upon histopathologic evaluation.

Excision of atypical pigmented lesions or variants of malignant melanoma is the treatment of choice. Destructive techniques including melanin targeting lasers and laser ablation with carbon dioxide or erbium YAG are not favored, since they are superficial in effect and can result in incomplete tumor removal and high risk of recurrence. However, laser therapy might be considered for patients who are nonsurgical candidates due to age and/or medical comorbidities.