Brown collected data on histopathologically confirmed cutaneous malignancies with a disease duration of 6 months or more. The results showed that.
(1) 78% of the 1195 skin malignancies were basal cell carcinoma (BCC), 14% were squamous cell carcinoma (SCC), 6% were malignant melanoma (MM), and the remaining 2% were Merkel cell carcinoma, malignant appendage carcinoma, and malignant freckle-like nevus.
(2) 81% of patients with tumors were treated by dermatologists, 91% of which were completely excised. 84% were correctly diagnosed by secondary care physicians, but 32% of squamous carcinomas were still not misdiagnosed before surgery.
(3) 77% of tumors were preferentially excised, 92% of which were completely excised.
Treatment methods of skin tumors.
1.Surgery.
2.Laser, microwave.
3.Cryotherapy.
4.Electrochemical therapy.
5.Laser photodynamic (PDT).
6, radiotherapy: X-ray, electron beam, 60Co, 32P and 90Se.
7, local injection of pinyamycin.
8, ultraviolet therapy: UVA and PUVA.
9, chemotherapy.
10, topical drugs: 5% 5-FU ointment, IFNα, γ solution, 1:5000~20,000 nitrogen mustard hydrochloride, imiquimod, etc.
11, adjuvant therapy: BCG polysaccharide nucleic acid, Mycobacterium grasserii F.U36, pidomod, interferon, thymidine, transfer factor, etc.
I. Surgical treatment.
Surgery is the most frequently chosen treatment for general skin tumors, among which Mohs microscopic tracing surgery is one of the most important procedures in dermatologic surgery, which can effectively treat common skin malignancies while ensuring minimal postoperative defects, and is now recognized as the gold standard for the treatment of common skin malignancies.
Mohs micrographic surgery requires excision, detection, re-excision, re-excision, re-examination, and so on, until the tumor is removed, and finally shaped to repair the surgical defect, so Mohs micrographic surgery involves repeated trips to the operating room and long waiting times.
The principle of Mohs procedure lies in directional staining, directional marking and directional resection. Preoperatively, the tumor is traced on a pattern map according to the location and shape of the tumor, and after cutting down the tumor specimen, the tumor is divided into several pieces and marked. One of the lateral edges of the specimen is stained with a special dye and marked on the pattern map, which does not elute during section production. The position of the residual tumor is precisely determined by the relationship between the tumor and the stain during the reading of the section, whereby the residual tumor can be further excised accurately and finely, with maximum preservation of normal skin.
Surgery + red light (He-Ne laser) irradiation.
(1) can increase the peroxidase activity of mitochondria and promote cell metabolism.
(2) Increases glycogen content, protein synthesis and adenosine triphosphate catabolism, promoting cellular regeneration.
(3) Promotes healing of wounds and ulcers and accelerates regeneration of damaged nerves.
(4) Increases phagocytosis of leukocytes and has anti-inflammatory, pain-relieving, discoloration and edema-reducing effects.
Note the role of promoting scar formation!
II. Laser treatment.
Appropriately powered CO2 laser has good efficacy for most body surface tumors, including non-metastatic melanoma. Because the cutting and cauterizing effect of laser can immediately close small blood vessels and lymphatic vessels around the tumor, it can prevent the spread and metastasis of tumor cells, and it can achieve the effect of hemostasis while cutting, and the operation is also simple and rapid with little or no bleeding. Smaller lesions result in lighter postoperative reactions, less pain and average healing time of 20~40 days. Smaller trauma results in more superficial scars after healing.
Method: Routine disinfection, local infiltration of normal tissues around the tumor and its deeper layers, and different laser output power for cutting and vaporization according to the size, nature and depth of the tumor.
The treatment starts from the normal tissues around 1cm of the tumor, and then gradually proceeds to the center of the tumor, and the tumor with more obvious elevation is cut first and vaporized later.
During vaporization, alcohol (saline) cotton ball is used to wipe until the tumor is light yellow. In case of bleeding from small arteries, the vaporization is continued after clamping the blood vessels with hemostatic forceps.
The main postoperative prevention of bacterial infections is to prevent small traumas from requiring special treatment. For larger wounds with more bleeding, topical application of silver sulfadiazine or Yunnan Baiyao can be applied. For local swelling and infection, antibacterial and anti-inflammatory treatment and local dressing change are given.
Microwave therapy: the efficacy is basically the same as that of CO2 laser therapy, but slightly better, and the postoperative reaction is mild.
Cryotherapy: the history of application is relatively long.
Advantages: easy to take materials, simple operation.
Disadvantages: the patient is more painful, imprecise positioning and control, large damage to the surrounding healthy tissue, edema and necrosis is obvious, and the scar is larger after healing.
V. Electrochemical therapy.
Electrochemical therapy for malignant tumors is clinically applied for a short period of time. It is the use of the principle of direct current to make the pH of tumor tissue change, denature proteins, and produce neo-ecological oxygen and oxygen, the latter of which has a powerful oxidative inactivation effect on tumor cells. Due to the effect of electro-osmosis, water moves with sodium ions from anode to cathode, edema occurs in cathode area, anode area is dehydrated and carbonized, and negatively charged tumor cells move to anode, thus preventing the spread and metastasis of cancer cells.
The anodic needle is inserted into the center of the lump, and the cathodic needle is placed at the edge with a distance of 3cm, one anodic needle is used for lumps less than 6cm in diameter, and two anodic needles are used for lumps larger than 6cm. The electrode insulating cannula was retired to the surface of the lump to protect the skin. The voltage is 6-10V, the current is 75-100mA, the power is calculated according to the tumor volume, i.e. 100 coulombs/cm3, and the treatment time is 100-240 minutes. For those whose masses are too large, treatment is taken in several sessions with an interval of 1~2 weeks. After electrochemical treatment, some cases can be combined with radiotherapy.
Indications: Treatment of postoperative recurrence, cancerous ulcers, body surface malignant tumors that cannot be surgically removed and poor radiotherapy effect, with an efficiency of 83.3%. It can reduce patients’ pain, improve survival quality and prolong survival period.
Advantages: easy to operate, safe, light and economic side effects, and good patient compliance.
Laser photodynamic (PDF) therapy.
Principle: PDT is a kind of light-excited chemotherapy. After the photosensitizer is injected into the patient’s body, a relatively high accumulation is formed mainly in the malignant tumor tissue. Afterwards, the tumor tissue is irradiated with specific wavelengths of light, and the photosensitizer absorbs the energy of photons to produce some oxidation-active molecules. The latter attacks the tumor cells by oxidation to make them die and achieve the therapeutic purpose. The appropriate clinical dose of photosensitizer is not toxic. Moreover, the laser has good controllability and its photochemical effect plays the main therapeutic role. Therefore, the therapy does not damage the function of normal tissues of patients and does not kill the normal tissue cells.
Instruments: IEAu-3 type gold vapor laser therapy machine (by the Institute of Electronics of the Chinese Academy of Sciences) has a laser wavelength of 627.8 nm and a total output power of 1000 mW; the British DIOMED semiconductor laser has a wavelength of 630 nm and an output power of 1500 mW. The treatment parameters of both lasers are: power density 100~150 mW/cm2, energy density l00 ~The photosensitizer is hematoporphyrin derivative (HpD), which needs to be stored at -20℃ and protected from light.
Methods: HpD negative skin test will be 5mg/kg of HpD added to saline injection (100m1) intravenously. 12 ~ 72h after the application of spot light guide fiber, once a day for 3 consecutive days to irradiate the lesion site, keep the lesion to receive a uniform amount. Larger lesions are irradiated in multiple spots, with overlap between each spot, and need to exceed the outermost edge of the lesion by at least 0.5 cm, so that the spot fully covers the lesion.
VII. X-ray irradiation.
Bowen’s disease, erythroplasia, basal cell carcinoma, squamous cell carcinoma: 4000~6000R.
Paget’s disease: 5000~8000R.
MF: 1200~2000R.
VIII. 32P, 90Se irradiation.
The penetration is relatively shallow, and needs to be carefully selected for the treatment of skin tumors.
There is no significant difference between the 5-year and 10-year survival rate of 60Co+X-ray combined treatment group and 60Co radiotherapy group alone, as well as the group with irradiation field more than 2cm from the tumor edge and less than 2cm. It suggests that radiation therapy for skin cancer is more effective, and as long as sufficient irradiation dose is given and correct treatment method is used, it is comparable to the efficacy of surgery.
For skin cancer of head and face, besides controlling the lesion, simple radiotherapy can also maintain the skin shape of face and enhance the cosmetic effect.
IX. Electron ray irradiation.
The treatment of skin malignant tumors with electronic wires has a history of more than 40 years. The 80% dose of 3MeV electron ray is about 1cm, so the treatment of skin malignant tumor with electron ray is more superior than conventional X-ray treatment, especially for the treatment of facial and large area skin malignant tumor, such as nasal skin cancer and skin T-cell lymphoma, and can better maintain the anatomy after treatment. It can maintain the post-treatment anatomy better. However, attention should be paid to eye protection.
Domestic ZJ-10 linear gas pedal. The energy range is 6-10 MeV depending on the lesion site and tumor size, and the irradiation field is more than 2 cm above the lesion tissue, with a skin distance of 100 cm from the source.
For cutaneous T-cell lymphoma, the extended source skin distance is 400 cm, and the energy is as low as 3.5 MeV for whole-body skin electron ray irradiation. The total dose is 3000cGy/82d.
Other irradiation doses: 7000 cGy for squamous carcinoma, 6000 cGy for basal cell carcinoma. 200 cGy per week and 5 times per week.
X. Chemotherapy: CHOP regimen
Cyclophosphamide: 750mg/m2iv day 1
Epiamphetamine: 50mg/m2iv day 1
Vincristine: 1.4mg/m2iv day 1
Prednisone: 100mg/m2p.o. day 1~5
XI. UVA or PUVA: Indication: MF.
XII. Local injection of Pingyangmycin: 2~8mg/time intra-tumor injection for the treatment of single tumor such as SCC of penis and mouth lip, hairy mother stroma cancer.
XIII. Topical drugs.
1. 5% 5-FU ointment.
2. IFNα, γ solution (50,000 U/mL).
3. 1:5000~20000 nitrogen mustard hydrochloride.
4. Imiquimod: It is a new immunomodulator, belongs to non-nucleoside isocyclic amines, and is usually made into a 5% cream. The United States has approved its use for the treatment of actinic keratosis and BCC, in addition, the drug can also be used to treat Bowen’s disease, cutaneous T-cell lymphoma, Kaposi’s sarcoma and melanoma, etc.
XIV. Immunotherapy.
1. BCG polysaccharide nucleic acid.
2. Mycobacterium graminearum F.U36.
3. pidomod tablets or oral solution.
4. interferon.
5. thymidine.
6. transfer factor, etc.