Dr Rajiv Nijhawan: Collaboration Advances Comprehensive Care for Patients With High-risk Skin Cancers

Collaborating with colleagues outside of dermatology helps to maximize the chances of cancer not coming back, especially in rare cases of noncontiguous tumors with nerve involvement that recur after treatment. In these cases, the tumor biology is much more aggressive, noted Rajiv Nijhawan, MD, associate professor of dermatology and Mohs surgeon at UT Southwestern (UTSW) Medical Center and director of the UTSW High Risk Skin Cancer Transplant Clinic, in Dallas, Texas.

Transcript

When Mohs surgery is not successful, what are next steps for treating patients?

Mohs surgery offers—honestly, for most skin cancers—a greater than 99% cure rate. And it's wonderful. If you think about cancer surgery, in general, there's no other cancer surgery that can come even close to that number of a high cure rate, and that's pretty amazing. And the reason it's so successful is because we're tracking 100% of the margin.

Lay people and people not in medicine—and even, honestly, other subspecialties within medicine—they don't realize that when other types of cancers are cut out and sent to the lab, it gets what we call “bread loaf,” meaning just little slices within it. And they just kind of look at those little slices under the microscope. But it's really just representing maybe even 0.1% of the margin or 1% of the margin, whereas with Mohs surgery, we're checking 100% of the margin. And that's the reason it's so successful.

There are times where the cancer that we're cutting out isn't what we call a contiguous tumor, meaning it's discontiguous. And so it’s just kind of jumping around. And we often see that when there's a lot of nerve involvement, where it just tracks along the nerve, but almost like skips and jumps around. And that's where our cure rates may be not as successful, and in those situations, the biology of the tumor is just a lot more aggressive when it's wrapping around nerves. We then have to rely on our colleagues in ENT surgery sometimes to see if maybe they need a lymph node biopsy or even lymph node removal.

We often rely on our colleagues in radiation oncology to add on radiation after surgery as well, what we call adjuvant radiotherapy, to kind of hopefully maximize the chance of this skin cancer not coming back again. That's where working within a team in a multidisciplinary setting is so helpful to really make sure that we're providing comprehensive care for these kinds of rare cases that are incredibly aggressive or have come back from previous treatments, etc.