Patient history and presentation

By Magnus Balslev Avnstorp, MD, Mike Mikkelsen Lorenzen and Simon Yde, MD

Patient history

The patient history should be documented in the patient journal prior to treatment and should include:

• Size and location of the tumor
• Verified by biopsy
• Anticoagulants
• Clinical evaluation of the regional lymph node status
• Other patient co-morbidities, eg diabetes, heart disease

Risk factors for NMSC:

• UV light exposure (sunlight)
• Light skin (especially Fitzpatrick type I + II)
• Smoking
• Alcohol abuse
• Family history of skin cancer
• Previous treatment for skin cancer
• Immunodeficiency
• Male with outdoor work

Patient presentation

Patients are often referred through their general practitioner or through a dermatologist for further evaluation and/or treatment depending on size and location of the tumor. Depending on location and the size the plastic surgeon then further determines the need for local excision and close/reconstruction or multidisciplinary conference (MDT).

In Denmark the MDT conference consists of a dermatologist, an oncologist, a head and neck Surgeon and a maxillo-facial surgeon who debates difficult cases and conclude on:

• Radiation therapy vs Surgery: In case the NMSC location is too large for excision, is located on the nose or eyelid, on where radiation will have a better aesthetic outcome.
• Biologic treatment (Ipililumap/Nivolumab/Vismodegib): The oncologist will in rare cases treat large tumors invading into deep tissues – with no surgical option.
• Aldara, Picato and Photo Dynamic Therapy (PDT): In cases of mild NMSC or pre-cancerous lesions the dermatologist will aplly topical treatment with Aldara or PDT. This treatment may also be neo-adjuvant to surgery – To get rid of pre-cancerous lesions befores excising a tumor on i.e. the scalp.
• Curretage: In cases of BCC in low-risk areas such as the thorax the dermatologisk will try treatment with curretage instead of excision.

Pre-operative work-up and preparation for surgery

The exact location, size and presentation of the cancer lesion should be documented in the journal. The tumor margins are marked following the preoperative drawing of the surgical excision margin. 

Surrounding tissue is evaluated, and the method of closure is evaluated prior to surgery. This can systematically be performed by utilizing the “ladder of reconstruction”.

Pre-operative information

The patient is informed about the surgery performed either under local or general anesthesia and possible complications including:

• Scarring
• Infection
• Bleeding
• Wound dehiscensce
• Damage to sensoric or functional nerves depending on region