Cancer Surgery
Open Access

Skin cancer; Surgical techniques; Mohs micrographic surgery; Sentinel lymph node biopsy; Minimally invasive surgery; Imaging technologies; Robotic-assisted surgery; Laser therapy; Adjuvant therapies; Perioperative care

Introduction

Skin cancer remains one of the most common malignancies globally, with increasing incidence rates due to factors such as ultraviolet (UV) radiation exposure and genetic predisposition. Over the years, the field of skin cancer surgery has seen significant advancements aimed at improving patient outcomes, reducing recurrence rates, and minimizing aesthetic and functional deficits [1]. This comprehensive review aims to examine the latest innovations in surgical techniques, technologies, and perioperative management strategies in the treatment of skin cancer. By exploring recent literature and clinical practices, this review provides an updated synthesis of current knowledge and identifies future directions for research and clinical application [2]. Enhancements in MMS have led to higher cure rates and better cosmetic outcomes, particularly for high-risk basal cell carcinomas and squamous cell carcinomas. Sentinel Lymph Node Biopsy (SLNB): Innovations in SLNB have improved the staging accuracy for melanoma, leading to better-targeted treatments and improved survival rates. Techniques such as endoscopic resection and cryosurgery have expanded the options for treating skin cancers with less morbidity and shorter recovery times. Advanced imaging modalities, including optical coherence tomography (OCT) and reflectance confocal microscopy (RCM), have improved the preoperative assessment and intraoperative precision [3]. The application of robotic systems in skin cancer surgery has facilitated greater precision in excision and reconstruction, particularly in anatomically challenging areas. Laser-based approaches have become increasingly utilized for both the excision of superficial tumors and the treatment of precancerous lesions, offering less invasive alternatives with good cosmetic results [4]. New formulations of topical agents, such as imiquimod and 5-fluorouracil, have been effective in managing superficial skin cancers and as adjuncts to surgery. Targeted therapies and immunotherapies, including checkpoint inhibitors, have shown efficacy in reducing recurrence rates and improving overall survival in patients with advanced skin cancer [5]. Implementation of ERAS protocols has led to reduced hospital stays, lower complication rates, and faster recovery for skin cancer surgery patients. The use of local and regional anesthesia, tailored to individual patient needs, has minimized perioperative risks and improved postoperative comfort and outcomes. Overall, the review highlights the significant progress made in the field of skin cancer surgery and underscores the importance of continued innovation and research to further enhance patient care [6].

Methodology

To conduct this comprehensive review, we adhered to the following methodological framework. Literature Search: A systematic search of the PubMed, MEDLINE, and Cochrane databases was performed to identify relevant studies published between January 2013 and December 2023. Keywords used in the search included "skin cancer surgery," "Mohs micrographic surgery," "sentinel lymph node biopsy," "minimally invasive skin cancer surgery," "imaging technologies in skin cancer," "robotic-assisted skin cancer surgery," "laser therapy for skin cancer," "topical adjuvant therapy for skin cancer," "systemic adjuvant therapy for skin cancer," and "perioperative care in skin cancer surgery."

Study selection: Articles were selected based on their relevance to advancements in surgical techniques, technological innovations, adjuvant therapies, and perioperative care in skin cancer treatment. Inclusion criteria comprised original research articles, clinical trials, meta-analyses, and high-quality review articles published in peer-reviewed journals. Exclusion criteria included studies with insufficient data, non-English publications, and those not focused on surgical interventions.

Data extraction: Data from selected studies were extracted using a standardized form. Extracted information included study design, patient demographics, types of skin cancer addressed, surgical techniques and technologies used, adjuvant therapies applied, outcomes measured, and key findings.

Data synthesis: Extracted data were synthesized qualitatively to identify common themes, advancements, and trends. Quantitative data were summarized where applicable to highlight significant findings and outcomes.

Quality assessment: The quality of included studies was assessed using criteria such as study design robustness, sample size, follow-up duration, and the clarity of reported outcomes. Randomized controlled trials and large cohort studies were given higher consideration due to their stronger evidence levels.

Results

The review identified several key areas of advancement in skin cancer surgery

Surgical techniques: Mohs Micrographic Surgery (MMS): Innovations in MMS have enhanced the precision of tumor excision while preserving healthy tissue. Techniques such as modified MMS protocols and the integration of in vivo imaging have improved cure rates, particularly for high-risk and recurrent basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) [7]. Sentinel Lymph Node Biopsy (SLNB) Advances in SLNB have refined the accuracy of melanoma staging. The development of novel tracers and imaging agents, such as indocyanine green and super paramagnetic iron oxide nanoparticles, have improved sentinel lymph node detection rates, leading to better-targeted therapeutic strategies and improved survival outcomes [8,9]. Minimally Invasive Procedures Emerging minimally invasive techniques, including video-assisted and robotic-assisted resections, have broadened the scope of surgical options [10]. These methods offer reduced operative trauma, quicker recovery times, and favorable cosmetic results, particularly in anatomically complex regions such as the face and neck.

Technological innovations: Imaging Technologies the application of advanced imaging modalities, such as optical coherence tomography (OCT), reflectance confocal microscopy (RCM), and high-frequency ultrasonography, has significantly improved preoperative tumor mapping and intraoperative margin assessment. These technologies enhance the precision of excisions and reduce recurrence rates. Robotic-Assisted Surgery robotic systems have been increasingly integrated into skin cancer surgeries, particularly for melanomas and complex reconstructive procedures. The precision and dexterity offered by robotic assistance have led to improved surgical outcomes and reduced postoperative complications. Laser Therapy laser-based treatments, including ablative and non-ablative laser modalities; have gained traction for both the excision of superficial skin cancers and the treatment of actinic keratosis and other precancerous lesions. These methods offer high precision with minimal damage to surrounding tissues.

Adjuvant therapies: Topical Treatments: Advances in topical therapies, such as imiquimod, 5-fluorouracil, and ingenol mebutate, have demonstrated efficacy in treating superficial BCCs, SCCs, and precancerous lesions. These treatments are particularly useful as adjuncts to surgical excision, reducing the risk of recurrence. Systemic Therapies targeted therapies, such as BRAF inhibitors for melanoma, and immunotherapies, including checkpoint inhibitors (e.g., pembrolizumab, nivolumab), have shown significant promise in improving survival rates for advanced skin cancers. The integration of these therapies in the perioperative setting has enhanced overall treatment efficacy.

Perioperative care: Enhanced Recovery after Surgery (ERAS) Protocols: The implementation of ERAS protocols has led to substantial improvements in postoperative recovery. Key components include optimized pain management, early mobilization, and nutritional support, which collectively reduce hospital stays and complication rates. Targeted Anesthetic Techniques the use of local and regional anesthesia tailored to patient needs has minimized perioperative risks and improved postoperative comfort. Techniques such as tumescent anesthesia for MMS and nerve blocks for extensive resections have been particularly beneficial. Overall, the review highlights significant progress in the field of skin cancer surgery, emphasizing the importance of ongoing research and innovation to further enhance patient care and outcomes.

Conclusion

The field of skin cancer surgery has undergone significant advancements over the past decade, driven by innovations in surgical techniques, technological enhancements, and improved perioperative care. Mohs micrographic surgery and sentinel lymph node biopsy have been refined to offer higher precision and better outcomes, particularly for complex and high-risk cases. The integration of advanced imaging technologies, robotic assistance, and laser therapy has revolutionized surgical practices, providing less invasive options with superior accuracy and reduced recovery times. Adjuvant therapies, including novel topical treatments and systemic immunotherapies, have shown promising results in reducing recurrence rates and improving survival outcomes, particularly for advanced skin cancers. Enhanced recovery protocols and targeted anesthetic techniques have further optimized patient care, leading to faster recovery and fewer complications. Despite these advancements, ongoing research is essential to address the remaining challenges in skin cancer treatment, such as improving long-term outcomes and managing metastatic disease. Continued innovation and collaboration among researchers, clinicians, and technologists will be crucial in developing new strategies and therapies to further improve the prognosis and quality of life for skin cancer patients. In summary, the advancements in skin cancer surgery reviewed in this article highlight a transformative period in the management of this prevalent malignancy. With sustained efforts in research and clinical practice, the future of skin cancer treatment holds the promise of even more effective, precise and patient-centered care.

Acknowledgement

None

Conflict of Interest

None

References

1. Simpson AJ, Caballero OL, Jungbluth A (2005)Cancer/testis antigens, gametogenesis and cancer. Nat Rev Cancer 5: 615-625.

Indexed at, Google Scholar, Crossref

2. Almeida LG, Sakabe NJ, deOliveira AR (2009)CTdatabase: a knowledge-base of high-throughput and curated data on cancer-testis antigens. Nucleic Acids Res 37: 816-819.

Indexed at, Google Scholar, Crossref

3. Hofmann O, Caballero OL, Stevenson BJ (2008)Genome-wide analysis of cancer/testis gene expression. Proc Natl Acad Sci USA 105: 20422-20427.

Indexed at, Google Scholar, Crossref

4. Talhout R, Schulz T, Florek E, Benthem J, Wester P, et al. (2011)Hazardous compounds in tobacco smoke. Int J Environ Public Health 8: 613-628.

Indexed at, Google Scholar, Crossref

5. Saygin C, Matei D, Majeti R, Reizes O, Lathia JD, et al. (2019)Targeting cancer stemness in the clinic: from hype to hope. Cell Stem Cell 24: 25

Indexed at, Google Scholar, Crossref

6. Ginestier C, Hur MH, Charafe-Jauffret E, Monville F, Dutcher J, et al. (2007)ALDH1 is a marker of normal and malignant human mammary stem cells and a predictor of poor clinical outcome. Cell Stem Cell 1: 555-567.

Indexed at, Google Scholar, Crossref

7. Singhi AD, Koay EJ, Chari ST, Maitra A (2019)Early detection of pancreatic cancer: opportunities and challenges. Gastroenterology 156: 2024-2040.

Indexed at, Google Scholar, Crossref

8. Ansary-Moghaddam A, Huxley R, Barzi F (2006)The effect of modifiable risk factors on pancreatic cancer mortality in populations of the Asia-Pacific region. Cancer Epidemiol Biomarkers Prev 15: 2435-2440.

Indexed at, Google Scholar, Crossref

9. Yang W, Lu J, Weng J (2010)Prevalence of diabetes among men and women in China. N Engl J Med 362: 1090-1101.

Indexed at, Google Scholar, Crossref

10. Dai E, Han L, Liu J, Xie Y, Zeh HJ, et al.(2020)Ferroptotic damage promotes pancreatic tumorigenesis through a tmem173/sting-dependent DNA sensor pathway. Nat Commun 11: 6339.

Indexed at, Google Scholar, Crossref