squamous cell carcinoma well differentiated.

[Issangeorge]

Just got the biopsy results back today. I have a growth on my ankle that is squamous cell carcinoma well differentiated. I'm going in for the operation tomorrow to have it removed. Is there anything I should be concerned about or aware of. Thanks.

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[jrtmedic]

Hi

You must be scared and more than a little worried. However, your problem is quite common and carries a very low mortality risk.

Your surgeon will excise the lesion with a wide margin of "safety" this may involve you needing a skin graft to close the deficit. The actual surgery can be undertaken using a general or local anaesthetic, you may get to choose depending on your surgeons preference.

Go to the hospital with a positive mind set ---- you will beat this and come up smiling !

Best wishes

JRT

[lopburi3]

As said it is relatively minor procedure (have had removed from both arm and lower leg using surgery - called wide margin as they cut much larger than the actual known cancer area to try and be sure it is all removed). I had both done at same time in general operating room but just local anesthetic with no pain and more time attaching ground and getting table adjusted than in actual operation. I did not need skin grafts. This is called SCC and along with BCC is quite common for Caucasians but also about the least serious cancer if attended to. I had first BCC removed more than 35 years ago and only recently have started to get more - but only about half dozen so far of both SCC and BCC types.

As for the skin cancer it is relatively slow growing and should be cured (they will check the margin to be sure it all removed) but you will need to be aware and check any new areas as soon as you can. In Thailand skin cancer is rare so best to go to someone with experience in Europe or USA where such is often encountered. And make sure they do not just burn other spots off without doing a pathology to make sure what it is.

[Sheryl]

+1 to both of the above. I would say, this being Thailand, the main thing is to make sure they do the biopsy and then post-operatively ask the doctor about the results of the biopsy and whether the margins were "clear" (meaning that the outer margins of what they removed were non-malignant and therefore they did excise a wide enough area to get it all).

So first thing pre-op ask the doctor if a biopsy will be done. If you mention something like "a biopsy to make sure the margins were clear and it really was SCC" he'll realize he has an informed pt on his hands and it'll instill any degree of caution that might not already have been there. (Not implying anything bad about your doc...just that "mai pen rai" sometimes carries over into medical practice which is not a good place for it).

[Issangeorge]

Ok the operation is done. I was under a local the whole time. They cut a large area around the growth and then grafted skin from my abdomen. They they thin put a semi cast around it to prevent me from moving the area and thus assit in the skin graft healing. I spent one night in the hospital and I am now home. I get the cast removed on Friday. I never had chance to ask the doctor about a biopsi. If he didn't take one is there an alternative? The care was excellant and the total cost was ฿1,500 to the doctor and ฿4,790 to the hospital.

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[jrtmedic]

I am delighted that you are OK and that your procedure went well.

From what you have told it would seem that you already have had a "biopsy" done --- see your first post.

What will now happen is that the specimen, excised by your surgeon, will undergo histological examination. The results from this examination will be available to your surgeon probably before your next appointment. Just ask for the result.

Best wishes for a rapid recovery !

[Issangeorge]

Okay I'm back. The operation went well and the Pathological Report came back and as far as I can tell the complete tumor was removed. There is one complication, The skin graft got infected, however that is being treated and slowly healing. When it is healed the doctor wants me to go for radiation treatment. If they got the tumor I'm not sure why I need the treatment, also he said there would be 25 treatments and I would be in the hospital for 12 days. This seems a little radical to me. Unfortunately the Doctors English is not that understandable so I can't get much info. Here is a redacted version of the Histopathology report. Maybe someone out there can read it and enlighten me a bit. Thank you.

Histopathology and Cytopathology Report

Patient name: Omitted Sex: M Age: 62

Hospital: Omitted Physician: Omitted

Received Date: 17 June. 56 Reported Date: Omitted

Pathological Number: Omitted Gross. Description:

Submitted is a skin biopsy, measured 6.6x3.7x1 cm. with subcutaneous tissue to a depth of 0.3 cm. On the surfaces, there is a firm grayish white mass, measured 1.5 x 1.3 cm, situated at 1.4 cm. to the nearest margin. Three dimensional sections included deep margin are taken as A and B.

Pathological Report:

Skin, left leg, wide excision:-

Squamous cell carcinoma, well differentiated.

Note:- The surgical ends are free from tumor.

- The tumor is 0.5 cm from the nearest surgical end (deep surgical end).

[Tolley]

Okay I'm back. The operation went well and the Pathological Report came back and as far as I can tell the complete tumor was removed. There is one complication, The skin graft got infected, however that is being treated and slowly healing. When it is healed the doctor wants me to go for radiation treatment. If they got the tumor I'm not sure why I need the treatment, also he said there would be 25 treatments and I would be in the hospital for 12 days. This seems a little radical to me. Unfortunately the Doctors English is not that understandable so I can't get much info. Here is a redacted version of the Histopathology report. Maybe someone out there can read it and enlighten me a bit. Thank you.

Histopathology and Cytopathology Report

Patient name: Omitted Sex: M Age: 62

Hospital: Omitted Physician: Omitted

Received Date: 17 June. 56 Reported Date: Omitted

Pathological Number: Omitted Gross. Description:

Submitted is a skin biopsy, measured 6.6x3.7x1 cm. with subcutaneous tissue to a depth of 0.3 cm. On the surfaces, there is a firm grayish white mass, measured 1.5 x 1.3 cm, situated at 1.4 cm. to the nearest margin. Three dimensional sections included deep margin are taken as A and B.

Pathological Report:

Skin, left leg, wide excision:-

Squamous cell carcinoma, well differentiated.

Note:- The surgical ends are free from tumor.

- The tumor is 0.5 cm from the nearest surgical end (deep surgical end).

Get another medical opinion would be your best bet.

[Issangeorge]

I will get another opinion when I go to Khon Kaen for the treatment. I was just curious about what questions to ask and also what the norm was for post operation radiation treatment as a precaution. I have not been able to find much on the net.

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[Sheryl]

Radiation is sometimes used instead of surgery if the cancer is in a location difficult to remove surgically, but its use after surgery is generally limited to situations in which all of the tumor was not removed (i.e. margins not clear) -- not true in your case -- or where there are factors known to create a high risk of recurrence. these would include size >2 cm in any direction (not true in your case), and a thickness (depth) of more than 0.6 mm. While the report does not specifically mention the thickness of the tumor, the excised specimen was only 0.3 cm deep so it is not sounding like the tumor was that deep.

A 4mm (0.4cm) clear margin is usually adequate, you have 5 mm.

In short: it is not usual to do radiation after primary excision of SCC with clear margins of a size described in the path report. I see nothing in the path report that would explain a decision to do post-op radiation. (primary excision = this was the first cancer in that location and not a recurrence. If this was a recurrence then that's another matter).

Possibly there is some other factor, not indicated by the path report or the history that you have given, that makes them think there is a high risk of cancer recurrence. One thing that would definitely make radiation advisable would be any evidence of metastasis but nothing you have said suggests this. Were any lymph nodes biopsied? (not mentioned in the path report)

Get another opinion and ask specifically why, with clear surgical margins, radiation is being recommended. If you get a vague "to prevent the cancer from coming back" probe further and ask if there is any reason why you are at higher than average risk of recurrence?

If you are at all dissatisfied/uncertain with what you hear I recommend you come to Bkk for a 3rd opinion before committing to an extensive course of radiation therapy. Thais tend not to get this type of cancer so Thai doctors do not have much experience with it unless they have trained or worked in the West.

In Bkk, I recommend either of these doctors at Bumrungrad, both US trained:

http://www.bumrungrad.com/doctors/Nopadon-Noppakun

http://www.bumrungrad.com/doctors/Niyom-Tantikun

A consultation will set you back maybe 1,000 - 1,500 baht (plus the trip to Bkk) and would be well worth it if it saves you an unnecessary course of radiation treatment, which is not without its own risks.

[lopburi3]

As I have mentioned have had both BCC and SCC removals and never a hint that radiation might be in the cards - as pro-active treatment have used Aldara cream treatment after healing and on other suspect sites (which for me has no side effects and easy to use).

[Issangeorge]

Sheryl, thank you for your well thought out response. This was the first tumour I had, but it grew from nothing to fairly large in a couple of weeks, then when the doctor took a biopsy he removed most of it, and again in a couple of weeks it grew back to the original size. The doctor did say he went as deep as he could without affecting my walking, but he said he got the entire tumour. He said I would have to have two sessions of radiation for twelve days and in two different places. The bottom of my left leg, top of the foot, where the tumour was. And in the groin area. I am going to have to try to get some more information from him. I know that Thai doctors tend to over prescribe. I wonder if this is a case of that.

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Edited July 6, 2013 by Issangeorge

[Sheryl]

Sheryl, thank you for your well thought out response. This was the first tumour I had, but it grew from nothing to fairly large in a couple of weeks, then when the doctor took a biopsy he removed most of it, and again in a couple of weeks it grew back to the original size. The doctor did say he went as deep as he could without affecting my walking, but he said he got the entire tumour. He said I would have to have two sessions of radiation for twelve days and in two different places. The bottom of my left leg, top of the foot, where the tumour was. And in the groin area. I am going to have to try to get some more information from him. I know that Thai doctors tend to over prescribe. I wonder if this is a case of that.

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This additional information changes the picture considerably.

That it grew so rapidly and then grew back so rapidly may well justify radiation to avoid recurrence.

Thai doctors definitely do tend to over-prescribe drugs, but I have never known them to do so in regard to radiation therapy. As a government hospital, KKU will not do it unless indicated.

The reason for radiation in the groin is that this is a major lymph node, they are concerned that some cancer cells may have spread to there in which case you would be at immediate risk of metastasis.

Still a good idea to get another opinion from a US trained doc who can explain things to you in detail in English, if you can do so without delaying matters. From the additional information you have now provided that they may well concur with the idea of radiation, as you seem to have an unusually aggressive cancer, but regardless it is important for you to understand the situation clearly so that you can make an informed decision.

[Issangeorge]

Thank you very much. Bangkok is little far to travel. I'm sure in Kong Kaen before the treatment starts threre will be someone who can explain it to me. For the treatment two times aday for 12 days, does that sound reasonable? Thank you. I guess I just don't want to spend 12 days in the hospital.

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[Sheryl]

Beyond my expertise to advise on radiation dose and frequency, need an intervention radiologist for that.

I can relate to your desire not to stay in hospital and it may indeed be possible to avoid this or at least reduce the duration if you can locate suitable lodging near the hospital.

Unlike the West they tend to readily hospitalize people in Thailand rather than have them come in daily for outpatient care, mainly because the room charge is not that high. I suggest you find suitable accommodation for yourself near the hospital and then firmly tell the doctor that you have a place to stay nearby, can come daily as an outpatient and really prefer not to be hospitalized unless absolutely necessary.

[Issangeorge]

I am definitely going to discuss that with them.

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[jrtmedic]

Hello George

I agree with Sheryl. It would seem your surgeon considers your "growth" to be aggressive despite the reassuring histopathology report.

The Oncological Radiologist will formulate a plan of treatment which is specific to your own,personal need.

In the West it would be usual for treatment to be delivered on an out-patient basis.

However don,t reject the offer of receiving your care as an In-patient before you have checked the costs ! ------- An all inclusive hospital stay may be cheaper than a hotel + transportation costs etc !

[Issangeorge]

Thank you Jrtmedic. I will be investigating both options. If I was able to leave the hospital every once in a while it might not be too bad.

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