- The Washington Times - Monday, August 4, 2003

Software engineer Yury Kutchinsky, a District resident, first noticed the growth between his upper nose and eye 2-1/2 years ago.

“I asked, ‘What can it be?’” he recalls. Initially, he thought it might be harmless — a sign of age or maybe a cold sore — because it didn’t resemble any of the warning photos he had seen of skin cancer.

Now 50, he is a healthy and athletic man who never had had any serious illness. That made it easier to ignore something that caused no pain and didn’t interfere with daily life. Later, seeing it grow and acting on a hunch that something wasn’t quite normal, he consulted two dermatologists.

Russian by birth, he says he may have misunderstood the words of the first doctor — he thinks she said she would cut it off at once — and so ignored her advice. After the second doctor did a biopsy — removing a tissue sample for analysis by a pathologist — he found out the spot was indeed a basal cell cancer. His was among the 20 percent of cases that do not look typically red and crusty.

Because his tumor was advanced and located in a critical area, he was referred to Dr. Martin Braun at 2112 F St. NW, a dermatologist who specializes in Mohs micrographic surgery, one of the surest methods for removing cancerous growths that penetrate beneath the upper layers of skin. Mohs is one of five methods used to destroy or remove basal cell and squamous cell skin cancers, the others being burning with an electric needle, cutting, freezing and radiation.

Basal cell cancer won’t kill a person, but it can maim. Left alone, such tumors can take root in invidious ways, causing serious harm to body tissues and, in severe cases, requiring extensive reconstructive surgery after removal. Unlike melanoma — the most malignant kind of skin cancer — basal and squamous cell cancers very seldom spread to other parts of the body.

“In general, basal cells are slow-growing,” Dr. Braun says. “You can postpone treatment for months, but not years, because it always is growing. Once it begins, it does not stop.”

The chief cause of any skin cancer is exposure to sun and its effect on pigmentation, although heredity is thought to play a part. Youths who get severe sunburns before age 20 are especially vulnerable later in life. More than 1 million cases of basal cell cancer were reported last year in the United States compared to about 51,000 melanomas and 200,000 squamous cell carcinomas, and numbers are increasing, says Dr. Lisa Kauffman, chief of dermatology at Georgetown University Hospital.

“We [doctors] have guaranteed job security,” she notes ruefully. A person with basal cell has a 50 percent chance of getting it in another location.

“I like sun,” says Mr. Kutchinsky, who has brown hair and fair skin. “As a child, I was in the water with everybody else. It was like the sun is your best friend.”

The reason for the increase in cases is thought to do with earlier detection and diagnosis as well as the decrease in the ozone layer protecting people from harmful ultraviolet rays.

Nearly all cases can be cured with early detection. The Mohs technique, named after the doctor who perfected the method many decades ago in Madison, Wis., (he had several basal cell cancers himself, one of his proteges says), is the recognized standard for dealing with advanced and unusual cases of basal and squamous cancers. Becoming a specialist takes at least a year of study and an internship beyond a physician’s residency. No more than 10 physicians in the greater Washington area are qualified out of some 600 nationwide.

In addition to having basic dermatological skills, the doctor must be an anesthesiologist, pathologist and plastic surgeon. The beauty of the procedure, which is done under local anesthetic, is the reassurance that not only can all cancer cells be detected and removed from beneath the tumor visible on the surface but, if necessary, the resulting wound can be closed with surgery the same day.

As many as 32 percent of basal cell and squamous cell surgery is done by Mohs these days, Dr. Kauffman says, mostly for tumors in what doctors call the critical “H” section of the face: the area around the nose and periphery and around the ears and forehead. The precise approach of Mohs helps reduce the need for cutting away a large safety margin.

“When I explain Mohs to patients, I like to use either the pie crust or cupcake analogy,” she says. “You are not interested in the cake or filling part, but in seeing the edge of the pie crust or the surface of the icing.”

A biopsy generally removes only one sample of tissue for examination; the Mohs technique requires taking several tissue samples in successive stages around the tumor area.

First, the visible tumor is removed and then a thin layer of tissue removed from the surrounding skin and base is mapped and sectioned. Specimens from each section are frozen and stained for examination under a microscope to check for additional cancer cells. If more are present, additional tissue layers are removed until the area is clear. The patient sits up with a temporary bandage for about 30 minutes to an hour between each excision.

“The whole concept is wonderfully simple,” says Dr. Braun, who has been performing the procedure for 20 years. “It’s just paying attention to every detail.”

The complete procedure normally takes no more than half a day, including closing the wound. In a very few cases, particularly when a person’s facial expression might be affected by the closure, the patient could be referred to a full-time plastic surgeon to finish the job — possibly under general anesthetic in a hospital setting.

Normally, the Mohs specialist closes the wound himself on the spot using stitches, a skin graft or skin flap. The flap is a piece of skin near the wound that is cut and stretched to hide all or most of the opening. “It’s basically borrowing from Peter to pay Paul,” Dr. Braun says. The graft is a piece of skin lifted from another part of the body and applied to the site. In either case, healing takes several weeks.

The method is labor-intensive and, to be successful, is highly dependent on the surgeon’s experienced eye as well as a steady hand. Dr. Braun treated President Reagan for basal cell cancer while he was in office. A souvenir photo and inscription to “Marty” hangs prominently on the doctor’s wall.

Mr. Kutchinsky sought help at the right time; his tumor was in an area perilously close to the brain. Nervous initially, he had to calm down enough to keep his eyelids closed throughout the procedure. A cover was put over his face only during the reconstructive flap repair segment.

“Stay put if you would,” the blue-gowned Dr. Braun periodically cautioned his patient, who was stretched out on the table under bright lights. “Let me know if anything hurts. It’s not supposed to hurt.” The anesthetic went in at 8 a.m., and the first cut was made at 8:13 a.m. “You’re a good patient,” Dr. Braun said reassuringly.

At 8:20 a.m., the external tumor was off and a bandage put on Mr. Kutchinsky’s nose. He was told to wait in a side room where there was tea and coffee. Less than an hour later, he was brought in for another round and then at 9:22 a.m. sent out again to wait, returning for an hour’s repair work — a flap closure — at 10:12 a.m. (The so-called first stage costs $750; each successive stage is $450. A closure can cost between $250 and $1,000. Insurance generally pays for all of it.)

What was Mr. Kutchinsky thinking about while lying there, so still? “My thoughts are about the future, when I am completely healed,” he said.

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