Squamous cell carcinoma of the skin
What is cutaneous squamous cell carcinoma?
Cutaneous squamous cell carcinoma (SCC) is a common type of keratinocytic or non-melanoma skin cancer. It is derived from cells within the epidermis that make keratin — the horny protein that makes up skin, hair and nails.
Cutaneous SCC is an invasive disease, referring to cancer cells that have grown beyond the epidermis. SCC can sometimes metastasise (spread to distant tissues) and may prove fatal.
Intraepidermal carcinoma (cutaneous SCC in situ) and mucosal SCC are considered elsewhere.
Who gets cutaneous squamous cell carcinoma?
Risk factors for cutaneous SCC include:
- Age and gender: SCCs are particularly prevalent in elderly males. However, they also affect females and younger adults.
- Previous SCC or other form of skin cancer (basal cell carcinoma, melanoma)
- Actinic keratoses
- Outdoor occupation or recreation
- Fair skin, blue eyes and blond or red hair
- Previous cutaneous injury, thermal burn, disease (eg cutaneous lupus, epidermolysis bullosa, leg ulcer)
- Inherited syndromes: SCC is a particular problem for families with xeroderma pigmentosum and albinism
- Other risk factors include ionising radiation, exposure to arsenic, and immune suppression due to disease (eg chronic lymphocytic leukaemia) or medicines. Organ transplant recipients have a massively increased risk of developing SCC.
What causes cutaneous squamous cell carcinoma?
More than 90% of cases of SCC are associated with DNA mutations in the p53 tumour suppression gene, caused by exposure to ultraviolet radiation (UV), especially UVB. Mutations in signalling pathways including epidermal growth factor receptor, RAS, Fyn, or p16INK4a signaling are also implicated.
Beta-genus human papillomaviruses (wart virus) are thought to play a role in SCC arising in immune suppressed populations. β-HPV and HPV subtypes 5, 8, 17, 20, 24, and 38 have also been associated an increased risk of cutaneous SCC in immunocompetent individuals.
What are the clinical features of cutaneous squamous cell carcinoma?
- They grow over weeks to months
- They may ulcerate
- They are often tender or painful
- Located on sun-exposed sites, particularly the face, lips, ears, hands, forearms and lower legs
- Size varies from a few millimetres to several centimetres in diameter.
More images of squamous cell carcinoma ...
Types of cutaneous squamous cell carcinoma
Distinct clinical types of invasive cutaneous SCC include:
- Cutaneous horn – the horn is due to excessive production of keratin
- Keratoacanthoma (KA) – a rapidly growing keratinising nodule that may resolve without treatment
- Carcinoma cuniculatum (‘verrucous carcinoma’), a slow-growing, warty tumour on the sole of the foot.
- Multiple eruptive SCC/KA-like lesions arising in syndromes, such as multiple self-healing squamous epitheliomas of Ferguson-Smith and Grzybowski syndrome
The pathologist may classify the tumour as well differentiated, moderately well differentiated, poorly differentiated or anaplastic cutaneous SCC. There are other variants.
Squamous epithelioma of Ferguson-Smith
Classification of squamous cell carcinoma by risk
Cutaneous SCC is classified as low-risk or high-risk, depending on the chance of tumour recurrence and metastasis. Characteristics of high-risk SCC include:
High-risk cutaneous squamous cell carcinoma has the following characteristics:
- Diameter greater than or equal to 2 cm
- Location on the ear, vermilion of lip, central face, hands, feet, genitalia
- Arising in elderly or immune suppressed patient
- Histological thickness greater than 2 mm, poorly differentiated histology, or with invasion of the subcutaneous tissue, nerves and blood vessels
Metastatic SCC is found in regional lymph nodes (80%), lungs, liver, brain, bones and skin.
In 2011, the American Joint Committee on Cancer (AJCC) published a new staging systemic for cutaneous SCC for the 7th Edition of the AJCC manual. This evaluates the dimensions of the original primary tumour (T) and its metastases to lymph nodes (N).
|TX||Primary tumour cannot be assessed|
|T0||No evidence of primary tumour|
|Tis||Carcinoma in situ|
|T1||Tumour ≤2cm without high-risk features|
Tumour ≤2 cm with high-risk features
|T3||Tumour with invasion of maxilla, mandible, orbit or temporal bone|
|T4||Tumour with invasion of axial or appendicular skeleton or perineural invasion of skull base|
|NX||Regional lymph nodes cannot be assessed|
|N0||No regional lymph node metastasis|
|N1||Metastasis in one local lymph node ≤3cm|
|N2||Metastasis in one local lymph node ≥3cm
Metastasis in >1 local lymph node ≤6cm
|N3||Metastasis in lymph node ≥6cm|
How is squamous cell carcinoma diagnosed?
Patients with high-risk SCC may also undergo staging investigations to determine whether it has spread to lymph nodes or elsewhere. These may include:
- Imaging using ultrasound scan, X-rays, CT scans, MRI scans
- Lymph node or other tissue biopsy
What is the treatment for cutaneous squamous cell carcinoma?
Other methods of removal include:=====
- Shave, curettage, and electrocautery for low-risk tumours on trunk and limbs
- Aggressive cryotherapy for very small, thin, low-risk tumours
- Mohs micrographic surgery for large facial lesions with indistinct margins or recurrent tumours
- Radiotherapy for inoperable tumour, patients unsuitable for surgery, or as adjuvant
What is the treatment for advanced or metastatic squamous cell carcinoma?
Locally advanced primary, recurrent or metastatic SCC requires multidisciplinary consultation. Often a combination of treatments is used.
- Experimental targeted therapy using epidermal growth factor receptor inhibitors
Many thousands of New Zealanders are treated for cutaneous SCC each year, and more than 100 die from their disease.
How can cutaneous squamous cell carcinoma be prevented?
There is a great deal of evidence to show that very careful sun protection at any time of life reduces the number of SCCs. This is particularly important in ageing, sun-damaged, fair skin; in patients that are immunosuppressed; and in those who already have actinic keratoses or previous SCC.
- Stay indoors or under the shade in the middle of the day
- Wear covering clothing
- Apply high protection factor SPF50+ broad-spectrum sunscreens generously to exposed skin if outdoors
- Avoid indoor tanning (sun beds, solaria)
Oral nicotinamide (vitamin B3) in a dose of 500 mg twice daily may reduce the number and severity of SCCs in people at high risk.
What is the outlook for cutaneous squamous cell carcinoma?
Most SCCs are cured by treatment. Cure is most likely if treatment is undertaken when the lesion is small.
About 50% of people at high risk of SCC develop a second one within 5 years of the first. They are also at increased risk of other skin cancers, especially melanoma. Regular self-skin examinations and long-term annual skin checks by an experienced health professional are recommended.
- Multi-professional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma 2009. RJ Motley, PW Preston, CM Lawrence - update of the original guideline which appeared in BJD, Vol. 146, No. 1, January 2002 (p18-25)
- Multi-professional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma 2009 update of original guideline
- Parikh SA, Patel VA, Ratner D. Advances in the management of cutaneous squamous cell carcinoma. F1000Prime Reports. 2014;6:70. doi:10.12703/P6-70.
- Chahoud J, Semaan A, Chen Y, et al. Association Between β-Genus Human Papillomavirus and Cutaneous Squamous Cell Carcinoma in Immunocompetent Individuals—A Meta-analysis. JAMA Dermatol. Published online December 30, 2015. doi:10.1001/jamadermatol.2015.4530.
On DermNet NZ:
- Squamous cell carcinoma – pathology
- Intraepidermal SCC (Bowen disease)
- Vulval intraepithelial neoplasia
- Penile intraepithelial neoplasia
- Bowenoid papulosis
- Vulval cancer
- Oral cancer
- Squamous cell carcinoma – common skin lesions course
- Head and Neck Squamous Cell Carcinoma – Medscape Reference
- Squamous Cell Carcinoma – British Association of Dermatologists
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