Dermatologic Physical Exam

Primary Lesions

1. Indurated papule (see Photo 58).

2. Indurated nodule (see Photo 59).

3. Indurated plaque.

The induration around papules and nodules is at the base. Surface character may be variable (see Secondary Lesions section). Color varies from gray to yellow-white to red. The surface is friable, and bleeds or splits easily with trauma. Lesions tend to be raised or exophytic.

Secondary Lesions

1. Hyperkeratotic adherent scale (see Photo 59).

2. Papillomatosis.

3. Cutaneous horn formation (see Photo 38).

4. Surface erosions.

5. Fissures.

6. Ulceration (see Photo 59).

Figure 11: Macrodistribution of squamous cell carcinoma.

Distribution

Microdistribution: None.

Macrodistribution: Squamous cell carcinoma of skin almost always arises on previously damaged skin, and is most common on the central face, pinna, dorsal forearms, and the top of the hands (see Fig. 11). In these locations, chronic solar injury is the most common cause. Dark-skinned people are more prone to develop SCC at sites of chronic injury on the lower extremities. The vermilion margin of the lip, penis, and vulva are also common sites. A special site that is often overlooked is the nail bed. Chronic X-ray exposure in medical personnel was once a provoking factor in this location.

Configuration None.

Indicated Supporting Diagnostic Data

Biopsy

A punch, incisional, or excisional biopsy is the definitive laboratory study. The pathology report should specify whether the tumor is well, moderately, or poorly differentiated. This is determined by the number of atypical mitosis, degree of tumor cell adhesiveness, proportion of differentiated cells, and the tumor's overall general architecture. The older Broder's classification is seldom used today. Poorly differentiated tumors should be treated more aggressively because of a greater tendency to metastasize.

Therapy

Surgical Excision

Treatment of small primary uncomplicated squamous cell skin cancers can be best accomplished by surgical excision. Well-differentiated lesions in areas of chronic solar injury can be resected with a clear clinical margin of 5 mm, and should be submitted for step sections to confirm clear microscopic margins. Larger tumors or those exhibiting rapid growth or lesser degrees of differentiation should be removed more aggressively.

When tissue exam shows an inadequate margin, reexcision of the site should be undertaken promptly because of the greater tendency for SCC to spread into the lymphatics or to distant sites.

Follow-up, similar to that with BCC, should be every 3 months for the first year, then yearly for the next 5 years. Regional lymph nodes should be examined along with the primary excision site on each visit.

Other Treatments

Other treatment modalities employed are similar to those used for BCC. These include:

1. Excision with complicated flap and graft closures.

2. Curettage and electrodesiccation.

3. Cryosurgery.

4. Radiation.

5. Excision under frozen control, employed for complicated closures and lesions with indistinct margins.

6. Moh's fresh tissue microscopic excision, which is employed for problem tumors or where preservation of maximal amounts of uninvolved adjacent tissue is essential.

Here also, the decision as to which method is optimal involves consideration of the lesion's size, site, and histologic pattern along with the patient's age, general health, and expectations in regard to the final cosmetic result. When the tumor is large, poorly differentiated, or penetrates deeply into the dermis, consideration should be given to adjunctive postoperative radiation once complete excision has been achieved.

Conditions That May Simulate Squamous Cell Carcinoma

Molluscum Contagiosum

A giant, rapidly growing molluscum lesion as might occur in a person with immune suppression could be confused with SCC. The squamous cell lesion should have an indurated base. A molluscum smear or biopsy will distinguish the two.

Verruca Vulgaris

VV with rapid growth and formation of a cutaneous horn may mimic SCC. Again, the latter has a more indurated base. Biopsy may be needed to distinguish the lesions, especially those involving the nail bed. Any refractory lesion in this location should be promptly referred, especially when there is a history of radiation exposure.

Actinic Keratosis

Hypertrophic AKs or those with a prominent cutaneous horn may be confused with SCC. The diagnosis is more likely to be SCC if there is induration at the base. A biopsy is usually needed to distinguish them.

Seborrheic Keratosis

SKs can usually be distinguished clinically by their "stuck-on" appearance and waxy surface feel. SKs also do not have the indurated base seen with SCC.

Keratoacanthoma

Both tumors evolve rapidly and show similar clinical and microscopic features. Differentiation must made microscopically; however, this is not always possible.

Bowen's Epithelioma/Superfidal Spreading BCC

Early invasive SCC developing in a Bowen's lesion may not show enough clinical induration to distinguish it from a preinvasive Bowen's or superficial spreading BCC except by biopsy.

Nodular Melanoma

Amelanotic NM and an exophytic SCC that has lost its keratotic surface may be very similar in appearance. Location on chronically sun-damaged skin favors the latter; however, this can be confirmed only by biopsy with microscopic examination.

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