Squamous cell carcinoma Flashcards
This 80-year-old man (a retired army officer who spent 30 years in the Far East) presents with the lesion shown in his preauricular region. It has been present for 6 months.
- Cervical lymphadenopathy.
- Facial nerve function
- Parotid function
- Oral hygiene
- Dental status
How woudl you describe this nodule?
- Cervical lymphadenopathy.
- Facial nerve function
The presence of associated metastatic adenopathy is important.
Erythematoud, superficial erosion, no keratinal scale, rolling of edges (this is more common in a BCC but the history of onset here makes it SCC), painful. Poorly differentiated because well differentiated ones produce keratin.
How would you make a diagnosis initially in this case?
- Excisional biopsy
- Incisional biopsy
- From the patients history
- Curettage of the lesion
- Fine needle aspiration biopsy
This is a large lesion likely to require surgical reconstruction or radiotherapy (depending on histology). A biopsy is the most sensible 1st procedure.
Incisional biopsy
The incisional biopsy confirms the diagnosis of squamous cell carcinoma (SCC). Which of the following are reasonable treatment opinions?
- Surgery with appropriate reconstruction
- Radiotherapy
- Chemotherapy
- Cryotherapy
- Curettage alone
- Surgery with appropriate reconstruction)
- Radiotherapy
This lesion is too large to treat other than with surgery or radiotherapy as these lesions are radiosensitive, but not chemosensitive.
Which of the following are relevant prognostic factors for SCC?
- Size of the lesion
- Age of the patient
- Sex of the patient
- Cervical lymph node involvement
- Heavy smoking
- Cervical lymph node involvement
- Size of the lesion
Prognosis is determined by the possible spread of the skin malignant cells through the blood system or lymphatics. Enlarged lymph nodes would suggest that there may be spread to other organs. Such patients would have poorer prognosis.
Which of the following are considered to be relevant to the development of a SCC?(4)
- Over-exposure to sunlight (UV)
- Outdoor occupation
- Racial background
- Immunosuppression (e.g. following renal transplant)
- Alcohol intake
All of the above are relevant except alcohol intake. Obviously, outdoor occupation involves overexposure to the sunlight. Skin cancers, in general, are less common in those of Asian and African descendants. Immunosuppression increases the risk of both basal and squamous cell carcinomas.
- Over-exposure to sunlight (UV)
- Outdoor occupation
- Racial background
- Immunosuppression (e.g. following renal transplant)
Which of the following are useful in preventing SCCs?
- Sun cream
- Broad brimmed hats
- Solar swim suits
- Vitamin D tablets
- 5 – fluorouracil cream
Sun protection is the key. Fluorouracil is used to treat solar keratoses.
- Sun cream
- Broad brimmed hats
- Solar swim suits
Define squamous cell carcinoma.
Cutaneous squamous cell carcinoma (SCC) is the proliferation of atypical, transformed keratinocytes in the skin with malignant behaviour. It ranges from in situ tumours (also known as Bowen’s disease) to invasive tumours and metastatic disease.
How common is SCC of the skin?
- Second most common non-melanoma skin cancer worldwide, secondary to basal cell carcinoma.
- More common in men
- Related to sun exposure and proximity to equator
- Tropical Australia has the highest incidence of all types of skin cancer, with incidence of SCC of around 1/100 for the white population
What are the causes/RFs of squamous cell carcinoma?
- Fair skin
- Sun exposure
- Living near equator
- Ionising radiation
- Burns
- Previous psoralen and UV-A light therapy
- Hereditary skin conditions
- Actinic keratosis (thiazide diuretics and cardiac drugs may predispose to this)
- Environmental toxins - arsenic, tar, HPV
- Immunocompromise
- Old age and male sex
- Red tattoo ink
- Smoking
Where are SCCs most commonly found?
Most commonly detected on head and neck (84%) and extensor upper extremities (13%)
What is the typical presentation of SCC?
Often present with multiple actinic keratoses (AK). These are skin-coloured, yellowish, or erythematous, ill-defined, irregularly shaped, small, scaly macules or plaques localised to sun-exposed areas of the body that have the potential to progress into SCC
- Growing tumours - tend to grow over time but keratoacanthomas may grow rapidly.
- Bleeding
- Crusting
- Evidence of sun damage to skin
- Tender/itchy non-healing wound caused by trauma
- Erythematous papules/plaques, may be thin and flesh coloured
- Dome-shaped nodule (keratoacanthoma)
- Exophytic, fungating, verrucous nodules or plaques - verrucous carcinoma
- Constitutional symptoms
What investigations would you do for a suspected SCC?
Biopsy - shows full thickness keratinocyte atypia (in Bowen’s disease this is confined to the epidermis and intact BM but may become an invasive tumour)
Other: if suspected metastasis:
- FBC - check bone marrow involvement
- CT/MRI/PET/ LFTs/ CXR
Can you distinguish between actinic keratoses and SCC?
Because AKs and SCCs are on a spectrum, it is often difficult to clinically distinguish between the two. In general, SCCs tend to be symptomatic and are thicker, larger, more indurated than AKs.
What is the difference between the superficial scale on an SCC and a BCC?
SCC *shown below*- You should always take off the scale (in hyperkeratotic lesions) when examining. It will bleed and be tender and painful. You need to take a punch biopsy for diagnosis from the naked lesion.
BCC - when scale is taken off, you would just see a superficical lesion with no bleeding.
When does an SCC make keratin?
When it is well differentiated
Poorly differentiated SCCs will look eroded and not make keratin. Below.
