Thissiteisintendedforhealthcareprofessionals

CutaneousSquamousCellCarcinomaClinical
Presentation
PRESENTATION

History
Theinitialpresentationofcutaneoussquamouscellcarcinoma(cSCC)typicallyincludesahistoryofa
nonhealingulcerorabnormalgrowthinasunexposedarea(seetheimagebelow).

Large,suninducedsquamouscellcarcinoma(SCC)ontheforehead/temple.ImagecourtesyofGlennGoldman,
MD.

ViewMediaGallery
TheclinicalassessmentshouldbeginwithathoroughreviewoftheriskfactorsforcSCC
development.Anassessmentoftherateoftumorgrowthisalsoimportant,asthisoftenreflectsthe
aggressivenessofthelesion.Theclinicianshouldaskaboutfeaturesthatsuggestperipheralnerve
involvementbythetumor,suchaslocalpain,numbness,twitchingormuscleweakness,and,with
cSCCsoftheface,visualchanges.

PhysicalExamination
Approximately70%ofallcSCCsoccurontheheadandneck,mostfrequentlyinvolvingthelowerlip,
externalearandperiauricularregion,orforeheadandscalp.Consequently,theheadandneckshould
beofparticularinterestinacomprehensiveexaminationofapatientwithsuspectedcSCC.The
followingfeaturesofthelesionshouldbenoted(seealsotheimagesbelow):
Location(eg,eyelidSCCismorecommononthelowereyelid)
Size
Character(eg,smooth/nodular,vascularity,color):SCCmayappearasplaquesornoduleswith
variabledegreesofscale,crust,orulceration

Presenceofulceration

A35yearoldmanwithhumanimmunodeficiencyvirus(HIV)infectionpresentedwitha2yearhistoryofa
slowlyenlarging,leftlowereyelidlesionincisionalbiopsyrevealedsquamouscellcarcinoma.

ViewMediaGallery

Alarge,ulcerated,invasivesquamouscellcarcinomaoftheleftlowereyelid.Thispatientalsohad
perineuralinvasionoftheinfraorbitalnerveextendingintothecranialbase.

ViewMediaGallery
Frequently,thepresentationofcSCCisprecededbythepresenceofactinickeratoses.[52]These
precancerouslesionsappearasscalyplaquesorpapules,oftenwithanerythematousbase.An
actinickeratosisisusuallyonlyseveralmillimetersinsizeandrangesfromnormalskincolortopinkor
brown.Patientswithmultipleactinickeratoseshaveanestimated610%lifetimeriskofdeveloping
skincancer.
Theoverallappearanceofanyskinlesionmustbedetailed.TheclassicpresentationofacSCCis
thatofashallowulcerwithheapedupedges,oftencoveredbyaplaque.Ofcourse,thepresenting
appearanceofeachcSCCvariesaccordingtothesiteandextentofdisease.

Tumorsizeandlocation
Inadditiontogeneralappearance,thesizeandlocationofthelesionshouldberecorded,asboth
haveprognosticandtherapeuticimportance.Forinstance,lesionslargerthan2cmandthoselocated
ontheexternalearorliphavebeenshowntohaveahigherrateofmetastaticspread.

Additionally,tumorsizeandlocationaffectthecosmeticandfunctionaloutcomeofsurgicalexcision.
Therefore,reconstructiveoptionsshouldbecarefullyconsideredintheassessmentofeveryheadand
neckcSCC.Lesionslocatednearcriticalareas,suchasaroundtheeyes,mayrequireadditional
evaluationbyadedicatedreconstructivesurgeonbeforeexcision.

Tumorcharacteristics
SurfacechangesonatypicalSCCmayincludescaling,ulceration,crusting,orthepresenceofa
cutaneoushorn.Lesscommonly,thelesionmaymanifestasapinkcutaneousnodulewithout
overlyingsurfacechanges.
Theabsenceofsurfacechangesshouldraisesuspicionofametastaticfocusfromanotherskinor
nonskinprimarysiteorofadifferentandpotentiallymorelethaltumor,suchasaMerkelcell
carcinoma.Abackgroundofseverelysundamagedskin,includingsolarelastosis,mottled
dyspigmentation,telangiectasia,andmultipleactinickeratoses,isoftennoted.
Clinically,lesionsofSCCinsitu(SCCIS)rangefromascaly,pinkpatchtoathinkeratoticpapuleor
plaquesimilartoanactinickeratosis.BowendiseaseisasubtypeofSCCIScharacterizedbya
sharplydemarcated,pinkplaquearisingonnonsunexposedskin(seetheimagebelow).

Squamouscellcarcinomainsitu(Bowendisease).CourtesyofHonPak,MD.

ViewMediaGallery
SCCofthelipusuallyarisesonthevermillionborderofthelowerlip.Itissometimespredatedbya
precursorlesion,actiniccheilitis,whichmanifestsasxerosis,fissuring,atrophy,anddyspigmentation.
Actiniccheilitisisanalogoustoactinickeratosisoftheskin.

Perineuralinvasion
Upto14%ofcSCCsexhibitperineuralinvasion.Evidenceofcranialnervedysfunctionon
examinationshouldraiseconcernofsignificantperineuralinvasion.Themostfrequentlyinvolved
cranialnervesarethefacialandtrigeminalnerves,[53]underscoringtheimportanceofassessmentof
facialmovementandsensation.Therefore,everypatientwithheadandneckcSCCshouldundergo
systematicevaluationofcranialnervefunction.

Tumormetastasis
InvestigateregionalspreadofheadandneckcSCCbypalpatingforenlargedpreauricular,
submandibular,andcervicallymphnodes.Regionalmetastasisoccursin26%ofcasesofcSCC.The

riskofmetastasiscorrelatesroughlywithtumorsizeanddifferentiation.Ingeneral,metastasisfrom
cSCCoftheforehead,temples,eyelids,cheeks,andearsistotheparotidnodesmetastasisfrom
cSCCofthelipsandperioralregionisprimarilytothesubmentalandsubmaxillary(uppercervical)
nodes.
Rarely,cSCCpresentsasaparotidorneckmassbecauseoflymphaticspreadfromanoccult
cutaneouslesionorremotelytreatedskincancer(seetheimagebelow).[54]Themediantimefrom
initialtreatmenttopresentationwithaparotidorneckmassrangesfrom10to13months.Fineneedle
aspirationbiopsycanbeofassistanceintheevaluationofanymasssuspectedtorepresentoccult
metastasis.

Preauricularandhelicalscars(blackarrows)frompriorexcisionsarenotedinapatientwhopresentedwith
cervicalmetastases(whitearrow)fromanoccultcutaneoussquamouscellcarcinoma.

ViewMediaGallery

Conjunctivalsquamouscellcarcinoma
MostSCCsinvolvingtheconjunctivamanifestaschronic,unilateral,localizedpatchesofrednessor
morediffuseconjunctivitis(seetheimagebelow).Theycanalsopresentasamassinthe
interpalpebralfissureatthenasalortemporallimbuswithagelatinousandvelvety,papilliform,or
leukoplakicappearance.Prominentfeedervesselsmaybeseen.Thecorneosclerallimbusisthemost
commonlocation,althoughthepalpebralconjunctivaorcorneamaybeinvolved,particularlyinthe
interpalpebralregion.

Extensiveconjunctivalsquamouscellcarcinomaofthelefteye.Thepatienthadlimbalandcornealinvolvement
temporally,aswellasscleralinvasionwithintraocularspread.Amalignantcellularreactionintheanterior
chamberwaspresent.Thepatientwastreatedwithalidsparingexenteration.

ViewMediaGallery
IndividualswithHIVinfectionandthosewithxerodermapigmentosaaremorelikelytodevelop
conjunctivalSCC,probablybecauseoftheirdiminishedimmunestatus.Often,smallconjunctival
massesarenotedonroutineeyeexaminations.
DistinguishingconjunctivalSCCfromconjunctivalintraepithelialneoplasiaisdifficultonclinical
examinationalone.[55]ConjunctivalSCCrepresentsatypeofconjunctivalintraepithelialneoplasia
thathaseitherbrokenthroughthebasementmembranetoinvolvethesubepithelialtissueorhas
metastasized.[56,57,58]
Givenitsvariableappearance,conjunctivalSCCmayposeadiagnosticchallengeasamasquerade
syndrome.Patientswithanatypicalpterygiummayhaveaconjunctivaltumorandshouldbeobserved
muchmorecloselythanpatientswithaclassicpterygium.Unsuspectedocularsurfaceneoplasiamay
bepresentwithinexcisedpterygia.Forthisreason,onestudyrecommendsthesubmissionofall
excisedpterygiaforhistopathologicanalysis.[59]
TheexaminationofconjunctivalSCCshoulddeterminethefullextentofthelesionroseBengaldyeis
helpfulforthisevaluation.Inaddition,assessanysuspicionofintraocularinvolvementviaslitlamp
examination,gonioscopy,andechography.Orbitalinvolvementshouldbeinvestigatedwithcomputed
tomography(CT)scanningormagneticresonanceimaging(MRI).
DifferentialDiagnoses
WhattoReadNextonMedscape
RelatedConditionsandDiseases

SkinCancerMelanoma
SkinCancerMerkelCellCarcinoma
TheRoleofSentinelNodeBiopsyinSkinCancer
CutaneousManifestationsofSmoking
BasalCellCarcinomaGuidelines
MalignantMelanomaGuidelines

News&Perspective

SkinCancerScreeningUrgedforNonwhiteOrganTransplantRecipients
ConfocalMicroscopyHelpsSpotSkinCancerNoninvasively

USPSTF'sFinalWordonSkinCancerExamsinPrimaryCare
Tools

DrugInteractionChecker
PillIdentifier
Calculators
Formulary
Slideshow

DeadlySkinCancersYouNeedtoKnow
MostPopularArticles

AccordingtoOncologist/Hematologists
1.IndicationsforAdjuvantRadiationTherapyinBreastCancer
2.ForCancerDistress,HallucinogenHasUnprecedentedResults
3.ExerciseBenefitsPatientsWithCanceronActiveTherapy
4.What'sHotatASH2016Meeting?
5.AClinicopathologicAnalysisof45PatientsWithMetaplasticBreastCarcinoma

ViewMore