Squamous cell carcinoma

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DEFINITION AND PATHOGENESIS

  • Marjolin ulcer is a carcinoma arising in post-traumatic scars
  • "Post-traumatic squamous cell carcinoma" a generic term for tumors arising from scars and sinuses
  • A keratinocyte carcinoma

IMPORTANCE

  • 2nd most common skin cancer
  • Population-based case-fatality rate of ~0.7%
  • Early dx can only be made by a high index of suspicion which leads to bx; early bx and tx may improve outcome
  • Incidence varies
  • Overall incidence 250X in renal transplant pts

CLINICAL FEATURES

  • Susceptiblity may be higher in Japan, N India, and China due to cultural practices
  • ↑ ESR (average 33mm/hr)
  • Time from initial injury to tx avarages 17.8 yrs
  • Non-healing ulcer after bx of a "benign lesion"
  • Can arise from chronic granulomas, leukoplakia, actinic keratosis, cutaneous horns, keratotic lesions (plantar feet)
  • Risk factors
    • Solar radiation
    • Ionizing radiation
    • Phototherapy with psoralens
    • Prior SCC
    • Smoking
    • Chronic inflammation or infection
    • Squamous carcinoma of the nail bed has been associated with a subungual lipoma and secondary chronic infection
    • Chemical exposure
      • Arsenicals
      • Polycyclic/polyaromatic hydrocarbons)
    • Disease states (eg, xeroderma pigmentosa, Bowen's disease, leukoplakia, epidermis dysplasia verruciformis, epidermolyis bullosa dystrophica)
    • Xeroderma pigmentosa: (AD) defective DNA repair after UV radiation
    • Epidermis dysplasia verruciformis: defect in cell-mediated immunity, susceptibility to human papilloma virus
    • Human papiloma virus
    • Actinic keratosis
      • 1% progress to SCC
      • 60% of SCC arise in an actinic keratosis
    • Organ transplant patients
      • 65X ↑ risk due to immunosupression
  • Staging
    • T     Primary tumor
    • TX   Primary tumor cannot be assessed
    • T0   No evidence of primary tumor
    • Tis  Carcinoma in situ
    • T1   Tumor ≤2 cm in greatest dimension with less than two high-risk features
    • T2   Tumor ≥2 cm in greatest dimension or a tumor of any size with two or more high-risk features
    • T3   Tumor with invasion of maxilla, mandible, orbit, or temporal bone
    • T4   Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base
    • (High-risk features: perineural invasion; location of ear, nonglabrous lip; depth ≥ 2 mm, Clark levle IV; poor- or un- differentiation

RADIOLOGIC FEATURES

  • Preop CT of lungs and liver
  • MRI may be more useful than CT for regional LN metastases

GROSS PATHOLOGY

  • Varying sizes of sinus tracts and chronic ulcers, which may be infected

HISTOLOGIC FEATURES

  • Keratinocytes, polygonal cells with abundant cytoplasm
  • Keratin pearls
  • Invasion of the dermis through the basement membrane
  • Grading according to the WHO criteria
    • Grade I: well differentiated
    • Grade II: moderately well differentiated
    • Grade III: poorly differentiated

DIFFERENTIAL CLINICOPATHOLOGIC DIAGNOSIS

  • Atypical verruca
  • Kerato-acanthoma
  • Plantar keratosis

DISEASE COURSE AND TREATMENT

  • Biopsy
    • Shave or punch bx
      • Bx the border between normal skin and tumor to avoid sampling only necrotic tissue
    • Excision biopsy in small lesions when tension-free closure possible
  • 0.0028-5.9% metastasis in primary lesions (usually only in advanced, deeply invasive lesions)
  • 50% over-all metastatic rate in post-traumatic lesions (possibly ? incidence with prophylactic XRT to regional LNs for those lesions at higher risk for metastasis)
  • 10% for grade I
  • 59% for grade II
  • 86% for grade III
  • Wide local excision, attempt to get 4-6mm margin and one clear tissue (fascia preferably) plane deep to the tumor
  • Chemotx for high grade lesions
  • Cryotherapy for superficial, well-differentiated, and well-defined lesions of < 1 cm
    • 94% 5-year cure rate
  • Electrodessication and curettage for superficial, well-differentiated, and well-defined lesions
    • 96% 5-year cure rate
  • 100% of pts who develop metastases will develop regional LN metastases
  • 5-yr survival with metastatic disease 27-39%
  • Regional LN dissection of no benefit in improving survival
  • Sentinel node bx has been reported
    • Metastases in up to 11.2-16.9% with tumor size > 2 cm the independent risk factor
  • Metastatic lesions in <2% of cases due to chronic sun exposure
  • XRT for patients who are poor surgical candidates
    • 90% 5-year cure rate

SPECIAL CONSIDERATIONS

  • CARCINOMA (EPITHELIOMA) CUNICULATUM
    • Well-differentiated, bulbous mass with multiple sinuses usually on plantar surface with foul-smelling expelled material
    • Also has been reported in locations other than the foot
    • "Burrowing" invasion of the dermis
  • BOWEN'S DISEASE
    • Carcinoma in situ, where the basement membrane remains intact

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