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Squamous cell carcinoma (SCC)
Dr Nabeel Yahiya
Kottayam Medical college
 skin cancer is the most common of all cancers
 97% of these are nonmelanoma skin cancer
(NMSC).
 Basal cell carcinoma ...
 Exposure to ultraviolet solar radiation, especially
ultraviolet B
 Painful sunburn before age 20 is related to later
de...
Host risk factors
blonde or red hair, fair complexion, blue
eyes, and tendency to burn rather than tan
 Genetic predisposition
 xeroderma pigmentosum
 basal cell nevus (Gorlin's) syndrome
 epidermodysplasia verruciformis
...
 Infections- An association exists between
cutaneous SCC and human papillomavirus
 Immunosuppression- Transplant recipie...
 more frequent and aggressive in areas of chronic
skin damage
 ulcers, osteomyelitis, sinus tracts and burn
(Marjolin's ...
 IONIZING RADIATION
 Exposure to ionizing radiation is a risk factor for
both BCC and SCC
 especially in those people w...
 Chemical skin cancer carcinogens
 Arsenic (herbicide, pesticide ), soot, and
polycyclic aromatic hydrocarbons from coal...
 Actinic (Solar) Keratoses-
 Actinic keratoses tend to be multiple.
 AKs are red, pink, or brown papules with a scaly
t...
 Malignant transformation to SCC occurs in about
1% of lesions
 with cumulative lifetime risk 6% to 10%
depending on num...
 Treatment
 Excision
 Cryotherapy
 desiccation and curettage
 Dermabrasion
 topical therapy with 5-FU or imiquomod
...
Bowen's Disease
 typically appears as a reddish-brown
 scaly patch or thin plaque on the sun-exposed
head, neck, extrem...
 Other features include confluent parakeratosis,
and, not infrequently, the adnexal extension of
neoplastic cells
 It ma...
 TREATMENT
 Surgical excision is usually preferred
 radiation therapy may be considered as an
alternative.
 45 to 50 G...
Keratoacanthoma
 benign, self-healing lesions
 presents as a rapidly enlarging papule that
becomes a crateriform nodule...
 Lesions can be treated with radiation
 Doses of 35 Gy in 12 to 14 fractions or 45 Gy in
15 to 20 fractions have been us...
 Lentigo Maligna and nevi are precursors of
melanoma
 a neoplasm of keratinizing cells that shows
malignant characteristics
 Anaplasia
 rapid growth
 local invasion
 meta...
 Invasive tumor lobules push downward from the
overlying epidermis and detached tumor islands
are noted within the dermis...
 Verrucous carcinoma
 is an indolent, well-differentiated squamous cell
carcinoma
 grows slowly as an exophytic, caulif...
 This may arise in the anogenital region
(Buschke-Lowenstein tumor)
 oral cavity (oral florid papillomatosis)
 on the p...
 Spindle cell carcinoma
 a rare subtype of squamous cell carcinoma
 usually develops in sun-exposed areas in lightly-
p...
 subtypes associated with clinically aggressive
behavior
 adenoid (pseudoglandular)
 Acantholytic
 Adenosquamous
 des...
 A careful history
 should include questions regarding patient risk
factors
 personal and family history of skin cancer...
 Slowly enlarging growth on or just beneath the
skin surface
 History of sore that will not completely heal
 Bleeding o...
 Site, size, mobility of the primary lesion should
be documented
 Evidence of PNI is assessed
 Any features of cartilag...
 Typical lesions are round-to-irregular, plaquelike
 nodular, and overlaid with a warty keratotic
scale or conical kerat...
 Biopsy should be performed before deciding on
treatment
 Small lesion occurring on free skin areas ( not
involving eye ...
 Biopsy should include deep reticular dermis
 This is preferred because infiltrative pathology
may be found only in deep...
 Done in extensive disease such as
 bone involvement
 PNI
 deep soft tissue involvement
 lymphovascular invasion is s...
 In the case of carcinomas involving the medial or
lateral canthi of the eyes
 one should consider obtaining either a (C...
CT Scan is done to role out bone and cartilage
invasion
 Lymph node status can also be assessed
MRI preferred over CT w...
 Clinically or radiologically if lymph node present
 Proceed with fnac
 If negative repeat fnac or excision biopsy of n...
 SURGERY
 RADIOTHERAPY
 offer equivalent excellent cure rates of 90% to
95%
 treatment approach must be individualized...
 The management of skin cancer is guided by the
biologic and histologic nature of the tumor, the
anatomic site, the under...
 Localized scc are most commonly treated with
surgery
 Curettage with electrodesiccation is the
alternatively scraping a...
 Curettage with electrodesiccation reserved for
 actinic keratoses (AKs), and SCC in situ without
follicular involvement...
 EXCISION WITH POST OP MARGIN
ASSESSMENT (POMA)
 Standard surgical excision followed by post op
pathological evaluation ...
 Mohs surgery or excision with intra operative
frozen section assessment
 Preferred technique for high risk scc
 Mohs' micrographic surgery
 involves fixation of tumor to enable tumor
mapping and surgical excision with multiple
froz...
 A key defining feature of MMS is that the
surgeon excises, maps, and reviews the
specimen personally, minimizing the cha...
 Although surgery is main treatment for nmsc
 Patient preference and other factor may lead to
choice of RT
 early skin ...
 Elderly patients who are not fit for surgery
 Patients with PNI with gross tumor extending to
the sites which makes les...
 positive surgical margins
 perineural invasion
 invasion of bone, cartilage, and skeletal muscle
 Cure rates lower
 Reserved where surgery or radiotherapy is
contraindicated or impractical
 Cryotherapy , topical 5 FU...
 immune-response modifier that promotes a cell-
mediated immune response
 through induction of cytokine production,
part...
 PDT involves application of photo sensitizing
agent on skin followed by irradiation with light
source
 Used for premali...
 exposes skin cancers to destructive subzero
temperatures.
 Heat transfer occurs from the skin, which acts as a
heat sin...
 inability to evaluate thoroughness of tumor
eradication.
 The absence of margin
control
 development of dense scar, wh...
 Involvement increase the chance of recurrence
and mortality
 Associated with PNI, LVI, poor differentiation
 Lymph node dissection followed by adjuvant RT
 Cervical node
 Neck dissection alone if only one involved
 If 2 or mor...
 Metastatic to parotid node is common if cervical
lymph nodes are involved (60-80%)
 Superficial or total parotidectomy ...
 EBRT
 Ortho voltage x rays
 Electron beam
 High energy x rays
 OR
 INTERSTITIAL IMPLANT
 100- 250 Kvp
 Most early skin cancer can be treated
 Advantages
 Maximum dose at skin surface, no bolus
required
 Le...
 DISADVANTAGES
 Higher dose to deeper tissues and to underlying
bone and cartilage
 It is unavailable in most RT Dept.
 It is usually used for treatment of scalp lesion
inorder to reduce dose to brain
 If tumor is located near eye – gold p...
 Advanced skin cancer that are deeply invasive
are often treated with higher energy
 To adequately cover the deeper tiss...
 Wedge pair technique – external ear
 3 field technique- lesion extending along 5 th
nerve
 Even IMRT can be used when ...
 Proper immobilization to ensure consistent
delivery of treatment is essential
 primary skin collimation with custom lea...
 The margin of normal-feeling tissue included in
the target volume is usually 0.5 to 1.0 cm for skin
cancers of 2.0 cm
 ...
 Sequelae of Radiation Therapy
 Moist desquamation
 The skin in the radiation field may gradually
become telangiectatic...
 Ectropion and epiphora may develop after the
treatment of eyelid carcinomas (particularly ones
involving the lower eyeli...
 3-4 % of scc can have distant metastases
 Systemic chemotherapy
 Platinum based chemotherapy
 Interferon @ or cis- re...
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
Squamous cell carcinoma skin
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Squamous cell carcinoma skin

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Squamous cell carcinoma skin

  1. 1. Squamous cell carcinoma (SCC) Dr Nabeel Yahiya Kottayam Medical college
  2. 2.  skin cancer is the most common of all cancers  97% of these are nonmelanoma skin cancer (NMSC).  Basal cell carcinoma (BCC) comprises about 80%  Squamous cell carcinoma (SCC) 20% of NMSC
  3. 3.  Exposure to ultraviolet solar radiation, especially ultraviolet B  Painful sunburn before age 20 is related to later development of premalignant lesions as well as NMSC and melanoma  Cumulative lifetime sun exposure is related to increased risk of SCC and BCC.
  4. 4. Host risk factors blonde or red hair, fair complexion, blue eyes, and tendency to burn rather than tan
  5. 5.  Genetic predisposition  xeroderma pigmentosum  basal cell nevus (Gorlin's) syndrome  epidermodysplasia verruciformis  Muir-Torre syndrome  Porokeratosis  Bazex syndrome  Rombo syndrome  Albinism  phenylketonuria.
  6. 6.  Infections- An association exists between cutaneous SCC and human papillomavirus  Immunosuppression- Transplant recipients on immunosuppressive therapy  AIDS , multiple myeloma, leukemia, and lymphoma also are at increased risk
  7. 7.  more frequent and aggressive in areas of chronic skin damage  ulcers, osteomyelitis, sinus tracts and burn (Marjolin's ulcer), or vaccination scars.  Areas of chronic skin inflammation  discoid lupus erythematosus, lichen sclerosus, lichen planus, dystrophic epidermolysis bullosa, and lupus vulgaris
  8. 8.  IONIZING RADIATION  Exposure to ionizing radiation is a risk factor for both BCC and SCC  especially in those people with sun-sensitive phenotype and younger age at exposure  risk is directly related to cumulative radiation dose  Increased incidence of NMSC also occurs with chronic radiation dermatitis following therapeutic radiation.
  9. 9.  Chemical skin cancer carcinogens  Arsenic (herbicide, pesticide ), soot, and polycyclic aromatic hydrocarbons from coal tar, cutting oils  An association exists between cigarette or pipe smoking and cutaneous SCC
  10. 10.  Actinic (Solar) Keratoses-  Actinic keratoses tend to be multiple.  AKs are red, pink, or brown papules with a scaly to hyperkeratotic surface  They occur on sun-exposed areas and are especially common on the balding scalp, forehead, face, and dorsal hands
  11. 11.  Malignant transformation to SCC occurs in about 1% of lesions  with cumulative lifetime risk 6% to 10% depending on number and length of time lesions are present
  12. 12.  Treatment  Excision  Cryotherapy  desiccation and curettage  Dermabrasion  topical therapy with 5-FU or imiquomod  laser resurfacing.
  13. 13. Bowen's Disease  typically appears as a reddish-brown  scaly patch or thin plaque on the sun-exposed head, neck, extremities, or trunk of an older individual  On histopathologic evaluation demonstrates full- thickness epidermal atypia, with more pronounced nuclear polymorphism and apoptosis
  14. 14.  Other features include confluent parakeratosis, and, not infrequently, the adnexal extension of neoplastic cells  It may arise from a pre-existing actinic keratosis or de novo.  Progression to invasive SCC occurs in 5% to 20% of cases
  15. 15.  TREATMENT  Surgical excision is usually preferred  radiation therapy may be considered as an alternative.  45 to 50 Gy at 2.5 to 3.5 Gy per fraction  Facial lesions require 56 Gy at 2.0 Gy per fraction for improved cosmesis
  16. 16. Keratoacanthoma  benign, self-healing lesions  presents as a rapidly enlarging papule that becomes a crateriform nodule with a central keratinous plug over a period of weeks to months.  have the potential to destroy large volumes of tissue and may be associated with SCC
  17. 17.  Lesions can be treated with radiation  Doses of 35 Gy in 12 to 14 fractions or 45 Gy in 15 to 20 fractions have been used
  18. 18.  Lentigo Maligna and nevi are precursors of melanoma
  19. 19.  a neoplasm of keratinizing cells that shows malignant characteristics  Anaplasia  rapid growth  local invasion  metastatic potential
  20. 20.  Invasive tumor lobules push downward from the overlying epidermis and detached tumor islands are noted within the dermis  Both cytoplasmic and cystic keratinization may be observed.  The degree of keratinocyte differentiation within these tumors is variable and an important prognostic factor.
  21. 21.  Verrucous carcinoma  is an indolent, well-differentiated squamous cell carcinoma  grows slowly as an exophytic, cauliflower-like lesion  may be associated with human papilloma virus infection
  22. 22.  This may arise in the anogenital region (Buschke-Lowenstein tumor)  oral cavity (oral florid papillomatosis)  on the plantar surface of the foot (epithelioma cuniculatum)
  23. 23.  Spindle cell carcinoma  a rare subtype of squamous cell carcinoma  usually develops in sun-exposed areas in lightly- pigmented individuals older than 40 years of age.  The prognosis primarily depends on the depth of invasion  Verrucous and spindle cell carcinomas are managed similar to more conventional squamous cell carcinomas.
  24. 24.  subtypes associated with clinically aggressive behavior  adenoid (pseudoglandular)  Acantholytic  Adenosquamous  desmoplastic squamous cell carcinoma.
  25. 25.  A careful history  should include questions regarding patient risk factors  personal and family history of skin cancer  UV exposure history,  history of ionizing radiation therapy  occupational exposures  immunosuppression
  26. 26.  Slowly enlarging growth on or just beneath the skin surface  History of sore that will not completely heal  Bleeding or pain unusual  Paresthesia and formication in case of perineural spread (3-14%)
  27. 27.  Site, size, mobility of the primary lesion should be documented  Evidence of PNI is assessed  Any features of cartilage or bone invasion should be examined  Complete skin examination should be done  Regional lymph nodes
  28. 28.  Typical lesions are round-to-irregular, plaquelike  nodular, and overlaid with a warty keratotic scale or conical keratinized cutaneous horn.  Surrounding erythema may be present, and bleeding results from minimal trauma  usually superficial, invasion of the subcutis does occur with muscle invasion and extension along periosteal, perineural, and angiolymphatic channels.
  29. 29.  Biopsy should be performed before deciding on treatment  Small lesion occurring on free skin areas ( not involving eye lid, ear or periorbital areas ) can undergo biopsy and simultaneous excision  Larger lesion or those involving areas where cosmetic or functional deficit will occur with excision  Incisional biopsy or punch biopsy
  30. 30.  Biopsy should include deep reticular dermis  This is preferred because infiltrative pathology may be found only in deep tissues  Superficial biopsy will frequently miss this
  31. 31.  Done in extensive disease such as  bone involvement  PNI  deep soft tissue involvement  lymphovascular invasion is suspected
  32. 32.  In the case of carcinomas involving the medial or lateral canthi of the eyes  one should consider obtaining either a (CT) or (MRI) scanto assess the depth of invasion  because apparently superficial cancers sometimes extend along the wall of the orbit
  33. 33. CT Scan is done to role out bone and cartilage invasion  Lymph node status can also be assessed MRI preferred over CT when PNI is suspected
  34. 34.  Clinically or radiologically if lymph node present  Proceed with fnac  If negative repeat fnac or excision biopsy of node
  35. 35.  SURGERY  RADIOTHERAPY  offer equivalent excellent cure rates of 90% to 95%  treatment approach must be individualized based on specific risk factors and patient characteristics for the most acceptable cosmetic and functional outcome.
  36. 36.  The management of skin cancer is guided by the biologic and histologic nature of the tumor, the anatomic site, the underlying medical status of the patient  It is desirable to avoid RT in young patients  Late effect of RT progress with time
  37. 37.  Localized scc are most commonly treated with surgery  Curettage with electrodesiccation is the alternatively scraping away the tumor tissue with a curette down to a firm layer of normal dermis and denaturing the area with electrodessication  It is fast and cost effective  Margin cannot be assessed
  38. 38.  Curettage with electrodesiccation reserved for  actinic keratoses (AKs), and SCC in situ without follicular involvement located on the trunk or extremities  but are contraindicated in deeply infiltrating lesions  Wound contracture may cause tissue distortion and impaired cosmesis  Cure rate is about 90-95% for low risk tumors  Recurrence rate high about 20-25% for high risk features
  39. 39.  EXCISION WITH POST OP MARGIN ASSESSMENT (POMA)  Standard surgical excision followed by post op pathological evaluation of margins  For low risk tumors < 2 cm – 4-6mm margin  For high risk tumors higher margins are required
  40. 40.  Mohs surgery or excision with intra operative frozen section assessment  Preferred technique for high risk scc
  41. 41.  Mohs' micrographic surgery  involves fixation of tumor to enable tumor mapping and surgical excision with multiple frozen sections taken until microscopically clear.  Cosmesis, often poor just after the procedure, improves with time.
  42. 42.  A key defining feature of MMS is that the surgeon excises, maps, and reviews the specimen personally, minimizing the chance of error in tissue interpretation and orientation  This technique is employed for BCC and SCC in embryonic fusion zones  recurrent or deeply invasive lesions  tumors with potential for diffuse lateral spread or perineural invasion
  43. 43.  Although surgery is main treatment for nmsc  Patient preference and other factor may lead to choice of RT  early skin cancer of eyelid, external ear ,or nose may result in significant cosmetic deformity and necessitates complex reconstructions
  44. 44.  Elderly patients who are not fit for surgery  Patients with PNI with gross tumor extending to the sites which makes lesion unresectable  Such lesions are treated with RT alone
  45. 45.  positive surgical margins  perineural invasion  invasion of bone, cartilage, and skeletal muscle
  46. 46.  Cure rates lower  Reserved where surgery or radiotherapy is contraindicated or impractical  Cryotherapy , topical 5 FU, imiquimod, Photo dynamic therapy
  47. 47.  immune-response modifier that promotes a cell- mediated immune response  through induction of cytokine production, particularly interferon @ and b and interleukin- 12.  treatment of Aks, scc insitu and superficial BCCs on the trunk, neck, or extremities
  48. 48.  PDT involves application of photo sensitizing agent on skin followed by irradiation with light source  Used for premalignant or low risk superficial on face and scalp
  49. 49.  exposes skin cancers to destructive subzero temperatures.  Heat transfer occurs from the skin, which acts as a heat sink.  Tissue damage is caused by direct effects initially  subsequently by vascular stasis, ice crystal formation, cell membrane disruption, pH changes, hypertonic damage, and thermal shock
  50. 50.  inability to evaluate thoroughness of tumor eradication.  The absence of margin control  development of dense scar, which might obscure recurrence
  51. 51.  Involvement increase the chance of recurrence and mortality  Associated with PNI, LVI, poor differentiation
  52. 52.  Lymph node dissection followed by adjuvant RT  Cervical node  Neck dissection alone if only one involved  If 2 or more or ECE neck dissection followed by RT
  53. 53.  Metastatic to parotid node is common if cervical lymph nodes are involved (60-80%)  Superficial or total parotidectomy followed by RT  If inoperable parotid node – high dose preop RT 60-70 Gy followed by parotidectomy  20 % decrease in local recurrence with addition of RT  5 YR survival also increased by 15-20%
  54. 54.  EBRT  Ortho voltage x rays  Electron beam  High energy x rays  OR  INTERSTITIAL IMPLANT
  55. 55.  100- 250 Kvp  Most early skin cancer can be treated  Advantages  Maximum dose at skin surface, no bolus required  Less beam constriction both at surface and at deapth so smaller field can be used  Shielding of eye is easier
  56. 56.  DISADVANTAGES  Higher dose to deeper tissues and to underlying bone and cartilage  It is unavailable in most RT Dept.
  57. 57.  It is usually used for treatment of scalp lesion inorder to reduce dose to brain  If tumor is located near eye – gold plated lead eye shield is directly placed over anaesthetised cornea
  58. 58.  Advanced skin cancer that are deeply invasive are often treated with higher energy  To adequately cover the deeper tissue  Bolus is kept to ensure the adequate surface dose  Field arrangement may vary depending on sites
  59. 59.  Wedge pair technique – external ear  3 field technique- lesion extending along 5 th nerve  Even IMRT can be used when we have to treat till base of skull in case of PN
  60. 60.  Proper immobilization to ensure consistent delivery of treatment is essential  primary skin collimation with custom lead cutouts can also be used to define the field in case of electrons  To minimize normal-tissue toxicity, underlying structures such as the lens, cornea, nasal septum, and teeth should be protected by placing a lead shield under the eyelids over or in the nasal cavity or under the lips
  61. 61.  The margin of normal-feeling tissue included in the target volume is usually 0.5 to 1.0 cm for skin cancers of 2.0 cm  1.5 to 2.0 cm for larger cancers.  At least a 0.5-cm margin on the suspected depth of invasion should be included in the target volume  Wider margin while using electrons
  62. 62.  Sequelae of Radiation Therapy  Moist desquamation  The skin in the radiation field may gradually become telangiectatic, atrophic, and hypopigmented over a period of years and is more sensitive to trauma.  healing may be delayed after surgery on an irradiated region.  Hair loss and a loss of sweat gland function are usually permanent
  63. 63.  Ectropion and epiphora may develop after the treatment of eyelid carcinomas (particularly ones involving the lower eyelid)  The incidence of soft tissue necrosis is typically less than 3%.  Osteoradionecrosis occurs in approximately 1% of patients  radiochondritis is rare
  64. 64.  3-4 % of scc can have distant metastases  Systemic chemotherapy  Platinum based chemotherapy  Interferon @ or cis- retinoic acid  Cetuximab and gefitinib is also tried

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