Basal and Squamous Cell

Carcinoma - a review

Trefor Nodwell MDCM

Resident Division of Plastic Surgery
Dalhousie University
Overview
 Address BCC and SCC in regards to:
– Skin embryology and Anatomy
– Epidemiology
– Pathophysiology and risk factors
– Clinical presentation
– Associated syndromes
Overview
– Histopathology
– Pre-malignant lesions
– Management
– Outcomes
– Cases
Primary Skin Malignancies
 Embryology-
– ectodermal derivatives:
 epidermis,
pilo-sebaceous and apocrine units eccrine
sweat glands, nail units
– Neuro-ectoderm:
 melanocytes, nerves, sensory receptors
– Mesoderm:
 macrophages, mast cells, Langerhans cells, Merkel
cells, fibroblasts, blood and lymph vessels, fat cells.
Primary Skin Malignancies
 Anatomy:
– Epidermis
 stratified squamous
epithelium (keratinized)
 four cell types-
keratinocytes,
melanocytes,
Langerhans cells and
Merkel cells
 0.04-1.4mm thick.
Primary Skin Malignancies
 Dermis:
 Primarily acellular.
 15-40 times thicker than
the epidermis
 Upper thin papillary
layer
 Lower thicker reticular
layer
Primary Skin Malignancies
Epidemiology
 700-800 thousand cases in the US per
annum
 1% of all cancer deaths
 77% BCC, 20% SCC, 3% melanoma and
other
 Incidence increasing 3-7% per year in the
white population
 Doubled between 1970-86
Primary Skin Malignancies
 Pathophysiology
– Etiologic factors
 UV(B) exposure
 Therapeutic (Ionizing)
Radiation Exposure
 Chemical Carcinogens
 Viral Carcinogens
– Multistep Hypothesis
of Carcinogenesis
 Initiation
 Promotion
 Progression
Primary Skin Malignancies
 Biophysical Risk
factors
– Male
– White (Celtic Origin)
– Sunburn Easily
– Increasing Age
– Blue Eyes
– Fair Complexion
Skin Phototypes
No. Skin Phototype Skin Colour Tanning history
I Never Pale/ Alabaster Red sunburn, painful
tans/always swelling, skin peels
burns
II Sometimes Very light Brown: Pinkish or red, light
tans/usually sometimes freckles brown tan can
burns gradually develop
III Usually tans/ Light tan, brown or Rarely burns,
sometimes olive moderately rapid
burns tanning response
IV Always Brown, dark brown, Rarely burns, very
tans/rarely black. rapid tanning response
burns
Basal Cell Carcinoma
Basal Cell Carcinoma
 Most Common Malignancy of whites
 Typically sporadic
 Immature cells of the Basal Layer, External
root sheath of the hair follicle.
 No cellular anaplasia (a true carcinoma?)
 Rare metastasis
Basal Cell Carcinoma - Subtypes

 Nodular Ulcerative
– Most common
– Usually on the face
– Small, slow growing
– Firm
– Telangectasias
– Ulceration
Basal Cell Carcinoma - Subtypes

 Superficial
– Single or multiple
patches
– Trunk
– Indurated scaly
– Differential - eczema,
psoriasis or tinea.
Basal Cell Carcinoma - Subtypes

 Sclerosing
(Morpheaform)
– Yellow white plaques
– Ill defined boarders
– Most aggressive
– Most likely to recur
– Central sclerosis and
scarring
Basal Cell Carcinoma - Subtypes

 Pigmented
– Similar to nodular type
– Deep brown
pigmentation
– Differential- malignant
melanoma
Basal Cell Carcinoma - Subtypes

 Fibroepithelioma
– Pinkus Tumour
– Raised
– Moderately firm
– Erythematous and
smooth
– Lower trunk
(lumbosacral area)_
Basal Cell Carcinoma - Syndromes

 Basal Cell Nevus

(Gorlin’s) Syndrome
– Autosomal Dominant, no
sex linkage, low penetrance
– ? Mutated tumour
suppressor at Ch 9q23.1-
q31
– Childhood onset
– BCC (average age 20y)
– Pitting of palms and soles
Basal Cell Carcinoma - Syndromes

 Basal Cell Nevus

(Gorlin’s) Syndrome
– odontogenic keratocysts
(epithelial jawline cysts)
– CNS calcifications (dura),
mental retardation
Basal Cell Carcinoma - Syndromes

 Bazex Syndrome  Possible

– AD responsiveness to
– Adolescence Retinoic acid.
– Multiple facial BCC
– “Ice pick” marks
– Hair abnormalities
– Foregut Neoplasms
Basal Cell Carcinoma - Syndromes

 Rombo Syndrome
– Autosomal Dominant
– Manifestation >35 y
– Atrophoderma
Vermiculatum
– Milia
– Peri follicualr pitting
– Scarring alopecia
– Peripheral vasodilation
and cyanosis
Other Associated Syndromes
 Xeroderma
pigmentosum
– Incomplete sex-linked
recessive
– Deficiency of
endonuclease
– Childhood onset
– Extreme sun sensitivity
– BCC,SCC,Melanoma
Other Associated Syndromes
 Albinism
 Genetic abnormality
of the pigment system.
Other Associated Syndromes
 Nevus Sebaceous of
Jadassohn
– Usually sporadic
– Solitary patch/plaque
– Scalp
– Yellow-brown
– Present at birth/early
childhood
Basal Cell Carcinoma -
Histopathology
 Resemble normal basal
cells
 Hyperchromatic nuclei,
scant cytoplasm
 Clustered separate from
stroma
 Peripheral palisading
 Desmoplastic reaction
 Nests or in continuity
Squamous Cell Carcinoma
Squamous Cell Carcinoma
 Originates from spindle cell layer
 Older men sun exposed skin
 Sharply defined, erythematous plaque
 Elevated border
Squamous Cell Carcinoma
 Painless firm nodule,
scaling and horn
formation
 Verrucous variant -
fungating, slow
growing, deeply
invasive, less
metastasis
Squamous Cell Carcinoma
 Etiologic Factors
– Sun exposure
– Chronic ulceration (osteomyelitis, burn
wounds)
– Cytotoxic agents, immunosuppressives
– Discoid Lupus
– Hydradenitis suppurativa
– Smoking, tobacco and Betel nut chewing
Squamous Cell Carcinoma
 Histopathology
– Atypical cells
replacing dermis
– Pleomorphic, multiple
mitotic figures
– Migration through
basement membrane
– Horn pearls
– Graded from well to
poorly differentiated
Squamous Cell Carcinoma
Precursor Lesions
 Actinic (Solar)
Keratosis
– Rough, scaly
– Erythematous plaques
– Forehead, nose,
cheeks, pinna
– Multiple
– 25% Regress
– 1:1000 convert per
year
Squamous Cell Carcinoma
Precursor Lesions
 Bowens Disease
– Older men
– Carcinoma in situ of
skin or mucous
membranes
– Mostly solitary
– Sharply defined.
– Dull scaly plaque
– Indolent history
Squamous Cell Carcinoma
Precursor Lesions
 Keratoacnathoma
– Rapid initial growth
– Latent period
– Fleshy, elevated,
nodular
– Possible regression
– Grossly and
microscopically
resemble SCC
– Excision recommended
Squamous Cell Carcinoma
Precursor Lesions
 Leukoplakia
– Oral, vulvar, vaginal
mucosa
– Smoking history
– Ill fitting dentures
– Elevated, sharply
defined, patchy
keratinization
BCC and SCC- Approach to
Treatment
 Surgical Excision
– Simple, versatile, fast
– Elliptical excision and primary closure
applicable to 80% of BCC,SCC
– Large questionable lesions - biopsy
– ? - Delayed closure (awaiting pathology)
– Skin grafts, composite grafts, local flaps.
– Optimal surgical margin unknown
Planning Margins for Primary
excision BCC
Tumour Area Margin (mm) Frozen
Section
Solid
<2cm Non-critical 5-10 No
>2cm Non-critical 5-10 Yes
<1cm Critical 2-3 Yes
1< = >2 cm Critical 3-5 Yes
>2cm Critical 5-10 Yes
Morpheform Any 7-10 Yes
BCC and SCC- Approach to
Treatment
 Mohs’ (Micrographic)
Surgery:
– Frederic Mohs, 1941
– Frozen Section
– Examine margins in
three dimensions
– Medial canthus, alar
regions
BCC and SCC- Approach to
Treatment
 Laser Excision
– CO2 laser
 Focusedmode -coagulate and excise tissue
 Unfocused mode - vaporize small tumours.

– May hinder microscopic evaluation

– May damage the recipient bed for a graft.
BCC and SCC- Approach to
Treatment
 Non-Operative
– Radiation for BCC (4000-6000 cGy, 10-30
fractions)
 older infirm patients
 difficult areas
 Complications: dry eye, lacrimal duct scarring, skin
necrosis
– Draw backs - no margins, multiple visits.
BCC and SCC- Approach to
Treatment
 Non -Operative:
– Chemotherapy (5FU)
 hydrophilic base 5-20%
concentration
 applied at night and
covered
 4-12 weeks
 Diffuse,Superficial
Lesions, 5-20 mm.
 Heals over 1-2 months
BCC and SCC- Approach to
Treatment
 Non-Operative
– Isotretinoin
 in vivo antineoplastic effects, promoting cellular
differentiation
 topical form only

– Interferon alpha
 nonspecific activation of macrophages and Natural
Killer Cells.
BCC and SCC- Approach to
Treatment
 Non Operative
– Photo therapy
 Inactiveagent administered
 Accumulates in tissue of interest
 Activated by LASER light.

– Cryosurgery
 Small nodular ulcerative, well-defined
 5-15mm, wound contraction acceptable
 Liquid N2 (-195.6 C) used to reach intracellular
temp of -40 C.
BCC and SCC- Outcomes
 Risk Factors for Recurrence
– Long Duration
– High-risk area
– Large size
– Aggressive subtype
– Neglected
– Recurrent
– Radiation exposure
BCC and SCC- Outcomes
 Acceptable goal
– Surgical excision
– Evaluation of margins
– Re-excision of involved margins
– Yields 95% cure rate for primary tumours
BCC and SCC- Outcomes
 The Positive Margin
– Microscopic: re-excise wound scar
– Observe: Recurrence typically within 2 years,
30%.
– ? increased risk for deep and lateral margins

– Grossly Recurrent tumour: re-excise wide

margins. Poor cosmetic result
Primary Skin Malignancies
 Common
 Increasing incidence
 High cure rates
 High patient-surgeon satisfaction.
 Can be a technical challenge
 Still many unanswered questions ...
The Cases