Squamous Cell carcinoma

What is a Squamous Cell Carcinoma?

Squamous Cell Carcinoma also referred to as (SCC) is a malignant skin cancer that arises from the flat (squamous) cells in the uppermost layers of the skin known as the epidermis

It appears in the upper layer of the epidermis and usually on the most sun exposed areas (head, neck, hands, forearms and lower legs).

It is one of the most common cancers in Australia, and accounts for around 15-20% of non-melanoma skin cancers.

In 2016 there were 120,000 cases in Australia. This equates to 499 Squamous Cell Carcinomas per 100,000 people per year - which is equal to all forms of other major malignancies combined (bowel, bladder, breast, melanoma, brain, leukaemia etc).

When treated early the vast majority of Squamous Cell Carcinomas are not life-threatening.

Squamous Cell Carcinoma Risk Factors

Anyone with a history of sun exposure can develop Squamous Cell Carcinoma. However groups of people at greater risk include:

  • Fair Skin Types - people who are at highest risk have fair skin, freckles, blond or red hair, and blue, green, or grey eyes. They have a tendency to burn rather than tan
  • Prior Actinic Keratoses - People who have had prior Actinic Keratoses and increased number of unusual moles
  • Prior Skin Cancer - People who have had one Squamous Cell Carcinoma are at risk for developing others, in the same area or elsewhere on the body. If you’ve had a Squamous Cell Carcinoma you have a 10 times higher risk of developing another skin cancer of any type so routine reviews are advised every 6 months
  • Family History - The tendency to develop Squamous Cell Carcinoma may also be inherited. Such as people who have certain genetic disorders like Xeroderma Pigmentosa - which causes photosensitivity
  • Older People - Those most often affected are older people, but as the number of new cases in younger patients has increased sharply each year in the last few decades, the average age of patients at diagnosis has decreased. The disease is rarely seen in children, but occasionally a teenager is affected
  • Weak Immune Systems - Patient with immunosuppression from any cause: HIV, immunosuppressive therapies after transplants, general debility, etc
  • Occupational - Workers in occupations that require long hours outdoors or people who have had exposure to cytotoxic substances such as Aniline dyes in the printing industry
  • Recreational -  People who pursue outdoor recreation activities for hours at a time

Where Are Squamous Cell Carcinomas Found?

Squamous Cell Carcinomas may occur on any body area. It appears in the upper layer of the epidermis and usually on the most sun exposed areas (head, neck, hands, forearms and lower legs). But they can also appear on mucous membranes and genitals.

What Causes Squamous Cell Carcinoma?

95% of Squamous Cell Carcinomas in Australia are the result from skin damage caused by

  • Cumulative long-term sun exposure  
  • Intermittent overexposure to ultraviolet (UV) radiation from the sun (typically leading to sunburn)

Most Squamous Cell Carcinomas occur on parts of the body exposed to the sun — especially the face, ears, neck, bald scalp, shoulders, and back, but many can be found in areas that are only burned or exposed occasionally - such as the abdomen or upper thighs

It is not possible to pinpoint a precise, single cause for a specific tumour, especially tumours found on a sun-protected (un-exposed) area of the body or in an extremely young individual. Some Squamous Cell Carcinoma can also result from less common causes such as:

  • contact with arsenic,
  • exposure to ionising radiation such as X-rays (used in radiotherapy)
  • open sores that resist healing,
  • chronic inflammatory skin conditions, and
  • as complications of burns and scars.

Symptoms of Squamous Cell Carcinoma?

A key factor used to identify a Squamous Cell Carcinomas is any ongoing change that persists beyond a few weeks in a lesion on the skin.

Squamous Cell Carcinomas typically appear as persistent, thick, rough, scaly patches that can bleed if bumped, scratched or scraped.

If you observe two or more of the signs below, you should consult the Bondi Junction Skin Cancer Clinic immediately.

  • A wart like appearance - as well as loss of elasticity and broken blood vessels
  • A pigment change - as well as freckles, “age spots,”
  • An open sore with a raised border and a crusted surface that bleeds, oozes, or crusts and remains open for a few weeks, only to heal up and then bleed again. A persistent, non­–healing sore is a very common sign of early Squamous Cell Carcinoma
  • A reddish patch or irritated area, frequently occurring on the face, chest, shoulders, arms, or legs. It may develop a crust. It may itch or hurt. Mostly they produce, no
  • discomfort and local tenderness.
  • A shiny bump or nodule that is pearly or clear and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a normal mole.
  • A pink growth with the profile of a small volcano with a crust on top. The growth slowly enlarges, and tiny blood vessels may develop on the surface.
  • A scar-like area that is white, yellow or waxy, and often has poorly defined borders; the skin itself appears shiny and taut. This warning sign may indicate the presence of an invasive Squamous Cell Carcinoma that is larger than it appears to be on the surface.

Squamous Cell Carcinoma can sometimes resemble non-cancerous skin conditions such as psoriasis or eczema.

Squamous Cell Carcinoma Warning Signs

At the Bondi Junction Skin Cancer Clinic we use the adage ‘The faster a Squamous Cell Carcinoma grows the faster it needs to go’.

Faster growing Squamous Cell Carcinoma (which can double in size in a few weeks) are more likely to be

  • aggressive,
  • Invade and potentially penetrate the skin
  • spread (metastasise).

If they do spread this high growth rate is often maintained leading to a rapidly progressive clinical course which is associated with higher fatality rates.

Any rapidly growing lump or change in a pre-existing or new skin growth, should prompt an immediate visit to a Bondi Junction Skin Cancer Clinic.

Stages of Squamous Cell Carcinoma

Squamous Cell Carcinomas are usually slow growing, but occasionally SCCs grow in subtle ways and may be quite extensive and advanced by the time of diagnosis.

The general stages of a Squamous Cell Carcinoma are:

  • T - stands for the main (primary) tumour (its size, location, and how far it has spread within the skin and to nearby tissues).
  • N - stands for spread to nearby lymph nodes (bean-sized collections of immune system cells, to which cancers often spread first).
  • M - is for metastasis (spread to other parts of the body).

If a Squamous Cell Carcinoma is advanced the outcome (prognosis) can vary and this may affect your treatment choices.

A small number of Squamous Cell Carcinomas, especially those diagnosed late or were not treated are fatal.

Squamous Cell Carcinoma Screening

Diagnosis and management of Squamous Cell Carcinoma is best performed via a Full Body Scan. In the first incidence, this process includes

  • Digitally Mapping a patient's entire body for any suspicious skin damage or lesion
  • Followed by a detailed Dermoscopic Examination by a trained skin cancer Specialist
  • Recording and combining all images and skin metrics (size, shape, colour, and other attributes) into the patient record

Our expert Doctors at Bondi Junction Skin Cancer Clinic will then clearly identify and diagnose any skin cancers.  Having a digital molemap or a baseline of all your skin’s sun damage for all family members with

  • any suspicious sun damage,
  • those with a large number of moles, or
  • have been diagnosed with melanoma is recommended.

Any changes can be more easily spotted and understood.

Squamous Cell Carcinoma Diagnosis

Occasionally a punch or shave biopsy may be required to confirm the diagnosis and to guide effective treatment.

This diagnostic process involves a Doctor taking a tissue sample for biopsy by removing a portion of the lesion with a biopsy punch or by scraping the lesion with a curette (an instrument with a sharp ring-shaped tip).
Usually a biopsy is sufficient to establish the diagnosis  of a Squamous Cell Carcinoma. In the rare case of suspected metastatic Squamous Cell Carcinoma, lymph nodes may be examined by the Doctor to see if the cancer has spread or by the use of imaging technologies like ultrasound, CT, or PET scanning.

Untreated Squamous Cell Carcinomas

The incidence of Squamous Cell Carcinoma is rising and can be life-threatening.

While Squamous Cell Carcinomas seldom spread to vital organs, Squamous Cell Carcinomas respond well to early treatment. If untreated the consequences could include:

  • Disfigurement
  • Nerve, or muscle injury, or other injury to nearby structures like eyelids or nostrils
  • Certain rare, aggressive forms can be lethal if not treated promptly.

The larger the tumour has grown, the more extensive any surgical treatment would be. This could result in scarring.

In 2016 it is estimated that there were 560 deaths in Australia from non-melanoma skin cancers. It is not possible to identify how many of these are Squamous Cell Carcinomas as this data is not separately recorded.

Squamous Cell Carcinoma Treatment

Surgical Removal of Squamous Cell Carcinoma

Surgical removal or excision of the Squamous Cell Carcinoma is the most common treatment.

Non-melanoma skin cancers are almost always surgically removed under local anaesthetic and this is the safest form of treatment due to the potential of Squamous Cell Carcinomas to spread. This approach offers:

  • high cure rates
  • Is immediate,
  • Lesion margins are checked to ensure complete clearance
  • In more advanced skin cancers, some of the surrounding tissue may also be removed to make sure that all of the cancerous cells are cleared.

Excision Treatment Process - After careful administration of local anaesthetic, the Doctor uses a scalpel to remove the entire growth, along with surrounding apparently normal skin as a safety margin. The wound around the surgical site is then closed with sutures (stitches).

Excision Treatment Recovery - For a few days post excision there may be minor bruising and swelling. Scarring is usually minimal. Pain or discomfort is minor. Typically, where sutures are used, they are removed soon afterwards.

Surgical Excision Prognosis -  Studies indicate the cure rate for primary tumours with this technique is around 92 percent.  Clearance rates for recurrent Squamous Cell Carcinomas are lower around 77 percent. A repeat excision may be necessary on a subsequent occasion if evidence of skin cancer is found in the specimen.

Chemotherapy for Squamous Cell Carcinoma

Superficial Squamous Cell Carcinoma (also known as Bowen’s Disease) may be able to be treated with topical chemotherapy that is applied to the skin as an ointment or cream. This type of treatment is only for skin cancers that biopsy-proven to affect only the top layer of skin.

5-fluorouracil (5-FU) is approved for the treatment of Superficial Squamous Cell Carcinoma, however, invasive Squamous Cell Carcinoma should not be treated topically due to the risk of spread.

Mohs Micrographic Surgery for Squamous Cell Carcinoma

It is often used on tumours that have recurred, are poorly demarcated, or are in hard-to-treat, critical areas around the eyes, nose, lips, ears, neck, hands and feet.

Mohs Micrographic Surgery Treatment Process - Using a scalpel or curette (a sharp, ring-shaped instrument), a Mohs Surgeon removes the visible Squamous Cell Carcinoma with a very thin layer of tissue around it. While the patient waits, this layer is sectioned, frozen, stained and mapped in detail, then checked thoroughly under a microscope.

If cancer is still present in the depths or peripheries of this excised surrounding tissue, the procedure is repeated on the adjacent area of the body which still contains tumour cells until the last layer viewed under the microscope is cancer-free.

Mohs Micrographic Surgery Treatment Recovery - After tumour removal, the wound may be allowed to heal naturally or may be reconstructed immediately.

Mohs Micrographic Surgery Prognosis -  The cosmetic outcome is often excellent.

Radiotherapy for Squamous Cell Carcinoma

Radiotherapy is generally used to treat Squamous Cell Carcinomas in areas near the eyes or on the nose or forehead, or other areas which are difficult to treat with surgery.

Radiotherapy Treatment Process - This treatment uses x-rays to target and kill cancer cells. X-ray beams are directed at the tumour, with no need for cutting or anesthesia.

Radiotherapy Treatment Recovery - Destruction of the tumour usually requires a series of treatments, administered several times a week for one to four weeks, or sometimes daily for one month.

Radiotherapy Treatment Prognosis - Cure rates range widely, from about 65 to 95 percent, since the technique does not provide precise control in identifying and removing residual cancer cells at the margins of the tumour.  

The technique can involve long-term cosmetic problems and radiation risks, as well as multiple visits. For these reasons, though this therapy limits damage to adjacent tissue, it is mainly used for tumours that are hard to treat surgically, as well as patients for whom surgery is not advised, such as the elderly or those in poor health.

General Prognosis After Treatment

An individual's prognosis depends on the type and stage of cancer, as well as their age and general health at the time of diagnosis. The majority of Squamous Cell Carcinoma cancers are successfully treated.

When small Squamous Cell Carcinomas are removed, the scars are usually cosmetically quite acceptable. If the tumours are very large, a skin graft or flap may be used to repair the wound in order to achieve the best cosmetic result and facilitate healing.

Squamous Cell Carcinoma Recurrence

Squamous Cell Carcinomas on the scalp and nose are especially troublesome, with higher rates of recurrence and with these recurrences typically taking place within the first two to three years following surgery.

Should a cancer recur, your Doctor might recommend a different type of treatment. Some methods, such as Mohs micrographic surgery, may be highly effective for recurrences.

Squamous Cell Carcinoma Prevention

Anyone who has had one Squamous Cell Carcinoma has an increased chance of developing another, especially in the same skin area or nearby. That is usually because the skin has already suffered irreversible sun damage.

Thus, it is crucial to pay particular attention to any previously treated site, and any changes noted should be shown immediately to your Doctor at the Bondi Junction Skin Cancer Clinic.

Squamous Cell Carcinomas on the nose, ears, and lips are especially prone to recurrence.

Even if no suspicious signs are noticed, regularly scheduled follow-up visits including total-body skin exams are an essential part of post-treatment care every 6 months.

To prevent Squamous Cell Carcinoma make sure you follow the recommendations below:

  • Seek the shade, especially between 10am and 3pm when UV levels are most intense
  • Avoid sunburn by minimising sun exposure when the SunSmart UV Alert exceeds 3 and especially in the middle of the day in the warmer half of the year
  • Avoid tanning and never use UV tanning beds
  • Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses
  • Use Nicotinamide (Vitamin B3) 500mg twice a day unless contraindicated
  • Use a broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher
  • Apply sunscreen to your entire body 10 minutes before going outside. Reapply every two hours or immediately after swimming or excessive sweating, or towelling down
  • Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months
  • Examine your skin head-to-toe every month looking for unique changes.
  • If you see unique changes anywhere and of any kind, keep an eye on it and if it continues to change for more than 2-3 weeks the notify the Bondi Junction Skin Cancer Clinic without delay.

6 monthly checks are recommended if you have had a previous skin cancer