Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published June 14, 2023


How are localized cases of cutaneous squamous-cell carcinoma managed?

Skin cancer is the most frequently diagnosed cancer in the United States and worldwide. One in five Americans will have skin cancer in their lifetime. Read the NEJM Review Article here.

Clinical Pearls

Q: How common is cutaneous squamous-cell carcinoma?

A: Cutaneous squamous-cell carcinoma is the second most common type of skin cancer. It accounts for an increasing number of deaths from skin cancer in the United States.

Q: What are some of the clinical features of cutaneous squamous-cell carcinoma?

A: Cutaneous squamous-cell carcinoma can develop on any surface of the skin. It is more common in men than in women (3:1 ratio), and the risk increases dramatically with age. Patients typically present with scaly, erythematous, or bleeding lesions, most often on sun-exposed areas. Areas of the body that are not exposed to the sun, such as the palms of the hands, soles of the feet, nails, and anogenital regions, as well as areas of chronic inflammation or scarring, are common locations for cutaneous squamous-cell carcinoma in non-White populations.

Morning Report Questions

Q: Name some of the risk factors for cutaneous squamous-cell carcinoma.

A: The most important factors are cumulative exposure to ultraviolet radiation, age, and systemic immunosuppression. Innate, acquired, and iatrogenic immunosuppression can increase the risk of cutaneous squamous-cell carcinoma, the number of lesions, and the aggressiveness of any single lesion. Acquired immunosuppression, most commonly due to receipt of a solid-organ transplant, human immunodeficiency virus infection, chronic lymphocytic leukemia, lymphoma, or long-term immunosuppressive therapy, puts patients at increased risk for cutaneous squamous-cell carcinoma. Specifically, the incidence of disease has been reported to be higher by a factor of 5 to 113 among organ-transplant recipients than among immunocompetent persons. A family history of cutaneous squamous-cell carcinoma is associated with a risk that is two to four times that in persons without a family history. Other risk factors for the development of cutaneous squamous-cell carcinoma include chronic inflammation (from burn scars, chronic ulcers, sinus tracts, or inflammatory dermatoses), smoking, hypothyroidism, and medications (e.g., voriconazole, hydrochlorothiazide, BRAF inhibitors, and tumor necrosis factor inhibitors). Human papillomavirus is a risk factor for periungual and anogenital squamous-cell carcinoma in particular.

Q: How are localized cases of cutaneous squamous-cell carcinoma managed?

A: The majority of localized, low-risk cases of cutaneous squamous-cell carcinoma can be managed with destructive or surgical techniques performed in most outpatient office settings while the patient is receiving local anesthesia. With this technique, which involves the use of a curette to manually scrape the lesion and an electrosurgical device to remove cancerous cells without pathological assessment, the cure rate is as high as 95% for appropriately selected lesions. Surgery remains the mainstay of treatment for localized, high-risk cutaneous squamous-cell carcinoma. Mohs micrographic surgery or resection with peripheral and deep exhaustive margin assessment is recommended to achieve local control for high-risk and very high-risk cutaneous squamous-cell carcinoma. Mohs micrographic surgery has been shown to be highly effective for control of primary cutaneous squamous-cell carcinoma, with very low rates of local recurrence (1.2 to 4.1%), nodal metastasis, and disease-specific death.

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