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Squamous Cell Carcinoma of the Skin

I. Definition:

A squamous cell carcinoma of the skin is a form of skin cancer which is usually the
result of long term sun damage to the skin. Squamous cell carcinomas enlarge
slowly and steadily and can invade neighboring tissue, like the eye. They can also
spread to distant parts of the body (metastasize) if not treated early. The only way
to tell for sure if a skin growth is cancerous is to biopsy it. This involves removing a
small piece of the skin and having a pathologist look at it under the microscope in a
medical laboratory. A biopsy does not remove the cancer, it only takes off the very
top (like the tip of an iceberg). Sometimes the skin will heal after the biopsy because
it grows over the cancer. This does not mean the cancer is gone, it means the
cancer is now covered with a blanket of skin. If the cancer is not removed
completely it can go deep into the skin and metastasize to the internal organs
causing death.

II. Causes:

Repeated, prolonged sun exposure causes skin damage which may develop
into squamous cell carcinoma.
The sun damage responsible for a squamous cell carcinoma usually occurred
years before the cancer begins.
Squamous cell carcinomas are most common on the face because the face
receives more sunlight than other parts of the body.
Fair-skinned individuals are more prone to skin cancer than darker persons,
since skin pigment protects the skin. Persons of African ancestry with very
dark skin practically never get squamous cell carcinoma of the skin.
People who get one squamous cell carcinoma are likely to develop more.
Often people will develop a second squamous cell carcinoma close to the spot
were one has been treated because the surrounding skin is just as damaged by
the sun as the skin where the first squamous cell carcinoma grew.

III. Prevention:

Sun exposure and sunbathing produce gradual skin damage even if sunburn is
avoided. Ten to forty years can pass between the time of sun exposure and
the development of a squamous cell skin cancer.
Sun damage is permanent and irreversible. You should put on sun-screen or
moisturizer with an SPF of 15 or higher everyday before leaving the house.
Don't go overboard and try to avoid the sun completely. The damage is
already done; a little more sun will not make much difference.
Some who have had a squamous cell carcinoma need to come back every
three months for two years for a skin exam and then every six months for life.
Most recurrences are in the first two years.

IV. Treatment:

After a biopsy has been done and a squamous cell carcinoma is found by the
pathologist, the tumor needs to be removed. Squamous cell carcinomas are not
cured by doing a biopsy. The skin will often heal after a biopsy. This is
because the skin grows over the cancer like a blanket - further surgery is
required. Surgery always leaves a scar. There is no way to remove a
squamous cell carcinoma without leaving a scar. Often the scar can be hidden
in the skin folds. Squamous cell carcinomas are often much bigger under the
skin then they appear on the surface. What one can see on the surface is only
the tip of the iceberg. That is why the hole left after removing a squamous cell
cancer is often much larger than what can be seen before surgery.
The most important point about skin cancer is it needs to be completely
removed. Many people have lost body parts because of these tumors and
some people have lost their lives.
After the cancer is removed, the patient needs to be closely monitored. Even if
the cancer is removed, there is a chance the cancer has all ready spread to
other body areas. You need to see the doctor every three months for two
years for a skin exam and then every six months for life.

Why Do I Need Surgery?



You have a biopsy which shows that you have skin cancer (figure 1). Skin cancers
enlarge slowly and steadily and can invade neighboring areas, like the eye. They can
also spread to distant parts of the body if left untreated. Several weeks ago you had
a biopsy done. The purpose of the biopsy was to find out if the growth that you or
the doctor found was dangerous. A biopsy does not remove the cancer, it only takes
off the very top (like the tip of an iceberg) (figure 2).
skin_cancer.gif (4649 bytes)
Figure 1 - Most of Cancer is Under the Skin Surface.




skin_cancer2.gif (4372 bytes)
Figure 2 - The Biopsy Removes Only a Small Portion of the Cancer. After 1-2
Weeks the Skin Grows Over the Cancer.



Sometimes the skin will heal after the biopsy because it grows over the cancer. This
does not mean the cancer is gone; it means the cancer is now covered with a
blanket of skin. If the cancer is not removed completely it can go deep into the skin
and cause great harm.

In order to remove your skin cancer, the doctor will first scrape the area with a
spoon-like tool called a curette. The cancerous tissue is very soft, like a bad spot in
an apple. The soft cancerous tissue spoons right out. The doctor knows when to
stop because normal skin is firm or hard compared to the cancer. Skin cancers are
much larger than they appear on the surface of the skin. What one sees on the skin
surface is only the tip of the iceberg. It is not uncommon for the hole remaining
after skin cancer removal to be the size of a nickel. Some patients have a hole the
size of a quarter or larger after the skin cancer is removed.
skin_cancer3.gif (13451 bytes)
Figure 3 - After the Cancer is Removed, a Large Hole Remains.

After the doctor has scraped out all of the cancerous tissue, he will cut all around
the hole with a margin of normal skin measuring about 1/8 of an inch. The tissue
removed will than be sent to a pathologist. The pathologist will look at the edges to
make sure the cancer is all out. If the pathologist finds cancer at the edges of the
removed skin, the doctor will have to go back one week later and remove more
tissue. The chances of needing a second surgery to remove all of the cancer is 1 in
20. There is a 1 in 100 chance of needing three surgeries to remove all of the skin
cancer. The doctor may fix the hole right away if it is not too large and a side to side
closure can be done, or he may wait one week to fix the hole. The reason for
waiting one week is to be sure the cancer is all out before closing the wound. This is
especially important when a side to side closure cannot be done because of the
location of the wound.

There is no way to remove a skin cancer without leaving a scar. Often the scar can
be hidden in your natural skin folds. The most important point about skin cancer is
that it needs to be completely removed. Many people have lost ears and eyes
because their doctor did not remove the entire tumor and some people have lost
their lives. The techniques we use give you a 99% chance of being cured of your
cancer. Other dermatologist and doctors often scrape and burn skin cancers which
can be done in one visit, but this technique has only a 90-95% cure rate. When skin
cancers are not cured they come back more aggressive and more difficult to treat.
Every 2 weeks we see a patient that has had a recurrence of a skin cancer and some
of these have been over 2 inches in size.

All surgery has risks. The risks of complications are low for skin surgery. All
patients will have a scar. You need to be patient because the scar will not have its
final appearance for six to twelve months after the surgery. Most patients will have
numbness in the area for six months, but this can last up to two years. The risk of
infection is low, but studies show that no matter how clean the surgery is, some
wounds will get infected. If your wound gets infected, the doctor will put you on an
antibiotic for one week. The scar will not heal as well if your wound becomes
infected. It is very important that you follow the wound care instructions given to
you at the end of surgery. Sometimes a blood clot will form under the skin. It this
occurs you will have a hard lump in the area for six to twelve months until your
body absorbs it. The only danger from a blood clot under the skin is an increased
risk of infection.
skin_cancer_nose_before_graft.gif (16372 bytes)skin_cancer_nose_graft.gif (18131 bytes)skin_cancer_nose_after_graft.gif (16204 bytes)


Low resolution unretouched photographs. Left, typical defect of the nose after
removal of a basal cell skin cancer of the nose. Right, defect repaired with a full
thickness skin graft; graft obtained from behind the right ear. Bottom, appearance
one month later.

 

 
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