Squamous cell carcinoma of the skin physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2], Raviteja Guddeti, M.B.B.S. [3]; Jesus Rosario Hernandez, M.D. [4]

Overview

The findings of physical exam helps us in diagnosis and provides information about the prognosis of the disease. Many times physical exam done for some other reason may give us a hint for this.

Physical Examination

Skin

• SCC can develop on any cutaneous surface, including the head, neck, trunk, extremities, oral mucosa, periungual skin, and anogenital areas.
• In fair-skinned individuals, SCCs most commonly arise in sites frequently exposed to the sun.
• The most common distribution in individuals with dark skin is non sun exposed skin.
• In black individuals, common sites for SCC include the legs, anus, and areas of chronic inflammation or scarring.
• Infection with high-risk human papillomavirus (HPV) can lead to genital and periungual lesion but are rare overall.
• administration of psoralen plus ultraviolet A (PUVA) phototherapy without genital shields can also leads to genital lesions.

• The clinical appearance of cutaneous SCC is influenced by the lesion type and site
  • Bowen's disease(SCC in situ)
• Well-demarcated, scaly patch or plaque.
• Lesions are often erythematous but can also be skin colored or pigmented.
  • Erythroplasia of Queyrat
• Squamous cell carcinoma in situ involving the penis.
• Well-defined, velvety, red plaque

• • Invasive Squamous cell carcinoma:
• Well-differentiated lesions :Indurated hyperkeratotic papules,plaques or nodules.
• Poorly differentiated lesions :Fleshy, soft, granulomatous papules or nodules without hyperkeratosis.

Squamous cell carcinoma (SCC) accounts for about 20% of non-melanoma skin cancers, (with basal cell carcinomas accounting for about 80%), and are clinically more significant because of their ability to metastasize.

• Presence of ulcer makes a point to observe more in detail. It will be a shallow ulcer with heaped up edges, covered by a plaque.
• Irregularity of edges is a striking feature which differentiates it from other inflammatory conditions.
• One third of the lesions are white (Leukoplakia). They may have red articulation at times making it erythroplakia. But only few of them turn up as carcinomas.
• Surface changes are very peculiar for SCC. They are:
  • Scaling
  • Crusting
  • Cutaneous horns

If not seen we can think of a metastatic lesion or any other lesion instead.

• It can be warty/exophytic fungating mass most of the times,especially in the regions of ear, nose at times on tongue even.
• SCC of skin of head neck may at times metastasise to lymph nodes, so they demand a look. Risk of metastasise to lymph nodes depends on the size of the tumour.
• SCC of head neck need a special mention for examination of cranial nerves as they may be involved depending upon the tumour site.

Tongue and oral cavity

Squamous cell carcinoma is usually developed in the epithelial layer of the skin and sometimes in various mucous membranes of the body.

• Leukoplakia/Eryhtroplakia of tongue is seen, mostly on the lateral borders.
• There are chances of spreading to the adjacent temporo mandibular joint, so checking up with the movements of joint is important.

• SCC of esophagus doesn't show any physical signs as such except for difficulty/ pain during swallowing.

Lungs

Patients do not have any pulmonary signs per se. But if it is malignant it may make the person cachexic. Exophytic lesions have good prognosis.

• It can be source of ectopicc PTH causing hypercalcemia, a para-neoplastic syndrome, which can cause symptoms in turn.

Penis

It can present to the physician as nodule, ulcer or as a inflammatory lesion. Erythroplasia of Queyrat is squamous cell carcinoma in situ of the penis.

Genitals

• Subtle induration can be noticed in pre malignnant lesions.
• Papillary lesions can coalesce to become a large fungating masss.
• ulcers are shallow, round and flat on an elevated base.
• Both these kinds of lesions can be a infected leading to pus, necrosis.
• Palpable lymphadenopathy can be noticed in many cases.

Variants of SCC with specific characteristics:

• Adenoid SCC - It is more aggressive clinically, seen most of the times in elderly individuals.It has glandular differentiation.
• Keratocanthoma- They appear as solitary nodule,which may involute spontaneously. They have a rapid growth and well differentiated.
• Spindle cell - Resembles SCC, but histologically differentiated into spindle cells (atypical)
• Verrucous - it has very slow,exophytic growth which is well differentiated and locally destructive. It rarely metastasizes.

References

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