Plastic surgical approach of the basal cell and the squamous cell carcinoma

Basal cell and squamous cell carcinoma

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) comprise the vast majority of nonmelanoma skin cancers. Over one million white Americans are affected by these two entities yearly. They predominantly affect fair-skinned individuals, and their incidence is rising rapidly. Etiology may be multifactorial, but sun exposure appears to play a critical role.

When detected early, their prognosis is generally excellent. However, both are malignant cutaneous lesions with inherent metastatic potential. Thus appropriate diagnosis, treatment and surveillance are of utmost importance.

Premalignant lesions

The most common precursor of cutaneous squamous cell carcinoma is the actinic keratosis, also known as the solar keratosis. It appears as a scaly, discrete, maculopapular lesion that arises primarily on sun-damaged skin.

Palpation of these flat lesions may reveal roughness that is not apparent on visual inspection. Due to the potential for progression to SCC, actinic keratoses are commonly treated by curettage and electrodessication, liquid nitrogen or topical 5-FU (Efudex).

Bowen's disease is a type of squamous cell carcinoma-in-situ marked by a solitary, sharply demarcated, erythematous, scaly plaque of the skin or mucous membranes. A second form of squamous cell carcinoma-in-situ is erythroplasia of Queyrat, which appears as glistening red plaques on the uncircumcised penis. Both have the potential for progression to invasive carcinoma and should be resected completely with conservative surgery.

Leukoplakia is a condition found on the oral mucosa commonly in association with smokeless tobacco use. These white patches may undergo malignant transformation to SCC in 15% to 20% of cases if left untreated. Epidermodysplasia verruciformis is a rare autosomal recessive disorder in which the body is unable to control human papilloma viral infections.

It manifests itself as flat wart-like lesions that frequently degenerate into SCC. A keratoacanthoma, on the other hand, grows rapidly to form a nodular, elevated lesion with a hyperkeratotic core. It may involute spontaneously or appear indistinguishable from a SCC, and early conservative excision is recommended.

Tumor staging

All nonmelanoma skin cancers are staged by the TNM system established by the American Joint Committee on Cancer (AJCC). Characteristics of the primary tumor (T), regional lymph node status (N) and distant metastasis (M) are considered. BCC rarely metastasizes, although it may be locally destructive. The malignant potential of SCC is real and is related to the size and location of the tumor, as well as the degree of anaplasia.

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