Skin Cancer

  • Dana-Farber/Brigham and Women's Cancer Care

    Skin cancer forms in tissues of the skin. Basal cell or squamous cell cancer forms in cells that do not make pigment. Both types usually occur in skin that has been exposed to sunlight, such as on the face, neck, hands, and arms. Learn about skin cancer and find information on how we support and care for people with skin cancer before, during, and after treatment.

Skin Cancer Treatment at the Center for Cutaneous Oncology 

At the Center for Cutaneous Oncology, we believe that each case of skin cancer is as unique as the individual facing the diagnosis. Experts from a wide variety of medical fields are here to evaluate and treat your particular skin cancer, no matter how rare or complex.

As a patient in the Center for Cutaneous Oncology, you will be cared for by a dedicated team that focuses exclusively on skin cancers. Our experts include dermatologic oncologists, dermatopathologists, medical oncologists, surgical oncologists, radiation oncologists, radiologists, and other specialists.

Our skin cancer specialists work together, and with you, to create individualized treatment that supports all your medical, nutritional, and emotional needs.

Our clinicians are experts in treating all types of skin cancer, including: 

  • Cutaneous T cell and B cell lymphoma (CTCL, CBCL)
  • Merkel cell carcinoma (MCC)
  • Basal cell carcinoma  (BCC)
  • Squamous cell carcinoma  (SCC)
  • Rare adnexal neoplasms:  eccrine, apocrine, sebaceous, and hair follicle tumors
  • Other rare cutaneous cancers

We also treat cutaneous complications of therapy for cancers in general, including:

  • Graft-versus-host disease (GVHD)
  • Skin reactions to cancer chemotherapy

Learn more about skin cancer treatment at the Center for Cutaneous Oncology  

Contact us 

New patients 

If you have never been seen before at Dana-Farber/Brigham and Women's Cancer Center, please call 877-442-3324 or use this online form to make an appointment.

Established patients: 617-632-6571 

Referring physicians: 617-632-6869 

Fax: 617-632-6727 

Mohs Micrographic Surgery Center 

Phone: 617-983-4626 

Fax: 617-983-4504 

Information for: Patients | Healthcare Professionals

General Information About Skin Cancer

Skin cancer is a disease in which malignant (cancer) cells form in the tissues of the skin.

The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. Skin also helps control body temperature and stores water, fat, and vitamin D. The skin has several layers, but the two main layers are the epidermis (upper or outer layer) and the dermis (lower or inner layer). Skin cancer begins in the epidermis, which is made up of 3 kinds of cells:

  • Squamous cells: Thin, flat cells that form the top layer of the epidermis.
  • Basal cells: Round cells under the squamous cells.
  • Melanocytes: Found in the lower part of the epidermis, these cells make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to darken.
Skin anatomy; drawing shows layers of the epidermis, dermis, and subcutaneous tissue including hair shafts and follicles, oil glands, lymph vessels, nerves, fatty tissue, veins, arteries, and a sweat gland.  
Anatomy of the skin, showing the epidermis, dermis, and subcutaneous tissue.

Skin cancer can occur anywhere on the body, but it is most common in skin that is often exposed to sunlight, such as the face, neck, hands, and arms. There are several types of cancer that start in the skin. The most common types are basal cell carcinoma and squamous cell carcinoma, which are nonmelanoma skin cancers. Actinic keratosis is a skin condition that sometimes develops into squamous cell carcinoma.

This summary refers to the treatment of nonmelanoma skin cancer and actinic keratosis. Nonmelanoma skin cancers rarely spread to other parts of the body. Melanoma, the rarest form of skin cancer, is more likely to invade nearby tissues and spread to other parts of the body. See the following PDQ summaries for information on melanoma and other kinds of skin cancer:

  • Melanoma Treatment
  • Mycosis Fungoides and the Sézary Syndrome Treatment
  • Kaposi Sarcoma Treatment

Skin color and exposure to sunlight can affect the risk of developing nonmelanoma skin cancer and actinic keratosis.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for basal cell carcinoma and squamous cell carcinoma include the following:

  • Being exposed to a lot of natural or artificial sunlight.
  • Having a fair complexion (blond or red hair, fair skin, green or blue eyes, history of freckling).
  • Having scars or burns on the skin.
  • Being exposed to arsenic.
  • Having chronic skin inflammation or skin ulcers.
  • Being treated with radiation.
  • Taking immunosuppressivedrugs (for example, after an organ transplant).
  • Having actinic keratosis.

Risk factors for actinic keratosis include the following:

  • Being exposed to a lot of sunlight.
  • Having a fair complexion (blond or red hair, fair skin, green or blue eyes, history of freckling).

Nonmelanoma skin cancer and actinic keratosis often appear as a change in the skin.

Not all changes in the skin are a sign of nonmelanoma skin cancer or actinic keratosis, but a doctor should be consulted if changes in the skin are seen.

Possible signs of nonmelanoma skin cancer include the following:

  • A sore that does not heal.
  • Areas of the skin that are:
    • Small, raised, smooth, shiny, and waxy.
    • Small, raised, and red or reddish-brown.
    • Flat, rough, red or brown, and scaly.
    • Scaly, bleeding, or crusty.
    • Similar to a scar and firm.
     

Possible signs of actinic keratosis include the following:

  • A rough, red, pink, or brown, raised, scaly patch on the skin.
  • Cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.

Tests or procedures that examine the skin are used to detect (find) and diagnose nonmelanoma skin cancer and actinic keratosis.

The following procedures may be used:

  • Skin examination: A doctor or nurse checks the skin for bumps or spots that look abnormal in color, size, shape, or texture.
  • Biopsy: All or part of the abnormal-looking growth is cut from the skin and viewed under a microscope by a pathologist to see if cancer cells are present. There are 3 main types of skin biopsies:
    • Shave biopsy: A sterile razor blade is used to “shave-off” the abnormal-looking growth.
    • Punch biopsy: A special instrument called a punch or a trephine is used to remove a circle of tissue from the abnormal-looking growth.
      Punch biopsy; drawing shows a hollow, circular scalpel being inserted into a lesion on the skin of a patient’s forearm. The instrument is turned clockwise and counterclockwise to cut into the skin and a small sample of tissue is removed to be checked under a microscope. The pullout shows that the instrument cuts down about 4 millimeters (mm) to the layer of fatty tissue below the dermis.  
      Punch biopsy. A hollow, circular scalpel is used to cut into a lesion on the skin. The instrument is turned clockwise and counterclockwise to cut down about 4 millimeters (mm) to the layer of fatty tissue below the dermis. A small sample of tissue is removed to be checked under a microscope. Skin thickness is different on different parts of the body.
    • Excisional biopsy: A scalpel is used to remove the entire growth.
     

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends mostly on the stage of the cancer and the type of treatment used to remove the cancer.

Treatment options depend on the following:

  • The stage of the cancer (whether it has spread deeper into the skin or to other places in the body).
  • The type of cancer.
  • The size and location of the tumor.
  • The patient’s general health.

Stages of Skin Cancer

After nonmelanoma skin cancer has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

The process used to find out if cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. A biopsy is often the only test needed to determine the stage of nonmelanoma skin cancer. Lymph nodes may be examined in cases of squamous cell carcinoma to see if cancer has spread to them.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for nonmelanoma skin cancer:

Stage 0 (Carcinoma in Situ)

Stage 0 nonmelanoma; drawing shows skin anatomy with abnormal cells in the epidermis (outer layer of the skin). Also shown are the dermis (inner layer of the skin) and subcutaneous tissue below the dermis.  
Stage 0 nonmelanoma. Abnormal cells are shown in the epidermis (outer layer of the skin).

In stage 0, abnormalcells are found in the squamous cell or basal cell layer of the epidermis (topmost layer of the skin). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Tumor size compared to everyday objects; shows various measurements of a tumor compared to a pea, peanut, walnut, and lime  
Pea, peanut, walnut, and lime show tumor sizes.

Stage I

Stage I nonmelanoma skin cancer; drawing shows a tumor in the epidermis (outer layer of the skin) that is no more than 2 centimeters wide. Also shown are the dermis (inner layer of the skin) and the subcutaneous tissue below the dermis.  
Stage I nonmelanoma skin cancer. The tumor is no more than 2 centimeters.

In stage I, cancer has formed and the tumor is 2 centimeters or smaller.

Stage II

Stage II nonmelanoma skin cancer; drawing shows a tumor that is more than 2 centimeters wide that has spread from the epidermis (outer layer of the skin) into the dermis (inner layer of the skin). Also shown is the subcutaneous tissue below the dermis.  
Stage II nonmelanoma skin cancer. The tumor is more than 2 centimeters wide.

In stage II, the tumor is larger than 2 centimeters.

Stage III

Stage III nonmelanoma skin cancer; drawing shows a tumor that has spread from the epidermis (outer layer of the skin) and dermis (inner layer of the skin) into the subcutaneous tissue and to cartilage, bone, or muscle below the skin and/or to nearby lymph nodes.  
Stage III nonmelanoma skin cancer. The tumor has spread below the skin to nearby tissues and/or lymph nodes.

In stage III, cancer has spread below the skin to cartilage, muscle, or bone and/or to nearby lymph nodes, but not to other parts of the body.

Stage IV

Stage IV nonmelanoma skin cancer; drawing shows that the primary tumor has spread to other places in the body, such as the brain or lung. The pullout shows cancer in the lymph nodes, lymph vessels, and blood vessel in the arm with the primary tumor.  
Stage IV nonmelanoma skin cancer. The tumor has spread to other places in the body, such as the brain or lung.

In stage IV, cancer has spread to other parts of the body.

Treatment choices are based on the type of nonmelanoma skin cancer or precancerous skin condition diagnosed:

Basal cell carcinoma

Basal cell carcinoma is the most common type of skin cancer. It usually occurs on areas of the skin that have been in the sun, most often the nose. Often this cancer appears as a small raised bump that has a smooth, pearly appearance. Another type looks like a scar and is flat and firm to the touch. Basal cell carcinoma may spread to tissues around the cancer, but it usually does not spread to other parts of the body.

Squamous cell carcinoma

Squamous cell carcinoma occurs on areas of the skin that have been in the sun, such as the ears, lower lip, and the back of the hands. Squamous cell carcinoma may also appear on areas of the skin that have been burned or exposed to chemicals or radiation. Often this cancer appears as a firm red bump. Sometimes the tumor may feel scaly or bleed or develop a crust. Squamous cell tumors may spread to nearby lymph nodes.

Actinic keratosis

Actinic keratosis is a skin condition that is not cancer, but sometimes changes into squamous cell carcinoma. It usually occurs in areas that have been exposed to the sun, such as the face, the back of the hands, and the lower lip. It appears as rough, red, pink, or brown, raised, scaly patches on the skin, or cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.

Treatment Option Overview

There are different types of treatment for patients with nonmelanoma skin cancer and actinic keratosis.

Different types of treatment are available for patients with nonmelanoma skin cancer and actinic keratosis. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Four types of standard treatment are used:

Surgery

One or more of the following surgical procedures may be used to treat nonmelanoma skin cancer or actinic keratosis:

  • Mohs micrographic surgery: The tumor is cut from the skin in thin layers. During surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used to remove skin cancer on the face.
    Mohs surgery; drawing shows a patient with skin cancer on the face. The pullout shows a block of skin with cancer in the epidermis (outer layer of the skin) and the dermis (inner layer of the skin). A visible lesion is shown on the skin’s surface. Four numbered blocks show the removal of thin layers of the skin one at a time until all the cancer is removed. 
    Mohs surgery. A surgical procedure to remove skin cancer in several steps. First, a thin layer of cancerous tissue is removed. Then, a second thin layer of tissue is removed and viewed under a microscope to check for cancer cells. More layers are removed one at a time until the tissue viewed under a microscope shows no remaining cancer. This type of surgery is used to remove as little normal tissue as possible and is often used to remove skin cancer on the face.
  • Simple excision: The tumor is cut from the skin along with some of the normal skin around it.
  • Shave excision: The abnormal area is shaved off the surface of the skin with a small blade.
  • Electrodesiccation and curettage: The tumor is cut from the skin with a curette (a sharp, spoon-shaped tool). A needle-shaped electrode is then used to treat the area with an electric current that stops the bleeding and destroys cancer cells that remain around the edge of the wound. The process may be repeated one to three times during the surgery to remove all of the cancer.
  • Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormaltissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
    Cryosurgery; drawing shows an instrument with a nozzle held over an abnormal area on the lower arm of a patient. Inset shows a spray of liquid nitrogen or liquid carbon dioxide coming from the nozzle and covering the abnormal lesion. Freezing destroys the lesion. 
    Cryosurgery. An instrument with a nozzle is used to spray liquid nitrogen or liquid carbon dioxide to freeze and destroy abnormal tissue.
  • Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
  • Dermabrasion: Removal of the top layer of skin using a rotating wheel or small particles to rub away skin cells.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Chemotherapy for nonmelanoma skin cancer and actinic keratosis is usually topical (applied to the skin in a cream or lotion). The way the chemotherapy is given depends on the condition being treated.

Retinoids (drugs related to vitamin A) are sometimes used to treat or prevent nonmelanoma skin cancer. The retinoids may be taken by mouth or applied to the skin. The use of retinoids is being studied in clinical trials for treatment of squamous cell carcinoma.

Photodynamic therapy

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. For skin cancer, laser light is shined onto the skin and the drug becomes active and kills the cancer cells. Photodynamic therapy causes little damage to healthy tissue.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's clinical trials database.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options for Nonmelanoma Skin Cancer

A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.

Basal Cell Carcinoma

Treatment of basal cell carcinoma may include the following:

  • Mohs micrographic surgery.
  • Simple excision.
  • Electrodesiccation and curettage.
  • Cryosurgery.
  • Radiation therapy.
  • Laser surgery.
  • Topical chemotherapy with fluorouracil.
  • Photodynamic therapy.
  • A clinical trial of biologic therapy.

Follow-up skin exams are important for people with basal cell carcinoma because they are likely to have a new or recurrent tumor within 5 years of the first one. After treatment, the patient should have skin exams every 6 months for 5 years and once a year after that.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with basal cell carcinoma of the skin. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Squamous Cell Carcinoma

Treatment of squamous cell carcinoma may include the following:

  • Mohs micrographic surgery.
  • Simple excision.
  • Electrodesiccation and curettage.
  • Cryosurgery.
  • Radiation therapy.
  • Topical chemotherapy with fluorouracil.
  • Laser surgery.
  • A clinical trial of biologic therapy.
  • A clinical trial of biologic therapy and retinoids.

Follow-up skin exams are important for people with squamous cell carcinoma. Because squamous cell carcinoma can spread, patients should have skin exams every 3 months for several years after treatment and then every 6 months.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with squamous cell carcinoma of the skin. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Treatment Options for Actinic Keratosis

Actinic keratosis is not cancer but is treated because it may develop into cancer. Treatment of actinic keratosis may include the following:

  • Topical chemotherapy.
  • Cryosurgery.
  • Electrodesiccation and curettage.
  • Dermabrasion.
  • Shave excision.
  • Laser surgery.
  • Photodynamic therapy.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with actinic keratosis. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

To Learn More About Skin Cancer

For more information from the National Cancer Institute about skin cancer, see the following:

For general cancer information and other resources from the National Cancer Institute, see the following:


This information is provided by the National Cancer Institute.

This information was last updated on March 31, 2009.


Purpose of This PDQ Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of skin cancer. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board.

Information about the following is included in this summary:

  • Clinical features.
  • Cellular classification.
  • Staging.
  • Treatment options for different types of tumors.

This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for reimbursement determinations.

This summary is available in a patient version, written in less technical language, and in Spanish.

General Information

Note: Separate PDQ summaries on Screening for Skin Cancer and Prevention of Skin Cancer are also available.

Basal cell carcinoma is the most common form of skin cancer, and squamous cell carcinoma is the second most common type of skin malignancy. Although the two types of skin cancer are the most common of all malignancies, they account for less than 0.1% of patient deaths caused by cancer. Both of these types of skin cancer are more likely to occur in individuals of light complexion who have had significant exposure to sunlight, and both types of skin cancer are more common in the southern latitudes of the Northern hemisphere.[1]

The overall cure rate for basal cell carcinoma and squamous cell carcinoma is directly related to the stage of the disease and the type of treatment used.[2] Since neither basal cell carcinoma nor squamous cell carcinoma are reportable diseases, precise 5-year cure rates are not known.

Although basal cell carcinoma and squamous cell carcinoma are by far the most frequent types of skin tumors, the skin can also be the site of a large variety of malignant neoplasms. Other types of malignant disease include malignant melanoma, cutaneous T-cell lymphomas (e.g., mycosis fungoides), Kaposi sarcoma, extramammary Paget disease, apocrine carcinoma of the skin, and metastatic malignancies from various primary sites. (Refer to the PDQ summaries on Melanoma Treatment; Mycosis Fungoides and the Sézary Syndrome Treatment; and Kaposi Sarcoma Treatment for more information.) Guidelines for the care of cutaneous squamous cell carcinoma have been published.[3]

References:

  1. Wagner RF, Casciato DA: Skin cancers. In: Casciato DA, Lowitz BB, eds.: Manual of Clinical Oncology. 4th ed. Philadelphia, Pa: Lippincott, Williams, and Wilkins, 2000, pp 336-373.  

  2. Rowe DE, Carroll RJ, Day CL Jr: Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 15 (3): 315-28, 1989.  

  3. Guidelines of care for cutaneous squamous cell carcinoma. Committee on Guidelines of Care. Task Force on Cutaneous Squamous Cell Carcinoma. J Am Acad Dermatol 28 (4): 628-31, 1993.  

Cellular Classification

Basal cell carcinoma and squamous cell carcinoma are both of epithelial origin. They are usually diagnosed on the basis of routine histopathology.[1] Squamous cell carcinoma is graded 1 to 4 based on the proportion of differentiating cells present, the degree of atypicality of tumor cells, and the depth of tumor penetration.[2] Apocrine carcinomas, which are rare, are associated with an indolent course and usually arise in the axilla.[3]

References:

  1. Lever WF, Schaumburg-Lever G: Histopathology of the Skin. New York: JB Lippincott, 6th ed., 1983.  

  2. Immerman SC, Scanlon EF, Christ M, et al.: Recurrent squamous cell carcinoma of the skin. Cancer 51 (8): 1537-40, 1983.  

  3. Paties C, Taccagni GL, Papotti M, et al.: Apocrine carcinoma of the skin. A clinicopathologic, immunocytochemical, and ultrastructural study. Cancer 71 (2): 375-81, 1993.  

Stage Information

Basal cell carcinoma rarely metastasizes, and thus a metastatic work-up is usually not necessary.[1] Regional lymph nodes should be routinely examined in all cases of squamous cell carcinoma, especially for high-risk tumors appearing on the lips, ears, perianal and perigenital regions, or high-risk areas of the hand.[2] In addition, regional lymph nodes should be examined in cases of squamous cell carcinoma arising in sites of chronic ulceration or inflammation, burn scars, or sites of previous radiation therapy treatment.

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[3] The TNM classification is used to stage both basal cell carcinoma and squamous cell carcinoma.

TNM Definitions

Primary tumor (T)

  • TX: Primary tumor cannot be assessed
  • T0: No evidence of primary tumor
  • Tis: Carcinoma in situ 
  • T1: Tumor not larger than 2 cm in greatest dimension
  • T2: Tumor larger than 2 cm but not larger than 5 cm in greatest dimension
  • T3: Tumor larger than 5 cm in greatest dimension
  • T4: Tumor invades deep extradermal structures (e.g., cartilage, skeletal muscle, or bone)

    In the case of multiple simultaneous tumors, the tumor with the highest T category will be classified, and the number of separate tumors will be indicated in parentheses, e.g., T2 (5).

Regional lymph nodes (N)

  • NX: Regional lymph nodes cannot be assessed
  • N0: No regional lymph node metastasis
  • N1: Regional lymph node metastasis

Distant metastasis (M)

  • MX: Distant metastasis cannot be assessed
  • M0: No distant metastasis
  • M1: Distant metastasis

AJCC Stage Groupings

Stage 0

  • Tis, N0, M0

Stage I

  • T1, N0, M0

Stage II

  • T2, N0, M0
  • T3, N0, M0

Stage III

  • T4, N0, M0
  • Any T, N1, M0

Stage IV

  • Any T, any N, M1

Basal cell carcinoma  

Basal cell carcinoma is at least three times more common than squamous cell carcinoma in nonimmunocompromised patients. It usually occurs on sun-exposed areas of skin, and the nose is the most frequent site. Although there are many different clinical presentations for basal cell carcinoma, the most characteristic type is the asymptomatic nodular or nodular ulcerative lesion that is elevated from the surrounding skin and has a pearly quality and contains telangiectatic vessels. Basal cell carcinoma has a tendency to be locally destructive. High-risk areas for tumor recurrence include the central face (e.g., periorbital region, eyelids, nasolabial fold, or nose-cheek angle), postauricular region, pinna, ear canal, forehead, and scalp.[4] A specific subtype of basal cell carcinoma is the morpheaform type. This subtype typically appears as a scar-like, firm plaque. Because of indistinct clinical tumor margins, the morpheaform type is difficult to treat adequately with traditional treatments.[1]

Squamous cell carcinoma  

Squamous cell tumors also tend to occur on sun-exposed portions of the skin such as the ears, lower lip, and dorsa of the hand. However, squamous cell carcinomas that arise in areas of non–sun-exposed skin or that originate de novo on areas of sun-exposed skin are prognostically worse since they have a greater tendency to metastasize. Chronic sun damage, sites of prior burns, arsenic exposure, chronic cutaneous inflammation as seen in long standing skin ulcers, and sites of previous x-ray therapy are predisposed to the development of squamous cell carcinoma.[1]

Actinic keratosis  

Actinic keratoses are potential precursors of squamous cell carcinoma. These typical red scaly patches usually arise on areas of chronically sun-exposed skin, and are likely to be found on the face and dorsal aspects of the hand. Although the vast majority of actinic keratoses do not become squamous cell carcinomas, as many as 5% of actinic keratoses will evolve into this locally invasive carcinoma. Due to this premalignant potential, the destruction of actinic keratoses is advocated.[1]

References:

  1. Wagner RF, Casciato DA: Skin cancers. In: Casciato DA, Lowitz BB, eds.: Manual of Clinical Oncology. 4th ed. Philadelphia, Pa: Lippincott, Williams, and Wilkins, 2000, pp 336-373.  

  2. Rayner CR: The results of treatment of two hundred and seventy-three carcinomas of the hand. Hand 13 (2): 183-6, 1981.  

  3. Carcinoma of the skin (excluding eyelid, vulva, and penis). In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 203-208.  

  4. Dubin N, Kopf AW: Multivariate risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 119 (5): 373-7, 1983.  

Basal Cell Carcinoma of the Skin

The traditional methods of treatment involve the use of cryosurgery, radiation therapy, electrodesiccation and curettage, and simple excision. Each of these methods is useful in specific clinical situations.[1] Depending on case selection, these methods have cure rates ranging from 85% to 95%.

Mohs micrographic surgery has the highest 5-year cure rates for surgical treatment of both primary (96%) and recurrent (90%) tumors. This method uses microscopic control to evaluate the extent of tumor invasion.

Treatment options:  

  1. Mohs micrographic surgery.[2][3] Although this method is complicated and requires special training, it has the highest cure rate of all surgical treatments because the tumor is microscopically delineated until it is completely removed. While other treatment methods for recurrent basal cell carcinoma have failure rates of about 50%, cure rates have been reported at 96% when treated by Mohs micrographic surgery. In addition, its use is indicated for the treatment of primary basal cell carcinomas when they occur at sites known to have a high initial-treatment failure rate with traditional methods (e.g., periorbital area, nasolabial fold, nose-cheek angle, posterior cheek sulcus, pinna, ear canal, forehead, scalp, or tumors arising in a scar). Mohs micrographic surgery is also indicated for:
    • Tumors with poorly defined clinical borders.
    • Tumors with diameters more than 2 cm.
    • Tumors with histopathologic features showing morpheaform or sclerotic patterns.
    • Tumors arising in regions where maximum preservation of uninvolved tissue is desirable such as the eyelid, nose, finger, and genitalia.
     
  2. Simple excision with frozen or permanent sectioning for margin evaluation. This traditional surgical treatment usually relies on surgical margins ranging from 3 mm to 10 mm, depending on the diameter of the tumor.[4]

    Tumor recurrence is not uncommon because only a small fraction of the total tumor margin is examined pathologically. Recurrence rate for primary tumors more than 1.5 cm in diameter is at least 12% within 5 years; if the primary tumor measures more than 3 cm, the 5-year recurrence rate is 23.1%. Primary tumors of the ears, eyes, scalp, and nose have recurrence rates ranging from 12.9% to 25%.

  3. Electrodesiccation and curettage. This method is the most widely employed method for removing primary basal cell carcinomas. Although it is a quick method for destroying the tumor, adequacy of treatment cannot be assessed immediately since the surgeon cannot visually detect the depth of microscopic tumor invasion.

    Tumors with diameters ranging from 2 mm to 5 mm have a 15% recurrence rate after treatment with electrodesiccation and curettage. When tumors more than 3 cm are treated with electrodesiccation and curettage, a 50% recurrence rate should be expected within 5 years.

  4. Cryosurgery. Cryosurgery may be considered for patients with small, clinically well-defined primary tumors. It is especially useful for debilitated patients with medical conditions that preclude other types of surgery.

    Absolute contraindications for cryosurgery include abnormal cold tolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud disease (only for treatment of lesions on hands and feet), and platelet deficiency disorders. Morphea or sclerosing basal cell carcinoma should not be treated by cryosurgery. Relative contraindications to cryosurgery include tumors of the scalp, ala nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid margin, upper lip vermillion border, and lower legs. Caution should also be used before treating nodular ulcerative neoplasia more than 3 cm, carcinomas fixed to the underlying bone or cartilage, tumors situated on the lateral margins of the fingers and at the ulnar fossa of the elbow, or recurrent carcinomas following surgical excision. Significant morbidity is associated with the use of cryosurgery.

    Edema is common following treatment, especially around the periorbital region, temple, and forehead. Treated tumors usually exude necrotic material after which an eschar forms and persists for about 4 weeks. Permanent pigment loss at the treatment site is unavoidable. Atrophy and hypertrophic scarring have been reported as well as instances of motor and sensory neuropathy.

  5. Radiation therapy. Radiation therapy is a logical treatment choice, particularly for patients with primary lesions requiring difficult or extensive surgery (e.g., eyelids, nose, or ears).[5] Radiation therapy eliminates the need for skin grafting when surgery would result in an extensive defect. Cosmetic results are generally good to excellent with a small amount of hypopigmentation or telangiectasia in the treatment port. Radiation therapy can also be used for lesions that recur after a primary surgical approach.[6]

    Radiation therapy is contraindicated for patients with xeroderma pigmentosum, epidermodysplasia verruciformis, or the basal cell nevus syndrome because it may induce more tumors in the treatment area.

  6. Carbon dioxide laser. This method is most frequently applied to the superficial type of basal cell carcinoma. It may be considered when a bleeding diathesis is present, since bleeding is unusual when this laser is used.
  7. Topical fluorouracil (5-FU). This method may be helpful in the management of selected patients with superficial basal cell carcinomas. Careful and prolonged follow-up is required, since deep follicular portions of the tumor may escape treatment and result in future tumor recurrence.[7]
  8. Interferon alpha. Several early studies have shown variable responses of basal cell carcinoma to intralesional interferon alpha.[8][9] Further reports are awaited until this treatment may be recommended for routine clinical practice.
  9. Photodynamic therapy.[10] Photodynamic therapy with photosensitizers may be effective treatment for patients with superficial epithelial skin tumors.[11]

Follow-up:  

  • Following treatment for basal cell carcinoma, patients should be clinically examined every 6 months for 5 years.[12] Thereafter, patients should be examined for recurrent tumors or new primary tumors at yearly intervals. Of the patients who develop a basal cell carcinoma, 36% will develop a second primary basal cell carcinoma within the next 5 years. Early diagnosis and treatment of recurrent basal cell carcinomas or another primary basal cell carcinoma is desirable since the treatment of the disease in its earliest stages results in less patient morbidity.

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with basal cell carcinoma of the skin. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

  1. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.  

  2. Malhotra R, Huilgol SC, Huynh NT, et al.: The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology 111 (4): 631-6, 2004.  

  3. Thomas RM, Amonette RA: Mohs micrographic surgery. Am Fam Physician 37 (3): 135-42, 1988.  

  4. Abide JM, Nahai F, Bennett RG: The meaning of surgical margins. Plast Reconstr Surg 73 (3): 492-7, 1984.  

  5. Caccialanza M, Piccinno R, Moretti D, et al.: Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: results in 405 lesions. Eur J Dermatol 13 (5): 462-5, 2003 Sep-Oct.  

  6. Lovett RD, Perez CA, Shapiro SJ, et al.: External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 19 (2): 235-42, 1990.  

  7. Dabski K, Helm F: Topical chemotherapy. In: Schwartz RA: Skin Cancer: Recognition and Management. New York, NY: Springer-Verlag, 1988, pp 378-389.  

  8. Greenway HT, Cornell RC, Tanner DJ, et al.: Treatment of basal cell carcinoma with intralesional interferon. J Am Acad Dermatol 15 (3): 437-43, 1986.  

  9. Padovan I, Brodarec I, Ikić D, et al.: Effect of interferon in therapy of skin and head and neck tumors. J Cancer Res Clin Oncol 100 (3): 295-310, 1981.  

  10. Wilson BD, Mang TS, Stoll H, et al.: Photodynamic therapy for the treatment of basal cell carcinoma. Arch Dermatol 128 (12): 1597-601, 1992.  

  11. Wolf P, Rieger E, Kerl H: Topical photodynamic therapy with endogenous porphyrins after application of 5-aminolevulinic acid. An alternative treatment modality for solar keratoses, superficial squamous cell carcinomas, and basal cell carcinomas? J Am Acad Dermatol 28 (1): 17-21, 1993.  

  12. Rowe DE, Carroll RJ, Day CL Jr: Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 15 (3): 315-28, 1989.  

Squamous Cell Carcinoma of the Skin

Localized squamous cell carcinoma of the skin is a highly curable disease.[1] The traditional methods of treatment involve the use of cryosurgery, radiation therapy, electrodesiccation and curettage, and simple excision. Each of these methods may be useful in specific clinical situations.

Of all treatment methods available, Mohs micrographic surgery has the highest 5-year cure rate for both primary and recurrent tumors. This method uses microscopic control to evaluate the extent of tumor invasion. Lymphadenectomy is indicated when regional lymph nodes are involved.

Treatment options:  

  1. Mohs micrographic surgery.[2] Although this method is complicated and requires special training, it has the highest cure rate of all surgical treatments because the tumor is microscopically delineated until it is completely removed. It is indicated for the treatment of:
    • primary squamous cell carcinomas when they occur at sites known to have a high initial treatment failure rate following traditional methods;
    • primary tumors with poorly defined clinical borders, primary tumors with diameters more than 2 cm; or
    • primary tumors arising in regions where the maximum preservation of uninvolved tissue is desirable such as the face, head, and genitalia.

    Mohs micrographic surgery should be used for squamous cell carcinomas that show perineural invasion since tumor transit along nerves may extend many centimeters away from the primary or recurrent tumor site.[3] Recurrent squamous cell carcinomas can also be treated with this technique.

  2. Simple excision with frozen or permanent sectioning for margin evaluation. This traditional surgical treatment usually relies on surgical margins ranging from 3 mm to 10 mm, depending on the diameter of the original tumor.[4] Tumor recurrence is not uncommon because only a small fraction of the total tumor margin is examined pathologically.
  3. Electrodesiccation and curettage. This is a quick method for destroying the tumor, but the adequacy of treatment cannot be assessed immediately since the surgeon cannot visually detect the depth of microscopic tumor invasion. It should be reserved for very small primary tumors since this disease has metastatic potential.
  4. Cryosurgery. Cryosurgery is used for patients with clinically well-defined in situ tumors. It is especially useful for debilitated patients with medical conditions that preclude other types of surgery.

    Absolute contraindications for cryosurgery include abnormal cold tolerance, cryoglobulinemia, cryofibrinogenemia, Raynaud disease, and platelet deficiency disorders. Relative contraindications to cryosurgery include tumors of the scalp, ala nasi, nasolabial fold, tragus, postauricular sulcus, free eyelid margin, upper lip vermillion border, and lower legs. Caution should also be used before treating nodular ulcerative neoplasia more than 3 cm, carcinomas fixed to the underlying bone or cartilage, tumors situated on the lateral margins of the fingers and at the ulnar fossa of the elbow, or recurrent carcinomas following surgical excision. Significant morbidity is associated with the use of cryosurgery.

    Edema is common following treatment, especially around the periorbital region, temple, and forehead. Treated tumors usually exude necrotic material after which an eschar forms and persists for about 4 weeks. Permanent pigment loss at the treatment site is unavoidable. Atrophy and hypertrophic scarring have been reported as well as instances of motor and sensory neuropathy.

  5. Radiation therapy. Radiation therapy is a logical treatment choice, particularly for patients with primary lesions requiring difficult or extensive surgery (e.g., eyelids, nose, or ears).[5] Radiaiton therapy eliminates the need for skin grafting when surgery would result in an extensive defect. Cosmetic results are generally good to excellent with a small amount of hypopigmentation or telangiectasia in the treatment port. Radiation therapy can also be utilized for lesions that recur after a primary surgical approach.[6]

    Radiation therapy is contraindicated for patients with xeroderma pigmentosum, epidermodysplasia verruciformis, or the basal cell nevus syndrome because it may induce more tumors in the treatment area.

  6. Topical fluorouracil (5-FU). This method may be helpful in the management of selected in situ squamous cell carcinomas (Bowen disease). Careful and prolonged follow-up is required since deep follicular portions of the tumor may escape treatment and result in future tumor recurrence.[7]
  7. Carbon dioxide laser. This method may be helpful in the management of selected squamous cell carcinoma in situ. It may be considered when a bleeding diathesis is present, since bleeding is unusual when this laser is used.
  8. Interferon alpha. Clinical trials are ongoing to treat squamous cell carcinoma with intralesional interferon alpha.[8] The results should be available in several years. One report shows the combination of interferon alpha and retinoids is effective treatment for squamous cell carcinoma.[9]

Follow-up:  

  • Since squamous cell carcinomas have definite metastatic potential, patients should be re-examined every 3 months for the first several years and then followed indefinitely at 6-month intervals.

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with squamous cell carcinoma of the skin. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

  1. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.  

  2. Thomas RM, Amonette RA: Mohs micrographic surgery. Am Fam Physician 37 (3): 135-42, 1988.  

  3. Cottel WI: Perineural invasion by squamous-cell carcinoma. J Dermatol Surg Oncol 8 (7): 589-600, 1982.  

  4. Abide JM, Nahai F, Bennett RG: The meaning of surgical margins. Plast Reconstr Surg 73 (3): 492-7, 1984.  

  5. Caccialanza M, Piccinno R, Moretti D, et al.: Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: results in 405 lesions. Eur J Dermatol 13 (5): 462-5, 2003 Sep-Oct.  

  6. Lovett RD, Perez CA, Shapiro SJ, et al.: External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 19 (2): 235-42, 1990.  

  7. Dabski K, Helm F: Topical chemotherapy. In: Schwartz RA: Skin Cancer: Recognition and Management. New York, NY: Springer-Verlag, 1988, pp 378-389.  

  8. Padovan I, Brodarec I, Ikić D, et al.: Effect of interferon in therapy of skin and head and neck tumors. J Cancer Res Clin Oncol 100 (3): 295-310, 1981.  

  9. Lippman SM, Parkinson DR, Itri LM, et al.: 13-cis-retinoic acid and interferon alpha-2a: effective combination therapy for advanced squamous cell carcinoma of the skin. J Natl Cancer Inst 84 (4): 235-41, 1992.  

Actinic Keratosis

Actinic keratosis commonly appears in regions of chronic sun exposure such as the face and dorsa of the hands. Actinic cheilitis is a related condition that usually appears on the lower lips.[1] These conditions represent early epithelial transformation that may eventually evolve into invasive squamous cell carcinoma. Actinic keratosis is a premalignant condition that should be treated with one of the methods available.[2]

Treatment options:  

  1. Topical agents:
    • Fluorouracil (5-FU): Treats the clinically obvious disease as well as regions of subclinical involvement.
    • Imiquimod 5% cream.[3][4][5]
    • Diclofenac sodium 3% gel.
    • Trichloroacetic acid.
    • Phenol.
     
  2. Cryosurgery.
  3. Electrodesiccation and curettage.
  4. Dermabrasion.
  5. Shave excision.
  6. Carbon dioxide laser.
  7. Photodynamic therapy.

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with actinic keratosis. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

  1. Picascia DD, Robinson JK: Actinic cheilitis: a review of the etiology, differential diagnosis, and treatment. J Am Acad Dermatol 17 (2 Pt 1): 255-64, 1987.  

  2. Preston DS, Stern RS: Nonmelanoma cancers of the skin. N Engl J Med 327 (23): 1649-62, 1992.  

  3. Lebwohl M, Dinehart S, Whiting D, et al.: Imiquimod 5% cream for the treatment of actinic keratosis: results from two phase III, randomized, double-blind, parallel group, vehicle-controlled trials. J Am Acad Dermatol 50 (5): 714-21, 2004.  

  4. Tran H, Chen K, Shumack S: Summary of actinic keratosis studies with imiquimod 5% cream. Br J Dermatol 149 (Suppl 66): 37-9, 2003.  

  5. Lee PK, Harwell WB, Loven KH, et al.: Long-term clinical outcomes following treatment of actinic keratosis with imiquimod 5% cream. Dermatol Surg 31 (6): 659-64, 2005.  

More Information

About PDQ  

Additional PDQ Summaries  

Important:  

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).


This information is provided by the National Cancer Institute.

This information was last updated on January 4, 2008.

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