Squamous cell carcinoma. Causes, symptoms, signs, diagnosis and treatment of pathology

Date: 29.06.2020

The main cancers of the skin are: basal cell carcinoma (basal cell carcinoma), squamous cell carcinoma and melanoma. Other sections of the site are devoted to basalioma and melanoma.
Squamous cell carcinoma of the skin is the second most common malignant disease after basalioma. This is what oncologists call simply "skin cancer".
It can appear without any preconditions and precursors. And it can arise from precancerous skin diseases such as actinic (solar) keratosis, keratoacanthoma, cutaneous horn, Bowen's disease.
Precancerous diseases can last for many years and are not a cause for concern. Suddenly, precancer becomes malignant- This is a very common occurrence. For many people, this transition to squamous cell skin cancer is misleading and delays timely treatment. It seems to people that they simply injured, or caught a cold, or overheated a tumor, or these are side effects of drugs. And, over time, it will return to its previous size.

Skin cancer in the form of a dense knot on the dorsum of the finger. Similar to keratoacanthoma.

An ulcer on the leg appeared due to vascular problems. Then it turned into skin cancer.

Squamous cell carcinoma of the skin. What is the reason for the appearance?

Accumulated during life ultraviolet radiation- the main leading cause of the development of squamous cell skin cancer. This is evidenced by statistics in the form of the number of cases per year per one hundred thousand of the population (incidence).
Most neoplasms appear on open areas of the body of fair-skinned patients over the age of 60. 70% to 80% of tumors appear on the head and neck. Especially on the lower lip, ears, scalp. Slightly less common is the lesion of the dorsum of the hand, forearm, the anterior surface of the lower leg and the dorsum of the foot. Squamous cell carcinoma of the skin is much less common in areas inaccessible to sunlight.
The human papillomavirus (HPV) also makes its contribution. It can cause both precancerous diseases and skin cancer. HPV types 16, 18, 31, 33, 35, 39, 40, 51, 60 are often found in foci of squamous cell carcinoma of the skin; 5, 8, 9 types of HPV were also found. Of less importance is a decrease in immunity, constant trauma, inflammatory skin diseases, contact with harmful chemicals (in particular, arsenic compounds).

The incidence of squamous cell carcinoma of the skin.

The incidence of skin cancer is the number of sick people out of 100 thousand of the population. In white-skinned people in the southern regions, it increases significantly. In the United States, for example, the average incidence is 10 per 100,000 of the population, and in Hawaii, it is already 62 per 100,000. Roughly the same serious rates are observed in whites in Australia. In Russia, statistics are much more complicated. Many tumors are treated without proper histological examination. And, even if there is one, the patient may not be registered, considering the disease to be too mild.
In the United States, squamous cell skin cancer sooner or later will appear in 9-14% of men and 4-9% of women... The incidence increases dramatically with age and after intense sun exposure throughout life. Men get sick about twice as often as women. Over the past two decades, there has been a sharp increase in the incidence... Apparently, this is due to fashion for tan.
Most people (73%) will develop only one tumor in their lifetime. A smaller number (21.2%) will develop from two to four foci of squamous cell skin cancer. And only a small number of patients will develop several tumor foci during their life.

Squamous cell carcinoma of the skin, its signs.

Signs of squamous cell skin cancer and its danger depend largely on the degree of differentiation. Highly differentiated means that cancer cells under the microscope are enough similar to normal, such cancer is the least dangerous. Poorly differentiated most dangerous, his cells under a microscope very different from normal... Moderately differentiated occupies an intermediate position.
A sign of squamous cell carcinoma of the skin can be considered the appearance of a plaque or nodule with an oozing bleeding surface or with dense yellowish crusts. The density of formation varies considerably in each case. The symptoms of poorly differentiated cancer are softness of the knot to the touch and absence of corneous crusts... Usually, the skin cancer on the surface of which there is yellow horny masses, and, dense to the touch.
Cancer should be suspected in any case if there is a suspicious mass that has not gone away within a month. Rapidly growing squamous cell carcinoma can grow within several weeks, its symptoms are soreness, softness of the node.
The greatest likeness squamous cell carcinoma of the skin has non-pigmented melanoma, inflammatory ulcer, pyogenic granuloma, basoskamous or ulcerative basalioma.
For any doubt about the diagnosis, it is indicated tumor biopsy followed by histological examination. In diagnostics, the pronounced character of the skin tightening surrounding squamous cell carcinoma also helps.
If the tumor is up to 2 cm in diameter, and is highly differentiated, it is enough only to examine the regional lymph nodes with the doctor's fingers (palpation). Lymph node thickening and enlargement of more than 1.5 cm is a common sign of metastasis in it. It is possible to conduct a biopsy from the node using a needle from a syringe and an ultrasound machine.
If the tumor is more than 2 cm in diameter and / or is poorly differentiated, it is advisable to do an ultrasound of the regional lymph nodes, even if everything is fine with palpation. And, sometimes, conduct a deeper examination.

Squamous cell skin cancer. Grows quickly, bleeds, soft to the touch.

Highly differentiated skin cancer of the upper eyelid. It grew for a relatively long time, has horny masses on the surface.

Stages of skin cancer. TNM.

Squamous cell carcinoma of the skin is divided into stages, depending on the characteristics of the tumor. To determine the stage, it is first matched with suitable values in the TNM system. Where T characterizes the size of the tumor, N refers to regional lymph nodes, and M encrypts the absence or presence of distant metastases.

TNM scores for staging squamous cell skin cancer.

Index	Its signs
Tis	The tumor has just appeared, does not grow in the basement membrane of the epithelium (regardless of the size of the focus). Differently - Bowen's disease (cancer in situ)
T1	up to 2 cm
T2	From 2 cm to 5 cm
T3	more than 5 cm
T4	Germination into tissues located under the skin (muscles, cartilage, bones)
N0	There is no lesion in the regional lymph nodes
N1	There are metastases to the nearest regional lymph nodes
M0	There are no metastases in lymph nodes from other regions, or in internal organs
M1	There are metastases to lymph nodes from other regions, or to any other organ (liver, lungs, bones)

Determining the stage of skin cancer based on signs of TNM.

Clinical stage of skin cancer	T	N	M
0 Stage	Tis	N0	M0
Stage I	T1	N0	M0
Stage II	T2	N0	M0
Stage II	T3	N0	M0
Stage III	T4	N0	M0
Stage III	Any T	N1	M0
Stage IV	Any T	Any N	M1

Forecast. Metastases of squamous cell carcinoma of the skin.

Squamous cell carcinoma of the skin, basically, destroys tissues only in the area of appearance, causes metastases relatively less often than cancer of other organs. But the possibility of metastasis, nevertheless, is higher than that of basal cell carcinoma. First of all, the lymph nodes closest to the tumor (regional) are affected.
On average, abroad, high level of early diagnosis... In this regard, the treatment results are quite good. The relapse rate within five years does not exceed 8%. The risk of metastases in the nearest lymph nodes or internal organs (usually the lungs) is, on average, 5%. V Of Russia performance can vary significantly due to later diagnosis... Metastases of skin cancer (like any other) can appear several years after tumor removal, most often within 1-3 years. Most of all, they are likely from large tumors, recurrent, invading nerves.
Squamous cell carcinoma that penetrates into the subcutaneous fatty tissue, or more than 4 mm in depth, metastasizes almost 8 times more often (the risk of metastases is 45.7%) than tumors located within the upper layers of the skin.
Tumor size is the most important factor affecting the risk of recurrence or metastasis. With an increase in the tumor more than 2 cm, the risk of recurrence increases 2 times and the risk of metastases increases 3 times.
It has long been noted that squamous cell carcinoma of the skin from regions with scars, from ulcers, from areas of burns and radiation, much worse according to the forecast.

Squamous cell carcinoma of the skin. Influence of tumor signs on the number of relapses and metastases.

Sign	Relapse rate	Frequency of metastases
The size
less than 2 cm	7.4%	9.1%
more than or equal to 2 cm	15.2%	30.3%
Depth
less than 4 mm (1-2 degree of invasion according to Clark)	5.3%	6.7%
more than or equal to 4 mm (4-5 degree of invasion according to Clark)	17.2%	45.7%
Differentiation degree
Highly differentiated	13.6%	9.2%
Poorly differentiated	28.6%	32.8%
Region
We irradiate the sun	7.9%	5.2%
Ear	18.7%	11.0%
Lips	10.5%	13.7%
Scar skin cancer	Not investigated	37.9%
Previously already treated (relapse)	23.3%	30.3%
With sprouting into the nerves	47.2%	47.3%
Proven decreased immunity	Not investigated	12.9%

Treatment of squamous cell skin cancer.

In general, the success of treatment of squamous cell carcinoma stage 1 (up to 2 cm in diameter) is quite good. The effectiveness of treatment is assessed by the absence of relapses and metastases within 5 years. Often, this efficiency is higher than for basal cell carcinoma. Perhaps this is due to the more wary attitude of doctors and more clear contour of the tumor.
The end result of any treatment for squamous cell skin cancer depends on the skill and experience of the physician rather than the instruments used. In the right hands, treatment is more than 90% effective, regardless of the method chosen.

Surgical treatment of skin cancer.

The surgical method is the most common. It consists in cutting the flap where the squamous cell carcinoma of the skin is located, with a proper indent from the edge of the tumor. A skin tumor up to 2 centimeters is excised with a margin of 4 mm. Tumors more than 2 cm in diameter, as well as poorly differentiated, penetrating under the skin, or located in dangerous areas (scalp, ears, eyelids, nose, lips), need to be excised with a margin of more than 6 mm.

Mohs method against squamous cell skin cancer.

Removal by the Mohs method is more preferable than conventional surgical removal in the case of a large, deep tumor. Histological examination is carried out already at the time of the operation. Allows you to continue removal in the desired direction if squamous cell skin cancer cells are found at the edge of the flap. Mohs method gives the least number of relapses and metastases. Contraindications and cosmetic results are the same as for conventional surgical treatment.

Radiation treatment of squamous cell skin cancer.

Radiation therapy is also quite common. But its effectiveness seriously inferior to surgical treatment... It is indicated in those patients who cannot undergo surgical treatment.
It can also be indicated when the expected cosmetic results of surgical treatment are not at all ideal. For example, when squamous cell skin cancer appears on the lips, lower eyelid, and occasionally on the ears. Radiation therapy can be prescribed as an additional treatment after surgery. This is especially true when squamous cell skin cancer cells are found under the microscope at the edge of the removed skin flap (despite the indentation). Or in case of nerve penetration.
The scars from radiation treatment for squamous cell skin cancer begin to look worse and worse over time. Radiation treatment can also be given to regional lymph nodes. Over time, many new tumors may develop, caused by the radiation therapy itself.

Treatment of skin cancer with liquid nitrogen (cryodestruction).

Squamous cell skin cancer, like basalioma, can be treated with liquid nitrogen (cryodestruction). At the same time, the tumor literally freezes, turning into a piece of ice. During thawing, small ice crystals destroy cell membranes and clog blood vessels. Within a few weeks, the tumor masses are rejected and replaced by a scar similar in structure to the skin. The effectiveness of the method depends on the contractor and the availability of the proper equipment.

Electrodissection and curettage.

Electrodissection and curettage of squamous cell skin cancer is possible only in extremely rare cases, with very small and relatively favorable tumors. With this method, the tumor is scooped out with a special spoon - a curette, and also burned with a coagulator to stop the blood. The effectiveness of treatment with this method is highly dependent on the performer.

Prevention of skin cancer.

All patients diagnosed with skin cancer or precancerous lesions should avoid sun exposure. Especially during hot periods from 10 am to 4 pm.
Use sunscreen with a SPF of at least 15.
Regular observation by an oncologist and treatment of precancerous diseases using cryodestruction, or other methods, will help to avoid unnecessary surgical interventions.
As a preventive measure, it is possible to use retinoids (isotretinoin) in ointments (retinoic ointment).
Periodic use of 5-fluorouracil cream can reduce the severity of precancerous diseases, improve the appearance of the skin, but there is no proven reduction in the incidence of cancer.
Examine your skin once a month for any growths.

In contact with

Malignant skin tumors are among the most common human neoplasms. In terms of prevalence, they rank third in all age groups after lung and stomach cancer in men and second after breast cancer in women.

Squamous cell carcinoma of the skin is one of the most malignant tumors. Of all skin tumors, it is 1/5part. External factors play a significant role in the development of malignant skin tumors: insolation, exposure to carcinogens of the external environment, trauma, infection with the human papillomavirus, thermal and other local irritants, etc. While the participation of endogenous factors in this process is rather modest.

In the overwhelming majority of patients from the anamnesis it turns out that for a more or less long time at the site of the developed tumor, there were processes that can be regarded as precancerous. Patients are usually over 50 years old. Sometimes the development of skin cancer is associated with a decrease in immunity (AIDS, against the background of immunosuppression due to a kidney or other organ transplant, due to cytostatic therapy, as well as against the background of xeroderma pigmentosa), then the occurrence of a tumor does not depend on age.

Clinically, skin cancer appears as one or multiple loci. Their nature can be different in different foci: exophytic - in the form of a node, or endophytic - in the form of an ulcer of different depths (Fig. 18.1-18.4). On the surface of both types, necrosis and ulceration are characteristic. For ulcerated endophytic forms of cancer, regional metastasis is observed somewhat earlier.

Distinguish between squamous cell carcinoma with keratinization and without keratinization. There are also three degrees of differentiation. The processes of keratinization do not fully correspond to the degree of differentiation. Highly differentiated skin tumors are more common than poorly differentiated ones. Highly differentiated variants retain the usual stratification, cells are less discomplexed.

Rice. 18.1.Facial skin cancer exophytic-endophytic form of growth

Rice. 18.2.Cancer of the skin of the upper lip (nodular form) with spread to the red border of the upper lip

Rice. 18.3.The same patient after tumor cryodestruction

Rice. 18.4.Facial skin cancer, infiltrative-ulcerative growth

sioned than in poorly differentiated tumors. The latter are represented by strands of cells that have completely lost the signs of layers characteristic of the skin in accordance with cell differentiation. The cells are sharply anaplastic and polymorphic. The lower the degree of tumor differentiation, the earlier regional metastasis occurs and the potential for distant metastasis increases. In addition, the nature of tumor development is influenced by the surface size and thickness of the primary tumor, the nature of its growth, and the level of invasion.

For diagnosis, cytological and histological examination is of decisive importance. Differential diagnosis is carried out with precancerous diseases accompanied by a pronounced hyperplastic process: senile dyskeratosis, keratoacanthoma, cutaneous horn, Paget's disease, adenocarcinoma of the sweat glands, Bowen's disease and Keir's erythroplasia.

In treatment, depending on the localization and prevalence of the process, all three types of special treatment are used. Small tumors can be treated with radiation therapy, with X-ray therapy being preferred. Regardless of the prevalence of the process, X-ray therapy is often started in elderly people. In such cases, they expect either a complete cure, which can be revealed in the course of treatment, or a significant reduction in the tumor with the possibility of its subsequent removal. Cryotherapy and laser vaporization are widely used as a surgical treatment option. Both methods are used for relatively small and not deep spread of tumors, sometimes they are combined with preliminary radiation exposure. The use of laser destruction and cryotherapy allows treatment in 1-2 sessions, does not require large plastic surgeries, which is especially valuable when the tumor is localized on the face. The impact can be repeated in case of recurrent processes. Photodynamic therapy is being widely introduced.

During the operation, one should step back from the visible edge of the tumor by 1 - 2 cm. It is obligatory to control the radicality of the operation, for which the layers of skin are examined along the edge of the excised tumor. To replace the resulting skin defects, all types of modern plastics are used: a free skin flap (split and full-thickness), displaced variants of flaps from the skin adjacent to the defect, skin-fatty and skin-muscle-

fatty fragments with a feeding vessel, moved from more distant regions.

For large and inoperable tumors, systemic chemotherapy is used.

18.1. BASALIOMA SKIN

Basalioma (basal cell carcinoma) is one of the most common neoplastic diseases of the integumentary epithelium, although it is rare on the mucous membranes. Basalioma makes up the bulk of malignant skin tumors (more than 90%), develops from basal epithelial cells. The pronounced local-destructive properties of the tumor and frequent recurrence are noted. It rarely metastasizes (0.1% of cases), most authors associate metastasis with the transformation of basal cell carcinoma into metatypical.

The development of basal cell carcinoma is facilitated by prolonged insolation, exposure to chemical carcinogens, ionizing radiation. Basal cell carcinoma is often associated with retroviral infection. The development of basaliomas is noted more often after 50 years, which is usually explained by an age-related decrease in immunity. Some hereditary traits, such as fair skin, also play a role. Some variants of hereditary immunity and problems of differentiation of epithelial cells associated with genetic characteristics have been determined.

Clinically, a tumor manifests itself in the form of solitary or multiple nodes that arise synchronously or metachronically on open areas of the skin exposed to insolation. Typically, the development of basal cell carcinoma in the head and neck region, especially on the face, in the folds of the face. Tumors are very diverse in shape: nodular, cystic, ulcerative, superficial (Fig. 18.5-18.7).

In addition, a rather rare variant of tumor development is known - morphea-like. The tumor is a flat, dense plaque that rises slightly above the surface of the skin. Over time, it deepens into the tissue, resembling a rough scar. This type is determined by the predominant presence of the tumor stroma. Basaloid cells themselves are small cords located in the thickness of the fibrous tissue. The tumor is aggressive and often recurs. All macroscopic forms of a tumor

Rice. 18.5.Superficial basalioma of the skin of the parotid region. Areas of seborrheic keratosis on the skin of the forehead

Rice. 18.6.Nodular form of basal cell carcinoma of the face

Rice. 18.7.Multiple basal cell carcinomas of the scalp. A patient in childhood suffered from irradiation of the scalp due to ringworm

can be pigmented and then basal cell carcinoma should be differentiated from melanoma. Decisive in the diagnosis is the morphological cytological and histological examination of the tumor. Recurrent tumors occur at different times after primary treatment - after 2 years, after 10-15 years or more (Fig. 18.8).

Rice. 18.8.Recurrence of basalioma of the skin of the temporal region in the area of the scar after cryodestruction

In treatment, as in squamous cell carcinoma, all specific treatments are involved. Cryodestruction is the most frequently used method of treatment on an outpatient basis. Tissues are subjected to destruction in the volume of the visible borders of the tumor and another 1.5-2.0 cm around the tumor. A laser beam and scalpel can be used for the same purposes. Photodynamic destruction is widely used. The boundaries of tumor ablation are also within 1.5-2.0 cm of healthy tissue. Radiation therapy is used primarily in the form of close-focus X-ray therapy. Gamma therapy and electron beam irradiation can be used. Chemotherapy is used mainly locally in the form of intralesional injections (drugs - prospidium chloride or dibrospidium chloride). Chemotherapy is often combined with cryotherapy.

18.2. METATYPICAL SKIN CANCER

Quite a rare type of skin cancer, characterized by both the properties of squamous and basal cell carcinomas. Histological examination reveals two types of cells, arranged inside tumor complexes. The origin of this type of tumor is controversial. Some pathologists believe that the squamous cell component appears in the tumor due to metaplasia, possibly provoked by radiation therapy. Others consider the tumor originally developed from two types of cells with different differentiation. These tumors are characterized by cellular polymorphism, an infiltrative growth pattern. Around the tumor, local lymphoid-plasmacytic infiltration is manifested as an immune response to the tumor. These tumors are highly invasive and metastatic. Macroscopic manifestations are very similar to basal cell carcinoma. In the treatment, the same techniques are used as in the treatment of other skin cancers.

All these tumors are characterized by metastasis to regional lymph nodes (Fig. 18.9). The nodes are dense, relatively slowly increasing, with the prolonged existence of the

Rice. 18.9.Metastases of basal cell carcinoma of the skin of the auricle (basal cell carcinoma), which has recurred for more than 20 years and has transformed into metatypical cancer. The photograph shows metastases to the occipital lymph nodes

the cartilage of the larynx, bone structures, for example, the lower jaw, will melt. Depending on the moment of treatment, metastases can be detected simultaneously with the primary tumor or delayed during the observation process after the primary focus has been cured. Localization of the primary tumor near the midline can provoke the appearance of metastases simultaneously from both sides, due to the bilateral lymph flow from these regions. Treatment for metastases is usually combined: radiation + surgery.

TNM classification of skin tumors.

Th- insufficient data to assess the primary tumor.

T0- the primary tumor is not detected.

Тis- preinvasive carcinoma (in situ).

T1- swelling up to 2 cm in greatest dimension.

T2- the tumor is less than 5 cm in the largest dimension.

T3- the tumor is more than 5 cm in the largest dimension.

T4- a tumor invading deep extradermal structures (cartilage, muscles, bones).

NX- insufficient data to identify regional lymph nodes.

N0- there are no signs of metastatic lesions of regional lymph nodes.

N1- regional lymph nodes are affected by metastases.

Mx- insufficient data to determine distant metastases.

M0- there are no signs of distant metastases. M1- there are distant metastases.

The skin sometimes develops tumor-like xantho-like

defeat. This group includes the following histological species:

1) xanthoma;

2) fibroxanthoma;

3) atypical fibroxanthoma;

4) juvenile xanthogranuloma (xanthoendothelioma);

5) reticulohistiocytic granuloma (reticulohistiocytoma). In terms of differential diagnosis of skin tumors, it is important

know one more group of neoplasms that are allocated in the International Histological Classification as an independent group as other tumors and tumor-like lesions.

1. Granular cell tumor.

2. Osteoma of the skin.

3. Chondroma of the skin.

4. Mixoma.

5. Focal licking of the skin.

6. Myxoid cyst of the skin.

7. Fibrous hamartoma of infants.

8. Pseudosarcoma.

9. Rheumatoid nodule.

10. Pseudo-rheumatoid nodule (deep annular granuloma).

11. Tumor calcification.

12. Others.

Finally, it is important to know that almost unexplored tumors and tumor-like changes develop in the skin, developing from hematopoietic and lymphoid tissues. These changes are often histological findings. The final diagnosis and treatment tactics should be discussed with the hematologist.

18.3. MALIGNANT SKIN LYMPHOMAS

This is a tumor pathology characterized by monoclonal proliferation of lymphoid elements in the skin. This group of tumors includes those cases that manifest at least

within 6 months only skin lesions (Fig. 18.10). Later, specific growths appear in other organs and tissues. Malignant skin lymphomas should be distinguished from secondary skin changes that occur during generalization or systemic spread of leukemia and lymphosarcoma.

Rice. 18.10.Scalp lymphoma

Depending on the type of cells from which the tumor develops, there are T- and B-cell lymphomas. T-cells account for 70%, B-cells - 20%, 10% are rare and unclassified lymphoproliferative tumors. In the occurrence of this tumor, a large role is recognized for the hereditary instability of the chromosomal apparatus, for example, in Down's syndrome. In addition, retroviral infection is believed to play a significant role in the development of skin lymphomas (eg HTLV-I virus, which causes T-cell lymphoma / leukemia in adults). The participation of other traditionally mentioned carcinogens in the development of these tumors is not excluded: insolation, household and medicinal carcinogens and allergens.

Diagnosis of these visual tumors can be difficult due to the similarity of clinical manifestations with dermatitis, as well as the lack of clear signs of atypia in the lymphocytes infiltrating the skin. Unfortunately, morphological examination is often performed at a late stage of the disease, when peripheral lymph nodes, bone marrow, peripheral blood, and internal organs are involved. Differential diagnosis with non-pigmented melanoma, angioma, angiosarcoma and other neoplastic and non-neoplastic skin diseases is often possible only on the basis of a detailed morphological study.

Treatment, as with other forms of lymphoma, is chemoradiation. Perhaps surgical excision of small lesions on the background of chemotherapy. Using this disease as an example, we will present a variant of one of the most modern methods of treatment: extracorporeal photochemotherapy (photopheresis). The method is based on the effect of ultraviolet radiation and furophotocoumarin on neoplastic lymphocytes isolated from the blood of patients as a result of cytopheresis. After irradiation, these cells are reintroduced into the bloodstream. With this method of treatment, high efficiency (up to 95%), lengthening of the remission period, and good treatment tolerance were noted.

18.4. SARCOMA KAPOSHI

It is a malignant tumor originating from the adventitia of the blood and lymph vessels. As a rule, it occurs against the background of immunodeficiency and has a multicentric growth. The age of patients usually does not exceed 50 years.

In the development of the disease, the leading etiological factor is the human herpes virus HHV-8. In the pathogenesis of the disease, the main role belongs to the violation of antitumor immunity, activation of neoangiogenesis and suppression of the process of apoptosis of activated endothelial cells. The triggering mechanism for the development of the disease is a violation of the immune status and the resulting increased production of cytokines by cells: interleukins-1 and -6, tumor necrosis factor, etc. Unlike normal cells, tumor cells of Kaposi's sarcoma are especially sensitive to the effects of growth factors. The stimulation of neoangiogenesis is especially pronounced. Endothelial cells actively form a capillary network.

Clinical manifestations are usually external. In the affected area, spotty eruptions of an irregular shape of a red-violet or red-brown color appear. Characteristic changes are localized on the skin, in the area of the legs, face, neck, genitals. Subsequently, telangiectasias, hemorrhages, areas of hyperkeratosis, papillomatous outgrowths appear on the surface of the foci. Areas of pigmentation and cicatricial atrophy are noted. In advanced stages, internal organs are affected.

By the nature of the background external and internal conditions of the onset of the disease, four variants of the development of this type of sarcoma are noted: idiopathic, immunosuppressive, endemic and HIV-associated. In the first case, the tumor occurs without any connection with the patient's living conditions. The tumor develops in people after 50 years, men get sick 10 times more often than women (Fig. 18.11). As the rash develops, it captures more and more of the integumentary epithelium, including in the oral cavity.

The endemic (African) type, along with AIDS-associated forms, is the most common malignant disease in the countries of Central Africa. The disease occurs in adults and children. Men get sick more often 3-10 times. In children, there is often a lymphadenopathic form, accompanied by damage to the lymph nodes, internal organs with minimal skin manifestations.

The AIDS-associated type develops along with infectious diseases and other malignant tumors in people with acquired immunodeficiency syndrome. HIV-inf-

Rice. 18.11.Kaposi's sarcoma of the neck skin

Citizens get sick 300 times more often than the rest of the population. Typically, the disease affects homosexual men. The rash looks like scattered insect-like spots that soon develop into ulcerating and painful nodules. With this option, rashes on the face, mucous membranes of the oral cavity and skin of the hands are frequent localizations. The favorite localization is the tip of the nose and the hard palate.

The immunosuppressive (introgenic) variant is associated with the use of immunosuppressants after organ transplantation, used to prevent the rejection of an internal organ transplant, or immunosuppressive therapy for certain chronic somatic diseases (autoimmune, rheumatoid, etc.). Specific rashes quickly spread over the skin, mucous membranes and internal organs.

Differential diagnosis is carried out by histological examination with angiomas, hemangiomas, glomus tumor, angiosarcoma and other neoplasms.

Chemoradiation treatment, with limited lesions, cryotherapy and surgical treatment, photodynamic therapy, intrafocal injection of cytostatic drugs can be used.

18.5. MELANOMA (MELANOBLASTOMA)

It is a malignant tumor that develops from melanocytes. Melanocytes originate from the neuroectoderm, located in the ectodermal layer of the integumentary epithelium. Cells produce specific colored substances - melanins, which protect against excess solar radiation. Melanoma is most often observed in individuals with reduced skin and hair pigmentation, as well as those with an increased response to ultraviolet radiation. Patients often point out that a birthmark existed at the sites of melanoma for a long time (often from birth). Thus, nevi are an optional precancerous disease. Diseases that most often precede melanoma include atypical nevus, pigmented xeroderma and Dubreus melanosis. Atypical (dysplastic) birthmark syndrome is characteristic of some families. It is manifested by the development during life of many birthmarks that have some features of melanoma. Xeroderma pigmentosa is a hereditary disease characterized by the appearance of many age spots on the skin, mainly on the open parts of the body. Against this background, various skin tumors arise: basal cell carcinoma, infiltrative cancer and melanoblastoma. It is an obligate precancerous disease. Melanosis Dubreya (senile lentigo) is a kind of skin pigmentation of different colors and with an uneven edge in middle-aged and elderly people, more often on the face.

Melanoma is predominantly localized on the skin anywhere in the body, but more often in open areas (Fig. 18.12, 18.13). Less commonly, it affects the mucous membranes (occurs in the rectum, in the nasal cavity, in the oral cavity, on the conjunctiva). There have been cases of the development of melanoma on the membranes of the brain and spinal cord, the retina. This disease is classified as immunogenic. In about 1/3 of cases, partial or complete regression of the primary tumor is noted. Despite this, metastases may appear in the absence of signs of a primary tumor. Melanoma metastases develop both by lymphogenous and hematogenous type of spread. Hematogenous metastases should be looked for in the lungs, liver, gastrointestinal tract, brain, etc.

The incidence of melanoma is low. It ranges from 3 to 5 per 100 thousand in different European countries, but over the past three decades, the increase in the incidence of melanoma has taken one of the first places in

Rice. 18.12.Scalp melanoma

Rice. 18.13.Neck skin melanoma

statistics of oncological diseases. The highest incidence is registered in the USA and Australia, up to 20-40 per 100 thousand of the population. Melanoma is 2 times more common in women and has a more favorable localization than in men.

Epidemiological studies indicate that the etiology of melanoma is mainly the ultraviolet component of sunlight, which, with intense exposure to the skin, can cause tumor mutations in skin cells. It has been noticed that skin melanoma is more characteristic of the white race.

Blacks and representatives of the indigenous population of Southeast Asia and Australia rarely get melanoma. To a large extent, the increase in the incidence of melanoma is associated with the fashion prevailing in developed countries, for recreation in the southern regions, without fail, with intense tanning of the skin. The reduction of the ozone layer of the earth is also of great importance in the formation of tumors.

This tumor occurs at any age, but more often after 40 years. Melanoma of the skin refers to external neoplasms. Its clinical diagnosis in the area of the primary focus is quite accessible and usually does not require the use of other diagnostic methods of examination. In most cases, patients indicate the presence of a pigmented formation that has existed for a long time, more often from birth, at the site of the developed melanoma. If you suspect melanoma, you should pay attention to a change in the color and size of the pigmented formation, the appearance of uneven contours, the appearance of outgrowths on the surface of the birthmark, unusual sensations - itching, tingling. On examination, signs of inflammation, oozing, ulceration can be determined. Dermatologists at the University of Iowa have developed a rule according to which the malignancy of an ABCD pigment formation is determined: A - asymmetry, B - uneven edge, border (border irregularity), C - uneven color and darker than other pigment spots (color), D - larger diameter 6 mm (diameter).

According to the clinical course, 4 types of melanoma are distinguished, which have a clear clinical and morphological characteristics.

1. Superficially spreading form. This clinical type of melanoma looks like a brown spot interspersed with different shades of gray, brown, purple, blue, and even white and black. Clinical signs of infiltration of underlying tissues at the beginning of development are not determined, but this form has two phases: a phase of radial growth, which then turns into a phase of vertical growth. Phase 2 is much more aggressive than Phase 1.

2. A type of malignant lentigo. This form of melanoma usually develops on exposed areas of the scalp and neck. This tumor goes through two stages of development. In the first stage, superficial growth is noted, the tumor is brown, like the previous type, of uneven color with uneven contours. The first phase of the development of the disease is similar to the development of obligate precancer,

can last for years, in contrast to the superficially widespread form of growth, in which this stage of development fits into several months. In the second stage of the process, invasion into the papillary layer of the dermis is noted.

3. Nodal form. It looks like a nodular formation protruding above the surface of the skin of a bluish-black color with uneven contours with a flat base, or on a leg. Has only a phase of vertical growth, is quite aggressive.

4. Acral-lentigous form it is noted on the skin of the palms, soles, in the area of the nail bed. It also has two phases of development, but is much more aggressive than the previous forms of the tumor.

Diagnosis is clinical. Any invasive examination is contraindicated. Only with superficial ulceration of the tumor is it possible to take a smear-print from the tumor surface for diagnostic purposes for cytological examination. Interventional methods of examination are undertaken to exclude regional and distant metastasis. For these purposes, at a minimum, an ultrasound examination of the lymph nodes of the regional zones should be performed. For the organs of the head and neck, this is the neck region, the occipital region and the region of the large salivary glands. For the skin of the body, these can be the lymph nodes of the axillary and groin areas. It is also required to exclude distant metastasis. An x-ray examination of the chest organs, ultrasound of the liver and para-aortic lymph nodes are performed. In the presence of appropriate clinical symptoms, skeletal scans and other studies are performed.

There are a number of formations similar to melanoma. Melanoma should be differentiated from a number of pigmented skin formations and visible mucous membranes of a benign nature: with a pigmented nevus, angioma, papilloma, histiocytoma. The difference is often possible only during histological examination (Fig. 18.14). It should be remembered about the possible development of non-pigmented melanoma, the clinical manifestations of which are especially similar to hemangioma. Without fail, any removed skin formation should be subjected to histological examination. In the diagnosis of this form of the disease, as in all other doubtful cases, an urgent histological examination of the remote formation at the slightest

suspicion of a malignant tumor, in order to expand, if necessary, the boundaries of the excised altered area of the skin or mucous membrane.

Rice. 18.14.Melanoma of the skin. Histological specimen. Increase X 160. Staining with hematoxylin-eosin

To assess the degree of malignancy of melanoma in prognostic terms, the data obtained during the histological examination are important. In the twentieth century. American scientists W.H. Clark (1967) and A. Breslow. (1970) proposed variants of the microscopic classification of skin melanoma, which correlated with the clinical course of the disease. The level of invasion (according to Clarke) is assessed by tumor cells of the underlying dermis. There are 5 levels of skin melanoma invasion in the dermis (Fig. 18.15).

I level- melanoma cells are located within the epidermis and the invasion process corresponds in situ.

II level- the tumor destroys the basement membrane and infiltrates the upper sections of the papillary dermis.

III level- tumor cells spread to the entire papillary layer of the dermis, but do not penetrate into the underlying reticular layer.

IV level- invasion of the reticular layer of the dermis.

V level- invasion of the underlying fatty tissue.

Rice. 18.15.Clarke Staging Scheme for Melanoma. Explanations in the text

The essence of the method proposed by A. Breslow is to measure the thickness of the invasion, i.e. thickness of the vertical size of the tumor in millimeters. With the help of a micrometer built into the eyepiece of the microscope, the thickness of the tumor is measured from the granular layer of the epidermis to the most deeply located melanoma cells in the thickness of the dermal layers or subcutaneous adipose tissue. This second indicator of microscopic tumor assessment, according to most modern oncologists, correlates particularly clearly with survival after surgical removal. Preoperative classification of the extent of melanoma is not subject to.

The author noted that when the vertical size of the tumor is less than 0.75 mm, surgical excision leads to a cure, i.e. provides long-term follow-up without signs of relapse and metastases. It has now been determined that with a tumor thickness of up to 1.5 mm, there are mainly metastases to regional lymph nodes, and with a tumor thickness of more than 4 mm, the prognosis of the disease deteriorates sharply. So, in the absence of clinically detectable metastases, the likelihood of latent regional and hematogenous micrometastasis is very high. Currently, in case of melanoma, the technique of intraoperative search for a "sentinel" lymph node is being introduced, which allows at early stages to confirm or reject micrometastasis in the first-order lymph nodes. The method is based on the representation of lymph drainage, which is carried out strictly along the anatomical regions from each

area of the body to a specific node or group of nodes that are similar to the first-order lymph nodes. The exclusion of metastatic lesions in this node allows you to avoid traumatic surgery on the pathways of regional metastasis.

Establishing the stage of the prevalence of melanoma by microscopic signs should determine the need for additional special treatment methods. Assessment of the stage of the process of primary skin melanoma without signs of metastasis (symbol T) is carried out only after surgical removal of the neoplasm (pT, pathology Tumour).

pT1- the tumor corresponds to the II level of invasion with a tumor thickness of no more than 0.75 mm (stage of the process 1A).

pT2- the tumor corresponds to the III level of invasion, the thickness of the tumor is up to 1.5 mm (stage of the process 1B).

pT3- the tumor corresponds to the III-IV level of invasion, with a tumor thickness of up to 4 mm (process stage 2A).

pT4 -the tumor corresponds to the III-V level of invasion, its thickness is more than 4 mm (stage of the process 2B).

At the pT3 stage, damage to regional lymph nodes is noted or assumed. At the pT4 stage - lymph nodes and internal organs.

Melanoma of the oral and nasal mucosa is a rather aggressive disease, often preceded by melanosis of the oral mucosa. It is observed more often in men. It is usually localized on the hard palate and in the nasal cavity. Local relapses and metastases are frequent, both to regional lymph nodes and to distant organs. With melanoma of the mucous membranes of the organs of the head and neck, the prognosis is significantly less favorable than with lesions of the skin, which is associated with the late diagnosis of the disease. It should be noted that, in general, the facts of recurrence and metastases of skin melanoma occur in the first 5 years of follow-up. So if the patient has lived through them safely, we can talk about his practical cure.

Treatment.Early diagnosis of the tumor is essential for effective treatment. In the initial stages, a permanent cure can be achieved in more than 90% of cases. The main treatment is the excision of the tumor. It has now been shown that wide excision of the tumor 4–5 cm from the edge does not improve the results of treatment. Today, with melanoma without invasive growth, the tumor recedes from the visible edge of the tumor when removed by 0.5-1.0 cm.

primary tumor more than 4 mm from the edge of the tumor retreat 2 cm or more. The defect is replaced with local tissues or a free displaced skin graft. Intervention on the pathways of regional metastasis is performed only in the presence of metastases in these areas. In the complex treatment of melanomas, chemotherapy and immunotherapy are used. Radiation therapy is usually not used because it is ineffective.

Occurs quite often. Its varieties have a different course and differ from each other in external manifestations, as well as a tendency to metastasis.

Currently, the number of cases of diagnosing the considered skin condition has become much more, and this is largely due to the deteriorating environmental conditions in large metropolitan areas,

Squamous cell carcinoma should be considered a type of cancer that can occur anywhere on the skin. Its appearance in the tissues of bones and lungs is rare, and even more rare in the glands (sweat and sebaceous). No more than 10% of cases of this form of oncological lesions of the skin are observed with the formation of metastases.

A feature of all forms of this type of cancer is the high rate of its development and the transition from one stage to the next. Germination into neighboring tissues is observed, and aggressive cancer cells are spread throughout the body with lightning speed by blood and lymph.

What types of this type of skin cancer exist?

Forms of squamous cell skin cancer

For the considered form of oncological lesions, the following types are characteristic, which differ in their external manifestations, as well as the types of treatment used:

plaque form- this type of skin lesion outwardly looks like a sharply colored area that stands out above the surface of the body, on which small bumps can be visible even with the naked eye. The area is rough to the touch, the skin becomes denser than in other areas, and its growth rate is quite high.

As the plaque form of cancer develops, it grows into the tissue of neighboring areas, bleeding and severe pain may appear;

nodal shape- outwardly, this type of squamous cell carcinoma resembles a large accumulation of nodules of various sizes, with a large accumulation of them, the outer part of the affected tissue resembles a cauliflower inflorescence. To the touch, the flatness of such a neoplasm is dense, the color is pronounced brown, its base is significant, and the upper part is bumpy.

Often, the nodal form of the type of oncological disease under consideration arises in the places where the scar is located and the place of old injuries.

First, cracks appear in the skin, which are very painful, then gradually you can find small-sized nodules, which at first do not cause painful manifestations and have pronounced mobility, and as the pathological process develops, the nodules increase, lose mobility and become painful.

The process of development of this form of malignant neoplasm is quite fast, the penetration of an oncological malignant tumor into the deeper layers of the epidermis is observed;

ulcerative form- for this type of malignant lesion of the skin surface, crater-like ulcers appear on the upper layer of the epidermis, which are slightly raised above the surface of the body, the edges look like a roller, and the depression gradually descends downward.

Ulcers tend to grow rapidly, and their growth is observed both in width and in deeper layers of the epidermis.

A characteristic feature of this form of squamous cell type of oncology is the appearance of a specific smell - it is this symptom that should alert and become a reason for examining the surface of the whole body. When pressed on the surface of the crater ulcer, bloody discharge may appear.

All of the listed types of this type of oncology have a common specificity: the speed of their spread is very high, therefore, for the fastest possible cure, you should consult a doctor at the slightest change in the condition of the skin.

In the photo, squamous cell carcinoma of the skin of the face in the initial stage of development

You should also highlight separately conditional division of squamous cell carcinoma into non-keratinizing differentiated carcinoma, which tends to form from cells that do not undergo keratinization, and keratinized appearance.

The non-keratinizing type can be highly differentiated, which does not spread too quickly, since a small number of atypical cells appear in the body.
Poorly differentiated non-trading squamous cell type the disease develops rapidly, the number of aggressive atypical cells in the body is many.
Keratinizing differentiated skin cancer the form under consideration is more difficult to diagnose, since the neoplasms do not have a pronounced color, and the rate of its growth is quite high.

What is the cause of the pathology?

Oncological diseases in general do not have clear reasons for their appearance. However, there are a number of factors provoking this condition, which can cause the onset of the tumor process. Let's list the main ones.

The factors that can cause the development of squamous cell type of skin surface oncology include:

elderly age- it is the age group over 55 that is considered the most susceptible to cancer; older people suffer from it more often than young people: this is partly due to a decrease in the level of the body's resistance to infections and extraneous aggressive influences, a decrease in the production of immune bodies;
the presence of a light shade of the skin and living in the southern regions;
excessive insolation and insufficient use of sunscreens;
work in hazardous production- regular exposure to the body of substances such as resin, arsenic, soot cause the onset and rapid development of cancer in general;
untreated skin diseases, frequent occurrence of herpes, papilloma;
low level of immunity;
hereditary factor- genetic predisposition plays an important role in the possibility of cancer.

There are also a number of precancerous skin diseases that, without the necessary treatment, can degenerate into a malignant disease. These include dermatitis of a different nature, pustular lesions, not completely cured ulcers.

What are the manifestations of the onset and development of the disease?

Clinical picture

The onset of squamous cell carcinoma is the formation of small scattered neoplasms in the upper layer of the epidermis, on the very surface of the skin, more often they have a slightly yellowish color, pain is not felt on palpation.

Gradually, the neoplasms become larger in size, begin to merge into one, the density of the skin in this place becomes much higher, gradually the color changes to a more pronounced one.

A noticeable plaque is formed, which is located above the plane of the body. As the malignant tumor develops, the color of the formation becomes more pronounced - from reddish to brown with various shades.

The edges of the neoplasm are more raised, are distinguished by high roughness, depending on the belonging to a certain type of squamous cell carcinoma, the tumor acquires specific features. The common thing is an increase in size, the appearance of pain when pressed, as well as the release of exudate with a purulent, bloody or mixed composition.

The upper plane of the growing neoplasm is covered with a dense crust, which, at the slightest damage, breaks through and begins to bleed. Its edges become like a roller, the upper part is covered with ulcers.

Symptoms

The squamous form of this condition has quite pronounced manifestations, which are less noticeable at the initial stage of the development of this condition, but they can alert and push you to visit a medical institution.

The first symptoms of the considered form of cancer include the appearance of a small plaque or compaction on the surface of the body, which has a yellowish color. To the touch, such a formation is somewhat compacted, it can rise slightly above the level of the skin.

Gradually, malignant cells grow and the tumor becomes more pronounced - the affected area becomes wider, the tuberosity is more pronounced. Since the rate of development of the disease is high, such a neoplasm gradually ulcerates, the surface becomes rough, and tenderness may appear on palpation.

With further growth of the tumor, depending on its belonging to a certain form, a crater or a kind of plaque is formed on the surface of the body, pressure causes pronounced unpleasant sensations bordering on pain, exudate with blood clots can be released. An unpleasant specific odor may also appear.

The process of development of the disease has several pronounced stages, which differ in external manifestations and the degree of penetration of metastases into the adjacent tissues.

Stages of development

There are four periods of development of this type of skin cancer. Let's consider them in more detail.

The first

At the onset of the disease, a small seal appears on the surface of the body, which does not attract attention and does not cause pain, it can be mobile. The size of the area of the affected area is not more than 2 cm in diameter.

Metastases have not yet begun to appear, the color of such a neoplasm is from yellowish to light brown.

Diagnostics rarely reveals oncology at the first stage - patients do not often pay attention to the affected area that has appeared, which allows the disease to develop, and the first stage passes into the next.

The second

This stage is already characterized by the appearance of the first metastases, which mainly appear in the lymph nodes and cancer cells are carried by the blood stream to all tissues and organs.

The size of the affected area goes beyond 2 cm, there is a pronounced tightness of the skin, the color becomes more pronounced.

When pressing, soreness may not yet appear, but unpleasant sensations may occur when pressed.

The third

The progression of the disease is manifested both in an increase in the area of the lesion and in a greater metastasis; not only closely located lymph nodes are affected, but also tissues of healthy adjacent organs. Soreness when pressed becomes more noticeable, the appearance of discharge from ulcers on the surface of the tumor is possible.

The edges of the affected area have ridges of highly compacted epidermis, the entire surface is ulcerated.

Fourth

At the fourth, last stage of its development, squamous cell carcinoma has already metastasized to the lymph nodes and tissues, the soreness is expressed and can be constant, discharge from ulcers on the surface of the affected area is often observed.

At this stage, metastases have already penetrated into cartilage tissue, as well as bones. As a result, closely spaced joints begin to lose mobility.

What methods of diagnosing this type of malignant tumor can be used to obtain an accurate diagnosis?

Diagnostics

Three main methods are used to diagnose this type of cancer:

- for this, a small piece of tissue is examined under a microscope, and this study makes it possible to determine both the presence of atypical cells in the tissue and their belonging to a certain type of malignant neoplasm;
cytological scraping - here also the tissue taken by scraping from the surface of the ulcer or wound is examined;
laboratory methods.

The combination of these methods makes it possible to determine both the type of malignant tumor and the stage of its development.

To diagnose the presence of metastases is usually used as well. It is mandatory to separate squamous cell carcinoma with diseases similar in appearance to, and.

Treatment

After the diagnosis is made, treatment is prescribed.

And to determine his method, factors such as the stage of development of the disease, the location of the swelling, the presence and number of metastases, as well as the general indicators of the patient's health and belonging to a particular age category should be taken into account.

Currently, there are several most effective methods for treating the type of cancer under consideration. These include the following:

surgical intervention;
the use of photodynamic therapy;
laser tumor removal.

In parallel with the listed methods of cancer treatment, restorative procedures should be applied that increase the patient's immunity level and improve his general condition.

Let's take a closer look at some of these methods.

Surgical intervention

This method of treatment assumes a satisfactory condition of the patient who will be able to undergo surgery. This method is used in the presence of significant skin lesions, as well as in the late stages of cancer development.

Cryodestruction

This technique, in combination with electrocoagulation, is used for multiple lesions, as well as for minor skin lesions and relapses of the disease.

Chemotherapy

This method of treating the manifestations of squamous cell carcinoma is also considered one of the most effective. It is used both for relapses and in the presence of advanced stages of cancer and its extensive damage to the body.

X-ray therapy

This method of exposure is used for lesions of squamous cell carcinoma of the skin of the face (eyelids, the area near the lips, nose and mouth). Also, an indication for the use of this method is the elderly age of the patient.

Removal of skin cancer metastases is also carried out with irradiation of the affected areas.

Any of the listed methods of influencing a cancerous growth on the surface of the body will have more pronounced results in the case when the disease is not started and the stage of its development is not the latest.

Forecast and prevention

The prediction should be made by the attending physician and the conclusion is made on the basis of such data as the stage of development of the disease, the age of the patient, his state of health at the time of detection of squamous cell carcinoma, the treatment used and the condition after the transferred therapeutic effect.

If the disease is in the third or fourth stage of its development, then the prognosis for the next five years of life is about 60%, and with successful treatment and early stages of this form of cancer - more than 90%.

Much here depends on the degree of damage to the body by this form of cancer and the method of treatment.

The most important preventive actions to prevent the occurrence of squamous cell carcinoma include the following:

regular preventive examination - this allows you to detect any deviations from the norm in the condition of the skin and to start the necessary treatment in a timely manner;
knowledge of the manifestations of squamous cell oncological condition at the earliest stages;
attentive attitude to one's own state;
rapid initiation of treatment when an area of cancer is found;
lack of self-medication - this can only lead to the appearance of more advanced stages of cancer;
maintaining a healthy lifestyle - active sports, walking in the fresh air, rational and balanced nutrition, a positive attitude.

By showing attention to your health, you will protect yourself from many diseases, including cancer of the skin.

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Squamous cell carcinoma of the skin is a group of malignant neoplasms that develop from keratinocytes of the prickly layer of the cutaneous epidermis and are capable of producing keratin.

The prognosis of life with squamous cell skin cancer is characterized by the following statistics: during the first 5 years, 90% of people in whom the size of the formation is less than 1.5-2 cm survive, and when these sizes are exceeded and the neoplasm grows into the underlying tissues, only 50% of patients.

The reasons for the development of pathology

The main reason for the development of squamous cell skin cancer is considered a genetic predisposition. It can be hereditary or acquired and is expressed in:

Damage to cellular DNA under the influence of certain factors, resulting in a mutation of the TP53 gene, which encodes the p53 protein. The latter, as a regulator of the cell cycle, prevents tumor transformation of cells. "TP53" is one of the main genes involved in blocking the development of malignant neoplasms.
Disorders of the functions of the immune system directed against tumor formations (antitumor immunity). Many cell mutations constantly occur in the human body, which are recognized and destroyed by cells of the immune system - macrophages, T- and B-lymphocytes, natural killer cells. Certain genes are also responsible for the formation and functioning of these cells, a mutation in which reduces the effectiveness of anti-tumor immunity and can be inherited.
Violation of carcinogenic metabolism. Its essence lies in the mutation of genes that regulate the intensity of the function of certain systems, which are aimed at neutralizing, destroying and quickly removing carcinogenic substances from the body.

A favorable background for the development of squamous cell skin cancer are:

Age. The disease is extremely rare among children and young people. The percentage of cases increases sharply among people over 40, and after 65 years, this pathology occurs quite often.
Skin type. The disease is more susceptible to people with blue eyes, red and light hair and light skin that does not lend itself well to sunburn.
Male. Among men, squamous cell carcinoma develops almost 2 times more often than women.
Skin defects. Cancer can develop on clinically healthy skin, but much more often - against the background of freckles, telangiectasias and precancerous diseases (Bowen's disease, Paget's disease, xeroderma pigmentosa), in the area of scars formed as a result of burns and radiation therapy, after which cancer can even occur after 30 years or more, post-traumatic scars, trophic changes in the skin (with varicose veins), openings of the fistulous passages in osteomyelitis of the bone (the frequency of metastasis is 20%), lesions in tuberculous and systemic lupus erythematosus, etc.
Long-term decrease in general immunity.

Among the provoking factors, the main ones are:

Ultraviolet radiation with intense, frequent and prolonged exposure - sunbathing, with psoralen, carried out in order to treat psoriasis and desensitization in case of allergy to the sun's rays. UV rays cause mutation of the TP53 gene and weaken the antitumor immunity of the body.
Ionizing and electromagnetic radiation.
Prolonged exposure to high temperatures, burns, prolonged mechanical irritation and damage to the skin, precancerous dermatological diseases.
Local exposure for a long time (due to the specifics of professional activity) of carcinogenic substances - aromatic hydrocarbons, soot, coal tar, paraffin, insecticides, mineral oils.
General therapy with glucocorticoid drugs and immunosuppressants, local therapy with drugs of arsenic, mercury, chloromethyl.
HIV and human papillomavirus infection 16, 18, 31, 33, 35, 45 types.
Irrational and unbalanced nutrition, chronic nicotine and alcohol intoxication of the body.

The prognosis without treatment is poor - the incidence of metastases is on average 16%. In 85% of them, metastasis occurs in regional lymph nodes and in 15% - in the skeletal system and internal organs, most often in the lungs, which always ends in death. The greatest danger are tumors of the head and skin of the face (affected in 70%), especially squamous cell carcinoma of the nasal skin (nasal dorsum) and neoplasms localized in the forehead, in the nasolabial folds, periorbital zones, in the area of the external auditory canal, the red border of the lips, especially the upper one, on the auricle and behind it. Tumors that have arisen in closed areas of the body, especially in the area of the external genital organs, of both women and men, are also highly aggressive in terms of metastasis.

Morphological picture

Depending on the direction and nature of growth, the following types of squamous cell carcinoma are distinguished:

Exophytic, growing on the surface.
Endophytic, characteristic of infiltrating growth (grows into deeper tissues). It is dangerous in terms of rapid metastasis, destruction of bone tissue and blood vessels, and bleeding.
Mixed - a combination of ulceration with tumor growth deep into the tissues.

The microscope examined under a microscope is characterized by a picture common to all forms of this disease. It consists in the presence of cells, similar to cells of the thorny layer, growing deep into the dermal layers. Characteristic features are the proliferation of cell nuclei, their polymorphism and excessive staining, the absence of connections (bridges) between cells, an increase in the number of mitoses (division), the severity of keratinization processes in individual cells, the presence of cancerous cords with the participation of cells of the thorny layer of the epidermis and the formation of the so-called , "Horn pearls". The latter are rounded foci of excessive keratosis with the simultaneous presence of signs of incomplete keratinization in the center of the foci.

In accordance with the histological picture, there are:

squamous cell keratinizing skin cancer (highly differentiated);
undifferentiated form, or non-keratinizing cancer.

Common to both forms is the disorderly arrangement of groups of atypical flat epithelial cells with their proliferation into the deeper layers of the dermis and subcutaneous tissues. The severity of atypia in different cells may be different. It is manifested by a change in the shape and size of the nuclei and the cells themselves, the ratio of the volumes of the cytoplasm and the nucleus, the presence of pathological division, a double set of chromosomes, and many nuclei.

Highly differentiated squamous cell carcinoma of the skin

It is characterized by the most benign course, slow growth and gradual spread to deeper tissues. Signs of keratinization are determined both on the surface and in the thickness.

A keratinized tumor can have the appearance of multiple formations, but, as a rule, it is solitary, flesh-colored, yellowish or red in color. Its shape is round, polygonal or oval, sometimes with a depression in the center. On visual inspection, the neoplasm may look like a plaque, nodule or papule, the surface of which is covered with dense squamous scales of the stratum corneum separating with difficulty. In the central part, an ulcer or erosion is often determined with dense keratinized edges that rise above the surface of the skin. The erosive or ulcerative surface is crusty. When pressing on the tumor, horny masses are sometimes separated from its central or lateral sections.

Squamous cell non-keratinizing skin cancer

It has a more malignant course, compared with the previous form, manifested by rapid infiltrating growth into the deep dermal layers, faster and more frequent metastasis to regional lymph nodes.

With this form, cellular atypism and many mitoses of a pathological nature are sharply expressed with a slight reaction of the structural elements of the stroma. There is no keratinization at all. In the cells, either decaying or hyperchromic (excessively stained) nuclei are determined. In addition, in the case of an undifferentiated form of cancer, layers of epithelial cells that look like nests are separated from the epidermal layer, keratinization is absent or insignificant.

The main elements of the tumor are granulation "fleshy" soft formations like papules or nodes with elements of growth (vegetation). The most frequent localization is the external genital organs, much less often - the face or various parts of the trunk.

The neoplasm can be single or multiple, has an irregular shape and occasionally looks like a cauliflower. It quickly transforms into an erosion or ulcer with a necrotic bottom covered with a reddish-brown crust, easily bleeding with minor contact. The edges of the ulcer are soft, rise above the surface of the skin.

Depending on the clinical manifestations, the following main types of the disease are conditionally distinguished, which can be combined or changed at different stages of development:

nodular or tumor type;
erosive or ulcerative infiltrative;
plaque;
papillary.

Nodular or tumor type

Superficial, or nodular, squamous cell skin cancer is the most common type of tumor development. The initial stage is manifested by one or more painless nodules of dense consistency merging with each other, the diameter of which is about 2-3 mm. They rise slightly above the skin surface and have a dull white or yellowish color, very rarely brown or dark red, the skin pattern above them is not changed.

Quite quickly, the size of the nodule (s) increases, as a result of which the tumor becomes like a painless yellowish or whitish plaque with a gray tint, the surface of which may be slightly rough or smooth. The plaque also protrudes slightly above the skin. Its dense edges look like a roller with uneven, scalloped contours. Over time, a depression is formed in the central part of the plaque, covered with a crust or scale. When they are removed, a drop of blood appears.

In the future, there is a rapid increase in the size of the pathology, the central depression is transformed into erosion, surrounded by a roller with steep, uneven and dense edges. The erosive surface itself is crusty.

Ulcerative infiltrative type

For the initial stage of the ulcerative-infiltrative type of squamous cell carcinoma, the appearance of a papule is characteristic as a primary element that has endophytic growth. Over the course of several months, the papule transforms into a knot of dense consistency, fused with the subcutaneous tissue, in the center of which an ulcer with an irregular shape appears in 4-6 months. Its edges are raised in the form of a crater, the bottom of which is dense and rough, covered with a whitish film. Ulceration often takes on a fetid odor. As the node enlarges, bleeding appears even in the case of a slight touch to it.

On the peripheral parts of the main node, "daughter" nodules can form, and when they disintegrate, ulcers are also formed, which merge with the main ulcer and increase its area.

This form of cancer is characterized by rapid progression and destruction of blood vessels, invading the underlying muscles, cartilage and bone tissue. Metastases spread both by the lymphogenous route to the regional nodes, as a result of which dense infiltrates are sometimes formed, and by the hematogenous route to the bones and lungs.

Plaque squamous cell carcinoma of the skin

It has the appearance of a sharply distinguished dense red area of the skin surface, against the background of which small bumps, hardly noticeable upon visual inspection, sometimes appear. The element has a rapid peripheral and endophytic growth in adjacent tissues, often accompanied by severe soreness and bleeding.

Papillary squamous cell carcinoma of the skin

It is relatively rare and represents one of the exophytic forms. At first, it manifests itself as a primary, rising above the surface of the skin and rapidly growing, a nodule. A large number of horny masses are formed on it, as a result of which the surface of the node becomes lumpy with a central depression and a large number of small dilated blood vessels. This gives the tumor, located, as a rule, on a wide and little displaced base, the appearance of a dark red or brown "cauliflower". At the later stages of its development, papillary cancer transforms into ulcerative-infiltrative cancer.

A variety of the papillary form is verrucous, which in old age can manifest itself as a cutaneous horn. The verrucous form is characterized by very slow development and extremely rare metastasis. It has a yellowish or reddish-brownish color, a bumpy surface, covered with warty elements and a hyperkeratotic crust.

Treatment of squamous cell skin cancer

The choice of treatment method is influenced by:

The histological structure of the tumor.
Its localization.
The stage of the cancer process, taking into account the presence of metastases and their prevalence.

Surgical excision

A small tumor without metastases is surgically excised within the unaffected tissues, retreating 1-2 cm from its edges. If the operation is performed correctly, the cure within 5 years is 98% on average. Particularly good results are observed when the tumor is excised in one block with the subcutaneous tissue and fascia.

Radiation therapy

With small tumor sizes at T1 and T2 stages, it is possible to use close-focus X-ray radiation as an independent method. At T3-T4 stages, the radiation method is used for preoperative preparation and postoperative therapy. It is especially effective in the treatment of deeply growing skin tumors. In addition, radiation exposure is used to suppress possible metastases after surgical excision of the main tumor and as a palliative method for inoperable cancer (to slow its spread).

The large size of a cancer tumor in the absence of metastases is an indication for the use of external gamma therapy, and if they are available, combined therapy is carried out by means of X-ray and gamma irradiation, radical removal of the tumor itself with regional lymph nodes.

Cryodestruction and electrocoagulation

Treatment of small superficial highly differentiated squamous cell carcinoma with localization on the body is possible with cryodestruction, but with the obligatory preliminary confirmation of the nature of the tumor using a preliminary biopsy. Removal of a malignant skin formation of the same nature with a diameter of less than 10 mm in the face, lips and neck area can be carried out using the electrocoagulation technique, the advantage of which is less trauma.

Chemotherapy

Chemotherapy for squamous cell skin cancer is prescribed mainly before surgery in order to reduce the size of the neoplasm, as well as in combination with the method of radiation therapy for inoperable cancer. For this, drugs such as Fluorouracil, Bleomycin, Cisplastin, Interferon-alpha, 13-cis-retinoic acid are used.

Treatment with folk remedies for cancers is unacceptable. This can only lead to wasted time and the development of metastases. It is possible to use folk remedies as auxiliary only on the recommendation of a doctor for the treatment of radiation dermatitis.

Alternative therapies

Modern physical treatment in oncology also includes methods of photodynamic therapy using a pre-selected special sensitizing dye (PDT), as well as laser-induced light-oxygen therapy (LISKT). These methods are used mainly for the treatment of elderly patients, in cases of severe concomitant diseases, with localization of the neoplasm over the cartilage and on the face, especially in the periorbital zone, since they do not have a negative effect on the eyes, healthy soft and cartilaginous tissues.

Timely determination of the cause and background on which the malignant process develops, elimination (if possible) or reduction of the influence of provoking factors are important points in the prevention of metastasis and the prevention of recurrence of squamous cell carcinoma, which occurs on average in 30% after radical treatment.