Your diagnosis

Squamous cell carcinoma of the skin

This article will help you read and understand your pathology report for squamous cell carcinoma of the skin.

by Allison Osmond, MD FRCPC, updated March 16, 2021

Quick facts:
  • Squamous cell carcinoma is a common type of skin cancer.
  • It starts from the squamous cells on the surface of the skin.
  • Most tumours occur in older adults on sun-exposed skin usually as a result of the cells in the skin being damaged by UV light from the sun.
The skin

Skin is made up of three layers: epidermis, dermis, and subcutaneous fat. The surface and the part you can see when you look at your skin is called the epidermis. The cells that make up the epidermis include squamous cells, basal cells, melanocytes, Merkel cells, and cells of the immune system. The squamous cells in the epidermis produce a material called keratin which makes the skin waterproof and strong and protects us from toxins and injuries.

The dermis is directly below the epidermis. The dermis is separated from the epidermis by a thin layer of tissue called the basement membrane. The dermis contains blood vessels and nerves. Below the dermis is a layer of fat called subcutaneous adipose tissue.

What is squamous cell carcinoma?

Squamous cell carcinoma (SCC) is a common type of skin cancer. It develops from the squamous cells in the epidermis. Most tumours develop in sun-exposed areas of the body. Squamous cell carcinoma starts from a pre-cancerous condition called squamous carcinoma in situ (CIS).

What is the difference between squamous cell carcinoma and squamous carcinoma in situ?

In squamous carcinoma in situ, the tumour cells are found only in the epidermis. In contrast, in squamous cell carcinoma, the tumour cells have broken through the basement membrane and entered the dermis below. The movement of tumour cells from the epidermis into the dermis is called invasion (see picture below).

Once tumour cells enter the dermis they are able to spread to other parts of the body such as lymph nodes. The movement of tumour cells from the tumour to a different part of the body is called metastasis.

squamous cell carcinoma and in situ

What causes squamous cell carcinoma?

Most tumours that occur in older adults develop as a result of the cells in the epidermis being damaged by UV light from the sun. Long-term exposure to UV radiation from tanning beds can cause similar damage. People who have immunosuppression due to organ transplantation or HIV infection are also at increased risk of developing squamous cell carcinoma.

How do pathologists make this diagnosis?

The diagnosis is usually made after a small tissue sample is removed in a procedure called a biopsy. The diagnosis can also be made after the entire tumour is removed in a procedure called an excision. If the diagnosis is made after a biopsy, your doctor will probably recommend a second surgical procedure to remove the rest of the tumour.

Histologic grade

Pathologists use the word grade to describe the difference between the cancer cells in squamous cell carcinoma and the normal, healthy squamous cells in the skin. The grade is divided into four levels of differentiation based on how the cancer cells look when examined under the microscope.

  • Well differentiated – The cancer cells in this tumour look very similar to normal squamous cells.
  • Moderately differentiated – The cancer cells in this tumour are abnormal but they still resemble squamous cells.
  • Poorly differentiated – The cancer cells in this tumour look very little or nothing like normal squamous cells. Additional tests such as immunohistochemistry may be needed to prove the tumour is a squamous cell carcinoma.

The tumour grade is important because poorly differentiated tumours tend to grow faster and are more likely to spread to lymph nodes or other parts of the body.

What to look for in your report after the tumour has been removed

Tumour size

This is the size of the tumour. The tumour is usually measured in three dimensions but only the largest dimension is described in your report. For example, if the tumour measures 4.0 cm by 2.0 cm by 1.5 cm, your report will describe the tumour as being 4.0 cm.

Depth of invasion (tumour thickness)

All squamous cell carcinomas start in the epidermis on the outer surface of the skin. Depth of invasion describes how far the cancer cells have travelled from the epidermis into the tissue below. The movement of cancer cells from the epidermis into the tissue below is called invasion.

The depth of invasion is measured from the surface of the skin to the deepest point of invasion. Some pathology reports describe the depth of invasion as tumour thickness.

Tumours that grow deeper into the dermis are more likely to spread to a lymph node or to grow back after treatment. The movement of cancer cells to a lymph node or another part of the body is called metastasis.

Perineural invasion

Nerves are like long wires made up of groups of cells called neurons. Nerves send information (such as temperature, pressure, and pain) between your brain and your body. Perineural invasion means that cancer cells were seen attached to a nerve.

perineural invasion

Cancer cells that have attached to a nerve can use the nerve to travel into tissue outside of the original tumour. This increases the risk that the tumour will come back in the same area of the body (recurrence) after treatment.

Lymphovascular invasion

Blood moves around the body through long thin tubes called blood vessels. Another type of fluid called lymph which contains waste and immune cells moves around the body through lymphatic channels.

lymphovascular invasion

Cancer cells can use blood vessels and lymphatics to travel away from the tumour to other parts of the body. The movement of cancer cells from the tumour to another part of the body is called metastasis. Before cancer cells can metastasize, they need to enter a blood vessel or lymphatic. This is called lymphovascular invasion.

Lymphovascular invasion is important because it increases the risk that cancer cells will be found in a lymph node or a distant part of the body such as the lungs.

High-risk features

A high-risk feature is something that makes the tumour more likely to come back in the future, either at the same site or to spread to a distant site such as the lungs. The movement of cancer cells to a lymph node or another part of the body is called metastasis.

The following microscopic features are considered high risk:

  • A depth of invasion of more than 2 millimetres.
  • The presence of cancer cells in the lower half of the skin.
  • Perineural invasion.
  • Lymphovascular invasion.
  • Poorly differentiated tumours.
Margins

A margin is any tissue that was cut by the surgeon in order to remove the tumour from your body. Whenever possible, surgeons will try to cut tissue outside of the tumour to reduce the risk that any cancer cells will be left behind after the tumour is removed.

Margin

Your pathologist will carefully examine all the margins in your tissue sample to see how close the cancer cells are to the edge of the cut tissue. Margins will only be described in your report after the entire tumour has been removed.

A negative margin means there were no cancer cells at the very edge of the cut tissue. If all the margins are negative, most pathology reports will say how far the closest cancer cells were to a margin. The distance is usually described in millimetres.

A margin is considered positive when there are cancer cells at the very edge of the cut tissue. A positive margin is associated with a higher risk that the tumour will grow back (recur) in the same site after treatment.

Lymph nodes

Lymph nodes are small immune organs located throughout the body. Cancer cells can travel from the tumour to a lymph node through lymphatic channels located in and around the tumour (see Lymphovascular invasion above). The movement of cancer cells from the tumour to a lymph node is called a metastasis.

Lymph node

Lymph nodes are not removed for squamous cell carcinoma of the skin. However, if lymph nodes are removed your pathologist will carefully examine each one of them for cancer cells. Lymph nodes that contain cancer cells are often called positive while those that do not contain any cancer cells are called negative. Most reports include the total number of lymph nodes examined and the number, if any, that contain cancer cells.

Tumour deposit

A group of cancer cells inside of a lymph node is called a tumour deposit. If a tumour deposit is found, your pathologist will measure the deposit and the largest tumour deposit found will be described in your report. Larger tumour deposits are associated with a worse prognosis.

Extranodal extension

All lymph nodes are surrounded by a capsule. Extranodal extension means that cancer cells have broken through the capsule and into the tissue that surrounds the lymph node.

Extranodal extension is also associated with a higher risk of new tumours developing in the neck and is often used by your doctors to guide your treatment.

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