Guest: Dr. Bruce H. Thiers – Dermatologist
Host: Dr. Linda Austin – Psychiatrist
Dr. Linda Austin - Psychiatrist: I am Dr. Linda Austin. I am talking with Dr. Bruce Thiers, who is Professor and Chairman of Dermatology at MUSC. Dr. Thiers, let’s talk a bit about bout squamous cell carcinoma. You have talked already about basal cell carcinoma, squamous is more serious though, is that correct?
H. Thiers - Dermatologist: Squamous cell and basal cell carcinoma are both considered nonmelanoma skin cancers, but squamous cell tends to be a bit more aggressive. For example, while basal cell carcinoma really has no potential to metastasize despite growing in some patients to a very large size, squamous cell carcinoma can metastasize to regional lymph nodes and even to distant locations. So, squamous cell carcinoma really has to be respected for its potential not only to cause involvement of the skin, but also to spread to areas outsides the skin.
Dr. Linda Austin - Psychiatrist: How do tell a squamous cell carcinoma from other kinds of skin cancers?
Dr. Bruce H. Thiers - Dermatologist: Well, first of all clinically, the patients with squamous cell carcinoma often have very, very severely sun damaged skin. Patients with squamous cell carcinoma are often out to a work such as construction workers or farmers who had great deal of sun exposure over there entire life. The background of the patient with basal cell carcinoma may be a little bit different. These patients often are office workers who get short periods of intense sun exposure rather than repeated exposure to the sun on daily basis. In terms of appearance of the lesion sometime it’s difficult to distinguish basal cell carcinoma from squamous cell carcinoma, although in general basal cell carcinoma is a translucent or purely a bump on the skin with an overlying dilated blood vessel where as squamous cell carcinoma tend to be more scaly and hard as appose to soft lesion of basal cell carcinoma. Microscopically squamous cell carcinoma that could be similar from basal cell carcinoma from this cell that predominates in the tumor, in the basal cell carcinoma obviously predominate cell type is the basal cell. In squamous cell carcinoma predominate cell type is the squamous cell, which is located higher in the skin than the basal cell of the epidermis. I will also add predominate cell type in melanoma is the melanocyte, which is another cell type that’s found in the skin.
Austin - Psychiatrist: So let imagine, you have a patient with the suspicious looking lesion. You do a biopsy. You send it off. The pathologist looks at it under the microscope says indeed this is squamous cell carcinoma. What you do next?
Dr. Bruce H. Thiers - Dermatologist: When he diagnose this squamous cell carcinoma is made we really need to make sure that we remove the entire lesion. A biopsy as I said it in the basal cell carcinoma segment just removes the portion of the tumor. There is still additional tumor left then we need to be sure that entire is removed. When tumor is very superficial we can often get by with curettage, which is simply scrapping the tumor off with a curette. When the tumor is deeper we need to do either excision or micrographic surgery, which is the procedure, in which the tumor is removed in layers and checked under the microscope to be sure that the entire tumor is removed. In the unusual patient who presents with a very large tumor especially on the face we often do imaging studies to be sure that the tumor is not spread beyond the skin.
Dr. Linda Austin - Psychiatrist: Let’s imagine, I am a patient who has come to you I have specious looking lesion. You biopsy it, the pathologist looks at it and he says it’s squamous cell carcinoma. What do you do next?
Dr. Bruce H. Thiers - Dermatologist: Well, once the diagnosis of squamous cell carcinoma is made. We really want to be sure that the entire lesion is removed and let’s say in your case we do an excision. We try to do an excision with a small border of normal looking skin to be sure that we remove the entire lesion and that there are no microscopic remaining in the skin that can cause recurrence. We send the excision specimen to our pathologist and what we want to hear from him in the report is that the lesion is excised with no evidence of involvement of the excision border. If the tumor extends to the border we really need to go back and make sure that we remove any remaining tumor.
Dr. Linda Austin - Psychiatrist: Now you mentioned earlier that the problem with this cancer is that they can spread actually pretty distant from where they started. How would you then proceed to figure out if that happened?
Dr. Bruce H. Thiers - Dermatologist: If the pathologist can usually give us a good indication whether the patient is at risk because very often when these tumors spread they spread along the nerve sells so if the pathologist uses a term such as perineural invasion, which means involvement around the nerve then we become concerned that the lesion may be spreading from beyond the skin.
Dr. Linda Austin - Psychiatrist: And if suppose they can go to the lymph nodes. How do you examine the lymph node to say if they are involved?
Dr. Bruce H. Theirs: Lymph node examination is basically a manual examination. We use our fingers to palpate the regional lymph nodes, look for any enlargement, and if there is no enlargement that certainly reassuring that the tumor is not spread to that location.
Dr. Linda Austin - Psychiatrist: So let’s take two case scenarios. In one where there is not any evidence of spreading to the lymph nodes and the second where there is, if it’s not spread, does the patient have to get chemotherapy or follow-up treatment.
Dr. Bruce H. Thiers - Dermatologist: No. If there is no evidence of spread to lymph nodes we usually keep the patient on under observation and ask the patient to come for regular reexamination not only to check on any recurrence of treated tumor, but to see if there is any evidence of any of any new lesions because in general when one has a skin cancer there changes of developing another skin cancer down the road is certainly a lot higher than the patient who has never had skin a cancer. If the patient has what we called lymphadenopathy or enlargements of the lymph nodes we normally send the patient to an oncologic surgery who remove the lymph node and if the lymph node shows evidence of spread of the tumor we will ask the patient to see an oncologist.
Dr. Linda Austin - Psychiatrist: And then he might be candidate then for chemotherapy.
Dr. Bruce H. Thiers - Dermatologist:Depending on the recommendations of the oncologist - Yes.
Dr. Linda Austin - Psychiatrist: Dr. Bruce thanks so much for talking with us.
Dr. Bruce H. Thiers - Dermatologist: My pleasure.
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