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234 Part I Disorders Presenting in the Skin and Mucous Membranes Figure 11-7. Squamous cell carcinoma: invasive on the lip A large but subtle nodule, which is better felt than seen, on the vermilion border of the lower lip with areas of yellowish hyperkeratosis. This nodule can be felt to infiltrate the entire lip. keratotic scale or hyperkeratosis (Figs. 11-1, 11-7–11-9 and 11-12); when eroded or ulcerated, the lesion may have a crust in the center and a firm, hyperkeratotic, elevated margin (Figs. 11-8 and 11-9). Horny material may be expressed from the margin or the center of the lesion (Figs. 11-8, 11-9 and 11-11). Erythematous, yellowish, skin color; hard; polygonal, oval, round (Figs. 11-7 and 11-11), or umbilicated and ulcerated. Distribution. Usually isolated but may be multiple. Usually exposed areas (Fig. 11-6). Sun-induced keratotic and/or ulcerated lesions especially on the bald scalp (Fig. 11-1), cheeks, nose, lower lips (Fig. 11-7), ears (Fig. 11-12), preauricular area, dorsa of the hands (Fig. 11-11), forearms, trunk, and shins (females). Other Physical Findings. Regional lymphadenopathy due to metastases. Special Features. In UV-related SCC evidence of dermatoheliosis and solar keratoses. SCCs of the lips develop from leukoplasia or actinic cheilitis; in 90% of cases they are found on
Section 11 Precancerous Lesions and Cutaneous Carcinomas 235 Figure 11-8. Squamous cell carcinoma (SCC) A round nodule, firm and indolent with a central black eschar. Note yellowish color in the periphery of the tumor indicating the presence of keratin. The SCC shown in Fig. 11-7 and here is hard and occurs on the lower lip. SCC hardly occurs on the upper lip because this is shaded from the sun. SCC on the lip is easily distinguished from nodular BCC because BCC does not develop hyperkeratosis or keratinization inside the tumor and does not occur on the vermilion lip. the lower lip (Figs. 11-7 and 11-8). In chronic radiodermatitis, they arise from radiationinduced keratoses (see Fig. 10-33); in individuals with a history of chronic intake of arsenic, from arsenical keratoses. Differentiated (i.e., A B hyperkeratotic) SCC due to HPV on genitalia; SCC due to excessive PUVA therapy on lower extremities (pretibial) or on genitalia. SCCs in scars from burns, in chronic stasis ulcers of long duration, and in sites of chronic inflammation Figure 11-9. Squamous cell carcinoma, well differentiated (A) A nodule on the lower arm covered with a domeshaped black hyperkeratosis. (B) A large, round, hard nodule on the nose with central hyperkeratosis. Neither lesion can be clinically distinguished from keratoacanthoma (see Fig. 11-15).
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