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236 Part I Disorders Presenting in the Skin and Mucous Membranes Figure 11-10. Squamous cell carcinoma, undifferentiated There is a circular, dome-shaped reddish nodule with partly eroded surface on the temple of a 78-yearold male. The lesion shows no hyperkeratoses and is soft and friable. When scraped it bleeds easily. are often difficult to identify. Suspicion is indicated when nodular lesions are hard and show signs of keratinization. Special form: carcinoma cuniculatum, usually on the soles, highly differentiated, HPV-related but can also occur in other settings (Fig. 11-13); verrucous carcinoma, also florid oral papillomatosis, on the oral mucous membranes (see Section 35). Histopathology. SCCs with various grades of anaplasia and keratinization. Undifferentiated SCC Lesions. Fleshy, granulating, easily vulnerable, erosive papules and nodules, and papillomatous vegetations (Fig. 11-10). Ulceration with a necrotic base and soft, fleshy margin. Bleeds easily, crusting; red; soft; polygonal, irregular, often cauliflower-like. Distribution. Isolated but also multiple, particularly on the genitalia, where they arise from erythroplasia and on the trunk (Fig. 11-5), lower extremities, or face, where they arise from Bowen disease. Miscellaneous Other Skin Changes. Lymphadenopathy as evidence of regional metastases is far more common than with differentiated, hyperkeratotic SCCs. Histopathology. Anaplastic SCC with multiple mitoses and little evidence of differentiation and keratinization. Figure 11-11. Squamous cell carcinoma, advanced, well differentiated, on the hand of a 65-year-old farmer The big nodule is smooth, very hard upon palpation, and shows a yellowish color, focally indicating keratin in the body of the nodule. If the lesion was incised in the yellowish areas, a yellowish-white material (keratin) could be expressed.
Section 11 Precancerous Lesions and Cutaneous Carcinomas 237 Figure 11-12. Squamous cell carcinoma (SCC), highly differentiated, on the ear There is a relatively large plaque covered by adherent hard hyperkeratoses. Although SCCs are in general not painful, lesions on the helix or anthelix usually are, as was the case in this 69-year-old man. Figure 11-13. Squamous cell carcinoma (carcinoma cuniculatum) in a patient with peripheral neuropathy due to leprosy A large fungating, partially necrotic, and hyperkeratotic tumor on the sole of the foot. The lesion had been considered a neuropathic ulcer, ascribed to leprosy, but continued growing and became elevated and ulcerated.
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FITZPATRICK’S Color AtlAs And sYn
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