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Freeze or store tumor in formaldehyde if possible for later study.
Prevention: Education about aggressive sun precautions is vital: avoid the sun during hours when the
individual’s shadow is shorter than their height; wear long sleeves, pants and broad-brimmed hats (brim > 4
inches wide); apply sunscreen of SPF 30 or greater (with special attention to the nose, ears and lips).
Follow-up Actions
Evacuation/Consultant Criteria: Evacuate non-urgently (Routine status) if on long deployment. Otherwise
delay treatment until return from mission. Consult dermatology as needed.
Squamous Cell Carcinoma (SCC)
Introduction: SCC is the second most common skin cancer, affecting over 100,000 Americans each year.
The risk of metastasis is very real in invasive SCCs, especially on the lip or ear. Rates of metastasis range
from about 1-5 %. Non-invasive or in situ SCC can become invasive SCC with time. The variant of SCC in
situ known as Bowen’s disease has a 5% risk of invasion. Sun-exposed skin is at highest risk, and people
with fair complexions are at higher risk than are those who are darker-skinned. Other risk factors: a history
of radiation exposure or arsenic ingestion. In sun-protected areas, chronic ulcers or scars predispose to
SCC, with a high metastatis rate (around 30%). There is a variant of SCC called keratoacanthoma (KA),
which grows very quickly and may spontaneously regress. Mid-facial KAs can be especially aggressive and
destructive. Patients who are immunosuppressed after an organ transplant operation are at especially high
risk, and tend to develop more SCC than BCC, with a reversed incidence ratio.
Subjective: Symptoms
KAs grow rapidly, while SCCs usually are slow growing and much more common in sun-exposed areas;
usually painless lesion; history of chronic sun exposure is common, as is an inability to tan, with many
severe sunburns.
Objective: Signs
Using Basic Tools: Red, scaly (hyperkeratotic) papules are most characteristic for SCC. Size varies from
a few mm to several cm. SCC in situ can occur on the glans penis or within the foreskin, and usually has
a soft, red, velvety appearance, without hyperkeratosis (Bowen’s disease), since it arises from mucosa. It is
associated with a genital wart virus (HPV type 16) and can appear similar to genital warts, with dark at-
topped verrucous papules. Cervical and penile cancers are known to be caused by a genital wart virus.
KA has a distinctive appearance, similar to that of a volcano, with a central core of keratin surrounded by
domed, rolled borders, usually ranging in size from 1-3 cm. Metastatic SCC often presents with palpable
lymphadenopathy.
Assessment:
Differential Diagnosis - BCC, ulcers, chronic ulcerative herpes, benign adnexal tumors, contact dermati-
tis, Bowen’s disease. Differentiating some of these conditions in the eld is nearly impossible, requiring expert
microscopic evaluation of a biopsy.
Plan:
Treatment: Evacuate and refer to dermatology. If evacuation is not possible in the foreseeable future (1-2
months—relatively slow growing tumor), perform full thickness excisions with wide margins (5 mm) all around
the tumor. Freeze or store tumor in formaldehyde if possible for later study.
Prevention: Education about aggressive sun precautions is vital: avoid the sun during hours when the
individual’s shadow is shorter than their height; wear long sleeves, pants and broad-brimmed hats (brim > 4
inches wide); apply sunscreen of SPF 30 or greater (with special attention to the nose, ears and lips).
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate non-urgently (Routine status) if less than 2 months before
return from deployment. Otherwise delay treatment until return from mission. Consult dermatology as needed.