Squamous Cell Carcinoma (cSCC): Symptoms and Treatment

What is squamous cell carcinoma?

Cutaneous squamous cell carcinoma, or cSCC, is a malignant skin tumor that develops from keratinocytes in the skin.

Most cSCCs can be successfully treated with early diagnosis and appropriate surgical treatment. However, compared to basal cell carcinoma, it has a higher potential for metastasis to regional lymph nodes and, more rarely, to distant organs. Therefore, risk stratification is important. The European guidelines also recommend managing cSCC by dividing it into low-risk and higher-risk groups.

Briefly, what you need to know

cSCC is a type of skin cancer.

Most patients are successfully treated with surgery.

Not all cSCCs carry the same risk.

Sun damage is a major risk factor.

It may be associated with actinic keratosis and some other premalignant lesions.

It can be more aggressive in immunocompromised individuals.

The definitive diagnosis is made through histopathological examination.

The cornerstone of treatment for most patients is complete surgical excision and clean surgical margins.

What does cSCC look like?

It doesn't have a single appearance.

It may manifest in one of the following ways:

a hard, raised nodule,

thick crusted or hyperkeratotic lesion,

a wound that doesn't heal,

easily bleeding formation,

rapidly growing red-pink mass,

ulcerating plaque or nodule.

It is particularly important to evaluate lesions that grow rapidly, harden, or bleed repeatedly in a short period of time.

Where is it most commonly seen?

It is commonly seen in areas with chronic sun exposure:

face,

ear,

scalp,

lower lip,

backs of hands,

forearms.

However, it can also develop in other parts of the body.

Certain anatomical areas, particularly the ear and lip, may be associated with a higher risk, along with other characteristics of the tumor.

Why does it occur?

One of the most important environmental risks is cumulative ultraviolet exposure.

In addition:

old age,

light skin phenotype,

having previously had skin cancer,

chronic immunosuppression,

organ transplantation,

chronic wounds and scars,

some carcinogen exposures

It can increase the risk.

Immunosuppression is particularly important; European guidelines evaluate immunocompetent and immunosuppressed patients separately.

Is actinic keratosis cSCC?

No.

Actinic keratosis is not a cSCC, but it is evaluated within the premalignant/intraepidermal neoplastic spectrum associated with UV damage, and some lesions may progress to invasive cSCC over time.

Therefore, the architectural correction we made earlier is being preserved:

Actinic keratosis = discrete premalignant lesion. cSCC = invasive skin cancer.

We will not mix them up under the same heading.

What is Bowen's disease?

Bowen's disease is a condition known as squamous cell carcinoma in situ, where malignant cells have not yet invaded beneath the epidermis.

It differs from invasive cSCC, and treatment options may vary accordingly.

What is the difference between cSCC and BCC?

Both are classified as non-melanoma skin cancers, but they behave differently.

BCC: Distant metastasis is extremely rare; the main risk is local tissue destruction.

cSCC: Most cases have a good prognosis, but in certain high-risk tumors, the risk of lymph node metastasis and disease-related death is higher than in BCC.

Therefore, risk classification is particularly important in cSCC.

How is cSCC diagnosed?

Clinical and dermoscopic evaluation may suggest a diagnosis.

However, biopsy or excision and histopathological confirmation are necessary for suspicious lesions. European guidelines emphasize that histological diagnosis is essential for risk stratification and accurate treatment planning.

What is important in a biopsy?

Pathology only:

“"SCC exists / does not exist"”

It is not used to mean that.

In risk assessment:

tumor thickness and depth of invasion,

differentiation,

perineural invasion,

lymphovascular invasion,

surgical margins

Features like these can be important.

These factors can affect subsequent surgery and follow-up plans.

Do all cSCCs carry the same risk?

No.

The 2026 European approach specifically distinguishes between most cSCCs, noting that while some tumors are easy-to-treat, others become difficult-to-treat due to localization, size, histology, recurrence, or patient-related factors.

In case of increased risk:

large tumor,

certain high-risk anatomical regions,

deep invasion,

poor differentiation,

perineural invasion,

recurrent tumor,

immunosuppression

Factors such as these can play a role.

Because:

“"We acquired SCC, that's it."”

This approach is not sufficient for every patient.

How is cSCC treated?

Surgical excision

In most primary cSCC cases, the first-line treatment is surgery.

2026 European guidelines first option in common primary cSCC:

surgical excision + postoperative margin evaluation or micrographically controlled surgery

It is described as follows: Obtaining a clean histological margin is the main goal of the treatment.

When is Mohs/micrographic controlled surgery used?

Especially:

high-risk tumor,

critical anatomical regions of the face,

recurrent tumor,

tumor with ill-defined borders,

situations where tissue preservation is important

This can make micrographically controlled surgery more valuable.

Not every small, low-risk cSCC requires the application of Mohs testing.

Do destructive methods have a place?

For some low-risk, carefully selected lesions, methods such as curettage-electrodesiccation or cryosurgery may be considered.

However, the AAD specifically notes that cure rates for non-surgical treatments may be lower than those for surgical treatments. (American Academy of Dermatology)

The basic security principle is this:

A lesion suspected of having cSCC should not be cosmetically destroyed with CO₂ laser, Er:YAG, plasma, or radiofrequency before a diagnosis is made.

Because a malignant lesion first requires histopathological diagnosis and oncological risk assessment.

Is radiotherapy a viable option?

Yes.

Radiotherapy may be considered for patients unsuitable for surgery or in certain situations where the tumor characteristics necessitate it.

The 2026 European guidelines recommend considering radiotherapy for patients or tumors that are not suitable for surgery.

Can it spread to the lymph nodes?

Yes, but not in most patients.

Regional lymph node metastasis becomes clinically significant, especially in high-risk cSCC.

Suspicious lymph node findings may require ultrasound, imaging, or tissue sampling.

However, not everyone with small, low-risk cSCC undergoes automated PET/CT or lymph node imaging.

Is sentinel lymph node biopsy performed on everyone?

No.

The role of sentinel lymph node biopsy in melanoma is more clearly defined. However, its routine use is more limited in cSCC, and multidisciplinary evaluation may be necessary in selected high-risk patients.

Therefore, we will not be copying the melanoma algorithm to cSCC.

Is there a treatment for advanced or metastatic cSCC?

Yes.

In locally advanced or metastatic cSCC that cannot be cured with surgery or radiotherapy, immunotherapies targeting the PD-1 pathway are an important part of modern treatment.

The 2026 European guidelines recommend that treatment for macroscopic nodal or advanced disease be individualized in a multidisciplinary tumor board.

The important point from the patient's perspective is this:

Effective systemic immunotherapy options are available today, even in advanced cSCC.

Is cSCC completely curable?

In most early cSCCs, yes.

2023 Avrupa tanı kılavuzunda genel cSCC için tedavi sonrası 5 yıllık kür oranlarının %90’ın üzerinde olduğu belirtiliyor.

However, the prognosis may differ for high-risk tumors.

Therefore, we will explain that the abbreviation "SCC" alone does not determine the patient's prognosis.

Is follow-up necessary after treatment?

Yes.

Having developed a cSCC:

local recurrence,

another cSCC,

BCC or other skin cancers

This could increase the future risk.

The AAD recommends at least regular skin checks. The frequency of follow-up should be individualized according to the risk level of the tumor. (American Academy of Dermatology)

When should you consult a dermatologist?

Especially:

a scabbed wound that doesn't heal,

a growing, hard swelling,

easily bleeding lesion,

a formation that grows rapidly in an area exposed to the sun,

Significant thickening, pain, or rapid changes in a lesion suspected to be actinic keratosis.

If available, the assessment is appropriate.

Frequently Asked Questions

Is squamous cell carcinoma cancer? Yes.

Is SCC melanoma? No. They are different types of skin cancer that develop from different cell types.

Can SCC metastasize? Yes, it is possible, especially in certain high-risk tumors; however, most primary cSCC are successfully managed with appropriate treatment.

Is actinic keratosis SCC? No. Actinic keratosis is a premalignant lesion; some lesions may progress to invasive cSCC.

Should every SCC be surgically treated? Surgery is the first-line treatment for most primary invasive cSCCs. Radiotherapy or other methods may be used in selected cases.

Can SCC be burned with a laser? Suspected malignant lesions should not be removed with lasers or other destructive devices before a diagnosis is made. Some non-surgical methods may have a place in selected low-risk tumors, but surgical margin control offers a significant advantage.

Is it more important in immunocompromised individuals? Yes. Immunosuppressed patients may have an increased risk of developing cSCC and aggressive behavior.

Clinical Note by Dr. Utkan Kızıltaç

In squamous cell carcinoma, for me, it's not just the question of "is there cancer?" that matters, but also "what is the risk level of this tumor?". We cannot evaluate a small, superficial, low-risk cSCC in the same way as a tumor in a deep, recurrent, or immunosuppressed patient. Accurate biopsy, visualization of histopathological risk features, and ensuring clear surgical margins are fundamental to treatment.

Related content

Skin Cancers · Actinic Keratosis · Basal Cell Carcinoma · Melanoma · Dermoscopy · Sun Protection