Squamous Cell Carcinoma & Actinic Keratosis 101...Dermpath Basics & Beyond

[@haleyfulton7345]

on behalf of the brand new PGY-2 dermatology residents- thank you for helping us (for years past and years to come!!)

[@JMGardnerMD]

My pleasure! Welcome to dermatology residency! Good luck & best wishes. 😊

[@adamronMD]

I’m about half way through and this has been great. The most difficult distinction for me is on Frozen section for excision of SCC in situ especially in these sun exposed areas. Your pace is great. Thank you for putting this together!

[@indranrajendra2809]

I used to fall asleep during histology and pathology sessions in med school. You have a knack of making this subject interesting. Thankyou

[@JMGardnerMD]

This is the highest compliment! Thank you!

[@JordanDoyle-j7o]

super rad! Way more info than I need, but as a PA in a rural clinic running a derm clinic, there are loads of little nuggets that help with my day to day for patient management. Thanks

[@hairyllama5]

Thanks for this video, great practical tips on approaching squamoproliferative lesions in superficial shaves. As a trainee it’s easy to be blasé about these specimens, but with more experience I realise how tricky they can be.

[@vinvinvino3176]

Thank you Jerad for helping sort through one of the most confusing aspects of dermpath...Even though melanocytic lesions still takes the aces for confusion anyday, I find AK/SCC lesions and their many variants quite challenging too....Thanks a lot!

[@JMGardnerMD]

I still find them challenging almost daily!

[@sureshmenon1182]

Excellent Jerad! Thanks so much for your dedication to teaching.

[@teresinaamaro2206]

Thank you ...for making better pathologist

[@ghadabashat5138]

Thank you very much. This is really helpful.

[@johnfazio2892]

Fantastic video. Very helpful.

[@JMGardnerMD]

A complete organized library of all my videos, digital slides, pics, & sample pathology reports is available here: kikoxp.com/posts/5084 (dermpath) & kikoxp.com/posts/5083 (bone/soft tissue sarcoma pathology).

[@tablelegz]

Hey im not a science person so i use this to sleep nice and relaxing works 2 ways i guess

[@juney18]

So hard to find info on this. Thank you so much! It’s heavily dx in my fair English Scottish blooded family(and autoimmune diseases) . I noticed none of the videos on this are hardly viewed, just not exciting. It is ruining my sister and my skin. Sun beds were prescribed for her plaque psoriasis. I did it also, have autoimmune disease. The medication rubbed on the skin over weeks was blisteringly painful, impossible to continue when so covered in this actinic keratosis, darker and rougher than ever, along w an psA flare of 2 months. It’s taking me over and my derma doesn’t seem to listen. Says if they’re frozen they just come back and the old school topical med is all he offered, seemed bored and instinctive, wanting out of the room, didn’t want to be there. I’m covered in brown rough embarrassing noticeable spots, high speed increasing.

[@M4790ya]

Great session. Thanks alot DOC

[@tamilarasirenganathan8243]

Thank you sir. It was very helpful!

[@rikkuyunna8882]

Thank you Dr. Jerad. Atleast the descriptions mentioned in the book are not just an imagination but already real images from your cases.❤❤

[@kamilletuma1191]

Thank you very much for your lesson, Dr. Jerad!!! It helps me a lot during my residency!

[@caroll9858]

I have a very clear photo of Squamous Cell Carcenoma, necrotic centre through to ulna. Site was excised. Skin graft healed well. Would like to share photo.

[@evelyne7071]

Watche’d the whole thing ! Captivating ! That sure was a beautiful, ugly mitosis figure at the end. Thank you for keeping me engaged throughout.

[@jurgitaleskauskaite1415]

Thank you!

[@rabiataseer8369]

Great video.

[@amandaaulenti7643]

I have multiple lesions identical to the ones you are explaining for over a year now. It began when I collapsed in my bathroom on 3/30/2021 and I hit my head and smashed my face and my bottom teeth went completely through my bottom lip. Within a week my lip was 5 x the size with a large vacuole in the center and what i can only explain as leichmaniasis. I have had hundreds of lesions on almost every area of my body which are luminescent. I am desperate for a definitive diagnosis

[@docdihya2466]

Thank you very much sir 💝

[@rabiataseer8369]

Great video!Thank you!

[@anurudg1]

Awesome

[@pathpath2602]

Really thanks a lot to make such this wonderful video for pathologists. I want to make a simple question. I met a case which had features of seborrheic keratosis with definite basal keratinocytes atypia. I searched books and online sources, but actinic keratosis arising on seborrheic keratosis was not noted, except a case report of collision tumor of pigmented bowen's disease and seborrheic keratosis. Is AK commonly associated with SK?

[@JMGardnerMD]

Thanks! Yes I see this all the time in severely sun damaged skin...looks like SK but has atypia like AK. I suspect chronic sun damage causes the keratinocytes within the SK to become dysplastic/atypical over time. I see similar change in solar lentigo (which may be related to SK). Also I see atypia in inflamed SK but there it is probably due to the inflammation. My dermpath survival guide books explains in detail about how I practically handle confusing scenarios in daily dermpath practice (and how I explain them in my pathology report). You can purchase it here: bit.ly/2Te2haB. Ships worldwide.

[@TheObaachan]

Thank you so much for the educative video! Can you make a video on metastases of SCC vs primary SCC? I find this hard to tell apart and clinically it impacts patient care in terms of treatment decision making a lot..

[@JMGardnerMD]

It’s very difficult in some cases! If there is no connection to the epidermis, that raises possibility of metastasis. But often times when I see that on a biopsy it ends up being a primary cutaneous SCC that connects to the epiderm us elsewhere just not on the area sampled. I have rarely seen cutaneous metastases of SCC in my practice. Unfortunately there are no immunostains to my knowledge that can tell primary versus metastasis apart for SCC

[@ghubb]

very nice

[@earleneschmitt3326]

Im searching for clinical trials for a friends Mother. She has one tumor(sq cell carcinoma) on one leg, and unfort it has spread to other leg, 2 mets. Much apprec insights on current trials.

[@GatheringPlace123]

My Primary Care Physician saw me, examined my skin lesion, said it was fine, and healing. I went for a second opinion, he agreed with me it was infected (elevated WBC) helped, and sent me to Dermatologist. She looked at it, said it looked like Squamous Cell Carcinoma and wanted to biopsy. Biopsy confirmed. Borders not clean. Must I undergo more surgery?

[@JMGardnerMD]

It depends on the scenario. Often a dermatologist will do additional surgery to remove a squamous cell carcinoma after biopsy but it sometimes depends on the anatomic location, the type of biopsy done initially, if the tumor is invasive or not, and if there are any particular microscopic high risk feature to the tumor. Exact management approach may vary to some extent between dermatologists, as well, because there can be multiple correct ways to approach a given scenario. Please discuss with your dermatologist to see what they think is the best course of action for your case specifically. The good news is that the vast majority of squamous cell carcinoma of the skin can be cured with appropriate treatment. Best wishes for good health!

[@RRMOTORS88]

So much helpful information....I bit my tongue a few months ago and got diagnose with invasive cell carsionoma...can you take me in for a second opinion?

[@earleneschmitt3326]

What is "encased" squamous cell carcinoma? Is it keratized encasement? Schwann cell encasement? Do schwann facilitate metastasis, guiding tumor cells to travel along nerves to secondary met sites? How does squamous cell carcinoma metastasize from one leg to other leg? Is it traveling along nerves or vasculature?

[@szwalsam]

Many thanks for the fantastic teaching, this video though was a little bit dark, just more light would make it perfect

[@JMGardnerMD]

I agree. This was made 2 years ago on my old camera setup. My new camera setup doesn’t have this issue with white balance/ dark background. So hopefully won’t be a problem anymore! Thanks!

[@szwalsam]

@@JMGardnerMD Many thanks, Jerad for the reply. I have just finished watching your brilliant session on BCC's. Would you comment on an area of micropapillary differentiation in a BCC? Also, how often do you use IHC to rule out neuroendocrine differentiation? My best wishes.

[@JMGardnerMD]

I don’t think I’ve ever seen micropapillary pattern in a bcc. And I don’t usually perform neuroendocrine markers on BCC. If I think it’s BCC bit I’m still worried about Merkel cell carcinoma, I do CK20. See my Merkel Cell Carcinoma 101 video: kikoxp.com/posts/4306

[@luisfernandocardenascardon8100]

It was great!

[@ncorry8491]

Thanks, could you do a short video on acantholtic Squamous cell carcinoma Vs adenosquamous carcinoma?

[@Lansvacer]

Thanks!

[@gary4738]

Please Sir, what is your thought on addressing BBC and SCC with radiation? Have you ever heard of GentleCure to treat these? Thoughts?Especially on sensitive areas like the nose or around the eye? Thank you

[@EdwardEdmonds]

Hi Jared, currently I'm a Mohs Histotechnologist but have been in clincial and research histology for 20+ years. Your entire channel is an incredible resource. I'm still exploring your channel so I might just not have come across the relevant videos but how do you bridge the gap between interpreting formalin fixed sections versus frozen sections. The Mohs surgeon I work with has aptly described this as interpreting an oil painting versus a watercolor painting. I purchased and received your book, it's excellent.

[@JMGardnerMD]

Thank you! I don’t have any videos about frozen sections or Mohs but it’s on my to do list.

[@EdwardEdmonds]

@@JMGardnerMD Awesome. Looking forward to this!

[@jazzragu]

Hi! I’m a Clin Derm Masters student and also practicing doctor in London. Thank you for your videos! Quick question- Bowenoid AK vs Bowen’s disease… what are the differences that would be seen- in particular how much atypia laterally needs to be seen (I remember reading that bowenoid AK is focal full thickness atypia, but not sure what sort of size that represents). Many thank!

[@JMGardnerMD]

I honestly don’t know. The line between actinic keratosis and squamous cell carcinoma in situ/Bowen disease can be very subjective sometimes. For those in between cases, some people use the term bowenoid AK. I usually try to just Pick one or the other and make a decision because I think that bowenoid AK is a somewhat confusing term to many dermatologists. In my former practice I never used that term because the dermatologists I worked with were not familiar with it. In my current practice, some of the dermatopathologists use that term so our dermatologist colleagues are more familiar with it. I still only use it very rarely for cases just like you describe where the majority of the lesion is actinic keratosis But there is a focal area that approaches full thickness or has a few pagetoid atypical Keratinocytes. I use it when I want the dermatologist to perform curettage and/or keep a close eye on the area to make sure it does not recur. I’m working on a write up explaining all of the terminology that I use for AK and SCC (similar to this one I made for BCC: kikoxp.com/posts/5093). Hopefully I will finish in the next few months. When I do I will post it on my dermatopathology mega index page on Kiko: kikoxp.com/posts/5084. I’ll put a link under the squamous cell carcinoma and under the actinic keratosis sections. So keep checking back on that page from time to time to see when I posted it. I’ll try to prioritize that it’s been on my to do list for a while.

[@joanbaczek2575]

I wish my dr was like you. I got a radiology oncologist that minimizes, an oncologist that brushed off my symptoms for 2 years just cuz my scans kept comming up negative, and an ENT that’s probably the most right but over the top and doesn’t give me copies of reports and says radiation or chemo or auto immune therapy won’t help because it’s too “thick” and just wants me to have my throat removed when the problem is only on the left side. They didn’t even stage my cancer or check for hpv 16 and I’m supposed to be on board with a catastrophic surgery like that?. If they rip out my throat how does that fix the cancer in the posterior nasopharyngex? Posterior Oropharynx , posterior hypopharynex ? How the hell does a pet scan come up clear until the thing invade everything so bad? Then the pet scan only glows at the hypopharynex? Why are pet scans advertised to find cancer less than one cm when obviously I know that’s not true now

[@JMGardnerMD]

I’m so sorry to hear of your situation. I just want to clarify that the squamous cell carcinomas in my video are from skin not from larynx/pharynx. It’s the same kind of tumor more or less, but the clinical situation and treatment scenarios are obviously very different. Best wishes for health and healing! I hope your situation improves!

[@michellewaddell9679]

Thanks for a great video Dr Gardner. Question: I had biopsy on area on my upper lip/skin. Came back AK and they want to freeze it. but they did not address that it has a palpable “root” that is on the underside of the lip. What should I do with that? Get a biopsy and or removal by an oral surgeon?

[@JMGardnerMD]

Please ask your doctor about this. They can examine and decide if they are concerned that another deeper biopsy or excision would be needed. If they decide to freeze, please make sure you return to your doctor promptly if it grows back in the future. A mohs surgeon (surgical dermatologist) is a good type of doctor for dealing with issues like this. Best wishes for health and healing.

[@jurgitakm]

I would like to ask about the case shown on minute 55 of the video. If there is a crater filled with keratin, nests of atypycal squamous cells but no in situ component, how do you differentiate this lesion from keratoacanthoma? Thank you.

[@JMGardnerMD]

Here's a video about keratoacanthoma: kzbin.info/www/bejne/j2XXgqasjqeeoM0. I regard them as a type of SCC.

[@excelsiorhotelspabaku5663]

Jared, is there a way to understand if a persistent skin peel on the lip is cancer or a viral problem without cutting out a piece from my lip?

[@JMGardnerMD]

Please see your dermatologist for an examination. If the dermatologist is concerned about the possibility of skin (or lip) cancer, a biopsy is the next step to confirm the diagnosis.

[@angelyromero1435]

how to differentiate squamous cell carcinoma and basal cell carcinoma if the tumour cells found in the dermis

[@JMGardnerMD]

See my BCC video for contrast between SCC and bcc: kikoxp.com/posts/3826

[@drsandhyaramachandran4821]

Dr Jerad, there are very few who teach dermpath as good as you , a big thank you. At 50:11 & 50:25 is that orangish-pink cell a necrotic keratinocyte / apoptotic body?was just wondering if it has significance in the dx of SCC? I saw one at 32:49 too..

[@JMGardnerMD]

yes those are necrotic/apoptotic/dyskeratotic keratinocytes (all those words are used as synonyms in dermpath although technically there are some differences). They are often present in SCC but also in many other things. Not diagnostically useful for SCC in my experience. And thanks for your kind words, my old friend. :-)

[@SandhyaRamachandran]

@@JMGardnerMD thank you.

[@stanleylaurel6873]

Jerad do you have any helpful resources for practical Mohs slide interpretation? Thank you!

[@JMGardnerMD]

No I don’t but that’s a great idea. Maybe I can ask my Mohs colleagues to compile some good example Mohs slides for me.

[@stanleylaurel6873]

@@JMGardnerMD It would make for a new and exciting direction in your teaching

[@MerimaHerac]

The last case could also be a rhabdomyosarcoma

[@drsandhyaramachandran4821]

Continuing along the lines of "Reversed polarity" of keratinization as evidence of Invasive SCC, sometimes we see only keratin debris +/- surrounded by giant cells in the mid-dermis but no other clear-cut evidence of invasion. Does this also indicate Invasion? TIA.

[@JMGardnerMD]

Not always. Ruptured cyst or hair follicle could show same thing. But if you are worried you can add comment that there is an area suspicious for possible invasion. Deeper levels may also help.

[@SandhyaRamachandran]

@@JMGardnerMD oh ok thank you

[@goharrehman7710]

where do you live in California

[@JMGardnerMD]

I live in Pennsylvania, not California.

[@joeblow9295]

I have had 9 basal cell carcinomas removed only one with the light mohs incision no stitches just a little divot scoop no stitches needed the other eight needed a lot of stitches one basal cell I let go thinking it would a small divot scoop I let go but it was much worse the Dr said it looked like it was going on in center of my chest for over five years but it only started to get a scab and crack and bleed for less than a month before I went to get it removed That was so foolish he had to make what looked like the mark of zoro in the middle of my chest over 25 stitches to close the @t since then I get checked every 6 months with no malignancies for 31/2 years then after 3 1/2 years I just had my 9th basal cell removed got about a 2 inch scar on my right neck by the clavicle it took about 7 or eight very close stitches but I really want to say I have been taking Nicotinamide 1000 mg a day 500 mg 2 x a day 1 500 mg before breakfast and another 500 mg pill after lunch and I have only had 1 basal cell in 3 1/2 years I feel the Nicotinamide has helped keeping away the extra malignant basal cells I mostly just get pre -cancer cells that I have frozen off and that's a lot better than surgery last year the Dermatologist prescribed my with 5-fluorouracil (5-FU) but I only put the cream on my upper chest and shoulders front and back that stuff made me look like a went through a fire but I did not put enough on my neck area and that is where my last basal cell was The 5-fluorouracil (5-FU) is a very unsightly treatment and causes a lot of discomfort but the Dr Said it removed many furture pre cancers and cancers from forming .So I will keep taking the Nicotinamide and keep getting 6 month check ups and have these basal cells removed ASAP from now on good luck to all those who are suffering with life long skin cancers . But the sooner they are removed the smaller the scar . I learned the hard way you can say I got fooled by the small Mohs procedure I had the first time best of luck to all your friend Zoro lol

[@gary4738]

It maybe worth checking into the noninvasive procedure called GentleCure. No cutting equivalent cure rate. Best

[@fatemahiba5186]

I think its the undulation of the flag due to wind rather than the colors on the flag.

[@JMGardnerMD]

I like that explanation!!!

[@Aesthetic_leen]

Hi doc , Recently I got redness and burning on my lower lips and it and it was very painful I immediately for that I am going to get a cold sore and that it is Herpes I went to the doctor and the doctor told me that it is something called atopic dermatitis and not for herpes. I started using the ointment given by doctor The crack has almost healed but there is discoloration on that particular spot of the lip which makes me believe that it is something very serious liked cancer.. and today I cracked my lower lip again.... And it turned red ... Now I'm scared Went to another Dr said she at first she thought it's herpes but it actually doesn't look anything like herpes she termed it as lip chelitis. She said it can be due to subconscious lip licking. I have had chapped lower lip 3 times in 2 months on different locations of lower lip and 2 times was the worse What should I do

[@tonydemarco9315]

Dr Gardner does AK happen to the lip? The lip seems, like the back of hand, very sun exposed? I read but have never seen a histo section of human lip. Normal lip would be non-keratinized epithelium? If that is correct would you see it forming keratin?

[@JMGardnerMD]

Yes to all of above. Definitely see AK on lip often. When extensive and ulcerated and inflamed we give it a fancy name: “actinic cheilitis”. Normal lip shows a transition from keratinized (skin) to non keratinized (mucosa) stratified squamous epithelium. When irritated or abnormal, squamous mucosa often transitions to keratinized surface. To learn more normal histology be sure to follow @ihearthisto and @chapman_histo on Twitter. They are both awesome histology experts and have taught me a lot about a subject I thought I already knew a lot about!

[@tonydemarco9315]

Thank you Dr Gardner, that was very helpful. I am considering getting a Twitter account just for more histology and pathology.

[@JMGardnerMD]

@@tonydemarco9315 You should totally do it! Twitter is an amazing place to learn pathology & histology! And to meet cool people in our fields. The #pathTwitter community is like family. Everyone is so nice.

[@nathalienataren2335]

I'm having to review TMAs for my PhD, your video have been immensely helpful! Thank you!

[@miladisamira6535]

Thank you dr Gardner

[@ncorry8491]

Thanks excellent! Looking forward to adnexal tumour tumour approach videos.

[@JMGardnerMD]

It’s on my to do list! For now, check out our skin adnexal tumors made simple paper in @ArchivesPath: www.archivesofpathology.org/doi/pdf/10.5858/arpa.2018-0189-RA

[@ncorry8491]

Thanks i'm a trainee in the uk , your videos are invaluable.

[@augustostrapassola723]

The Flag looks more like an Icecream \^/

[@sameeraansar1343]

Thank you, this is very helpful for daily practice. Thanks for your amazing effort! Could you please tell me, what is an adequate/ideal shave biopsy or when do you call it very superficial for definite diagnosis?

[@JMGardnerMD]

Adequate totally depends on the situation and the lesion. Ideally I like to be able to see the base of keratinocyte lesions and the underlying dermis. But many times that does not happen.

[@sameeraansar1343]

@@JMGardnerMD Thank you.

[@razyrapizyt9526]

Thank you!

[@Mike89175]

What is the typical treament.... patient onlooker

[@JMGardnerMD]

Hi! It can vary depending on scenario, but actinic keratosis is often treated with freezing. Squamous cell carcinoma is usually removed surgically.

[@JMGardnerMD]

Hi! It can vary depending on scenario, but actinic keratosis is often treated with freezing. Squamous cell carcinoma is usually removed surgically.

[@Mike89175]

@@JMGardnerMD,can i get a dr to perform an application of cryoblation of squamous cell carcinoma,to my advanced tumor on my lip?

[@Mike89175]

size of an quarter

[@JMGardnerMD]

I am not an expert on treatment of skin cancer, just diagnosis of it. I also cannot give you official medical advice since I am not your doctor and you are not my patient. So I do not know the answer of your question for sure. Most squamous cell carcinoma of the skin (or lip) is treated with surgical excision. To my knowledge, my colleagues who treat squamous cell carcinoma do not use cryoablation for it. That is my general understanding of the treatment options. Be sure to see your own doctor to discuss different treatment options so you can make an informed decision about what care is best for you personally. Best wishes for good health!