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SKIN CANCER GALLERY Basal Cell Carcinoma BCC begins in the basal layer of the epidermis and causes slow-growing tumors in areas with a history of UV radiation damage. BCC almost never metastasizes to other parts of the body, but it can erode into healthy tissue, which can be dangerous. We will look at four subtypes of BCC. Nodular BCC: This is the most common version of BCC. On a light-skinned person it usually looks like a small ulceration with a raised pink, shiny border, sometimes with visible telangiectasias (tiny capillaries) around the borders. It is painless, but the scab may itch, fall off, and grow back without ever healing (Image 1). On darker skin, nodular BCC may be harder to identify. A raised area with shiny skin around an ulceration can sometimes be seen, but not in the example we have here. However, close inspection shows a raised nodule on the left side of the discoloration (Image 2). Pigmented BCC: Pigmented BCC is the most common type of BCC seen in people with skin of color. Ironically, it was not possible to find a photograph of this on a dark- skinned person to share in this article, but the resource "Galleries of Images" (page 40) lists several collections where this may be seen. The example we have here is on light skin, where the darkened, pigmented lesion is easy to see, but it has a variety of colors and textures. Without a biopsy to check, this looks like it could be melanoma—a much more dangerous situation (Image 3). Superficial BCC: Superficial BCC, as its name implies, is f lat and thin. It can look like psoriasis, eczema, actinic keratosis, or Bowen disease—all types of cSCC. It's easy to miss on light skin (Image 4). On darker skin, superficial BCC looks darker than the surrounding area. This example also demonstrates a more advanced case in a person with skin of color (Image 5). Morpheaform BCC: Morpheaform BCC is the most invasive type of BCC. Its name comes from its resemblance to a type of lupus called morphea. Its growth on the surface of the skin is often slow and subtle, but it sends projections deep into the tissues to invade muscles, bones, and nerve tissue (Images 6 and 7). Excision or burning off with liquid nitrogen are the preferred treatment options for BCC. If a lesion is not fully excised, it can recur. For morpheaform BCC, this can sometimes mean extensive plastic surgery to remove the growth and rebuild the affected part of the face or other part of the body. Cutaneous Squamous Cell Carcinoma Cancer that starts in the layer superficial to the basal cells is called squamous cell carcinoma. We add the qualifier cutaneous to denote that this is a type of skin cancer, because many organs have a squamous layer of epithelium, so it is possible to find many types of squamous cell carcinoma. Usually affecting areas with a history of repeated sunburns, cSCC also arises from skin injuries with chronic or repeating inf lammation. People who use tobacco may develop a type of cSCC inside the mouth called leukoplakia, but we won't look at that here. CSCC is more concerning than BCC because, although it happens relatively rarely, it is more likely to metastasize. Metastasis can happen through the lymphatic or cardiovascular systems, but cSCC is also capable of perineural invasion: Cancerous cells travel from the skin toward the central nervous system along the nerves. This pattern requires more aggressive treatment than most cases of cSCC. We will look at three types of cSCC. Actinic Keratosis, Actinic Cheilitis: Actinic keratosis (AK), or solar keratosis, is sometimes called a precancerous condition. But if AK lesions are not removed, they often go on to become more typical versions of cSCC, so some experts now refer to them as simply an early presentation of cancer. These growths often look like dry patches: f laky reddish or brownish areas on sun-exposed parts of the skin (the face, ears, extremities). The forehead is a common site for AK: A close look shows varying skin colors and textures where these f laky patches grow (Image 8). Actinic cheilitis is essentially the same as AK, but it appears on the lips. It can look like chapped lips, but it doesn't heal. This condition can become aggressive, and may require plastic surgery to remove the growths and reshape the lips (Image 9). L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 37 1. Nodular basal cell carcinoma (BCC) on a light- skinned person. Note the pearly border, scab in the middle, and tiny feeder capillaries around the edges. 2. Nodular BCC on a dark-skinned person. 3. Pigmented BCC on a light-skinned person. Note the variation in colors. 4. Superficial BCC on light skin— easy to miss because it looks like a flaky spot. Image courtesy Kelly Nelson, MD, National Cancer Institute. 5. Superficial BCC on dark skin, at an advanced stage. Image courtesy Dermnet.org. 6. Morpheaform BCC on the back of a person's shoulder. Note the scar-like appearance. 7. Advanced morpheaform BCC. Note the scar-like appearance on the upper right— that was probably the earliest sign of this case. 8. Actinic keratosis on the forehead. Note the varying coloration and scaling skin. 9. Actinic cheilitis. 3 6 9