Synopsis
Recognise invasive cutaneous squamous-cell carcinoma, identify clinical and pathological high-risk features, refer every suspected lesion urgently and coordinate excision, nodal assessment and prevention.
- Suspect SCC in a persistent enlarging tender indurated keratotic, crusted or ulcerated lesion, particularly on chronically sun-exposed skin.
- NICE recommends urgent suspected-cancer referral for every lesion clinically suspicious for cutaneous SCC.
- High-risk features include lip or ear site, diameter over 2 cm, depth over 6 mm or beyond subcutaneous fat, poor differentiation, perineural invasion, recurrence and immune suppression.
- Palpate the relevant nodal basin and document pain, numbness or weakness because clinical perineural and nodal disease alter urgency and staging.
- Excision with histological margin assessment is standard; Mohs or wider specialist surgery is considered for high-risk, recurrent or tissue-critical tumours.
- Do not curette, freeze or treat with field cream when invasive SCC is plausible; these approaches can delay depth and margin diagnosis.
- A cutaneous horn is a reaction pattern, not a diagnosis; assess and sample the indurated base where SCC may be present.
- Immune-suppressed patients need a lower biopsy threshold, rapid pathways and multidisciplinary review of prevention and immunosuppression.
Key red flags
Rapid growth, severe pain, numbness, fixation, recurrent tumour, lip or ear site, diameter over 2 cm, immune suppression, palpable nodes or chronic-scar ulceration requires urgent suspected-cancer referral and high-risk staging.
Persistent keratotic ulceration on vermilion lip or pinna carries higher metastatic risk and demands urgent referral.
Pain, tingling, numbness, facial weakness or other motor loss near a lesion suggests nerve invasion.
A new firm regional node, parotid mass or in-transit nodule may represent metastasis and requires urgent imaging and sampling.
Investigation priorities
Confirm SCC and measure invasive and pathological risk features.
Management branches
A persistent indurated keratotic, ulcerated or rapidly growing lesion could represent invasive SCC.
- Measure and document morphology, growth, site, immune status, neurological symptoms and regional nodes.
- Make an urgent suspected-cancer referral, leaving the lesion available for appropriately deep biopsy and definitive planning.
- Safety-net accelerated growth, bleeding, pain, numbness or nodes and track attendance and pathology outcome.