Basal cell carcinoma (syn.: basal cell carcinoma, basal cell epithelioma, ulcus rodens, epithelioma basocellulare) is a common skin tumor with pronounced destructive growth, a tendency to recur, as a rule, does not metastasize, and therefore is more accepted in the domestic literature the term "basal cell carcinoma".

ICD-10 code

C44.3 Malignant neoplasm of skin of other and unspecified parts of the face

Causes of skin basal cell carcinoma

The question of histogenesis has not been resolved; most researchers adhere to the dysontogenetic theory of origin, according to which basal cell carcinoma develops from pluripotent epithelial cells. They can differentiate into various directions. In the development of cancer, importance is attached to genetic factors, immune disorders, and adverse external influences (intense insolation, contact with carcinogenic substances). It can develop on clinically unchanged skin, as well as against the background of various skin pathologies (senile keratosis, radiodermatitis, tuberculous lupus, nevi, psoriasis, etc.).

Basal cell carcinoma is a slow-growing and rarely metastasizing basal cell carcinoma that arises in the epidermis or hair follicles, the cells of which are similar to the basal cells of the epidermis. It is considered not as cancer or a benign neoplasm, but as a special kind of tumor with locally destructive growth. Sometimes, under the influence of strong carcinogens, primarily X-rays, basal cell carcinoma develops into basal cell carcinoma. The question of histogenesis has not yet been resolved. Some believe that basaliomas develop from the primary epithelial rudiment, others - from all epithelial structures of the skin, including from embryonic rudiments and malformations.

Risk factors

Provoking factors are insolation, UV, X-rays, burns, and arsenic intake. Therefore, basal cell carcinoma often occurs in people with skin types I and II and albinos who are exposed to intense sun exposure for a long time. It has been established that excessive sun exposure in childhood can lead to the development of a tumor many years later.

Pathogenesis

The epidermis is slightly atrophic, sometimes ulcerated, and there is a proliferation of tumor basophilic cells similar to the cells of the basal layer. Anaplasia is mild, mitoses are few. Basalioma rarely metastasizes, since tumor cells that enter the bloodstream are not capable of proliferation due to the lack of growth factor produced by the tumor stroma.

Pathomorphology of skin basalioma

Histologically, basal cell carcinoma is divided into undifferentiated and differentiated. The undifferentiated group includes solid, pigmented, morphea-like and superficial basal cell carcinomas, the differentiated group includes keratotic (with piloid differentiation), cystic and adenoid (with glandular differentiation) and with sebaceous differentiation.

The WHO international classification (1996) identifies the following morphological variants of basal cell carcinoma: superficial multicentric, codular (solid, adenoid cystic), infiltrating, non-sclerosing, sclerosing (desmoplastic, morphea-like), fibro-epithelial; with adnexal differentiation - follicular, eccrine, metatypical (basosquamous), keratotic. However, the morphological boundary of all varieties is unclear. Thus, in an immature tumor there may be adenoid structures and, on the contrary, with its organoid structure, foci of immature cells are often found. Also, there is no complete correspondence between the clinical and histological pictures. Usually there is correspondence only for such forms as superficial, fibroepithelial, scleroderma-like and pigmented.

For all types of basal cell carcinomas, the main histological criterion is the presence of typical complexes of epithelial cells with dark-colored oval nuclei in the central part and palisade-like complexes located along the periphery. In appearance, these cells resemble basal epithelial cells, but differ from the latter in the absence of intercellular bridges. Their nuclei are usually monomorphic and not subject to anaplasia. The connective tissue stroma proliferates together with the cellular component of the tumor, located in the form of bundles among cellular strands, dividing them into lobules. The stroma is rich in glycosaminoglycans, staining metachromatically with toluidine blue. It contains many tissue basophils. Retraction gaps are often detected between the parenchyma and stroma, which many authors regard as a fixation artifact, although the possibility of exposure to excessive secretion of hyaluronidase is not denied.

Solid basal cell carcinoma among undifferentiated forms it occurs most often. Histologically, it consists of various shapes and sizes of strands and cells of compactly located basaloid cells with unclear boundaries, resembling a syncytium. Such complexes of basal epithelial cells are surrounded at the periphery by elongated elements, forming a characteristic “picket fence”. Cells in the center of the complexes can undergo dystrophic changes with the formation of cystic cavities. Thus, along with solid structures, cystic ones can exist, forming a solid-cystic variant. Sometimes destructive masses in the form of cellular detritus are encrusted with calcium salts.

Pigmented basal cell carcinoma Histologically it is characterized by diffuse pigmentation and is associated with the presence of melanin in its cells. The tumor stroma contains a large number of melanophages with a high content of melanin granules.

An increased amount of pigment is usually detected in the cystic variant, less often in the solid and superficial multicentric. Basaliomas with pronounced pigmentation contain a lot of melanin in the epithelial cells above the tumor, throughout its entire thickness up to the stratum corneum.

Superficial basal cell carcinoma often multiple. Histologically, it consists of small, multiple solid complexes associated with the epidermis, as if “suspended” from it, occupying only the upper part of the dermis to the reticular layer. Lymphohistiocytic infiltrates are often found in the stroma. The multiplicity of foci indicates the multicentric genesis of this tumor. Superficial basal cell carcinoma often recurs after treatment along the periphery of the scar.

Scleroderma-like basal cell carcinoma, or the “morphea” type, is distinguished by the abundant development of scleroderma-like connective tissue, in which narrow cords of basal epithelial cells are “embedded”, extending deep into the dermis down to the subcutaneous tissue. Polygarden-like structures can be seen only in large cords and cells. Reactive infiltration around tumor complexes located among the massive connective tissue stroma, as a rule, it is scanty and more pronounced in the zone of active growth on the periphery. Further progression of destructive changes leads to the formation of small (cribrozoform) and larger cystic cavities. Sometimes destructive masses in the form of cellular detritus are encrusted with salts. calcium.

Basal cell carcinoma with glandular differentiation, or adenoid type, is characterized by the presence, in addition to solid areas, of narrow epithelial strands consisting of several, and sometimes 1-2 rows of cells forming tubular or alveolar structures. The peripheral epithelial cells of the latter have a cubic shape, as a result of which the polysad-like character is absent or less clearly expressed. The internal cells are larger, sometimes with a pronounced cuticle; the cavities of the tubes or alveolar structures are filled with epithelial mucin. The reaction with carcinoembryonic antigen produces positive staining for extracellular mucin on the surface of cells lining the duct-like structures.

Basal cell carcinoma with cyloid differentiation characterized by the presence of keratinization foci in complexes of basal epithelial cells, surrounded by cells similar to spinous ones. In these cases, keratinization occurs bypassing the keratohyaline stage, which resembles the keratogenic zone of the isthmus of normal hair follicles and may have tricho-like differentiation. Sometimes there are immature milked follicles with initial signs of the formation of hair shafts. In some cases, structures are formed that resemble embryonic hair buds, as well as epithelial cells containing glycogen, corresponding to the cells of the outer layer of the hair follicle. Sometimes there may be difficulty in differentiating from follicular basaloid hamartoma.

Basal cell carcinoma with sebaceous differentiation It is rare and is characterized by the appearance of foci or individual cells typical of the sebaceous glands among the basal epithelial cells. Some of them are large, signet-shaped, with light cytoplasm and eccentrically located nuclei. When stained with Sudan III, fat is revealed in them. Lipocytes are much less differentiated than in a normal sebaceous gland; transitional forms are observed between them and the surrounding basal epithelial cells. This indicates that this type of cancer is histogenetically associated with the sebaceous glands.

Fibroepithelial type(syn.: Pincus fibroepithelioma) - a rare type of basal cell carcinoma that occurs most often in the lumbosacral region, can be combined with seborrheic keratosis and superficial basalioma. Clinically it may look like fibropapilloma. Cases of multiple lesions have been described.

Histologically, narrow and long cords of basal epithelial cells are found in the dermis, extending from the epidermis, surrounded by a hyperplastic, often edematous, mucoid-altered stroma with a large number of fibroblasts. The stroma is rich in capillaries and tissue basophils. Epithelial strands anastomose with each other and consist of small dark cells with a small amount of cytoplasm and round or oval, intensely stained nuclei. Sometimes in such cords there are small cysts filled with homogeneous eosinophilic contents or horny masses.

Nevobasocellular syndrome(syn. Gordin-Goltz syndrome) is a polyorganotropic, autosomal dominant syndrome related to phakomatoses. It is based on a complex of hyper- or neoplastic changes due to disorders embryonic development. The cardinal symptom is the appearance in the early period of life of multiple basal cell carcinomas, accompanied by odontoten cysts of the jaws and anomalies of the ribs. There could be cataracts and changes in the central nervous system. It is also characterized by frequent changes in the palms and soles in the form of “indentations”, in which basaloid structures are also found histologically. After the early nevoid-basaliomatous phase, several years later, usually during puberty, ulcerative and locally destructive forms appear in these areas as an indicator of the onset of the oncological phase.

Histological changes in this syndrome are practically no different from the types of basal cell carcinomas listed above. In the area of ​​the palmoplantar “indentations” there are defects in the stratum corneum of the epidermis with thinning of its remaining layers and the appearance of additional epithelial processes from small typical basaloid cells. Large basal cell carcinomas rarely develop in these places. Individual basal cell lesions of a linear nature include all types of organoid basal cell carcinomas.

Histogenesis of skin basalioma

Basalioma can develop both from epithelial cells and from the epithelium of the pilosebaceous complex. Using serial sections, M. Hundeiker and N. Berger (1968) showed that in 90% of cases the tumor develops from the epidermis. Histochemical examination of various types of cancer shows that in most cells glycogen and glycosaminoglycans are found in the tumor stroma, especially in adamantinoid and cylindromatous patterns. Glycoproteins are constantly detected in basement membranes.

Electron microscopy revealed that most cells of tumor complexes contain standard set organelles: small mitochondria with a dark matrix and free polyribosomes. There are no intercellular bridges at the contact sites, but finger-like projections and a small number of desmosome-like contacts are found. In areas of keratinization, layers of cells with intact intercellular bridges and a large number of tonofilaments in the cytoplasm are noted. Occasionally, zones of cells containing cellular membrane complexes are found, which can be interpreted as a manifestation of glandular differentiation. The presence of melanosomes in some cells indicates pigment differentiation. In basal epithelial cells, organelles characteristic of mature epithelial cells are absent, which indicates their immaturity.

It is currently believed that this tumor develops from pluripotent germinal epithelial cells under the influence of various types of external stimuli. Histologically and histochemically, the connection of basal cell carcinoma with the anagen stage of hair growth has been proven and the similarity with proliferating embryonic hair buds has been emphasized. R. Holunar (1975) and M. Kumakiri (1978) believe that this tumor develops in the germinal layer of the ectoderm, where immature basal epithelial cells with the potential for differentiation are formed.

Symptoms of skin basal cell carcinoma

Skin basalioma has the appearance of a single formation, hemispherical in shape, often round in outline, slightly rising above the skin level, pink or grayish-red in color with a pearlescent tint, but may not differ from normal skin. The surface of the tumor is smooth; in its center there is usually a small recess, covered with a thin, loosely adjacent squamous crust, upon removal of which erosion is usually detected. The edge of the ulcerated element is thickened like a roller, consists of small whitish nodules, usually designated as “pearls” and having diagnostic value. In this state, the tumor can exist for years, slowly growing.

Basaliomas can be multiple. Primary plural form, according to K.V. Daniel-Beck and A.A. Kolobyakova (1979), occurs in 10% of cases, the number of tumor foci can reach several dozen or more, which may be a manifestation of non-basocellular Gorlin-Goltz syndrome.

All symptoms of skin basalioma, including Gorlin-Goltz syndrome, allow us to distinguish the following forms: nodular-ulcerative (ulcus rodens), superficial, scleroderma-like (morphea type), pigmentary and fibroepithelial. With multiple lesions, these clinical types can be observed in various combinations.

Forms

Surface view begins with the appearance of a limited scaly patch of pink color. Then the spot acquires clear contours, oval, round or irregular shape. Dense small shiny nodules appear along the edge of the lesion, which merge with each other and form a roll-like edge raised above the skin level. The center of the hearth sinks slightly. The color of the lesion becomes dark pink, brown. Lesions may be solitary or multiple. Among the superficial forms, self-scarring or pagetoid basal cell carcinoma is distinguished with a zone of atrophy (or scarring) in the center and a chain of small, dense, opalescent, tumor-like elements along the periphery. The lesions reach a significant size. Usually has a multiple nature and a persistent course. Growth is very slow. Its clinical features may resemble Bowen's disease.

At pigmented form the color of the lesion is bluish, purple or dark brown. This type is very similar to melanoma, especially nodular, but has a denser consistency. Dermoscopic examination can provide significant assistance in such cases.

Tumor type is characterized by the appearance of a nodule, which gradually increases in size, reaching 1.5-3 cm or more in diameter, acquires a rounded appearance, and a stagnant pink color. The surface of the tumor is smooth with pronounced telangiectasias, sometimes covered with grayish scales. Sometimes its central part ulcerates and becomes covered with dense crusts. Rarely, the tumor protrudes above the skin level and has a stalk (fibroepithelial type). Depending on the size they distinguish small and large nodular forms.

Ulcerative appearance occurs as a primary variant or as a result of ulceration of the superficial or tumor form of the neoplasm. A characteristic feature of the ulcerative form is a funnel-shaped ulceration, which has a massive infiltrate (tumor infiltration) fused with the underlying tissues with unclear boundaries. The size of the infiltrate is much larger than the ulcer itself (ulcus rodens). There is a tendency to deep ulcerations and destruction of underlying tissues. Sometimes the ulcerative form is accompanied by papillomatous, warty growths.

Scleroderma-like, or scar-atrophic, appearance It is a small, clearly demarcated lesion with a thickening at the base, almost not rising above the level of the skin, yellowish-whitish in color. In the center can be detected atrophic changes, dyschromia. Periodically, along the periphery of the element, foci of erosion of various sizes may appear, covered with an easily removable crust, which is very important for cytological diagnosis.

Pincus fibroepithelial tumor classified as a type of basal cell carcinoma, although its course is more favorable. Clinically, it manifests itself in the form of a skin-colored nodule or plaque, of dense elastic consistency, and practically does not undergo erosion.

Malignant skin diseases originating from the epidermis and dermis include basal cell carcinomas, squamous cell carcinomas and melanomas.

Basalioma

Basal cell carcinoma (basal cell skin cancer, corroding ulcer, etc.) is a locally destructive tumor that does not metastasize. Destructive tumor growth can lead to significant tissue destruction. Currently, the prevailing point of view is that basal cell carcinoma develops from a primary epithelial rudiment, which can differentiate towards various structures. In its development, genetic factors, immune processes, and the influence of external factors(insolation, carcinogens, etc.). Basalioma can occur on unchanged skin, or it can be the result of malignancy of various precancerous diseases. The predominant localization is the face, more often in people of older age groups. The process is slow, often lasting for years.

Clinical picture. Basalioma most often initially has the appearance of a translucent dense pearl-like nodule, pinkish-colored. gray, sometimes such a nodule is covered with a tightly fitting crust. In other cases, a flat, slightly depressed, smooth red erosion occurs, the base of which is slightly compacted, and the appearance of the element resembles a scratch. As basal cell carcinoma develops, the central part of the tumor (nodule) begins to become wet, a superficial ulceration appears, covered with a crust, which, when removed, reveals a superficial bleeding erosion or ulcer. Around the erosion or ulcer you can usually see a thin, skin-colored, dense ridge. When the skin is stretched, it is clear that this roller consists of individual small “pearls”. Subsequently, the ulcer deepens, increases in size, its edges become roll-shaped, and the entire ulcer becomes dense. Ulceration and enlargement of the ulcer occurs very slowly. As the process spreads deeper, the tumor loses mobility. Scarring of the ulcer may simultaneously occur in the center or from one of its edges. Less commonly, deepening of the ulcer is observed; in this case, its infiltrate destroys the underlying tissue, including bone. Basalioma can have various clinical variations.

Among the types of basal cell carcinoma, we indicate:

superficial , located mainly on the skin of the body and manifested by slowly growing plaques along the periphery with a characteristic thin dense rim consisting of small pearly nodules; a scaly crust forms in the center, after rejection of which an atrophically altered erythematous surface is exposed;

flat scar , located superficially, usually on the skin of the temple, characterized by serpiginous spread along the periphery with the formation of a ridge-like edge and scar-atrophic changes in the center;

scleroderma-like - dense plaques up to the size of a small coin, ivory-colored, usually located on the skin of the forehead;

knotty - dense, spherical nodules ranging in size from lentils to peas, covered with small crusts and scars, localized on the skin of the forehead, eyelids, and scalp (uclus rodens). There is also a tendency to deep ulcerations with dense crateriform edges and an uneven bottom (the usual localization is the skin of the upper part of the face - uclus terebrans), characterized by a rapid progressive destructive process with necrosis of deep-lying tissues, the absence of a “pearl” ridge, destruction of bone and cartilage tissue, heavy bleeding and pain, but without a tendency to metastasize (usual localization - wings of the nose, earlobes, corners of the mouth, eyelids).

Histopathology. There are atypical growths of cells that are similar to the basal cells of the epidermis, in the form of anastomosing branched narrow cords that penetrate deeply into the dermis. Cells do not have a tendency to become keratinized.

Treatment. Removal of the tumor within healthy tissue. Currently, cryodestruction, diathermocoagulation, surgical excision, prospidin or colchamine ointments, etc. are usually used. Prospidin is used intramuscularly or intralesional.

Squamous cell carcinoma (spinocellular carcinoma, squamous cell epithelioma) comes from the cells of the spinous layer of the epidermis. Squamous cell carcinoma occurs on the skin much less frequently than basal cell carcinoma. It is mainly localized on the red border of the lower lip, in the perianal region, and on the external genitalia. Squamous cell skin cancer, unlike basal cell carcinoma, proceeds relatively quickly and severely, in general no different from cancer of other localizations, and gives metastases.

Squamous cell carcinoma can occur against the background of solar or senile keratosis, develop in scar tissue at the site of a burn, injury, chronic inflammation, x-ray dermatitis, xeroderma pigmentosum, etc.

In recent years, the importance of certain human papillomaviruses in the development of sludge cell carcinoma has been established. The process of carcinogenesis occurs due to the synergistic effect of the virus with physical and chemical carcinogens and is caused by genetically regulated immune mechanisms.

Clinical picture. Squamous cell carcinoma is usually a solitary tumor in the form of a dense spherical formation in the thickness of the skin, initially the size of a pea. Subsequently, the tumor acquires an exo- or endophytic form. In the exophytic form, the tumor rises above the skin level, has a wide base, and the surface of such cancer becomes uneven and warty. At the same time, the tumor grows deeper. Subsequently, it ulcerates. In the endophytic form, otherwise called ulcerative-infiltrating, a dense small node forms in the thickness of the skin, which quickly ulcerates. The resulting ulcer is painful, especially upon palpation, has an irregular shape, raised dense, everted and corroded edges, and often has a crater-like shape. The depth of the ulcer depends on the degree of infiltrating growth.

The growth of the tumor leads to significant destruction of the surrounding and underlying tissues, and it becomes immobile. The bottom of the ulcer is uneven, bleeds easily, and the tumor usually destroys blood vessels and even bones. Soon they get involved in the process lymph nodes(metastases). The general condition of the patients gradually worsens. Death occurs after 2-3 years from cachexia or bleeding caused by tumor disintegration and vascular damage.

Histopathology. An atypical growth (infiltrating growth) of the epithelium is detected due to the cells of the spinous layer in the form of intertwined strands, going deep into the thickness of the skin with germination of the basement membrane. The cells themselves are mostly atypical and randomly located. There are keratinizing and non-keratinizing, more malignant, skin cancers. Atypia is characterized by different size and shape of cells, hyperplasia and hyperchromatosis of nuclei, absence of intercellular bridges, and the presence of pathological mitoses. With keratinizing cancer, cells retain a tendency to become keratinized, as a result, so-called horny “pearls” are found in the thickness of the epithelial layer. It should be noted that atypia is more pronounced in non-keratinizing forms of cancer.

Diagnosis. The diagnosis must be confirmed by histological examination or the results of a cytological examination of scrapings from the surface of the ulcer, in which atypical cells are easily detected. One should remember about the possibility of metastasis of squamous cell carcinoma, primarily to regional lymph nodes.

Treatment. Carried out by an oncologist. In this case, the tumor is usually surgically excised within healthy tissue, and regional lymph nodes are also removed; If necessary, additional chemotherapy, etc. is carried out.

Melanoma (melanoblastoma, melanocarcinoma) is an extremely malignant tumor, the primary focus of which is most often in the skin. Skin melanoma occurs predominantly against the background of a pigmented nevus after its injury, severe insolation, etc.

A pigmented nevus, which can transform into melanoma, can be congenital or acquired, that is, appearing after birth, and malignancy can occur quickly or after a significant period of time. It all depends on the injury to the nevus in the broad sense of the word. Special attention In terms of injury, pigmented nevi located on the sole, foot bed, perianal area, in places injured by clothing, etc. deserve injury.

Clinical picture. The malignancy of a pigmented nevus can be schematically represented as follows. Previously “quiet” congenital or flat pigmented nevus that appeared during life, which looks like a spot or a flat papule slightly raised above the skin without hair, usually round in shape, black, brown or gray, does not increase and does not manifest itself in any way, after a single or repeated mechanical trauma or massive insolation begins to gradually increase along the plane of the skin or exophytically, sometimes changes color, becomes rough, and begins to peel off.

As exophytic growth increases, the possibility of re-injury increases. As a result, the nevus becomes easily wounded, bleeds after a slight touch of clothing, becomes infected, and becomes wet for a long time. Each subsequent injury increases exophytic growth. Gradually, at the site of the nevus, a tumor forms in the form of a flat nodule that rises slightly above the skin with an uneven rough surface, usually repeating the shape of the former nevus, or in the form of a node on a wide base, covered with easily removable dry and weeping, loose bloody crusts. On the surface of such a tumor there may be brownish-pink papillomatous growths.

The main malignant skin tumors are: basal cell carcinoma (basal cell carcinoma), squamous cell carcinoma and melanoma. Other sections of the site are devoted to basal cell carcinoma and melanoma.
Squamous cell skin cancer is the second most common malignant disease after basal cell carcinoma. This is what oncologists simply call “skin cancer.”
It can appear without any prerequisites or harbingers. And it can arise from precancerous skin diseases, such as actinic (solar) keratosis, keratoacanthoma, cutaneous horn, Bowen's disease.
Precancerous lesions can exist for many years without causing concern. Suddenly, precancer turns into a malignant form- this is very common occurrence. For many people, this transition to squamous cell skin cancer is misleading and delays timely treatment. People think that they simply injured themselves, or caught a cold, or overheated a tumor, or these are side effects of medications. And, over time, it will return to its previous size.

Skin cancer in the form of a dense node on the dorsum of the finger. Similar to keratoacanthoma.

The ulcer on the leg appeared due to problems with blood vessels. Then it turned into skin cancer.

Squamous cell skin cancer. What is the reason for the appearance?

Accumulated over a lifetime ultraviolet radiation - the main leading cause of the development of squamous cell skin cancer. This is evidenced by statistics in the form of the number of cases per year per hundred thousand population (morbidity).
Most tumors appear on exposed areas of the body in fair-skinned patients over 60 years of age. Between 70% and 80% of tumors appear on the head and neck. Especially on the lower lip, ears, and scalp. Slightly less common are lesions on the dorsum of the hand, forearm, anterior surface of the leg and dorsum of the foot. Squamous cell skin cancer is much less common in areas not exposed to sunlight.
The human papillomavirus (HPV) also makes its contribution. It can cause both precancerous lesions and skin cancer. HPV types 16, 18, 31, 33, 35, 39, 40, 51, 60 are often found in areas of squamous cell skin cancer; HPV types 5, 8, 9 were also found. Of lesser importance are decreased immunity, constant trauma, inflammatory skin diseases, and contact with harmful chemicals (especially arsenic compounds).

Incidence of squamous cell skin cancer.

The incidence of skin cancer is the number of affected people per 100 thousand population. Among white-skinned people in the southern regions it increases significantly. In the USA, for example, on average, the incidence is 10 per 100,000 population, and in Hawaii it is already 62 per 100,000. The rates for white-skinned people in Australia are approximately the same. In Russia, with statistics, everything is much more confusing. Many tumors are treated without proper histological examination. And even if there is one, the patient may not be registered, considering the disease too mild.
In the USA, squamous cell skin cancer sooner or later will appear in 9-14% of men and 4-9% of women. The incidence increases sharply with age and after intense sunbathing throughout life. Men get sick about twice as often as women. Over the past two decades, it has been celebrated sharp increase in incidence. Apparently this is due to tanning fashion.
Most people (73%) will only develop one tumor in their lifetime. A smaller number (21.2%) will develop two to four lesions of squamous cell skin cancer. And only a small number of patients will develop several tumor foci during their lifetime.

Squamous cell skin cancer, its symptoms.

The signs of squamous cell skin cancer and its danger depend largely on the degree of differentiation. Highly differentiated means that cancer cells under a microscope are quite look like normal, such cancer is the least dangerous. Poorly differentiated most dangerous, its cells under a microscope very different from normal. Moderately differentiated occupies an intermediate position.
A sign of squamous cell skin cancer can be considered the appearance of a plaque or node with a weeping, bleeding surface or with dense yellowish crusts. The density of the formation varies significantly in each case. Symptoms of poorly differentiated cancer are the node is soft to the touch and lacks horny crusts. Usually, the skin cancer on the surface of which has yellow horny masses, and dense to the touch.
Cancer should be suspected in any case if there is a suspicious formation that does not go away within a month. Rapidly growing squamous cell carcinoma can grow within several weeks, its symptoms are pain, softness of the node.
Greatest similarity squamous cell skin cancer has amelanoma, inflammatory ulcer, pyogenic granuloma, basoscamous or ulcerative basal cell carcinoma.
If there is any doubt about the diagnosis, it is indicated tumor biopsy followed by histological examination. The pronounced nature of the thickening of the skin surrounding squamous cell carcinoma also helps in diagnosis.
If the tumor is up to 2 cm in diameter and is highly differentiated, only examining the regional lymph nodes with the doctor’s fingers (palpation) is sufficient. Induration of the lymph node and an increase of more than 1.5 cm is a common symptom metastasis in it. It is possible to perform a biopsy from the node using a syringe needle and an ultrasound machine.
If the tumor is more than 2 cm in diameter and/or is poorly differentiated, it is advisable to do an ultrasound of the regional lymph nodes, even if everything is fine on palpation. And, sometimes, conduct a more in-depth examination.

Squamous cell poorly differentiated skin cancer. Grows quickly, bleeds, soft to the touch.

Highly differentiated skin cancer of the upper eyelid. It grows for a relatively long time and has horny masses on the surface.

Stages of skin cancer. TNM.

Squamous cell skin cancer is divided into stages, depending on the characteristics of the tumor. To determine the stage, suitable values ​​are first selected for it in TNM system. Where T characterizes the size of the tumor, N refers to regional lymph nodes, and M encrypts the fact of the absence or presence of distant metastases.

TNM values ​​for staging squamous cell skin cancer.

Indicator	Its signs
Tis	The tumor has just appeared and does not invade the basement membrane of the epithelium (regardless of the size of the lesion). Otherwise known as Bowen's disease (cancer in situ)
T1	up to 2 cm
T2	From 2 cm to 5 cm
T3	more than 5 cm
T4	Germination into tissues located under the skin (muscles, cartilage, bones)
N0	There is no lesion in regional lymph nodes
N1	There are metastases to the nearest regional lymph nodes
M0	There are no metastases in lymph nodes from other regions or in internal organs
M1	There are metastases to the lymph nodes from other regions, or to any other organ (liver, lungs, bones)

Determination of skin cancer stage based on TNM features.

Clinical stage of skin cancer	T	N	M
0 Stage	Tis	N0	M0
Stage I	T1	N0	M0
Stage II	T2	N0	M0
Stage II	T3	N0	M0
Stage III	T4	N0	M0
Stage III	Any T	N1	M0
Stage IV	Any T	Any N	M1

Forecast. Metastases of squamous cell skin cancer.

Squamous cell skin cancer mainly destroys tissue only in the area of ​​​​appearance and causes metastases relatively less frequently than cancer of other organs. But the possibility of metastasis is still higher than that of basal cell carcinoma. First of all, the lymph nodes closest to the tumor (regional) are affected.
On average, abroad high level of early diagnosis. In this regard, the treatment results are quite good. The relapse rate within five years does not exceed 8%. The risk of metastases to nearby lymph nodes or internal organs (usually the lungs) is, on average, 5%. IN Russia indicators may vary significantly due to later diagnosis. Metastases of skin cancer (like any other) can appear several years after tumor removal, most often within 1-3 years. Most likely, they are large tumors that recur and grow into nerves.
Squamous cell carcinomas that invade the subcutaneous fat or are more than 4 mm in depth are almost 8 times more likely to metastasize (45.7% risk of metastasis) than tumors located within the upper layers of the skin.
Tumor size is the most important factor affecting the risk of recurrence or metastasis. When the tumor grows more than 2 cm, the risk of relapse increases by 2 times and the risk of metastases increases by 3 times.
It has long been noted that squamous cell skin cancer from areas with scars, from ulcers, from areas of burns and radiation, much worse according to forecast.

Squamous cell skin cancer. The influence of tumor features on the number of relapses and metastases.

Sign	Relapse rate	Metastasis rate
Size
less than 2 cm	7.4%	9.1%
more than or equal to 2 cm	15.2%	30.3%
Depth
less than 4 mm (1-2 degree of invasion according to Clark)	5.3%	6.7%
more than or equal to 4 mm (4-5 degree of invasion according to Clark)	17.2%	45.7%
Degree of differentiation
Highly differentiated	13.6%	9.2%
Poorly differentiated	28.6%	32.8%
Region
We irradiate with the sun	7.9%	5.2%
Ear	18.7%	11.0%
Lips	10.5%	13.7%
Skin cancer from scar	Not studied	37.9%
Previously treated (relapse)	23.3%	30.3%
With germination into nerves	47.2%	47.3%
Proven decreased immunity	Not studied	12.9%

Treatment of squamous cell skin cancer.

In general, the success of treating stage 1 squamous cell carcinoma (up to 2 cm in diameter) is quite good. The effectiveness of treatment is assessed by the absence of relapses and metastases for 5 years. Often, this effectiveness is higher than for basal cell carcinoma. Perhaps this is due to the more wary attitude of doctors and more clear outline of the tumor.
The final result of treating squamous cell skin cancer by any method depends on the skills and experience of the doctor more than on the instruments used. In the right hands, treatment is more than 90% effective, regardless of the method chosen.

Surgical treatment of skin cancer.

The surgical method is the most common. It consists of cutting out a flap where the squamous cell skin cancer is located, with a proper indentation from the edge of the tumor. A skin tumor up to 2 centimeters is excised with a margin of 4 mm. Tumors more than 2 cm in diameter, as well as poorly differentiated, penetrating the skin, or located in dangerous areas ( hairy part heads, ears, eyelids, nose, lips) require excision with a margin of more than 6 mm.

Mohs method against squamous cell skin cancer.

Mohs removal is preferable to conventional surgery in cases of large, deep tumors. Histological examination is carried out at the time of surgery. Allows you to continue removal in the desired direction if squamous cell skin cancer cells are found in the edge of the flap. The Mohs method gives the least number of relapses and metastases. Contraindications and cosmetic results are the same as for conventional surgical treatment.

Radiation treatment of squamous cell skin cancer.

Radiation treatment also quite common. But its effectiveness seriously inferior to surgical treatment. Indicated in those patients who cannot undergo surgical treatment.
It may also be indicated in cases where the expected cosmetic results of surgical treatment are not at all ideal. For example, when squamous cell skin cancer appears on the lips, lower eyelid, and occasionally on the ears. Radiation therapy may be prescribed as an additional treatment after surgery. This is especially true when, under a microscope, squamous cell skin cancer cells are found in the edge of the removed skin flap (despite the indentation). Or in case of penetration into nerves.
The scar from radiation treatment for squamous cell skin cancer begins to look worse and worse over time. Radiation treatment can also be carried out on regional lymph nodes. Over time, many new tumors may appear due to the radiotherapy itself.

Treatment of skin cancer with liquid nitrogen (cryodestruction).

Squamous cell skin cancer, like basal cell carcinoma, can be treated with liquid nitrogen(cryodestruction). The tumor is literally frozen, turning into a piece of ice. During thawing, small ice crystals destroy cell membranes and clog blood vessels. Within a few weeks, the tumor masses are rejected and replaced by a scar similar in structure to the skin. The effectiveness of the method depends on the performer and the availability of proper equipment.

Electrodissection and curettage.

Electrodissection and curettage of squamous cell skin cancer are possible only in extremely rare cases, with very small and relatively benign tumors. With this method, the tumor is scooped out with a special spoon - a curette, and also burned using a coagulator to stop the bleeding. The effectiveness of treatment with this method is extremely dependent on the performer.

Prevention of skin cancer.

• All patients diagnosed with skin cancer or precancerous lesions should avoid sun exposure. Especially during hot periods from 10 am to 4 pm.
• Use sunscreen with a protection factor of at least 15.
• Regular monitoring by an oncologist and treatment of precancerous diseases using cryodestruction or other methods will help to avoid unnecessary surgical interventions.
• As a preventative measure, it is possible to use retinoids (isotretinoin) in ointments (retinoic ointment).
• Periodic use of 5-fluorouracil cream may reduce the severity of precancerous lesions and improve the appearance of the skin, but a reduction in the incidence of cancer has not been proven.
• Examine your skin once a month for the presence of new growths.

V.I. Volgin, T.V. Sokolova, M.S. Kolbina, A.A. Sokolovskaya

The problem of interdisciplinary interaction in making a diagnosis and choosing a treatment method for basal cell carcinoma (BCC) is currently very relevant. Most forms of BCRC, to one degree or another, go beyond narrow clinical specialties and are at the intersection of two or more disciplines. This problem is of great interest to dermatologists, oncologists and surgeons. This is due, firstly, to the absolute increase in the number of patients with various forms of BCC, and secondly, to the emergence of new diagnostic and treatment methods that make it possible to quickly make a diagnosis and effectively remove tumor foci.

Epidemiology

In recent decades, there has been a steady increase in the incidence of non-melanoma skin cancer worldwide. The annual increase ranges from 3 to 10%. In the structure of cancer incidence in the population Russian Federation in 2007, malignant neoplasms of the skin, with the exception of melanoma, took second place, accounting for 13.6% in female cancer patients and 9.8% in males. During the period from 1999 to 2007, the incidence of skin cancer increased 1.3 times (p< 0,01).

The growth of oncological pathology is due not only to the aging of the population, the deterioration of the environmental situation, but also to the improvement of detection malignant neoplasms. The incidence rate of skin cancer (excluding melanoma) increased by 34.3% from 1996 to 2006. The largest increase in the incidence of malignant skin tumors from 1995 to 2005 was registered in the Far Eastern (31.6%), Siberian (27.5%) and Ural (19.2%) federal districts. Among malignant neoplasms of the skin, BCC is the most common, amounting to 267.8 per 100,000 population in Russia.

BCC ranks second in frequency among all malignant neoplasms after lung cancer, accounting for 11-12%. Among malignant epithelial neoplasms of the skin, BCC is the leader, its share ranges from 75 to 97% and continues to increase steadily. According to the Moscow Cancer Registry for 2000–2003, BCC accounted for 91.5% of all non-melanoma malignant skin tumors. The annual increase in the number of patients with BCC in different countries of the world, according to data for 1980-1999, ranged from 40 to 65%. Every year in the United States, more than 40,000 new cases of BCC are registered, and the increase in the number of newly registered patients reaches 65% and ranges from 500 thousand to 700 thousand new cases. In the UK, the incidence of BCC increased threefold between 1970 and 1992. In Australia, the incidence reaches 1000-2000 cases per 100,000 population. In Switzerland, between 1976 and 1990, it was registered constant growth incidence by 2.6%.

BCC most often develops over the age of 50 years. However, cases of the onset of the disease at an earlier age, starting from 20 years, are often described. The average age is 64.4 ± 3.3 years. The share of elderly and senile people accounts for 72-78%. The likelihood of developing BCC in people over 55 years of age is 4-8 times higher than in people under 20 years of age. In the Siberian Federal District, the age of patients with BCC exceeded 60 years in almost half of the cases. Cases of BCC have been described in girls aged 15 and 17 years.

Some aspects of the etiology and pathogenesis of BCC

Numerous experimental and epidemiological studies have established that malignancy of epidermal structures can occur in response to various endogenous and exogenous factors.

Among them, the leading ones are hereditary predisposition to carcinogenesis, ultraviolet radiation (UVR), exposure to ionizing radiation, chemical carcinogens, mechanical damage to the skin, viral infections, as well as dysfunction of the immune and endocrine systems. However, the specific mechanisms of development of BCC under the influence of these factors are in most cases unknown. The course of basal cell carcinomas is also determined by the age of the patients.

Genetic factors play a significant role in the pathogenesis of tumors. In patients with BCC (), a hereditary predisposition (family cases) to the development of tumors has been established in 28% of cases. Of these, in more than 3/4 of cases, oncological pathology was detected among first-degree relatives and in the rest (21.4%) - second-degree. In recent years, much attention has been paid to studying the association of genetic markers with various diseases. Genetic markers can be blood groups, Rh factor, HLA histocompatibility antigens, etc. The RTCH gene was discovered on chromosome 9q22.3 of the human genome, mutations of which lead to the development of BCC. The genes encoding blood groups are also found on chromosome 9q, which undergoes changes that are detected in many types of cancer. In other words, cancer genes are controlled by blood group antigen genes. According to HLA typing of patients with BCC, it was revealed that multiple formations are reliably associated with the HLAB14 and HLADrl antigens.

Large clinical material has shown that in patients with BCC, compared with healthy donors, the incidence of blood groups I (0) and III (0B) was significantly different. Without taking into account the Rh factor, BCC developed 1.4 times more often in patients with blood group I (0) and 1.8 times less often in patients with group III (0B). Multivariate analysis distribution of patients with BCC and voluntary donors, taking into account two factors (blood group ABO and Rh factor) showed that in the presence of blood group III (0B) with Rh-, BCC was observed 11 times more often than with the same blood group and Rh+. In patients with group I (0) and Rh+, tumors occurred significantly 1.3 times more often than in Rh- patients.

Physical damage to the skin by ultraviolet radiation stimulates the development of carcinogenesis due to a direct effect on cell DNA. It has been proven that exposure to ultraviolet rays on the skin is accompanied by immune deficiency. Destruction of lymphocyte-activating la-antigens on the surface of lymphoid cells, disruption of the immune response, induction of suppressor lymphocytes, and disappearance of functionally active Langerhans cells from the epidermis occur. UVR activates keratinocytes, enhances the production of certain cytokines and growth factors. In skin exposed to chronic sun exposure, a tendency toward an increase in mast cells in the dermis was revealed. Any skin cell can undergo malignant degeneration, but basal cell and squamous cell carcinomas develop more often.

The most damaging effect is exerted by UV-B rays, but at the cellular level, various chromophores are also capable of absorbing UVA energy and generating free radicals. They act on membrane lipids and proteins by destroying DNA. Damage to biologically important macromolecules occurs not due to their direct absorption of light quanta, but as a result of the photodynamic action of substances. Low doses of UVA or even suberythemal doses can also form pyrimidine diamers and cause DNA damage, leading to cell mutation. Skin sensitivity to sunlight depends on its type. There are 6 skin phototypes. BCC occurs under the influence of radiant energy from the sun, mainly in individuals with skin photosensitivity types I and II.

The role of ultraviolet radiation in the pathogenesis of BCC is indicated by the high incidence of BCC in the southern regions, the overwhelming majority of patients are of the white race, and the predominant localization of lesions in open areas skin, where the ulcerative form significantly predominates (83%). In people with insufficient skin pigmentation, rays with a wavelength of 290-320 nm are the main cause of the disease. Skin cancer can occur not only under the influence of natural UV radiation, but also as a result of UV exposure from industrial sources. Increased sensitivity of the skin to solar insolation can be caused by medications (tetracyclines, sulfonamides, phenothiazines, thiazides, greseofulvin, etc.) and some herbs, especially if they contain coumarins.

It has been shown that mutations in chromosome 9q22.3 of the human genome can occur under the influence of ultraviolet radiation. This is confirmed by the high risk of developing skin cancer in patients with rare hereditary diseases that are aggravated by photosensitivity - albinism, xeroderma pigmentosum, nevoid basal cell carcinoma syndrome.

Chemical carcinogens, under the influence of which BCC can develop, can be petroleum hydrocarbons, coal, mineral oils, resins, arsenic compounds, insecticides, herbicides, petroleum products, etc. The use of photoactive agents (coal tar, 8-methoxypsoralenes) in the treatment of certain diseases , hematoporphyrins) in combination with UVA skin exposure also leads to an increased risk of developing skin cancer. Mediators involved in carcinogenesis caused by chemical products have been experimentally identified. They are represented by a group of pro-inflammatory cytokines, often similar to those caused by exposure to ultraviolet radiation.

The role of chemical carcinogens in the pathogenesis of skin cancer is indicated by 25 years of epidemiological studies in families where parents were exposed to potential carcinogens in industrial conditions. The risk of developing a tumor process in children was quite high. IN foreign research the main emphasis is on fathers, since in developed countries women are much less likely to be employed in production with harmful conditions labor. Studies conducted in Russia, where the share of women in industrial production is up to 46%, revealed a pronounced negative impact of harmful occupational factors on parents, which affected the health of children, including the risk of developing cancer.

Radiation radiation comes from natural sources approximately 80% of the time, including cosmic rays, UV light, and naturally occurring radionuclides, especially radon gas. The remaining 20% ​​arises from various man-made sources of radio and microwave radiation, nuclear power plants, etc. The pathological effect of high doses of radiation has been proven, but the total effect of low doses can be harmful to humans. X-ray, gamma and cosmic radiation are classified as ionizing radiation. There is radiation from elementary particles - electrons, neutrons, mesons and deuterinos. X-ray and gamma radiation at a frequency of 1018-1022 Hz contribute to the occurrence of malignant skin tumors, and ionizing radiation, in addition, contributes to leukemia, osteogenic sarcomas and lung cancer. Diseases often develop 10-20 years after irradiation.

The mechanism responsible for late carcinogenesis has not yet been well studied. Some scientists explain the long latent period between exposure to radiation and the development of cancer by the occurrence of so-called induced genetic instability. Pathological genes can be transmitted through a population of cells over several generations.

Anthropogenic pollution external environment radionuclides as a result of experimental nuclear explosions, intensive development of nuclear energy, the use of sources of ionizing radiation in industry, transport, agriculture, science, as well as the expanding volume of X-ray and radioisotope methods Research in medicine has led to an increase in external and internal human exposure.

Radiation doses from these sources in developed countries are already several times higher than natural background radiation levels. The latent period for solid tumors depends on the radiation dose and the age of the person and averages 20-30 years. Using the example of the population living around the Semipalatinsk test site, the highest incidence of BCC and melanoma is shown.

Analysis of the anamnesis data of 300 patients with BCC made it possible to study the frequency of exposure of their bodies to various carcinogens (radiation, microwave radiation, fuels and lubricants - fuels and lubricants, insolation, etc.). More than half (57.7%) of patients with BCC were exposed to carcinogens. Among them, 61.7% had fairly long contact with fuels and lubricants. More than half (57.3%) were exposed to insolation both at work and at home. Contact with microwave radiation occurred in 31% of patients, exposure to radiation was noted by 28.3%. These factors were often combined. In almost 2/3 of cases, patients with BCC were exposed to 2 or more carcinogens. Most often there were 2 (40.7%), less often - 3 (12.8%) and 4 (7.8%). It has been shown that the adverse effects of carcinogens (fuels, radiation and microwave radiation) most often occurred in hot climates. In 72.5% of patients with BCC who lived in the southern regions, a combined effect of these factors and insolation was detected.

A similar situation was revealed for patients living in various regions with a predominance of the south (66.4%). The fact of a delayed effect of the carcinogen has been established. Tumors in 68.6% of cases occurred during the retirement period or 12.6 ± 9.3 years after the end of the carcinogen.

The study of the association of skin cancer and blood group antigens of the AB0 system, taking into account the influence of factors contributing to carcinogenesis, revealed interesting patterns. It was found that the frequency of formation of BCC, the intensity of growth and the size of tumors depended on the combination of endo- and exogenous factors. When exposed to carcinogens, BCC developed 1.7 times more often in patients with blood group II (AO) and 2 times more often in patients with blood group IV (AB). The occurrence of BCC in the majority (82%) of cases occurred in patients exposed to carcinogens for 5 years or more. Statistical processing of the material using the Spearman correlation coefficient showed that certain carcinogens in patients with BCC with different blood groups were associated with tumor sizes. If there is a history of exposure to radiation, large tumors are registered in patients with blood groups III and IV, insolation - in patients with group I, DBS - with blood groups II and III.

Virus-induced carcinogenesis is of particular importance in the pathogenesis of cancer. This is due to the prevalence of viruses and the nature of their life cycle.

Of particular interest due to its pronounced oncogenic potential is the human papillomavirus (HPV). The widespread introduction of molecular biological research methods has made it possible to detect more than 200 HPV genotypes. HPV infects basal epithelial cells, and different types of the virus differ in their tropism for different tissues: some are associated with lesions of the skin (skin of the hands, feet and face), others infect the mucous membranes of the oral cavity, pharynx, respiratory tract and anogenital area or conjunctiva of the eyes.

There are high and low oncogenic risk HPV. The group of viruses with high oncogenic risk also includes types of viruses that are rarely detected in cancer, but are most often associated with the development of dysplasia varying degrees. This made it possible to distinguish them into separate group— “HPV of intermediate oncogenic risk.”

The products of early HPV genes - E6 and E7 and, to a lesser extent, E5 - have transformative and carcinogenic potential. The products of these genes interact with the cellular tumor suppressor genes p53 and Rb, which leads to their inactivation and uncontrolled growth of infected cells with the accumulation of genomic mutations in them. The affinity of the E6 and E7 proteins for p53 and Rb differs between high-oncogenic and low-oncogenic HPV types. The presence of HPV DNA in the tissues of benign epithelial tumors and BCC has been established. In patients with BCC, immunosuppression is determined, affecting the cellular component of immunity, phagocytic activity, the production of endogenous interferons, immunogbulins of classes A, M, G. The most pronounced immunodeficiency is detected in ulcerative, especially recurrent forms of BCC, which make up 64% of all basal cell carcinomas.

A decrease in the number of epidermal Langerhans cells in the skin and disruption of their function lead to a decrease in the protective mechanisms of antitumor growth. Cytokines, which regulate apoptosis and other mechanisms of cytotoxicity in malignant neoplasms, are of great importance in the differentiation and proliferation of tumor cells.

In patients with Gorlin-Goltz syndrome, a decrease in the activity of normal killer cells was revealed to 3% (with a norm of 50.4%). This leads to a pronounced deficiency of cellular immunity in the link responsible for antitumor activity, which is a prerequisite for the development of multiple lesions and pathology of internal organs in these patients. Autoimmune disorders also occur during carcinogenesis.

Classifications of basal cell skin cancer

There is no generally accepted classification of BCRC. In our country, the classification proposed by A.K. has been used for a long time. Apatenko.
All tumors were divided into three groups, including several options:

Undifferentiated or poorly differentiated basal cell carcinomas:

A) undifferentiated basal cell carcinoma of a predominantly solid structure (sometimes with the presence of subtle glandular or piloid differentiation);
b) pigmented basal cell carcinoma;
c) superficial multicentric basalioma.
Differentiated basal cell carcinomas:
a) with glandular differentiation (adenoid basal cell carcinoma);
b) with piloid differentiation (trichobasalioma); ,
c) with sebaceous differentiation;
d) with flat epithelial (epidermoid) differentiation;
d) complex structure (with the presence various types differentiation).
Special forms of basal cell carcinomas:
a) scleroderma-like;
b) basal cell carcinoma of the Pincus fibroepithelial tumor type;
c) basal cell carcinoma that occurs in the wall of the epidermal cyst.

Somewhat later, W. Lever and G. Shaumburg - Lever proposed their own classification of BCC depending on the type of cells and the direction of their differentiation. The division into three groups was preserved (differentiated, undifferentiated and special forms), poorly differentiated forms were excluded, the distribution of BCC variants belonging to one form or another was different, and new tumor variants were added. The authors included cystic, adenoid, keratotic, granular and adamantine-like variants in the group of differentiated tumors; in the undifferentiated group - solid, pigmented, scleroderma-like (morphea) and superficial.
E.S. Snarskaya proposes to maintain the division of BCC into differentiated forms (basaliomas with elements of differentiation towards the sweat, sebaceous glands or with elements of piloid differentiation) and undifferentiated (superficial, solid, morphea-like, adenoid) and take into account the possibility of the presence of transitional forms.

A.N. Khlebnikova, based on immunohistochemical research methods, identified histological types of BCC depending on the form of cell growth, their function and direction of differentiation without combining them into groups. These include superficial, multicentric, solid, adenoid (adenocystic), solid adenoid, pigmented, scleroderma-like BCC, with sebaceous differentiation, with piloid differentiation (trichobasalioma), with flat epithelial (epidermoid) differentiation and a tumor of complex structure (with the presence of different types of differentiation ).

Using the same method for diagnosing BCRC, T. Wade and A. Ackerman proposed their classification, which already included 26 independent histological variants of basal cell carcinomas, without combining them into groups.
In accordance with the WHO clinical and morphological classification (Lyon, 2006), the following forms of BCC are distinguished: superficial, nodular, (solid), micronodular, infiltrative, fibroepithelial, BCC with adnexal differentiation, basal squamous (metatypical) carcinoma, keratotic, cystic , adenoid, morphea-like, infundibulocystic, pigmentary and other rare variants.

However, in everyday practice it is often necessary to limit oneself to the clinical classification of BCC. According to T. Fitzpatrick, there are five clinical forms: tumor, ulcerative, scleroderma-like, superficial and pigmented. T.P. Pisklakova suggests distinguishing slightly more clinical forms of BCC: tumor with three varieties (exophytic, papillary and nodular), ulcerative, superficial, pigmentary, sclerodermiform (self-scarring) and cystic. R. Raichev and V. Andreev identified two types of superficial forms of BCC - pagetoid and erythematoid. Currently, the classification of B.A. is most often used. Berenbeina, A.M. Vavilov and V.V. Dubensky, distinguishing superficial, tumor, ulcerative, pigmentary and scleroderma-like forms of basal cell carcinoma.

Features of the course of basal cell skin cancer

When characterizing BCC, the doctor must take into account several clinical criteria - primary or recurrent tumor growth, their number, shape, location, combination with other skin tumors and internal organs. Recurrences of BCC are recorded after removal of lesions using various methods. In almost half (47.5%) of cases, relapses of BCC occurred after cryodestruction, in approximately 1/5 (18.4%) - after surgical excision tumors, less often - after laser destruction (11.8%), radiation therapy (10.5%) and electrocoagulation (9.2%) and in a single case - after photodynamic therapy and when using combined treatment methods.

According to the literature, the relapse rate ranges from 10 to 29.2%. Most often (89%) relapses occurred 5 years after completion of therapy. It is significant that relapses can be one-time (82%) or repeated (28%). Relapses should be distinguished from the appearance of new foci of proliferative growth in areas of healthy skin, which was observed in 10-20% of patients.

There are differences in the course of primary and recurrent BCC. Observation data from 429 patients with BCC of the eyelids in the ophthalmo-oncology center of the Chelyabinsk Regional Oncology Center (1999-2005) indicate a predominance (2.9 times) of single relapses over multiple ones. In case of recurrent BCC compared with the primary process, multiple tumors were observed significantly 2.7 times more often (24.5% versus 9%), and they were recorded 1.6 times more often in patients with stage T2N0M0 (36.9% versus 27.7 %) and 2.2 times more often - with T3-4N0M0 (24.6% versus 11%). A dependence of the relapse rate on tumor location was revealed. When it was located on the skin of the lower eyelid with involvement of the intermarginal space, relapses were observed 1.9 times more often (27.7% versus 15%) than with isolated localization only on the eyelid; 2.2 times more often (24.6% versus 12%) - with a common process involving two or more anatomical zones.

In the ulcerative form of BCC, relapses were recorded in 57% of cases, with aggressive-growing growth - in 46.7% and mixed growth - in 26.6%.
The number of tumor foci in BCC can be single or multiple. The appearance of neoplasms, according to the definition of primary multiple tumors, can be recorded synchronously (simultaneously), metachronously (sequentially) and combined.

The incidence of multiple foci of BCC varies widely - from 1 to 21.4%. Differences in the incidence of multiple basal cell carcinomas can be explained from several perspectives. First of all, regional characteristics should be taken into account ecological environment, where patients with BCC live, and technogenically caused contact with various carcinogens. Secondly, the volume of material analyzed by various researchers. The longer the period of time covered by the statistical analysis, the greater the likelihood of registering patients with multiple BCC. Thirdly, the presence of cancer alertness in patients, which is associated with the promotion of a healthy lifestyle among them. The sooner a patient contacts a specialist, the less likely the presence of multiple tumors.

When the disease was less than a year old, patients with single tumors predominated (85.6%). When the process was more than 12 years old, the number of patients with single tumors decreased by 1.9 times (85.6% versus 45.2%), and with multiple tumors increased by 3.8 times (14.4% versus 54.8%). ). It has been noted that in case of multiple basal cell carcinomas, superficial forms of BCC are more often recorded. At the same time, the frequency of their registration decreases as the duration of the disease increases.

It was revealed that the superficial form was significantly less common when the disease had been present for a period of one year to 12 years and more than 12 years compared with a disease duration of up to a year. The incidence of the ulcerative form, on the contrary, increased 2.6 times (from 1 year to 12 years) and 1.8 times (more than 12 years) compared with the incidence up to a year ago. Pigmented and scleroderma-like forms were detected in patients only when the process was aged from 1 to 6 years. The solid form predominated in patients with different duration of the process and ranged from 59.6% when the disease manifested more than 12 years ago to 78.4% when the tumor existed for a year or less. It is significant that as the duration of the disease increased, the number of patients with a combination of various forms of tumors increased by 5.7 times - from 4.6% (up to a year) to 26.2% (more than 12 years). The superficial form was more common when the disease was less than a year old and in patients with multiple lesions. Ulceration of the tumor occurred a year after its occurrence. Pigmented and scleroderma-like forms of BCC were formed when the disease duration was from 1 to 6 years.

Multiple basal cell carcinomas can be manifestations of genetic syndromes, in particular Gorlin-Goltz syndrome and xeroderma pigmentosum. In these cases, BCC may first appear in childhood and adolescence.

Gorlin-Goltz syndrome (basal cell nevus syndrome, nevoid basal cell carcinoma syndrome) is a genetically determined disease, the main symptom of which is the multiple nature of BCC in combination with malformations of the nervous, endocrine systems, skeleton, eyes and other organs and tissues. In this syndrome, the presence of mutations in the RTCH gene, located in the chromosomal locus 9q 22.3 q31, has been proven. In patients with Gorlin-Goltz syndrome, various malformations are detected - palmoplantar depressions, odontogenic cysts, bone cysts, hypertelorism, carinatum, cleft ribs, congenital blindness, cataracts, etc. The frequency of the syndrome in the population is estimated as 1:56 000 and accounts for 0.5% of cases of all basapiomas, and in the structure of multiple basapiomas - 6.7%.

At the same time, it should be remembered that multiple basal cell carcinomas do not always indicate the presence of Gorlin-Goltz syndrome. In addition to the absence of malformations of the nervous, endocrine systems, skeleton, eyes and other organs and tissues, there are other clinical criteria. Middle age patients with Gorlin-Goltz syndrome are 46.7 years old, the average number of foci of proliferative growth is 25.1, which are localized in equal proportions on open and closed areas of the skin. The appearance of multiple basaliomas is a priority for patients with an average age of 63.9 years, the average number of foci is 3.7 with their predominant localization in open areas.
Multiple BCC may be a manifestation of a rare genetic syndrome - xeroderma pigmentosum. It occurs when each parent transmits to the child a recessive mutant gene responsible for DNA repair synthesis. Xeroderma pigmentosum is characterized by increased skin sensitivity to ultraviolet rays and ionizing radiation. The incidence of the disease among representatives of the European population is 1:250,000. Early symptoms dermatitis, photophobia, and conjunctivitis that occur in the first three years of life. After 10-15 years, BCC appears, which can be multiple in nature.

BCC can be combined with malignant tumors of the skin and other organs. The frequency is clinical picture almost the same in different regions of the Russian Federation: 7% - Chelyabinsk region, 10.7% - Middle Urals, 8% - Moscow region. More often, BCC precedes the development of and/or is combined with colon tumors.

BCRC is localized mainly in open areas of the skin. In almost 3/4 (72.7%) patients, BCC occurs on the scalp, in a small proportion of patients (8.7%) on the skin of the torso and in isolated cases on the lower extremities (2.3%), neck (1.7 %) and upper limbs (1%). In 13.6% of cases, tumors were localized in two or more anatomical areas.

A quantitative assessment of tumor locations was carried out. For this purpose, a complete count of them was made in 300 patients with BCC, taking into account the topic of the process. A correlation between the frequency of development and the average number of tumors in various areas of the skin, including various anatomical areas of the head, was revealed. The highest rates were recorded in the head region (83.3% and 1.4, respectively). Both indicators were significantly lower when tumors were localized in both open and closed areas of the skin of the torso and limbs. At the same time, on the skin of the body (21.3% and 0.42) and lower limbs(6.3% and 0.07) rates were higher than when assessing the skin of the neck (3.7% and 0.04) and upper extremities (3.3% and 0.11). The data obtained indicate that insolation does not always play a leading role in the pathogenesis of the disease.

When analyzing the localization of BCC on the head, the incidence rates and average number of tumors were highest in the nose (21.7% and 0.27), in the periorbital region (19.7% and 0.21), on the skin of the cheeks (15% and 0.22), auricle and external auditory canal (15.4% and 0.17), as well as the forehead (13.7% and 0.19). The rates were slightly lower when assessing the skin of the scalp (11.7% and 0.16) and temples (10.7% and 0.12) and minimal when calculating the incidence and average number of tumors on the skin of the lips (2.7% and 0.03) and nasolabial folds (1.7% and 0.02).

Conclusion

Analysis of literature data on epidemiology, etiology and pathogenesis, classification and features of the course of BCC allows the practitioner to expand the amount of knowledge on this problem and use it in their daily activities.

Basalioma, or skin cancer, is a malignant tumor that can arise from skin cells (epithelium). There are three types of skin cancer:

basal cell carcinoma or basal cell carcinoma (about 75% of cases); squamous cell carcinoma (about 20% of cases); other types of cancer (about 5% of cases).

Basalioma is the most common type of skin cancer. It does not give distant metastases. It is also called borderline skin tumor due to its benign course. Among doctors it is believed that you cannot die from basal cell carcinoma. However, as with squamous cell carcinoma, everything depends on the degree of neglect and the speed of the disease.

A feature of basal cell carcinoma that all oncologists note is the high risk of relapse. Not a single method of treating skin basal cell carcinoma, even deep excision, provides a guarantee that the cancer will not reappear. On the other hand, skin basal cell carcinoma may not reappear even with small-scale interventions.

Small basalioma of the skin is almost always a successful treatment. If you missed the time, the skin basalioma has probably already turned into a fetid ulcer about 10 cm in size. It begins to grow into blood vessels, tissues and nerves. In most cases, the patient dies from complications caused by the disease. 90% of skin basal cell carcinoma cases are located on the face.

Squamous cell skin cancer

Squamous cell skin cancer is also called true cancer. It often recurs, gives metastases to regional lymph nodes, and causes the appearance of isolated metastases in various organs.

The causes of squamous cell carcinoma and basal cell carcinoma are:

ionizing radiation radiation; thermal and mechanical injuries; scarring; impact of all kinds chemical compounds: tar, arsenic, fuels and lubricants.

Externally, squamous cell carcinoma and basal cell carcinoma of the skin can appear as an ulcer or tumor formation (nodule, plaque, “cauliflower”).

Diagnosis of skin cancer

The diagnosis is made to the patient after examination and a series of tests, including histological or cytological examination. For histological examination, a surgical biopsy of the tumor is necessary, and for cytological examination, a scraping or smear is sufficient.

If squamous cell carcinoma and enlarged lymph nodes are detected, a biopsy of these same lymph nodes may be required, followed by a cytological examination of the resulting material. Also, as part of a routine examination for this form of cancer, an ultrasound scan of regional lymph nodes, liver and lungs is performed.

Principles of treatment

If you are diagnosed with skin basal cell carcinoma or squamous cell carcinoma, the treatment may be different - it all depends on the stage of the disease. In most cases, squamous cell skin cancer, no matter what symptoms it causes, requires surgery. Thus, the method of excision of skin within healthy tissue is often used: the distance from the border should be about 5 mm. This procedure is performed under local anesthesia. If skin cancer has reached serious stages and has metastasized, then treatment involves excision of regional lymph nodes.

For skin basal cell carcinoma, treatment can be carried out using plastic surgery methods. This is justified in the presence of large tumors.

Another treatment method is Mohs surgery. This technique involves excision of the tumor to the borders of the end of the cancerous tissue. Radiation therapy is used when the tumor is very small or, conversely, in late stages. In some cases, the use of laser destruction, cryodestruction and photodynamic therapy is relevant. Metastatic, or advanced forms of cancer are treated with chemotherapy.

This disease has many names - it is basalioma, basal cell epithelioma, ulcusrodens or epitheliomabasocellulare. It refers to diseases that are common among sick people. Basically, in our country, the term “basiloma” is more common in the specialized literature. Since the tumor on the skin has a clear destabilizing growth that regularly recurs. But metastasis this cancer doesn't happen.

What causes skin basal cell carcinoma?

Many experts believe that the reasons lie in individual development body. In this case, squamous cell carcinoma begins its origin in pluripotent epithelial cells. And they continue their advance in any direction. When producing cancer cells The genetic factor plays a major role, as well as various types of disorders in the immune system.

The development of the tumor is influenced by strong radiation or contact with harmful chemicals that can cause malignant neoplasms.

Basalioma can also form on skin that does not have any changes. And the skin, which has different skin diseases(posriasis, actinic keratosis, tuberculosis-type lupus, radiodermatitis and many others) will be a good platform for the development of cancer.

In basal cell epithelioma, all processes proceed very slowly, so they do not develop into squamous cell carcinoma, complicated by metastases. Often the disease begins to arise in the upper layer of the skin, in the hair follicles, since their cells are similar to the basal epidermis.

Doctors interpret this disease as a specific tumor formation with local destructive growth. And not as malignant or benign tumor. There are cases when the patient was exposed, for example, to strong exposure to harmful rays from an X-ray machine. Then basal cell carcinoma can develop into basal cell carcinoma.

Regarding histogenesis, when the tissues of a living organism develop, researchers cannot yet say anything.

Some people think that squamous cell carcinoma begins in the primary skin germ. Some believe that formation will occur from all parts of the epithelial structure of the skin. Even from the embryonic primordium and developmental defects.

Risk factors for the disease

If a person often comes into contact with arsenic, gets burns, or is exposed to X-rays and ultraviolet radiation, then the risk of developing basal cell carcinoma is very high. This type of cancer often occurs in people with skin types 1 and 2, as well as in albinos. Moreover, all of them experienced the effects of radiation exposure for a long time. Even if in childhood If a person is often exposed to insolation, a tumor may appear after tens of years.

Origin and development of the disease

The outer layer of skin in patients is slightly reduced in size and sometimes ulcerated. Basophil cells begin to grow, the tumor becomes a single layer. Anaplasia is almost invisible, ontogenesis is slightly pronounced. There are no metastases in squamous cell carcinoma, because tumor cells entering the blood ducts cannot multiply. Since they do not have the growth factors that the tumor stroma should produce.

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Signs of cutaneous basalioma

Basal cell epithelioma of the skin is a single formation. The shape is similar to half a ball, the appearance is more round. The tumor may protrude slightly above the skin. The color is more pink or grayish-red, with a pearlescent tint. In some cases, basilioma cannot be distinguished from ordinary skin at all.

The tumor is smooth to the touch; in its middle there is a small depression, which is covered with a thin, slightly loose ichor crust. If you remove it, you will find a small erosion underneath. Along the edges of the neoplasm there is a thickening in the form of a roller, which consists of small whitish nodules. They look like pearls, by which basilioma is determined. A person can have such a tumor for many years, only becoming slightly larger.

There can be large numbers of such neoplasms on the patient’s body. Back in 1979, scientists K.V. Daniel-Beck and A.A. Kolobyakov found that the primary multiple type can be found in 10% of patients. When there are dozens or more tumor foci. And this is then revealed in non-basocellular Gorlin-Goltz syndrome.

All signs of such skin cancer, even Gorlin-Goltz syndrome, make it possible to divide it into the following forms:

nodular-ulcerative (ulcusrodens); superficial; scleroderma-like (morphea type); pigment; fibroepithelial.

If a sick person has a large number of lesions, then the forms can be of several types.

Types of basalioma

The superficial type manifests itself by appearing on the skin pink spots, a little flaky. Over time, the spot becomes clearer, acquiring an oval or round shape. Along its edges you can see small, slightly shiny nodules. They then merge into a dense ring, similar to a roller. In the middle of the spot there is a depression that becomes dark, almost brown. It can be single or multiple. There is also a rash of dense, small particles over the entire surface of the outbreak. Almost always the nature of the rash is multiple, and basilioma occurs constantly. Its growth occurs very slowly. Clinical features are very similar to Bowen's disease.

The pigmented type of basalioma resembles nodular melanoma, but only the density is stronger. The affected areas have a blue-violet or dark brown tint. For accurate diagnosis carry out dermoscopic examination of the spots.

The tumor type begins with the appearance of a small nodule. Then it gets bigger and bigger. Its diameter becomes about three centimeters. It looks like a round speck of stale pink paint. On the smooth surface of the tumor, dilated small vessels are clearly visible, some are covered with a grayish coating. The central part of the affected area may have a dense crust. The growth does not protrude above the skin, and it has no legs. There are two forms of this type: with small and large nodules. This depends on the size of the tumors.

The ulcerative type appears as a variation of the primary variant. And also as a result of the manifestation of superficial or tumor basilioma. Typical sign This form of the disease is considered to be a funnel-shaped ulcer. It looks massive, its fabric seems to be glued to the lower layers, their boundaries are not clearly visible. The size of the accumulations is much larger than the ulcer. In this embodiment, there is a noticeable tendency to severe ulcers, due to which the lower part of the tissue begins to collapse. There are cases when the ulcerative appearance is complicated by growths in the form of papillomas and warts.

The scleroderma-like or scar-atrophic type has a small, clearly defined focus of infection, compacted at the base, but not protruding above the skin. The color shade is closer to yellowish-whitish. In the middle of the spot, atrophied transformations or dyschromia occur. Sometimes erosive foci of different sizes appear. They have a crust on them that is very easy to remove. This is a positive point when conducting cytological studies.

Pincus fibroepithelial tumor is a type of squamous cell cancer, but it is quite mild. Externally, it looks like a nodule or plaque matching the color of a person’s skin. The consistency of such a stain is dense and elastic; erosion is not observed on it.

Basal cell epithelioma is treated conservatively. Doctors surgically remove lesions along the border of healthy skin. Cryodestruction is also practiced. This treatment is used if after surgery there may be cosmetic defect. You can smear the spots with prospidin and colchamine ointments.

Basalioma (syn. basal cell carcinoma) is the most common malignant epithelial neoplasm of the skin (80%), arising from the epidermis or hair follicle, consisting of basaloid cells and characterized by locally destructive growth; metastasizes extremely rarely.

Usually develops after 40 years of age due to prolonged insolation, exposure to chemical carcinogens or ionizing radiation. More common in men. In 80% of cases it is localized on the scalp and neck, in 20% it is multiple.

Clinically, the following forms of basal cell carcinoma are distinguished:

superficial– characterized by a flaky pink spot, round or oval in shape with a thread-like edge, consisting of small shiny pearl nodules, dull pink in color;

ABOUT downy begins with a dome-shaped nodule, reaching a diameter of 1.5–3.0 cm over several years,

ulcerative develops primarily or by ulceration of other forms; basalioma with a funnel-shaped ulceration of a relatively small size is called ulcus rodeus (“corroding”), and spreading deeper (down to the fascia and bone) and along the periphery is called ulcus terebrans (“penetrating”);

scleroderma-like basalioma has the appearance of a dense whitish plaque with a raised edge and telangiectasia on the surface.

Histologically, the most common (50–70%) type of structure, consisting of strands of various shapes and sizes and cells of compactly located basaloid cells, resembling a syncytium. They have round or oval hyperchromatic nuclei and scant basophilic cytoplasm, along the periphery of the cords there is a “picket fence” of prismatic cells with oval or slightly elongated nuclei - characteristic feature basal cell carcinomas. Mitoses often occur, the cellular fibrous connective tissue stroma forms fascicle structures, contains a mucoid substance and an infiltrate of lymphocytes and plasma cells.

The course of basalioma is long. Relapses occur after inadequate treatment, more often with a tumor diameter of more than 5 cm, with poorly differentiated and invasive basal cell carcinomas.

The diagnosis is established on the basis of clinical and laboratory (cytological, histological) data.

Treatment of solitary basaliomas is surgical, as well as using a carbon dioxide laser, cryodestruction; when the tumor diameter is less than 2 cm, intralesional administration of intron A is effective (1,500,000 units every other day No. 9, the course consists of two cycles). For multiple basal cell carcinomas, cryodestruction, photodynamic therapy, and chemotherapy are performed (prospidin 0.1 g intramuscularly or intravenously daily, 3.0 g per course). X-ray therapy (usually close-focus) is used to treat tumors located near natural openings, as well as in cases where other methods are ineffective.

Squamous cell skin cancer (syn.: spinocellular cancer, squamous cell epithelioma) is a malignant epithelial tumor of the skin with squamous differentiation.

Affects mainly elderly people. It can develop on any part of the skin, but more often on open areas (upper part of the face, nose, lower lip, back of the hand) or on the mucous membranes of the mouth (tongue, penis, etc.). As a rule, it develops against the background of skin precancer. Metastasizes lymphogenously with a frequency of 0.5% in malignant solar keratosis to 60–70% in squamous cell carcinoma of the tongue (on average 16%). Foci of squamous cell skin cancer can be solitary or primary multiple.

Clinically, tumor and ulcerative types of skin cancer are distinguished.

Tumor type, initially characterized by a dense papule surrounded by a rim of hyperemia, which turns over the course of several months into a dense (cartilaginous consistency) sedentary red-pink node (or plaque) fused with subcutaneous fatty tissue with a diameter of 2 cm or more with scales or warty growths on the surface (warty variety), easily bleeds at the slightest touch, necrotizing and ulcerating; its papillomatous variety differs more rapid growth, individual sponge-like elements on a broad base, which sometimes have the shape of a cauliflower or tomato. Ulcerates in the 3rd–4th month of the tumor’s existence.

Ulcerative type, characterized by a superficial ulcer of irregular shape with clear edges, spreading not in depth, but along the periphery, covered with a brownish crust (superficial variety); the deep type (spreading along the periphery and into the underlying tissues) is an ulcer with a yellowish-red color (“greasy”) base, steep edges and a lumpy bottom with a yellow-white coating. Metastases to regional lymph nodes occur in the 3rd–4th month of tumor existence.

Histologically, squamous cell skin cancer is characterized by cords of cells of the spinous layer of the epidermis proliferating into the dermis. Tumor masses contain normal and atypical elements (polymorphic and anaplastic). Atypia is manifested by cells of different size and shape, hyperplasia and hyperchromatosis of their nuclei, and the absence of intercellular bridges. There are many pathological mitoses. There are keratinizing and non-keratinizing squamous cell carcinoma. Well-differentiated tumors demonstrate pronounced keratinization with the appearance of “horny pearls” and individual keratinized cells. Poorly differentiated tumors do not have pronounced signs of keratinization; they contain strands of sharply polymorphic epithelial cells, the boundaries of which are difficult to determine. The cells have different shapes and sizes, small hyperchromic nuclei, pale shadow nuclei and nuclei in a state of decay are found, pathological mitoses are often detected. Lymphoplasmacytic infiltration of the stroma is a manifestation of the severity of the antitumor immune response.

The course is steadily progressive, with germination into the underlying tissues, pain, and dysfunction of the corresponding organ.

The diagnosis is established based on the clinical picture, as well as the results of cytological and histological studies. Differential diagnosis is carried out with basal cell carcinoma, keratoacanthoma, solar keratosis, Bowen's disease, cutaneous horn, etc.

Treatment is carried out by surgical removal tumors within healthy tissues (sometimes in combination with x-ray or radiotherapy); chemosurgical treatment, cryodestruction, photodynamic therapy, etc. are also used. The choice of treatment method depends on the stage, localization, extent of the process, the nature of the histological picture, the presence of metastases, age and general condition sick. Thus, when the tumor is localized in the area of ​​the nose, eyelids, lips, as well as in elderly people who are unable to undergo surgical treatment, radiotherapy is more often performed. The success of treatment largely depends on early diagnosis. Prevention of squamous cell skin cancer consists primarily of timely and active treatment of precancerous dermatoses. The role of sanitary propaganda among the population of knowledge about the clinical manifestations of squamous cell skin cancer is important, so that patients consult a doctor as early as possible when it occurs. It is necessary to warn the population about the harmful consequences of excessive insolation, especially for blondes with fair skin. Important also has compliance with safety precautions in production where there are carcinogenic substances. Workers employed in such industries must undergo systematic medical examinations.