Metastasizing squamous celi carcinoma of the skin 
Clinical study 
METASTASIZING SQUAMOUS 
CELL CARCINOMA OF THE SKIN 
P. Holl6 and B. Somlai 
ABSTRACT 
Metastases from carcinomas of the skin are rare. 
During 1994-1996 six patients, 4 males and 2 females, aged from 52 to 94 years, were treated at the 
Department of Dermato-Venereology of the Semmelweis University of Medicine far metastasizing squamous 
celi carcinoma of the skin. After being operated far the primary tumors they developed metastases within 
13 months. Presenting these cases, the authors discuss the main risk factors far metastasizing squamous celi 
carcinoma of the skin: the anatomical localization, thickness of the tumor, invasion of the subcutis, and the 
grade of dedifferentiation. 
KEY WORDS 
carcinoma, squamous cel!, skin, metastases 
INTRODUCTION PATIENTS AND METHODS 
The incidence of cutaneous squamous celi carcinoma 
has increased. The most common localization of the 
primary cutaneous squamous celi carcinoma is the 
skin of the hands, arms, face, and neck. The majority 
of these tumors are easily cured by surgical treatment. 
The incidence of metastases is between 2% and 5%, 
usually in patients with primary tumor of the hands 
and face (1,2). The metastases develop consistently 
in the regional lymph nodes in 85% of the cases. 
Very rarely other organs can be seeded as well: 
lungs, !iver, bones and the central nervous system. 
Fram 1994 to 1996 we treated 6 patients ( 4 men, 
2 women) with metastasizing squamous celi carcinoma. 
They were between 52 and 94 years old, mean 71,5 
years. In one case the metastasis and the primary 
tumor were diagnosed at the same tirne. The longest 
symptomless period lasted 13 months, the mean 
tirne until appearance of the metastases was 7 
months. The data of the patients and the main 
histological features of their primary tumors are 
summarized in Table No.l. The tumors were classified 
according to the Broders grading (3). The metastases 
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Metastasizing squamous celi carcinoma of the skin 
Fig.l . Large exulcerated lesion on the left hand 
caused by primary squamous celi carcinoma. 
are described in Table No.2, as well as their treatment 
and their actual status. 
Fig.3. Exulcerated retroauricular metastatic lymph node,. 
14 
Fig.2. Enlarged axillar lymph node due to metastases 
RESULTS 
During the 1994-1996 period 229 patients were 
treated for squamous celi carcinoma at the Department 
of Dermato-Venereology, Semmelweis University of 
Medicine. Metastases were found in 6 cases, 2.6% of 
the total number of patients. 
These six cases of metastasizing squamous cell 
carcinoma have been presented in this study. In five 
cases, the primary tumors were localized in areas 
where malignant tumors are more prone to metastasize, 
namely the hands and the face . One tumor developed 
on the basis of a chronic venous leg ulcer. Except 
for this case, the primary lesions were treated surgically. 
In all instances the metastases appeared within 13 
months after the diagnosis of the primary lesion. In 
one case, the primary tumor and the regional lymph 
node metastasis were diagnosed at the same tirne. 
The metastases developed in the regional lymph 
nodes in 5 cases, in one case in the lungs. The 
thickness of the primary tumors was more than 2 
mm in all cases. 4 tumors had invaded the subcutis, 
and all were classified histologically as non-diffe-
rentiated (according to Broders grades III-IV.). The 
regional lymph node metastases of 2 patients were 
excised, in 4 patients they were irradiated (Telecobalt, 
30 Grays ), and in 2 cases systemic chemotherapy 
was initiated. Of these 6 patients, 3 had died within 
2 years. 
DISCUSSION 
Severa! studies dealing with metastasizing squamous 
cell carcinoma have been published. In Southern 
Australia Czarneczki et al found that at least 2% of 
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Metastasizing squamous celi carcinoma of the skin 
Table l. Metastases from squamous cel! carcinomas of the skin: patients' sex and age, tumor localization and 
characteristics. 
N.P. male 64 years left hand, 9.6 mm yes III. 
4th finger 
M.P. male 69 years left face 2.4 mm yes IV. 
K.I. male 52 years right hand 3.5 mm no III. 
2nd. finger 
K.N. female 94 years left side 6.4 mm yes IV. 
preauricular 
Sz.S. female 72 years right leg ulcer >2 mm III-IV. 
F.J. male 78 years scalp 
patients with squamous cel! carcinoma of the skin 
would develop metastases within 3 years ( 4). In the 
United States Epstein et al. mentioned the same 
incidence (5). 
The most important risk factors for metastases are 
tumor localizations in the areas predisposed to 
metastasize, and the histological characteristics of 
>2 mm yes IV. 
the tumor: the thickness, the degree of invasion of 
the subcutis, and the grade of differentiation (6,7). 
Dedifferentiated tumors (Broders grades III-IV.), 
thickness greater than 2 millimeters and invasion of 
the subcutis are indications of an increased risk for 
metastases (8,9). 
We reported six patients with metastasizing squamous 
Table 2. Metastases from squamous cel! carcinomas of the skin: interval between detection of primary tumor 
and appearance of metastases, treatment and outcome. 
N.P. lungs 1 month Vincristin, Adriamycin death 
M .P. lymph nodes 13 months blockdissection dissemination 
submandibular irradiation 
K.I. lymph nodes axillar, 12 months blockdissection death 
neck irradiation, Bleomycin 
K.N. lymph nodes 4 months irradiation dissemination 
preauricular 
Sz.S. lymph nodes inguinal at the same tirne death 
F.J. lymph nodes 12 months irradiation dissemination 
retroauricular 
acta dennatovenerologica A.P.A. Vol 7, 98, No 1 15 
Metastasizing squamous celi carcinoma of the skin 
Fig.4. Multiple irregular strands of tumor cells 
cell carcinoma. All of them belonged to the high-
risk-group for developing metastasis. 
Although most patients with squamous cell carci-
noma are easily cured by surgical treatment, the 
Fig.S. lnvasion of tumor into a lymph node. 
possibility of metastas1zmg must always be taken 
into consideration, the rate of occurrence being 2-
5%. Taking the clinical and histological risk factors 
into account, the long-term follow-up of the patients 
is essen tial 
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16 
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zur Prognosebestimmung des spinocellularen Kaninoms 
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AUTHORS' ADDRESSES 
Peter Ho116 MD, Dept. of Dermato-Venereology, Semmelweis, University of Medicine, 
Maria st. 41. 1085 Budapest, Hungary 
Beata Somlai MD, same address 
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