Is the initial management of Squamous Cell Carcinoma (SCC) to perform a biopsy or cryotherapy (freezing it off)?

Management of Squamous Cell Carcinoma: Biopsy is Essential, Not Cryotherapy

The initial management of Squamous Cell Carcinoma (SCC) should always be a biopsy to confirm diagnosis and assess risk factors, not cryotherapy (freezing it off). 1

Diagnostic Approach for SCC

• Biopsy is the recommended first step for any suspected SCC to establish diagnosis and guide appropriate treatment planning 1
• Three acceptable biopsy techniques for SCC include:
  • Punch biopsy
  • Shave biopsy (including tangential technique)
  • Excisional biopsy 1
• The choice of biopsy technique depends on the lesion's characteristics (morphology, location) and physician judgment 1
• Biopsy specimen must be adequate in size and depth to provide necessary clinical information and pathology elements for accurate diagnosis 1

Why Biopsy is Essential Before Treatment

• Biopsy allows for histopathological confirmation of SCC diagnosis, which is necessary before initiating any treatment 1
• Histopathologic examination provides critical information about:
  • Degree of differentiation
  • Depth of invasion
  • Perineural invasion
  • Other high-risk features that determine prognosis and treatment approach 1
• Biopsy helps distinguish SCC from its mimics, which may require different management approaches 2

Risk Stratification After Biopsy

• After biopsy confirmation, SCCs are classified as low-risk or high-risk based on clinical and pathological parameters 1, 3
• High-risk features include:
  • Depth >2mm
  • Poor differentiation
  • High-risk anatomic locations (face, ears, genitalia, hands, feet)
  • Perineural involvement
  • Recurrent tumors
  • Immunosuppression 4, 3
• Risk stratification guides appropriate treatment selection 1

Treatment Options After Diagnosis

• For low-risk SCC:

  • Standard excision with 4-6mm margins is recommended 1
  • Curettage and electrodessication may be considered for low-risk primary SCC in non-hair-bearing locations 1
  • Cryosurgery may be considered ONLY for low-risk SCC when more effective therapies are contraindicated or impractical 1

• For high-risk SCC:

  • Mohs micrographic surgery is recommended 1
  • Standard excision with wider margins (≥10mm) may be considered for select cases 1, 3
  • Radiation therapy can be considered when surgery is not feasible 1, 3

Why Cryotherapy is Not First-Line Management

• Cryosurgery is only recommended as a secondary option for low-risk SCC when more effective therapies are contraindicated or impractical 1
• Cryotherapy does not allow for histological margin assessment, which is critical for ensuring complete removal 1
• Without prior biopsy, cryotherapy may lead to:
  • Inadequate treatment of aggressive or high-risk tumors
  • Missed diagnosis of invasive components
  • Lack of prognostic information needed for appropriate follow-up 1, 3

Common Pitfalls to Avoid

• Never treat a suspected SCC with cryotherapy without first obtaining a diagnostic biopsy 1
• Avoid inadequate biopsy sampling that fails to capture the full depth or aggressive components of the tumor 1
• Do not assume a lesion is low-risk without histopathologic confirmation 2, 3
• Remember that SCC can have various clinical presentations and may mimic other conditions, making biopsy essential 2, 5

Follow-Up Recommendations

• After diagnosis and treatment, patients should be monitored for recurrence and new skin cancers 1
• Annual skin examinations are recommended at minimum for all patients with a history of SCC 1
• More frequent follow-up may be necessary for high-risk tumors or patients with multiple risk factors 4, 3