Skin Cancer: Basal and Squamous Cell

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Early Detection, Diagnosis, and Staging TOPICS

How are basal and squamous cell skin cancers diagnosed?

Most skin cancers are brought to a doctor’s attention because of signs or symptoms a person is having.

If you have an abnormal area that might be skin cancer, your doctor will do exams and tests to find out if it is cancer or some other skin condition. If there is a chance the skin cancer may have spread to other areas of the body, other tests may be done as well.

Medical history and physical exam

Usually the first step is for your doctor to take your medical history. The doctor will ask when the mark on the skin first appeared, if it has changed in size or appearance, and if it is causing any signs or symptoms (pain, itching, bleeding, etc.). You may also be asked about past exposures to causes of skin cancer (including sunburns and tanning practices) and if you or anyone in your family has had skin cancer.

During the physical exam, the doctor will note the size, shape, color, and texture of the area(s) in question, and whether there is bleeding or scaling. The rest of your body may be checked for spots and moles that could be related to skin cancer.

The doctor may also feel the nearby lymph nodes, which are bean-sized collections of immune system cells under the skin in certain areas. Some skin cancers may spread to lymph nodes. When this happens, the lymph nodes may become larger and firmer than usual.

If you are being seen by your primary doctor and skin cancer is suspected, you may be referred to a dermatologist (a doctor who specializes in skin diseases), who will look at the area more closely.

Along with a standard physical exam, some dermatologists use a technique called dermatoscopy (also known as dermoscopy, epiluminescence microscopy [ELM] or surface microscopy) to see spots on the skin more clearly. The doctor uses a dermatoscope, which is a special magnifying lens and light source held near the skin. Sometimes a thin layer of alcohol or oil is used with this instrument. The doctor may take a digital photo of the spot.

When used by an experienced dermatologist, this test can improve the accuracy of finding skin cancers early. It can also often help reassure you if a spot on the skin is probably benign (non-cancerous) without the need for a biopsy.

Skin biopsy

If the doctor thinks that a suspicious area might be skin cancer, he or she will take a sample of skin from the area and have it looked at under a microscope. This is called a skin biopsy. If the biopsy removes the entire tumor, it’s often enough to cure basal and squamous cell skin cancers without further treatment.

There are different ways to do a skin biopsy. The doctor will choose one based on the suspected type of skin cancer, where it is on your body, its size, and other factors. Any biopsy is likely to leave at least a small scar. Different methods may result in different scars, so ask your doctor about possible scarring before the biopsy is done. No matter which type of biopsy is done, it should remove as much of the suspected area as possible so that an accurate diagnosis can be made.

Skin biopsies are done using a local anesthetic (numbing medicine), which is injected into the area with a very small needle. You will probably feel a small prick and a little stinging as the medicine is injected, but you should not feel any pain during the biopsy.

Shave (tangential) biopsy

For a shave biopsy, the doctor first numbs the area with a local anesthetic. The doctor then shaves off the top layers of the skin with a small surgical blade. Usually the epidermis and the outer part of the dermis are removed, although deeper layers can be taken as well if needed. Bleeding from the biopsy site is then stopped by applying an ointment or a small electrical current to cauterize the wound.

Punch biopsy

A punch biopsy removes a deeper sample of skin. The doctor uses a tool that looks like a tiny round cookie cutter. Once the skin is numbed with a local anesthetic, the doctor rotates the punch biopsy tool on the skin until it cuts through all the layers of the skin, including the dermis, epidermis, and the upper parts of the subcutis. The sample is removed and the edges of the biopsy site are often stitched together.

Incisional and excisional biopsies

To examine a tumor that may have grown into deeper layers of the skin, the doctor may use an incisional or excisional biopsy. An incisional biopsy removes only a portion of the tumor. An excisional biopsy removes the entire tumor.

After numbing the area with a local anesthetic, a surgical knife is used to cut through the full thickness of skin. A wedge or sliver of skin is removed for examination, and the edges of the wound are stitched together.

Examining the biopsy samples

All skin biopsy samples are sent to a lab, where they are looked at under a microscope by a pathologist (a doctor trained in looking at tissue samples to diagnose disease). Often, the samples are sent to a dermatopathologist, a doctor who has special training in looking at skin samples.

Lymph node biopsy

It’s rare for basal or squamous cell cancer to spread beyond the skin, but if it does it usually goes first to nearby lymph nodes, which are bean-sized collections of immune cells. If your doctor feels lymph nodes near the tumor that are too large and/or too firm, a lymph node biopsy may be done to determine whether cancer has spread to them.

Fine needle aspiration biopsy

For a fine needle aspiration (FNA) biopsy, the doctor uses a syringe with a thin, hollow needle to remove very small tissue fragments. The needle is smaller than the needle used for a blood test. A local anesthetic is sometimes used to numb the area first. This test rarely causes much discomfort and does not leave a scar.

An FNA biopsy is not used to diagnose a suspicious skin tumor, but it may be used to biopsy large lymph nodes near a skin cancer to find out if the cancer has spread to them. FNA biopsies are not as invasive as some other types of biopsies, but they may not always provide enough of a sample to find cancer cells.

Surgical (excisional) lymph node biopsy

If an FNA does not find cancer in a lymph node but the doctor still suspects the cancer has spread there, the lymph node may be removed by surgery and examined. If the lymph node is near the surface of the body, this can often be done in a doctor’s office or outpatient surgical center using local anesthesia. It will leave a small scar.


Last Medical Review: 10/21/2013
Last Revised: 02/20/2014