Head and Neck Cutaneous Squamous Cell Carcinoma Differential Diagnoses

  • Author: Marcus Monroe, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jul 7, 2011
 
 

Diagnostic Considerations

The key diagnostic consideration is that early detection and treatment by multiple modalities is important for better prognosis in head and neck cancer. A complete head and neck examination with indirect nasopharyngeal and laryngopharyngeal mirror examination is mandatory.

Keep in mind that although the typical patient with squamous cell carcinoma (SCC) is of northern European descent and presents with a family history of skin cancer, a personal history of previous skin cancer, and/or an extensive history of sun exposure, a detailed history and physical examination is crucial (see Clinical Presentation),and the clinician should be aware of the risk factors for high-risk disease (see Prognosis).Cutaneous SCCs can be experimentally produced with ultraviolet (UV) light exposure, almost to the exclusion of other types of cancer. Marjolin ulcer appears as a new area of induration, elevation, or ulceration at the site of a preexisting scar or ulcer. The diagnosis of Marjolin ulcer should be considered in any ulcer that fails to heal with standard therapy.

Pseudoepitheliomatous hyperplasia (PEH) is a histologic finding found in keratoacanthoma and SCC and in certain other reactions such as tattoo reactions; this is important to remember when presented with the diagnosis of an SCC arising in a tattoo. That is, the clinician must ensure that the PEH is associated with cancer. PEH can also be present in lesions of hypertropic lupus. When lesions with PEH are found in patients with a history of lupus, the clinician must differentiate between lesions that are definitely SCC and lesions of hypertropic lupus that are mimicking SCC or keratoacanthoma.

Other Conditions to Be Considered

The following conditions should also be considered when evaluating a patient with suspected SCC:

  • Cancerous lesions - Sebaceous cell carcinoma and rhabdomyosarcoma
  • Congenital tumors - Dermoids, dermolipomas, and episcleral osseous choristoma
  • Conjunctival degeneration - Pinguecula and amyloidosis
  • Hereditary lesions - Benign hereditary intraepithelial dyskeratosis
  • Lymphoid tumors - Lymphoid neoplasia, benign reactive lymphoid hyperplasia, and leukemic infiltrates
  • Neuroectodermal tumors - Nevus, primary acquired melanosis, and melanoma
  • Papillomas – Human papillomavirus (HPV)-induced papillomas
  • Pseudocancerous lesions - Pseudoepitheliomatous hyperplasia and keratoacanthoma
  • Vascular lesions - Angioma, lymphangioma, Kaposi sarcoma, and pyogenic granuloma
  • Xanthomatous lesions -Juvenile xanthogranuloma and fibrous xanthoma

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Marcus Monroe, MD  Resident Physician, Department of Otolaryngology, Head and Neck Surgery, Oregon Health and Science University

Marcus Monroe, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Coauthor(s)

Murad Alam, MD  Associate Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery, Department of Dermatology, Northwestern University; Director, Mohs Micrographic Surgery, Northwestern Memorial Hospital

Murad Alam, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, American Society of Cosmetic Dermatology and Aesthetic Surgery, American Society of Transplantation, Dermatology Foundation, Illinois Dermatological Society, Phi Beta Kappa, Society for Investigative Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

William Joseph Campbell, MD  Resident Physician, Department of Surgery, University of Florida

William Joseph Campbell, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Jorge I de la Torre, MD, FACS  Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Gregory Caputy, MD, PhD, FICS  Chief Surgeon, Aesthetica Plastic and Laser Surgery Center, Inc

Gregory Caputy, MD, PhD, FICS is a member of the following medical societies: American Society for Laser Medicine and Surgery, Canadian Medical Association, International College of Surgeons, International College of Surgeons US Section, Pan-Pacific Surgical Association, and Wound Healing Society

Disclosure: Syneron Corporation Salary Speaking and teaching

Christopher DeBacker, MD  Clinical Assistant Professor of Ophthalmology, University of Texas Health Science Center at San Antonio; Clinical Assistant Professor of Ophthalmology, University of California, San Francisco Medical Center, Veterans Affairs Medical Center

Christopher DeBacker, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Ophthalmology, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Robert M Dryden, MD, FACS  Clinical Professor, Department of Ophthalmology, University of Arizona School of Medicine

Robert M Dryden, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Cosmetic Surgery, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting

Jerre Freeman, MD  Founder and Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center College of Medicine

Jerre Freeman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Jaime R Garza, MD, DDS, FACS  Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Neil D Gross, MD  Assistant Professor of Head and Neck Surgery and Oncology, Department of Otolaryngology – Head and Neck Surgery, Oregon Health and Science University

Neil D Gross, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American College of Surgeons, and American Head and Neck Society

Disclosure: Nothing to disclose.

Shahin Javaheri, MD  Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Lorraine Jennings, MBBCh, MRCPI  Fellow, Department of Dermatology, Mohs Micrographic Surgery Center, Brigham and Women's Hospital, Harvard Medical School

Lorraine Jennings, MBBCh, MRCPI is a member of the following medical societies: British Association of Dermatologists, International Transplant and Skin Cancer Collaborative (ITSCC), Irish Association of Dermatologists, Photomedicine Society, and Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Lawrence Ketch, MD, FAAP, FACS  Head, Program Director, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief, Pediatric Plastic, The Children's Hospital of Denver

Lawrence Ketch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Association for Hand Surgery, American Association of Plastic Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Plastic Surgery Research Council

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Deepak Narayan, MD, FRCS  Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center

Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Ron W Pelton, MD, PhD  Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Noah S Scheinfeld, MD, JD, FAAD  Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

Chrysalyne D Schmults, MD, MSCE  Assistant Professor of Dermatology, Harvard Medical School; Director, Mohs Micrographic Surgery Center, Department of Dermatology, Brigham and Women's Hospital and Dana Farber Cancer Center

Chrysalyne D Schmults, MD, MSCE is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Society for Dermatologic Surgery, and International Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Marvin Spann, MD  Staff Physician, Department of General Surgery, New York Hospital Queens

Disclosure: Nothing to disclose.

Wayne Karl Stadelmann, MD  Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mia Talmor, MD  Assistant Professor, Department of Surgery, Weill Medical College of Cornell University

Mia Talmor, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

R Stan Taylor, MD  The JB Howell Professor in Melanoma Education and Detection, Departments of Dermatology and Plastic Surgery, Director, Skin Surgery and Oncology Clinic, University of Texas Southwestern Medical Center

R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Michael T Yen, MD  Associate Professor of Ophthalmology, Department of Ophthalmology, Division of Ophthalmic Plastic, Lacrimal, and Orbital Surgery, Cullen Eye Institute, Baylor College of Medicine

Michael T Yen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Marc S Zimbler, MD, FACS  Director of Facial Plastic and Reconstructive Surgery, Director of Residency Education, Department of Otolaryngology, Head and Neck Surgery, Beth Israel Medical Center

Marc S Zimbler, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Samia Nawaz, MBBS, MD  Associate Professor, Department of Pathology, University of Colorado Health Science Center

Samia Nawaz, MBBS, MD is a member of the following medical societies: American Society for Clinical Pathology, American Society of Cytopathology, and International Academy of Pathology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

M Sherif Said, MD, PhD, FCAP  Associate Professor of Pathology, Director of Head and Neck Pathology, Department of Pathology, University of Colorado, Denver

M Sherif Said, MD, PhD, FCAP is a member of the following medical societies: American Society for Clinical Pathology and College of American Pathologists

Disclosure: Nothing to disclose.

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Stephen D Hess, MD, PhD, Glenn Goldman, MD, Debjani Sahni, MBBS, MRCP, Laurence M Baibak, MD, FACS, and Charles W Vaughan, MD, FACS, to the development and writing of the source articles.

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Large, sun-induced squamous cell carcinoma on the forehead/temple with superficial erosion. Image courtesy of Glenn Goldman, MD.
Preauricular and helical scars (black arrows) from previous excisions are noted in a patient who presented with cervical metastases (white arrow) from an occult cutaneous squamous cell carcinoma (cSCC).
Contrast-enhanced, axial computed tomography (CT) scan of a patient with soft-tissue invasion of the right parotid gland (arrow) by an ulcerative cutaneous squamous cell carcinoma (cSCC).
Large, neglected cutaneous squamous cell carcinoma (cSCC) of the right ear that requires wide local excision via auriculectomy and reconstruction. The risk of lymph node metastasis with this deeply ulcerative tumor is sufficient enough to warrant elective neck dissection.
Squamous cell carcinoma in situ (Bowen disease). Courtesy of Hon Pak, MD.
cell carcinoma of the penis. Courtesy of Hon Pak, MD.
Extensive conjunctival squamous cell carcinoma of the left eye. The patient has limbal and corneal involvement temporally, as well as scleral invasion with intraocular spread. A malignant cellular reaction in the anterior chamber was present. The patient was treated with a lid-sparing exenteration.
A 35-year-old man who is positive with human immunodeficiency virus (HIV) infection presented with a 2-year history of a slowly enlarging, left lower eyelid lesion; incisional biopsy revealed squamous cell carcinoma.
Axial magnetic resonance image (MRI) of a large squamous cell carcinoma of the left lower eyelid with invasion of the anterior orbit.
External photograph of a large, ulcerated, invasive squamous cell carcinoma of the left lower eyelid. This patient also had perineural invasion of the infraorbital nerve extending into the cranial base.
Progressively severe atypia. The epithelium to the left is close to normal, but the epithelium to the right shows full-thickness atypia (ie, carcinoma in situ). This image illustrates carcinogenesis, the process whereby the cells exposed to a carcinogen become cancerous over time.
Squamous cell carcinoma. The lesion closely approximates the specimen in the previous image. Field cancerization is illustrated; that is, if >1 cell is exposed to a carcinogen, >1 cell becomes cancerous. Note the marked inflammatory-cell response. Should limited biopsy reveal only severe atypia with a severe inflammatory response, the lesion should be investigated further. A cancer is likely nearby.
Squamous cell carcinoma with spindle cell elements illustrates the totipotential nature of epithelial-cell malignancies.
Carcinoma in situ. Full-thickness atypia is clinically observed as a red-velvet patch (erythroplasia) and stains strongly with supravital stain, such as toluidine blue O.
Microinvasion and cellular atypia are observed deep to the expected junction between the epithelium and the stroma. Pink material (basement membrane) is evident around the clumps of malignant cells in the stroma. Surface keratin is present. On clinical evaluation, this lesion would have been observed as a white patch that does not rub off.
Invasion with normal surface. The top 4-5 cell layers are without atypia and mucosal surface changes. Toluidine blue O would not reveal the underlying cancer.
Specimen on a carrier. Vocal-fold epithelium has been stained with toluidine blue O, and all suspected tissue is excised (excisional biopsy). The specimen has been unfolded and laid flat onto a slice of cucumber. The specimen and cucumber are then flooded with fixative (10% formalin) and together serially sectioned for histologic evaluation.
This excisional biopsy specimen is well prepared for evaluation. The amorphous material deep to the specimen is the cucumber carrier. The specimen has been serially sectioned with alignment perpendicular to the surface to make evaluation of the entire specimen easy and reliable.
Fine-needle aspirate from a neck node. Clumps of cells obtained by means of fine-needle aspiration by using a 20-gauge needle and strong negative suction allow for histologic and cytologic evaluation. Sampling error is possible, particularly with small lesions.
This image depicts reddening of the soft palate, perhaps with scattered areas of white and velvet red patches; tobacco-induced squamous cell carcinoma involving the tongue base and/or supraglottis; and a firm, mobile mass that is palpable at the left carotid bifurcation.
This image shows scattered red and white patches, some of which are thick, with inflammation of the underlying mucosa.
Squamous cell carcinoma of the dorsal wrist. Courtesy of Hon Pak, MD.
Table 1. Estimated Number of New Cancer Cases and Deaths in Both Sexes in the United States in 2004
Cancer New Cases Deaths
Oral cavity and pharynx28,2607230
Tongue73201700
Mouth10,0801890
Pharynx82502070
Other oral cavity21601570
Larynx10,2703830
Source: American Cancer Society, 2004.[46]



Note: The US Census Bureau estimated that the US population was approximately 282,000,000.



Table 2. TNM Stage Grouping
Stage Primary Tumor Regional Lymph Nodes Distant Metastasis
Stage 0TisN0M0
Stage IT1N0M0
Stage IIT2N0M0
Stage IIIT3N0M0
T1, T2, T3N1M0
Stage IVT4N0, N1M0
Any TN2, N3M0
Any TAny NM1
Table 3. Histologic and Clinical Features of Squamous Cell Carcinoma (SCC) Variants
Tumor Histologic Characteristics Clinical Characteristics
KeratoacanthomaKeratin-filled crater



Well-differentiated (mild atypia)



Neutrophil microabscesses



Eosinophils in dermal infiltrate



Elastic tissue trapping



Lack of acantholysis



Solitary nodule



Central craterlike depression



Rapid growth



May spontaneously involute



Spindle cell carcinomaAtypical spindle cells



Foci of squamous differentiation



May resemble other spindle cell tumors (eg, atypical fibroxanthoma)



Resembles typical SCC



May be clinically aggressive



Acantholytic (adenoid) SCCGlandlike differentiation



Acantholysis



May resemble adenocarcinoma or sweat gland carcinoma



Arises on sun-damaged skin



Elderly patients



Resembles typical SCC



Clinically aggressive



Verrucous carcinomaWell-differentiated (glassy atypia)



Surface resembles verruca



Bulbous downward proliferation



"Bulldozing" invasion



Oral, genital, or plantar foot



Indolent growth



Locally destructive



Rarely metastasizes



Sarcomatoid SCCPoorly differentiated cells resembling sarcomaClinical appearance may be that of typical SCC or may have more nodular appearance with less surface change



Elevated risk of local recurrence and metastasis



Table 4. Summary of Characteristics of Papillary Epithelial Lesions and Verrucous Carcinoma
Tumor Epithelium Invasion and Inflammation
Benign squamous papillomaMinimal to no epithelial atypia without any stromal invasionNo inflammation in stroma; no epithelial cells, nests, or broad fronts in stroma
Papillary SCCISFull-thickness epithelial atypia without invasionNo invasive epithelial component in stroma; minimal inflammatory reaction
Papillary SCC, invasiveEpithelial atypia, which may or may not be full thickness, overlying stromal invasion; invasion occurs by means of elongated, stabbing fronts, small nests or individual cells Pointed, narrow epithelium extending into stroma, with epithelial nests and/or individual cells surrounded by inflammatory cells, which may be eosinophils, neutrophils, macrophages, plasma cells, and/or lymphocytes in any combination
Verrucous carcinomaBland, highly keratinized, squamous epithelium, with invasion in broad, rounded, pushing frontsNo individual cells or squamous nests in stroma; advanced portion of the epithelial pushing front surrounded by tightly hugging infiltrate of mononuclear inflammatory cells
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