Giant basal cell carcinoma (GBCC) is defined as a tumor 5cm or greater in diameter. They present less than 1% of all basal cell carcinomas. We present a case of an 85-year-old male patient with a giant ulcerating tumor of the left forehead (measuring 7x6cm). Under local anesthesia tumor was surgically excised. No involvement of the underlying periostal or bone structure was noted. Pathohystological exam revealed the giant basal cell carcinoma, with free surgical margins. Giant basal cell carcinomas are rare tumors and are usually result of a long duration and patient neglect. In comparison to the ordinary basal cell carcinoma these tumors have a higher metastatic potential. Surgical resection with negative surgical margin is the best possible treatment option

Marijan Kovačić

Milan Rudić

Nataša Lisica-Šikić

Zoran Kranjčec

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Coll. Antropol. 36 (2012) 1: 317–319Case reportGiant Basal Cell Carcinoma of the Forehead:A Case ReportMilan Rudi}1, Zoran Kranj~ec1, Nata{a Lisica-[iki}2 and Marijan Kova~i}11 Zadar General Hospital, Department of Otorhinolaryngology and Head and Neck Surgery, Zadar, Croatia2 Zadar General Hospital, Department of Pathology and Forensic Medicine, Zadar, CroatiaA B S T R A C TGiant basal cell carcinoma (GBCC) is defined as a tumor 5cm or greater in diameter. They present less than 1% of allbasal cell carcinomas. We present a case of an 85-year-old male patient with a giant ulcerating tumor of the left forehead(measuring 7x6cm). Under local anesthesia tumor was surgically excised. No involvement of the underlying periostal orbone structure was noted. Pathohystological exam revealed the giant basal cell carcinoma, with free surgical margins.Giant basal cell carcinomas are rare tumors and are usually result of a long duration and patient neglect. In comparisonto the ordinary basal cell carcinoma these tumors have a higher metastatic potential. Surgical resection with negativesurgical margin is the best possible treatment option.Key words: giant, basal cell carcinoma, surgeryIntroductionBasal cell carcinoma (BCC) is the most common ma-lignant skin tumor1,2. It usually appears as painless, nohealing ulcer or nodule on the sun-exposed parts of thebody. Sun exposure is the primary etiologic agent for thedevelopment of the basal cell carcinoma. Risk is relatedto skin type and the degree of exposure to sunlight, par-ticularly UV-B radiation1. In addition to environmentalfactors, host factors (e.g. genetic syndromes and immu-nologic factors) play a critical role in the pathogenesis ofbasal cell carcinoma. It has a particular predilection forthe upper two thirds of the face2. Basal cell carcinoma isusually slow growing tumor, with incidence ofmetastases less than 0.1%2. Four different clinico-patho-logic types of basal cell carcinoma exist, each with dis-tinct biologic behavior: undifferentiated, nodular or nod-ular-ulcerative (more than 60% of all basal cellcarcinoma), superficial and morpheaform or sclerosingbasal cell carcinoma3. Giant basal cell carcinoma (GBCC)is defined as a tumor 5 cm or greater in diameter. Theyare very rare and present less than 1% of all basal celltumors2,4,5. Although the predilection site is also headand neck region, some studies report other location (ex-tremities, trunk)2,6–8. Giant basal cell carcinoma hasbeen associated with higher incidence of metastases2–4.They are usually result of a long duration, patient ne-glect and denial. With time they tend to ulcerate, with ar-eas of necrosis and hemorrhage causing severe medicalproblem to the patient. We present a case of an85-year-old-male patient that has been admitted to theEar Nose and Throat Department due to a large tumormass of the left forehead region. We describe its clinicalcourse, treatment and final outcome.Case ReportAn 85-year-old male patient has been admitted to theEar Nose and Throat Department due to a giant ulcerat-ing tumor of the left forehead. Over several years prior toadmittance the tumor has been slowly growing, with noother symptoms. Several weeks prior to admittance tu-mor became partially ulcerated with areas of hemor-rhage and necrosis. Patient’s medical history revealed apoor physical condition with a severe cardiovascular andneurological deficit. Physical finding included a giant ul-cerating tumor of the left forehead measuring 7x6cm indiameter (Figures 1a–c). It was tightly attached to thesurface. No vital structures have been affected. Therewas no clinical tumor lymph node involvement or distantmetastases present. Due to a poor physical condition of317Received for publication November 23, 2009the patient he was not a suitable candidate for a surgicalprocedure under the general anesthesia, thus we decidedto remove the tumor under the local anesthesia. Tumorwas surgically radically excised. No involvement of theunderlying periostal or bone structure was noted (Figure1d). The defect was closed using the free tissue transfer(Thiersch skin graft) from the left forearm (Figure 2).Postoperative period was uneventful. Pathohistologicalanalysis revealed an ulcerated tumor mass measuring7x6x3cm. Tumor consisted of solid infiltrative, epithelialbasal cells with palisade formation (Figure 3). Infiltra-tion of the dermis was 1.2cm. Surgical margins were freeof any tumor tissue. Final diagnosis was giant basal cellcarcinoma. One year following the surgery the patient isfree of recurrent disease and the defect site is cosmetic-ally acceptable.DiscussionGiant basal cell cancers are rare tumors. Risk factorsassociated with giant basal cell carcinomas are length oftime to presentation, patient neglect, previous treatmentand an aggressive histological type9–13. In the presentcase the tumor was slowly growing over the years and pa-tient requested medical attention at the time when tu-mor became ulcerated with areas of hemorrhage and ne-crosis, and has become a serious medical problem. Thepredominant region for these tumors is head and neck2,9.When compared to ordinary basal cell carcinomas thesetumors have an increased metastasis potential2. In thepresent case the tumor was located on the left foreheadregion. There was no local lymph node involvement orany sign of metastases. When metastases are presentsurvival is significantly decreased. Metastasis developsin 38.3% of patients despite optimal therapy14. The over-all optimal cure rate is 61.7%14. Risk of recurrence is di-rectly related to the initial tumor size. Radiation therapyhas been suggested as an alternative to surgical treat-ment, especially for patient that are not candidates forprolonged anesthesia15. In the present case the patientwas not a suitable candidate for a general anesthesia dueto a poor general medical condition. Giving the nature ofthe tumor that did not include any vital structure andthat there was no metastases or local lymph node in-volvement present, we decided to surgically remove thetumor under local anesthesia, which was very well toler-ated by the patient. Reconstructive option for this type oftumor depends on the extent of the disease. It has to bedone with careful consideration for the surroundingstructures (e.g. eye-structures and hairline). The possi-ble reconstructive options include the use of local flaps(e.g. lateral forehead or Esser cheek rotation flap)15, freeflaps and tissue expansion. In our case after the tumorhas been removed and there was no involvement of thedeeper structures and with the respect for the poor gen-eral patient’s condition we decided to close the defectwith the split-thickness skin graft (Thiersch) taken fromthe left forearm. Postoperative period was uneventfuland this procedure gave a suitable postoperative cos-metic result.M. Rudi} et al.: Giant Basal Cell Carcinoma, Coll. Antropol. 36 (2012) 1: 317–319318Fig. 1a–b. Forehead skin tumor with areas of hemorrhage andnecrosis; 1c. Tumor after excision measuring 7x6 cm in diame-ter; 1d. No visible periostal tumor involvement.Fig. 2. Defect reconstruction with the split-thickness skin-graft(Thiersch).Fig. 3. Patohistological analysis of the tumor, hemalaun-eosinstaining x4.ConclusionGiant basal cell carcinomas are rare tumors and areusually result of a long duration and patient neglect.Compared to the ordinary basal cell carcinoma they havea higher metastatic potential. Surgical resection withnegative surgical margin is the best possible treatmentoption. Regular follow up is mandatory.R E F E R E N C E S1. American Cancer Society. Detailed guide: skin cancer: nonmelano-ma: Accessed 15.01.2012. Available from: URL: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=51. — 2. LACKEY LP, SARGENT LA,WONG L, BRZEZIENSKI M, KENNEDY JW, Ann Plast Surg, 58 (2007)250. — 3. RUBIN AI, CHEN EH, RATNER D, N Eng J Med, 353 (2005)2262. — 4. RANDLE HW, ROENIGK RK, BRODLAND DG, Cancer, 72(1993) 1624. — 5. MANSTEIN CH, GOTTLIEB N, MANSTEIN ME,BEIDAS OE, Plast Reconstr Surg, 128 (2011) 1105. — 6. SASH WJ,SNOW SN, LEVINE NS, J Am Acad Dermatol, 30 (1994) 856. — 7.LORENZINI M, GATTI S, GIANNITRAPANI A, Br J Plast Surg, 58(2005) 1007. — 8. BOGDANI] B, SMU\ S, BAGATIN D, NOLA M,MIJATOVI] D, MAJEROVI] M, Coll Antropol, 1 (2009) 315. — 9.FATTAH A, POLLOCK J, MAHESHMUR A, BRITTO JA, J Plast Recon-str Surg, 63 (2010) 433. — 10. NAMBI GI, GUPTA AK, KOSHY S,KUMARAN S, J Plast Reconstr Surg, 61 (2008) 1248. — 11. ASLAN G,KARGI E, GORGU M, ERDOGAN B, Ann Plast Surg, 44 (2000) 574. —12. NEUMANN IC, CORDES SR, Ann Otol Rhino Laryngol, 116 (2007)663. — 13. KOKAVEC R, FEDELES J, Acta Chir Plast, 46 (2004) 67. —14. ARCHONTAKI M, STAVRIANOS SD, KORKOLIS DP, ARNOGIAN-NAKI N, VASSILIADS V, LIAPAKIS IE, CHRIST H, RAPIDIS AD, KOK-KALIS G, Anticancer Res, 29 (2009) 2655. — 15. FRESINI A, ROSSIEL-LO L, SEVERINO BU, DEL PRETE M, SATRIANO RA, Skinmed, 6(2007) 204. — 16. WEERDA H, Reconstructive Facial Plastic Surgery – AProblem-Solving Manual (Thieme Medical, New York, 1981).M. Rudi}Department of Otorhinolaryngology, General Hospital Zadar, B. Peri~i}a 5, 23000 Zadar, Croatiae-mail: milan.rudicºyahoo.comGIGANTSKI BAZOCELULARNI KARCINOM ^ELA – PRIKAZ SLU^AJAS A @ E T A KGigantski bazocelularni karcinom ko`e definira se kao tumor ko`e ve}i od 5 cm. Ovi tumori predstavljaju svega 1%od svih bazocelularnih karcinoma ko`e. U radu prikazujemo slu~aj 85 godi{njeg bolesnika s velikom, ulcerativnom,tumorskom tvorbom ko`e ~ela (veli~ine 7x6 cm). Tumor je uklonjen u lokalnoj anesteziji. Nije uo~eno {irenje tumora uokolno tkivo. Patohistolo{ka analiza pokazala je da se radi o gigantskom bazocelularnom karcinomu ko`e. Gigantskibazocelularni karcinomi ko`e izuzetno su rijetki tumori i naj~e{}e su rezultat vi{egodi{njega rasta i nebrige bolesnika.U odnosu na obi~ni bazocelulurani karcinom ko`e, imaju ve}i metastatski potencijal. Radikalna kirur{ka ekscizija pred-stavlja najbolji terapeutski postupak.M. Rudi} et al.: Giant Basal Cell Carcinoma, Coll. Antropol. 36 (2012) 1: 317–319319

Giant Basal Cell Carcinoma of the Forehead: A Case Report

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