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Slow progression and sequential documentation of a giant basal cell carcinoma of the face
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Slow progression and sequential documentation of a giant basal cell carcinoma of the face John E. Sherman, MD, and Mia Talmor, MD, New York, NY
From the Department of Surgery and the Division of Plastic Surgery, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, NY
74-YEAR -OLD MAN came to the Emergency Department for evaluation of a massive lesion encompassing the nose, the left side of the face, the upper lip, and conjunctiva of the left lower eyelid. His complaints at that time included loss of vision in the left eye and pain of the left side of the face. The patient reported that the lesion had been present for many years. It was his practice to make a yearly visit to the local Woolworth store to take a photo of himself in the photographic booth. On review of a photograph taken 27 years before admission, a lesion suggestive of early basal cell carcinoma (BCC) could be identified at the apex of the left nasolabial fold (Fig 1). Fifteen years later, the lesion was clearly visible at the left nasolabial fold and was approximately 1 to 2 cm in maximal diameter (Fig 2). Ten years after this, the lesion had approximately doubled in size (Fig 3). In the 5 years before his admission to the Emergency Department, the tumor had grown rapidly, invading local structures of his left hemiface (Fig 4). On admission, the patient could only perceive light in his left eye. A CT scan was obtained, which revealed a large mass beginning from the soft tis-
A
Fig 1. A photograph taken by the patient in a photography booth 27 years before admission. There is possibly the suggestion of a lesion at the apex of the left nasolabial fold.
Accepted for publication September 10, 2000. Reprint requests: John Sherman, MD, 1016 Park Ave, New York, NY 10028. Surgery 2001;130:90-2. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/60/111705 doi:10.1067/msy.2001.111705
90 SURGERY
sue of the maxillary region; invading the left maxillary sinus, ethmoidal sinus, sphenoidal sinus, orbital and extraocular muscles; and impinging on the left optic nerve. Destruction of the bony maxilla and left pterygoid plate could also be appreciated. An incisional biopsy was performed, which
Surgery Volume 130, Number 1
Fig 2. Similar photograph taken by the patient 12 years before admission. Here it is easy to appreciate the presence of an early lesion in the left nasolabial fold.
Sherman and Talmor 91
Fig 3. Photograph taken by the patient 5 years before admission. The lesion had clearly doubled in size when compared with the photograph of 7 years earlier.
Fig 4. Appearance of the patient on admission to the Emergency Department. The giant basal cell tumor encompassed the entire left face, including the left orbit, nose, upper lip, and maxillary sinus.
revealed BCC. A complete blood cell count drawn on admission was remarkable for a hematocrit of 33.2 with hypochromic microcytic indexes. All other laboratory tests were normal. A metastatic work-up, including a bone scan, was negative. Surgical excision and radiation were planned. The patient refused to consent to a surgical proce-
dure and signed out of the hospital against medical advice. After many attempts to have the patient return for treatment, he was lost to follow-up, and presumably died of his disease. DISCUSSION “Doc, what would happen if I do nothing at all?”
92 Sherman and Talmor
How often does the surgeon hear that question in relation to the treatment of skin cancer? This case graphically depicts the importance of prompt surgical therapy for BCC. BCCs are the most commonly diagnosed skin cancer. First described in 18271 as a rodent ulcer, these lesions arise from the pluripotential epithelial cells of the epidermis and hair follicles. BCC are locally invasive, but rarely metastasize. While the cell cycle of a BCC is about 9 days, these tumors grow slowly, taking years to reach a large size.2 This apparent discrepancy is explained by the fact that only the outer layer of cells of a tumor nodule is actively dividing, which underscores the importance of adequate excision of peripheral BCC extensions. BCCs can be classified according to diameter as small (< 2 cm, T1), intermediate (2-5 cm, T2), or giant (> 5 cm, T3). Giant BCCs have a greater propensity to metastasize, particularly after they reach a critical size of 10 cm.3 Characteristics that are more common in giant BCCs than in smaller lesions are duration, patient neglect, recurrence after previous treatment, aggressive histologic pattern, and history of radiation exposure.3 While
Surgery July 2001
giant BCCs have been reported with some frequency in the literature, they have only rarely been reported on the face. This is likely because tumors of the face are obvious to the patient, and large tumors impinge upon critical structures early, so that patient neglect is far less likely than in a tumor arising in a more concealed region. Those cases that have been reported are usually among patients with a poor socioeconomic status or physical or psychiatric disability that impedes judgment or access to health care. The latter was probably relevant in the case of our patient, though by strict criteria, the patient was found by our consulting psychiatrist to be competent to consent (or refuse consent) for his own medical care.
REFERENCES 1. Jacob A. Observations respecting an ulcer of peculiar character which attacks the eyelids and other parts of the face. Dublin Hospital Report 1827;4:231. 2. Weinstein GD, Frost P. Cell proliferation in human basal cell carcinoma. Cancer Res 1970;30:724-8. 3. Randle HW, Roenigk RK, Brodland DG. Giant basal cell carcinoma (T3). Who is at risk? Cancer 1993;72:1624-30.
Slow progression and sequential documentation of a giant basal cell carcinoma of the face John E. Sherman, MD, and Mia Talmor, MD, New York, NY
From the Department of Surgery and the Division of Plastic Surgery, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, NY
74-YEAR -OLD MAN came to the Emergency Department for evaluation of a massive lesion encompassing the nose, the left side of the face, the upper lip, and conjunctiva of the left lower eyelid. His complaints at that time included loss of vision in the left eye and pain of the left side of the face. The patient reported that the lesion had been present for many years. It was his practice to make a yearly visit to the local Woolworth store to take a photo of himself in the photographic booth. On review of a photograph taken 27 years before admission, a lesion suggestive of early basal cell carcinoma (BCC) could be identified at the apex of the left nasolabial fold (Fig 1). Fifteen years later, the lesion was clearly visible at the left nasolabial fold and was approximately 1 to 2 cm in maximal diameter (Fig 2). Ten years after this, the lesion had approximately doubled in size (Fig 3). In the 5 years before his admission to the Emergency Department, the tumor had grown rapidly, invading local structures of his left hemiface (Fig 4). On admission, the patient could only perceive light in his left eye. A CT scan was obtained, which revealed a large mass beginning from the soft tis-
A
Fig 1. A photograph taken by the patient in a photography booth 27 years before admission. There is possibly the suggestion of a lesion at the apex of the left nasolabial fold.
Accepted for publication September 10, 2000. Reprint requests: John Sherman, MD, 1016 Park Ave, New York, NY 10028. Surgery 2001;130:90-2. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/60/111705 doi:10.1067/msy.2001.111705
90 SURGERY
sue of the maxillary region; invading the left maxillary sinus, ethmoidal sinus, sphenoidal sinus, orbital and extraocular muscles; and impinging on the left optic nerve. Destruction of the bony maxilla and left pterygoid plate could also be appreciated. An incisional biopsy was performed, which
Surgery Volume 130, Number 1
Fig 2. Similar photograph taken by the patient 12 years before admission. Here it is easy to appreciate the presence of an early lesion in the left nasolabial fold.
Sherman and Talmor 91
Fig 3. Photograph taken by the patient 5 years before admission. The lesion had clearly doubled in size when compared with the photograph of 7 years earlier.
Fig 4. Appearance of the patient on admission to the Emergency Department. The giant basal cell tumor encompassed the entire left face, including the left orbit, nose, upper lip, and maxillary sinus.
revealed BCC. A complete blood cell count drawn on admission was remarkable for a hematocrit of 33.2 with hypochromic microcytic indexes. All other laboratory tests were normal. A metastatic work-up, including a bone scan, was negative. Surgical excision and radiation were planned. The patient refused to consent to a surgical proce-
dure and signed out of the hospital against medical advice. After many attempts to have the patient return for treatment, he was lost to follow-up, and presumably died of his disease. DISCUSSION “Doc, what would happen if I do nothing at all?”
92 Sherman and Talmor
How often does the surgeon hear that question in relation to the treatment of skin cancer? This case graphically depicts the importance of prompt surgical therapy for BCC. BCCs are the most commonly diagnosed skin cancer. First described in 18271 as a rodent ulcer, these lesions arise from the pluripotential epithelial cells of the epidermis and hair follicles. BCC are locally invasive, but rarely metastasize. While the cell cycle of a BCC is about 9 days, these tumors grow slowly, taking years to reach a large size.2 This apparent discrepancy is explained by the fact that only the outer layer of cells of a tumor nodule is actively dividing, which underscores the importance of adequate excision of peripheral BCC extensions. BCCs can be classified according to diameter as small (< 2 cm, T1), intermediate (2-5 cm, T2), or giant (> 5 cm, T3). Giant BCCs have a greater propensity to metastasize, particularly after they reach a critical size of 10 cm.3 Characteristics that are more common in giant BCCs than in smaller lesions are duration, patient neglect, recurrence after previous treatment, aggressive histologic pattern, and history of radiation exposure.3 While
Surgery July 2001
giant BCCs have been reported with some frequency in the literature, they have only rarely been reported on the face. This is likely because tumors of the face are obvious to the patient, and large tumors impinge upon critical structures early, so that patient neglect is far less likely than in a tumor arising in a more concealed region. Those cases that have been reported are usually among patients with a poor socioeconomic status or physical or psychiatric disability that impedes judgment or access to health care. The latter was probably relevant in the case of our patient, though by strict criteria, the patient was found by our consulting psychiatrist to be competent to consent (or refuse consent) for his own medical care.
REFERENCES 1. Jacob A. Observations respecting an ulcer of peculiar character which attacks the eyelids and other parts of the face. Dublin Hospital Report 1827;4:231. 2. Weinstein GD, Frost P. Cell proliferation in human basal cell carcinoma. Cancer Res 1970;30:724-8. 3. Randle HW, Roenigk RK, Brodland DG. Giant basal cell carcinoma (T3). Who is at risk? Cancer 1993;72:1624-30.