Abstract
Introduction and importance
The predominant variant of skin cancer is Basal cell carcinoma (BCC), constituting about 80 % of all non-melanoma skin cancers on a global scale. Typically, it manifests on skin surfaces that are frequently exposed to sunlight, such as the neck, face, and ears.
Case presentation
A 65-year-old man presented to a specialized cancer hospital with a large pigmented lesion on the left cheek that had gradually increased in size for about a year. The tumor had become raised and ulcerated, which necessitated deep surgery on his face due to extensive invasion of BCC was done.
Clinical discussion
Basal cell carcinoma is a slow-growing, locally invasive cancerous tumor of the basal cells of the skin, which line the deepest layer of the epidermis. BCC often occurs on areas of the body that are exposed to the sun. It develops in response to cumulative UV irradiation and sporadic UV irradiation, as occurs with sunburns.
Conclusion
BCC is a common and potentially devastating skin cancer that primarily affects fair-skinned people over the age of 50. Lesions on the face can be particularly challenging. Early detection and treatment is critical to minimize the need for extensive excision and reconstruction.
Keywords: Basal cell carcinoma, Head and neck, Surgery, Tumor, Case report
Highlights
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Basal cell carcinoma (BCC) is the most common type of skin cancer.
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BCC primarily affects fair-skinned individuals over the age of 50.
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The most common sites of BCC on the face include the nose, forehead, cheeks.
1. Introduction
The most prevalent form of skin malignancy in the United States is Basal cell carcinoma (BCC), accounting for approximately 80 % of nonmelanoma skin cancers. It primarily affects individuals over the age of 50 with fair skin who have had prolonged exposure to ultraviolet (UV) radiation, typically from sunlight (1). BCC commonly appears on areas of the skin that are frequently exposed to the sun, such as the face, neck, head, and arms. While BCCs usually exhibit slow growth and rarely metastasize, they can locally invade and cause significant damage, necessitating extensive facial surgery in severe cases (2).
The face is particularly vulnerable to BCC due to its constant exposure to sunlight. The most commonly affected facial sites include the nose, forehead, cheeks, and periocular region (3). As a result, facial BCCs can have both physical and psychological consequences for patients. Visible lesions can lead to social anxiety, depression, and cosmetic disfigurement, especially when excision is required. The reconstruction process following excision can be challenging, particularly if the cancer has deeply penetrated the skin, bone, or surrounding tissues (4).
Early diagnosis and treatment of BCC are crucial in order to minimize the extent of excision and subsequent reconstruction. Dermatologists and other healthcare professionals employ various diagnostic methods, such as clinical examination, dermoscopy, and biopsy, to identify and assess BCCs (5). Treatment options range from surgical excision and curettage to radiation therapy and Mohs micrographic surgery, depending on the location and severity of the cancer (6).
Academically, BCC represents a significant area of research. Scientists are investigating the genetic and molecular mechanisms involved in the development and progression of BCC, as well as developing new diagnostic and treatment modalities. Recent advancements in imaging, dermatopathology, and immunotherapy hold promise for enhancing treatment outcomes and reducing the cosmetic and functional impact of BCC on the face (7). This study adheres to the SCARE 2020 Criteria (8), and it has received approval from the Ethics Committee of the relevant University of Medical Sciences (Ethics No. REC.1402.808).
2. Case presentation
A 65-year-old male presented to our specialized cancer hospital with a large pigmented lesion on his left cheek. The lesion had gradually increased in size over the course of one year, becoming raised, ulcerated, and occasionally accompanied by bleeding and itching. The patient reported no constitutional symptoms or significant medical history. Upon examination, a firm, raised, and ulcerated pigmented lesion measuring 5 cm in diameter was observed on the left cheek. The surrounding skin appeared erythematous and indurated, with no palpable regional lymphadenopathy.
The patient underwent a punch biopsy of the lesion, which revealed infiltrative basal cell carcinoma with deep invasion into the dermis. Histological evaluation of the excised tissue confirmed a moderate to poorly differentiated nodular basal cell carcinoma (Fig. 1), with the tumor invading the surrounding skin, subcutaneous tissue, and left orbit. Consequently, referral to a surgical oncologist for further management was necessary.
Fig. 1.
Histological examination of the malignant site.
The surgical oncologist conducted a comprehensive evaluation of the patient and performed an MRI, revealing infiltration of the basal cell carcinoma into the skin, subcutaneous tissue, and left orbit, accompanied by orbital destruction. Considering the urgency and the lack of time for radiotherapy or chemotherapy, the surgical team recommended complete resection of the lesion. With consent obtained, wide excision of the BCC was successfully performed, involving deep tissue excision of the left eye and cheek (Fig. 2). Unfortunately, due to unavailability of specialists in the local area and financial constraints, reconstructive surgery could not be carried out. The patient experienced an uneventful recovery postoperatively and was discharged for outpatient follow-up. Tragically, the patient succumbed to extensive infection caused by septicemia.
Fig. 2.
Deep excision of eye and cheek which has been conducted by surgeon.
3. Discussion
Cancers occurring in the head and face regions pose particular challenges due to the complex anatomy and delicate structures involved (9). These cancers can arise from various tissues, including the skin, oral cavity, nasal cavity, paranasal sinuses, salivary glands, and thyroid gland (10). The incidence of head and neck cancer varies worldwide, with certain risk factors, such as smoking, alcohol consumption, and human papillomavirus infection, being more prevalent in specific populations (11).
A kind of skin malignancy that arises from the basal layer of the skin is Basal cell carcinoma (BCC) which is distinguished as the most frequently diagnosed form of skin cancer. It is characterized by the uncontrolled growth of abnormal cells in the lowest layer of the skin, leading to the formation of slow-growing, non-painful, and non-metastatic tumors (12). However, when left untreated or misdiagnosed, BCC can invade adjacent tissues and organs, resulting in severe complications and necessitating aggressive interventions, including surgery (13).
Early detection and treatment of BCC have a high success rate, with treatment options ranging from Mohs surgery and topical chemotherapy to radiation therapy and topical immunotherapy. In advanced cases, more invasive treatments, such as complete surgical removal of the cancer and surrounding tissues, may be necessary (14).
In rare and severe instances, BCC can cause significant disfigurement, requiring the removal of entire facial regions, including the eye and cheek (15). This approach is typically the last resort after other treatment options have failed or when the cancer has been left untreated, resulting in rapid and extensive growth. Patients undergoing surgery of this nature undergo significant emotional and psychological stress as they navigate the challenges of adapting to their altered appearance and potential vision loss (16).
While the primary aim of BCC surgery is to eliminate all cancer cells, the cosmetic outcome is also of utmost importance, as it significantly influences the patient's quality of life. Collaborating with plastic surgeons and other healthcare professionals is crucial to achieve the best possible cosmetic outcome and provide emotional support to patients throughout their surgical journey. Additionally, the use of appropriate prostheses to cover the surgical area is vital, as it acts as a protective barrier against infection and the surrounding environment. Failure to do so significantly increases the risk of infection, which can ultimately be life-threatening for the patient.
4. Conclusion
Basal cell carcinoma (BCC) is a prevalent and potentially devastating form of skin cancer that may necessitate extensive excision and subsequent reconstruction. Early detection and treatment play a crucial role in minimizing the need for aggressive excision and reconstruction. Patient education regarding sun protection and regular skin examinations is vital in the timely detection and treatment of BCC. When BCC is diagnosed, treatment should be individualized, taking into account factors such as lesion size, location, depth, patient factors, and preferences.
Ethical approval
Ethical approval for this study was provided by the Ethics Committee of Urmia University of medical Sciences, West Azerbaijan, Iran on 10th May 2023. (Ethice No. REC.1402.808).
Funding
This CASE REPORT did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Author contribution
Sogand Esmaeili: study concept, laboratory and pathology examination, writing the paper.
Navid Faraji, Behnam Mostafaei: study concept, data collection, writing the paper, revising the comments of reviewers.
Soheila Bahrami, Sevda Shaddeli, Abdolhadi Ahmadi: writing the paper, reviewing and validating the manuscript's credibility.
Guarantor
Sogand Esmaeili
Research registration number
Not applicable.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor- in-chief of this journal on request.
Conflict of interest statement
None.
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