Neglected Basal Cell Carcinoma on Scalp

Abstract

Giant basal cell carcinoma (BCC) is a very rare entity. Usually, they occur due to the negligence of the patient. Local or distant metastasis is present in most cases. Here, we present a case of giant BCC that clinically resembled squamous cell carcinoma and demonstrated no metastasis at presentation.

Introduction

What was known?

• Giant basal cell carcinoma (BCC) is usually associated with metastasis

• Palisading is lost in infiltrative BCC.

Basal cell carcinoma (BCC) is a neoplastic proliferation of basaloid cells probably originating from basal cells of follicular origin. It may appear on any nonglabrous site though commonly seen on sun-exposed areas particularly face. Involvement of palm and sole is very rare except in nevoid BCC syndrome. Most BCCs are slowly progressing due to the apoptosis taking place in tumor cells. In very rare conditions (<0.5% of all diseases) tumor attains a size larger than 5 cm in diameter. This type is called giant BCC.[1,2]

Case Report

A 45-year-old smoker male presented to surgery outpatient department (OPD) of a Tertiary Care Hospital in Eastern Bihar with a large ulcer on the scalp. According to history, the lesion started as a papule 15 years back which was ulcerated eventually. The ulcer gradually and slowly increased to reach the present size 5 years back. After that it remained stationary. The patient denied any kind of treatment or medical attention prior attending to our OPD. On examination, the ulcer was located on the right frontoparietal region. It had a size of 14 cm × 10 cm. The ulcer was well marginated with focal hyperpigmentation of the border. The ulcer base was covered with nodular growth [Figure 1]. There was no significant regional lymphadenopathy. Considering the long duration and morphology a provisional diagnosis of squamous cell carcinoma was reached. An incisional biopsy was obtained from margin of the lesion under local anesthesia and sent for histopathology.

Figure 1.

Clinical photograph

Histopatholgy findings

Epidermis was edematous and necrosed at places with the formation of overlying crust [Figure 2]. The dermis was infiltrated with thin strands of basaloid cells interconnected with each other forming paisley tie appearance [Figure 3]. Peripheral palisading was maintained in most of the basaloid strands [Figure 4]. Tumor stroma was grossly sclerosed. In view of these findings, a diagnosis of an infiltrative variety of BCC with overlying ulceration was made. X-ray of the skull ruled out bony involvement [Figure 5]. Chest X-ray was also normal.

Figure 2.

H and E stain (scanner view)

Figure 3.

H and E stain (×10)

Figure 4.

H and E stain (×40)

Figure 5.

X-ray skull

Before we could plan for future treatment modality, the patient was lost to follow-up.

Discussion

BCC, a neoplastic proliferation of follicular basal cells, is a slow growing tumor. In <0.5% of all cases,[3] the tumor reaches a diameter larger than 5 cm and then is called giant BCC. In most of the giant basal cells carcinoma, the risk factors are a lack of awareness and a condition of self-negligence.[4,5] In more than 50% of the cases, there is a strong association with smoking.[6] Most of the giant BCC are locally or distally metastatic at the time of presentation.[1] Due to the late presentation and larger size many giants, BCC may not maintain the morphological characteristic of the original tumor and mimic squamous cell carcinoma.

In our case, the man presented with neglected giant BCC located on the right frontoparietal region. Though located in a visible area the person attended medical facility late owing to poverty and remoteness of his residence. He was a chronic smoker. The ulcer did not have the morphologic character of the BCC and mimicked squamous cell carcinoma. Histology confirmed the case as infiltrated BCC with ulceration but unlike infiltrated BCC where palisading of basaloid cells is mostly lost our case demonstrated significant palisading. There was also no demonstrable local or distant metastasis in our case, unlike most of the giant BCCs.

We present this case because rarity of giant BCC, semblance of our case clinically to squamous cell carcinoma, absence of local or distal metastasis at presentation and histological features of infiltrated BCC maintaining peripheral palisading of basaloid cells.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

• Absent local and distant metastasis in a giant basal cell carcinoma (BCC)

• Maintenance of palisading pattern in infiltrative BCC.