Sir,

Basal cell carcinoma (BCC) account for 77% of all skin cancers. Giant basal cell carcinom (GBCC) is a clinical variant of basal cell carcinoma, and it represents between 0.5% and 1% of cases [1]. It is characterized by a diameter of ≥5 cm, and differs from the classic CBC by its aggressive behavior with invasion to deep tissues, infiltration of bone structures, muscle, or cartilage, and the development of metastasis; and frequently carries a poor prognosis.these lesions are attributable to patient neglect and loss to follow-up. The American Joint Cancer Committee classifies GBCCs as T3 tumors [2].

Here, we report two cases of GBCC which resulted secondary to neglect.

Case 1: A 70-year old patient, with no notable pathological history, was referred to our Institute with an ulcerating tumor of the upper lip that has been evolving for at least 12 years. the physical examination has shown a wide ulcerated lesion measuring 10x6cm, with Multiple small pigmented nodules along the margin (Fig. 1). Dermoscopic features include: arborizing vessels, blue–grey ovoid nests and ulceration. A punch biopsy confirmed the diagnosis of BCCThe patient was referred to oncology, where he was treated for a stage 3 nonresectable tumor.

Figure 1: Ulcerating tumor of the upper lip.

Case 2: A 63-year-old patient presented with a an invasive, non-healing ulcerative lesion, located on the scalp; The lesion had been present for many years, during which time it had progressively increased in size.Physical examination revealed a 6×8 cm, well-defined, round black-colored patch on the frontal scalp (Fig. 2). Regional lymph nodes were not palpable. The dermoscopic findings include arborizing vessels, large blue–grey ovoid nests, multiple blue–grey dots, globules and ulceration (Fig. 2b). A punch biopsy of the lesion confirmed the diagnosis of a nodular BCC. The patient underwent an extensive excision for the tumor.

Figure 2: (a) Well-defined, round black-colored patch on the frontal scalp. (b) Arborizing vessels, large blue–grey ovoid nests, multiple blue–grey dots, globules and ulceration.

Basal Cell Carcinoma (BCC) is the most common non-melanoma malignant skin tumor. its incidence is increasing in the world. BCCs are generally slow growing with a low risk for metastasis. in rare cases, the tumor increases in size to more than 5 cm with local invasion and invasion of surrounding organs. metatstases are common and the prognosis is poor. The American Joint Committee on Cancer (AJCC) defines giant basal cell carcinoma (GBCC) as a tumor that is larger than 5 cm. By the TNM classification, these tumors are characterized as T3.

The causes are not totally elucidated, in addition to the negligence that represents the main cause, unfavourable socio-economic status, physical or psychiatric disability that hinders access to care are also incriminated [3]. Some common epidemiological factors that include race, multiplicity of tumors, development on sun-covered areas are also present. Immunodeficiency and genetic predisposition to BCC in other family members are not consistent factors [4].

Histopathological subtypes of BCC can be grouped as nonaggressive (nodular and superficial subtypes) and aggressive (morpheaform, micronodular and metatypical subtypes) [5].

The size of these tumors is mostly related to their duration of evolution rather than to an abnormally rapid growth. metastases are rare and occur in the lymph nodes but also by lymphatic route to distant organs and bone.

Various therapeutic modalities have been used for the treatment of GBCC with inconsistent results. Treatments include surgical excision, Mohs micrographic surgery, or radiation therapy. Similarly, imiquimod has been shown to be effective in the treatment of superficial and nodular BCCs [6].

This report presents two cases of Gianat Basal Cell Carcinoma fostered by patient neglect. Which may result from lack of general awareness due to educational limitations.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.

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