Page 108 - Journal of Special Operations Medicine - Spring 2014

greater than 5cm, it is classified as a GBCC. Various Giant Basal Cell Carcinoma
treatment options are discussed, to include surgery, but Most cases of BCC are identified early, but, due to ne-
due to the size of the plaque, electrodesiccation and cu- glect, recurrence, or absence of medical care, 0.5% to
rettage with subsequent treatment with imiquimod 5% 1% of BCCs reach measurements of 5cm in diameter or
®
topical cream (Aldara ) 5 times a week for 6 weeks was greater and are classified as GBCCs. 3,7,9 In a study of 51
chosen. The patient is provided hydroxyzine for symp- cases of GBCC, Archontaki et al. (2009) reported that
tomatic management of pruritis with plans to follow up the average length of time before diagnosis was 14.5
in 3 months. years with average diameter of 14.77cm, and the age
of eventual diagnosis with the highest incidence was in
7
the 60s. GBCCs were most likely to occur on the back,
Overview
face, and upper extremity at rates of 27.5%, 23.5%, and
Basal Cell Carinoma 13.7%, respectively. Of GBCCs, 0.03% to 0.5% me-
7

BCC is the most common of skin cancers and is often tastasize, typically to lymph nodes, bone, and lung. 3–5,9
described as a scaly plaque with pearly white borders Per report, approximately 45% of GBCCs that reach
and telangiectasias apparent on close examination or larger than 10cm and 100% of those that reach larger
dermoscopy. 1,3,4 BCC occurs in 23% to 28% of white than 25cm result in metastasis. This may result in sub-
3,7
females and 33% to 39% of white males, and these per- sequent death.
centages are increasing each year. 2,4,5 Defino et al. (2006)
reported on BCC cases between 1994 and 2003 and doc- Mollet et al. (2013) depicts a GBCC found in the late
umented an overall increase of 2.3% per year and, more stages after a 62-year-old man sought medical care after
specifically, of 5.4% per year for those younger than 35 10 years, when a “spider bite” was enlarging. On presen-
6
years ; additional literature supports a higher increase tation, the plaque on his back measured 19cm × 19cm and
of 3% to 10% each year. 2,4,5 Due to reported thinning had invaded and exposed vertebrae, with imaging studies
3
of the ozone layer in conjunction with different recre- concerning for metastases. The patient was placed on
ational and clothing patterns, as well as an increased life palliative care and died 18 months from the time of di-
span, humans are exposed to greater doses of ultraviolet agnosis. The reported average time from the diagnosis
3
5
(UV) rays than in previous centuries. Only 5% of cases of metastasis to death ranges from 8 to 14 months. 3,7,9
are reported to occur in those aged 40 and younger. 4 Archontaki et al. (2009) reported higher rates of 17.6%
for metastasis and 17% for mortality in their 51 cases re-
Males are also roughly twice as likely to have BCC as viewed. Even if death does not ensue, limb amputations
7
4,7
are females. It appears that males become more eas- may occur due to massive tissue destruction. 4
ily immunosuppressed with UV doses than do females,
suggesting that dose exposure due to occupation or
recreation alone may not fully explain higher rates of Treatment
skin cancer in males. Cytokines are also released and Basic clinical subtype classification of BCC includes
8
Langerhans cells are altered on UV penetration, both of nodular, superficial, fibroepithelial, cystic, morphea-
which may cause immunosuppression. In addition to form, infiltrated, and micronodular; the subtype will
5
UV damage affecting DNA via the p53 gene, Patched-1 determine what treatment modalities are effective. 1,2,9
gene, and sonic hedgehog pathway in the epidermal Often, GBCCs are of the nodular, micronodular, infil-
basal layer and adenexa, other associations are burns, trating, fibroepithelial, or morpheaform type, which
arsenic exposure, chronic trauma, immunosuppression, are considered more aggressive, thus necessitating wide
radiation, hereditary diseases, and light skin color. 1-3,5,8,9 margins of approximately 10mm during surgical exci-
sion, often with postoperative radiotherapy. 2,3,7,9 Recur-
Ultraviolet B (UVB) exposure is especially damaging to rence rates for BCC of greater than 3cm that are treated
the dermis, causing direct DNA changes, while UVA with surgery approximate 23%, while in BCC greater
causes deeper dermal damage via oxygen species devel- than 5cm, a tumor may be inadvertently left behind in
8
opment. Interestingly, evidence supports that chronic 68% of cases. Thus, follow-up is paramount; within 3
2,7
exposure to UV rays increases rates of squamous cell years, the individual is 10 times more likely to develop
carcinoma, while short and intense, albeit infrequent, another BCC. 1,5,7
UV ray exposure resulting in sunburns may lead to in-
8
creased rates of BCC, as well as melanoma. In addition Mohs surgery for GBCC cases has had a success rate of
to UV rays, UV light from welding and sterilization may 99%. Although time consuming, this has the additional
8
contribute to overall risk. Despite the fact that 75% benefit of being a tissue-sparing technique, which will
7
of BCCs occurs on the head and neck, the shoulders also consider aesthetic parameters. Conversely and
8,9
actually receive roughly two-thirds of UV exposure, fortunately for the patient in this case, the superficial
allowing for the development of BCC as in our case. subtype is considered the least aggressive form of BCC,

100 Journal of Special Operations Medicine Volume 14, Edition 1/Spring 2014