Page 109 - Journal of Special Operations Medicine - Spring 2014

although it has still been reported as a subtype for neoplasms in the military population. Often exposed to
3,7
GBCC in the literature. Treatment options include, extreme environments with sun exposure, Servicemem-
in addition to surgery, electrodesiccation and curettage bers are at risk, but they also have the opportunity for
with imiquimod or fluorouracil application for several annual required health screenings. Due to occupational
weeks afterward. 1,3,5 Clearance from imiquimod therapy risks, the military population in general would benefit
is reported as 70% to 94% for superficial BCC of 2cm greatly from increased education. Through increased
2
1
or less, and recurrence is up to 20% at 2 years. An- sur veillance, providers could decrease percentages of un-
other treatment option for consideration of superficial diagnosed skin cancers. Incorporating additional sur vey
GBCC is CO laser, with 80% of cases reported to clear and review questions regarding sun-protective measures
2
completely after single treatment and recurrence rates during annual health assessments could help Service-
2
of 3.7% to 15.5%. If found, the patient may also ben- members consider their daily habits in occupations that
efit from treatment for associated hypoproteinemia and may have increased sun exposure.
iron deficiency anemia, which have been reported to oc-
cur with GBCC. 7 BCC is often caused by intense sunburn versus chronic
exposure, and typically risk due to past sunburns is estab-
5,8
lished by age 20. This means that new recruits, who are
Differential
most likely employed in the sun, are laying the foundation
The differential diagnoses are important to discuss, as for future skin cancer. Although increased sunscreen use
a misdiagnosis by either layperson or provider early on may decrease the incidence of squamous cell carcinoma,
may have led to subsequent disregard by the Servicemem- there is evidence to support that this does not cause any
ber, allowing for the cancer to progress. Common simi- decrease in BCCs, thus necessitating the additional need
lar diagnoses include Bowen’s disease, eczema, psoriasis, for protective clothing, hats, and shade to minimize po-
8
and extramammary Paget’s disease. Bowen’s disease, or tential sunburn. Also, sunscreens are often applied inap-
8
squamous cell carcinoma in situ, has is characterized by propriately and may give a false sense of security. It is
an erythematous plaque with scale and fissures on sun- important for leadership to be aware of the benefits of ro-
exposed portions of the body or mucous membranes, tating Servicemembers through tasks that require ongo-
often without the smooth pearly white borders found ing sun exposure as well as ensuring adequate protection
in superficial BCC. However, clinical distinction can be against sunburn with personal sunscreen, long-sleeved
1
extremely difficult, thus often necessitating a biopsy. clothing, and wide-brimmed hats, in addition to the use
Eczema does have similar scale formation, which BCC of shade throughout the day to help decrease the risk for
8
can create when serum oozes and forms crusts, as seen skin cancer. Establishing smoking pits or other areas
in our patient. However, eczema can have patterns of of congregation that are well covered and shaded, even
vesicles, erythema, scaling, fissuring, and potentially li- through the simple provision of awnings for this purpose,
1
8
chenification, depending on its stage. Psoriasis differs would be beneficial. Also, members should be educated
in that the distribution is usually along the gluteal cleft, on sunglass use in an increasing post Photorefractive Ker-
elbows, knees, and scalp, rather than just one localized atectomy (PRK) and Laser-Assisted in situ Keratomileusis
1
area, and often presents with a thicker silvery scale. Fi- (LASIK) population, as roughly 3 million lose vision each
nally, extramammary Paget’s disease is different in that year from pathology due to sun exposure. 8
although rarely (2%) may present on other surfaces, it
commonly is found in the genital and perianal areas. To truly decrease skin cancer rates in the military popu-
Typically, the plaque is erythematous and may weep. 1 lation, there is an overall need to change habits through
education, such that one chooses to seek shade that
In general, one distinguishing characteristic of superfi- leadership provides and encourages instead of basking
8
cial BCC is its white pearly ridge and telangiectasias, in the sun without protection. Currently, habits and
which may be clearly delineated with dermoscopy or surveillance methods do not exemplify this, which al-
when overlying scale is removed and tension is applied lowed a BCC to grow to giant proportions in an active
1
on the adjacent normal skin. When a biopsy of superfi- duty Servicemember.
cial BCC is performed, there are atypical basaloid cells
exhibiting a peripheral pallisading pattern with buds of
these cells in the epidermal basal layer lengthening into Conclusion
the underlying dermis. 1,3,5 In summary, this case raises the concern that despite
95% of BCCs occurring in those older than 40 years, a
BCC developed into a GBCC over the course of 10 years
Prevention and Early Identification
in a Seabee who had increased occupational exposure
This dramatic case presentation demonstrates the impor- risks. Thus, military providers should have heightened
tance of early prevention and identification of cutaneous awareness for these neoplasms even in those members in

Giant Basal Cell Carcinoma 101