Giant Basal Cell Carcinoma

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A 72‐year‐old white man presented with a large cutaneous tumor on his back. The patient said the lesion, mostly asymptomatic, had increased in size for about 7 years. Physical examination revealed a vegetating mass ( Figure 1 ), partially ulcerated, measuring 30 × 20 cm, which easily dripped serum and blood, with small necrotic areas and a sclerotic border. Perilesional skin appeared edematous, probably owing to inflammation and impaired lymphatic flow. Clinically, there was no evidence of lymph node involvement. His family history was noncontributory. Hematologic examination revealed hypochromic microcytic anemia. Laboratory test results showed hyperuricemia and hypercholesterolemia. The patient's history revealed mild hypertension, ischemic cardiopathy treated with percutaneous transluminal coronary angioplasty and anticoagulant drugs, and moderate chronic renal insufficiency. Histologic examination of a biopsy specimen taken from the margin of the lesion displayed a superficial area of ulceration and invasion of the deeper dermis and subcutaneous tissue ( Figure 2 A and Figure 2 B). The tumor mostly showed an adenoid pattern: gland‐like structures and cystic spaces sometimes containing amorphous or granular material, surrounded by strands of basaloid cells devoid of any peripheral palisading ( Figure 2 C). In some areas, the adenoid pattern coexisted with infiltrated areas characterized by thin and elongated strands or cords of basaloid cells with irregular and jagged peripheral contours within a fibrous or edematous stroma ( Figure 2 D). Basaloid cells often revealed nuclear atypia, marked pleomorphism and hyperchromatism ( Figure 2 C and Figure 2 D). Therefore, a diagnosis of basal cell carcinoma, adenoid subtype, was made. Magnetic resonance imaging showed a 10‐cm wide thickening of the subcutaneous layer on the lumbar region, with a partial neoplastic infiltration of the muscle fascia. No evidence of metastases was found with a total body computed tomography scan. Because the patient was taking anticoagulant drugs and had unstable renal and cardiac function, surgical treatment was at least temporarily excluded, and the patient was referred for radiation therapy. A vegetant mass 30 × 20 cm in size, partially ulcerated, on the lumbar region. image (A) Infiltrating adenoid pattern with a superficial ulcerated area (hematoxylin‐eosin stain, original magnification ×50). (B) Same view at higher magnification (hematoxylin‐eosin stain, original magnification ×200). (C) Pseudoglandular appearance and remarkable nuclear atypia of tumor cells (hematoxylin‐eosin stain, original magnification ×400). (D) Elongated and irregular strands of tumor cells with absence of peripheral palisading (hematoxylin‐eosin stain, original magnification ×400). image

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