Giant nodular basal cell skin cancer

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Relevance. Giant basal cell carcinoma (GBC) is a rare type of basal cell carcinoma (BCC) characterized by dimensions exceeding 5 cm in diameter, a long-term course of the disease, the absence of subjective symptoms, the formation of a pronounced cosmetic soft tissue defect, and the complexity of radical surgical treatment. [1, 2, 3, 4, 5].
HCC occurs in 0.3-1.5% of cases of BCC, is characterized by slow progressive growth over several decades of life, frequent recurrence (in 3-15% of patients) and metastasis (in 0.1-0.5% of cases). Rarely, rapid tumor growth is recorded, accompanied by progressive skin ulceration, destruction of cartilage and bones, involvement of underlying internal organs, vascular and perineural invasion, and metastases. Metastasis to regional lymph nodes occurs in 60-70% of patients with an aggressive type of BCC, to the skin in 10% of patients, to bones and internal organs in 20% and 42% of cases, respectively. The risk of developing metastases increases in every second patient with a BCC size of more than 10 cm in diameter and tumor localization in the head and neck region (85% of cases). Mortality from aggressive clinical and morphological forms of HBCC reaches 10-20% [1, 2, 3, 4, 5, 6].
Age-sex characteristics indicate the predominance of HBCC among males in the age group of 70 years and older; in women, giant basaliomas are detected at a younger age - 50-60 years. According to the literature data, HCC occurs de novo in 70-90% of cases, giant recurrent carcinomas are recorded in a third of patients. The duration of the disease varies in a wide range from 2 to 30 years, averaging 10 years or more [1, 2, 4, 5, 7].
Risk factors for the development of HBCC include: long-term cumulative ultraviolet radiation (UVR); immunosuppressive conditions; genetic syndromes; professional activity and occupational hazards; aggravated solar anamnesis; I - III skin phototypes according to T. Fitzpatrick; burdened personal and family oncological anamnesis; concomitant chronic dermatoses; severe somatic diseases; mental disorders; tumor recurrence after inadequate therapy; low socio-economic level; bad habits (alcoholism, smoking); loneliness; neglect of health [1, 2, 3, 4, 8, 9, 10].
The clinical picture of HBCC is characterized by the appearance of a large solitary tumor on the skin of the face, scalp, trunk, or extremities. The size of the giant basalioma varies from 5 to 30 cm or more, averaging 6-8 cm.

The superficial clinical form of HBCC is most common (55% of cases), localized mainly on the skin of the trunk, characterized by slow peripheral growth, reaching several tens of centimeters in the largest dimension. In the central part of the tumor, there are areas of atrophy, thin crusts and scales, multiple telangiectasias or foci of uneven pigmentation, along the periphery - small dense nodules with a waxy sheen. Ulcerative GBCC is registered in 40-44.9% of patients, while the centrofacial region and the scalp are more often affected, less often the trunk and limbs. Giant ulcerative basaliomas are characterized by infiltrative peripheral growth and progressive destruction of the skin, underlying tissues, cartilage and bones, vascular and perineural invasion. In most cases, ulcerative GBCC shows clinical and morphological signs of ulcus terebrans or Marjolin ulcer. In advanced cases, ulcerative basaliomas reach 30 or more centimeters in diameter. Much less often (single observations) there is nodular GBKR with localization on the skin of the trunk. The clinical picture of giant nodular basalioma is characterized by the formation of a large, with a bumpy surface of a tumor of stagnant pink or stagnant red color with multiple translucent telangiectasias, ranging in size from 5 to 10 cm - a conglomerated form [1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14].
Dermoscopic examination of a superficial basalioma is characterized by specific signs - thin branching tree-like vessels, homogeneous red and white zones, erosion and thin serous-hemorrhagic crusts. In nodular BCC, bright red, large-caliber tree-like vessels, large blue-gray ovoid nests, chrysalis-like structures, and areas of ulceration with thick hemorrhagic crusts are often observed. Ulcerative BCC is characterized by ulceration with dark brown hemorrhagic crusts and multiple polymorphic vessels [11, 15, 16].
The pathomorphological picture of HBCC in every second case (51% of cases) is represented by aggressive histological variants of the tumor (morphea-like, infiltrative, micronodular, metatypical) and is characterized by severe atypia of basaloid cells, increased mitotic activity, invasion of the tumor into the reticular dermis and subcutaneous fat, stromal fibrosis [1, 4, 5, 7, 17, 18, 19].
Differential diagnosis of HCC is carried out with squamous and metatypical cancer, Paget's and Bowen's disease, benign and malignant tumors of the skin appendages [1, 5, 12].

In the treatment of HBCC, wide surgical excision with reconstructive plastics, micrographic surgery according to Mohs, chemotherapy (5-fluorouracil, vincristine, bleomycin, doxorubicin, methotrexate) in combination with radiation therapy, surgical excision in combination with radiation therapy are used. For the treatment of giant inoperable, recurrent and metastatic basaliomas, vismodegibol monotherapy is applicable, the drug is allowed to be used in combination with other methods [1, 2, 6, 7, 8, 13, 17, 18, 20].
Since 2017, a dermato-oncological appointment has been organized at the GBUZ PC "KKKVD". Over a 6-year period, 134 cases of BCC were identified, of which 3 (2.2%) patients had BCC verified. Two patients were diagnosed with giant nodular basaliomas.
We present our own clinical observations of giant nodular BCC.
clinical observation 1.
Patient B., born in 1958, was referred to a dermato-oncologist at the Regional Clinical Dermatovenerologic Dispensary with complaints of rapid growth and increased bleeding of the tumor in the scalp, without subjective symptoms.
Anamnesis of the disease: the formation appeared after an injury about 20 years ago, over the past 5 years it has been a progressive growth of the tumor, increased bleeding during trauma, the formation of hemorrhagic crusts. I did not self-medicate. Previously, she did not go to the doctors (carcinophobia), the growing tumor was covered with hair and hats.
Allergological anamnesis is not burdened. Solar anamnesis (she lived in Georgia for 15 years, did not use photoprotection during her life). Heredity for oncological diseases (personal and family) is not burdened.
Professional history: hairdresser, 35 years of service, currently retired. Marital status: married, 2 children. There are no bad habits.
objective status. Skin phototype III according to T. Fitzpatrick. The general condition is satisfactory. Consciousness is clear, position is active. Height - 172 cm, weight - 103 kg. Body mass index - 34.8. The skin and mucous membranes are clean, of physiological color. Vesicular breathing, no wheezing. The respiratory rate is 18 per minute. Heart sounds are muffled, rhythmic, pathological murmurs are not auscultated. Pulse - 62 beats per minute, rhythmic, symmetrical. Blood pressure - 140\80 mm Hg. Art. The abdomen is soft, regular in shape, painless on palpation. The liver is on the edge of the costal arch, the spleen is not palpable. General clinical laboratory parameters within the age norm.

Concomitant diseases: Arterial hypertension stage III, 1 degree, risk 4. Ischemic heart disease. Angina pectoris II FC. Chronic heart failure IIA stage / II FC. Diabetes mellitus type II, compensated. Obesity I degree.
Status localis: skin pathological process is limited, localized in the parietal region of the scalp (Fig. 1).

Fig. 1. Patient B., born in 1958. Giant nodular basal cell carcinoma of the parietal region of the head hairy part (T3N0M0)

It is represented by a mushroom-shaped tumor node on a wide pinkish-brown base with a large-tuberous smooth surface, densely elastic consistency, 9.5x7.0 cm in size. The tumor is raised above the surrounding tissues by 3.0 cm, does not move during palpation. On the surface, there are multiple rounded erosions with a wet surface and serous-hemorrhagic discharge. In the upper part of the tumor there is an irregularly shaped ulcerative defect with raised, undermined edges, the bottom of the ulcer is a bumpy bright red color with fibrin films and a hemorrhagic crust in the center. Numerous large telangiectasias are observed on the surface of the tumor; there are no hairs in the area of the neoplasm. Regional lymph nodes are not enlarged, painless on palpation, not soldered together, the skin over them is not changed, their mobility is not limited.
The patient underwent videodermatoscopy of the tumor (DUB SkinScaner TPM, Germany).
In the area of the neoplasm of the scalp, pinkish-red unstructured zones with multiple large tree-like vessels and thick chrysalis-like structures are visualized. On the surface of the tumor, there are multiple erosions of a bright red color with a moist shiny surface, thin serous-hemorrhagic crusts. In the upper part of the knot there is an unstructured area of red-black color with adhering hair.
The patient underwent radical surgical excision of the tumor at the Perm Regional Oncology Center.
Pathological examination of the postoperative skin material of the parietal region of the scalp: the tumor is represented by complexes of anaplastic epithelium, consisting of small hyperchromic cells of the basaloid type with foci of the adenoid structure - epithelial strands form alveolar structures with a palisade basal row along the periphery of the complexes. Germination of tumor strands over the entire thickness of the reticular layer of the dermis into the subcutaneous fat (invasion of more than 25 mm) is noted. There are areas of fibrosis between the tumor complexes. Conclusion: basal cell skin cancer, solid adenoid histological type.

The patient was diagnosed with giant nodular basal cell carcinoma of the parietal region of the scalp (T3N0M0).
clinical observation 2.
Patient G., born in 1954, was consulted by a dermato-oncologist at the Regional Clinical Dermatovenerologic Dispensary. At the reception, he complained about the presence of skin formation in the left suprascapular region, bleeding during trauma, subjectively - without features.
Anamnesis of the disease: notes the appearance of a neoplasm about 15 years ago, during the last 2 years there has been an increased bleeding of the tumor, the formation of thick hemorrhagic crusts. I have not previously consulted a dermatologist, surgeon or oncologist. The causes of neglect are the fear of surgery (tomophobia) and subsequent death (tanatophobia).
Allergological anamnesis is not burdened. Solar anamnesis (sunburns of the back and upper chest since childhood, did not use sunscreen during my life). Personal and family heredity for oncological diseases, including skin cancer, is not burdened.
Professional anamnesis: driver, work experience - 40 years. Marital status: married, 3 children. Smokes 15-20 cigarettes a day, denies alcohol abuse.
objective status. Skin phototype III according to T. Fitzpatrick. The general condition is satisfactory. Consciousness is clear, position is active. Height - 168 cm, weight - 73 kg. Body mass index - 25.9. Skin and visible mucous membranes of physiological color. Vesicular breathing, no wheezing. The respiratory rate is 20 per minute. Heart sounds are clear, rhythmic, there are no pathological murmurs. Pulse - 60 beats per minute, rhythmic, symmetrical. Blood pressure - 155\95 mm Hg. Art. The abdomen is soft, painless on palpation. The liver is on the edge of the costal arch, the spleen is not palpable. The concussion syndrome of the lumbar region is negative on both sides. General clinical laboratory parameters within the age norm.
Concomitant diseases: chronic obstructive pulmonary disease, severity II, without exacerbation. Respiratory failure I degree. Arterial hypertension of the II stage, 1 degree, risk 3. Chronic cardiovascular insufficiency of the 1st degree. Overweight.
Status localis: skin pathological process is limited, asymmetric, localized on the skin of the left suprascapular region (Fig. 2). It is represented by an exophytic mushroom-shaped formation on a wide base of a stagnant pink color with a conglomerated surface, 5.0x9.0 cm in size. On palpation, the formation of a densely elastic consistency rises 2.5 cm above the skin, soldered to the underlying soft tissues. On the surface of the tumor, multiple short tortuous vessels of different diameters, thick hemorrhagic and purulent-necrotic crusts are visualized. Supraclavicular, subclavian, cervical, occipital and axillary lymph nodes are not enlarged, painless on palpation, mobile and not soldered together, the skin over them is not changed.

Fig. 2. Patient G., born in 1954. Giant nodular basal cell skin carcinoma of the left suprascapular zona (T3N0M0)

The patient underwent videodermatoscopy of the tumor (DUB SkinScaner TPM, Germany).
In the area of the neoplasm, structureless zones of stagnant red color with multiple tree-like vessels of various sizes, short thin telangiectasias, and chrysaloid-like structures are visualized. On the surface of the tumor, multiple thick hemorrhagic and purulent-necrotic crusts are observed.
The patient underwent radical surgical excision of the tumor with skin graft plasty at the Perm Regional Oncology Center.
Pathological examination of the postoperative material of the skin of the left suprascapular region: the epidermis is thinned, the tumor is represented by complexes and strands of basaloid cells with large nuclei and poor cytoplasm. Along the periphery of the tumor nests, a “palisade” is pronounced. Single mitoses are observed in the tumor. The stroma is fibrotic. Germination of tumor strands in all layers of the skin is noted (35 mm invasion). Conclusion: basal cell skin cancer, solid adenoid histological type.
The patient was diagnosed with giant nodular basal cell skin cancer of the left suprascapular region (T3N0M0).
Patients are under dispensary registration with an oncologist, the postoperative period in both cases is uneventful.
Discussion. It is known that HBCC is extremely rare in the population of 0.3-1.5% of cases of BCC, we observed 3 (2.2%) patients with giant basaliomas. Of these, 2 patients had primary nodular BCC with a gender ratio of 1:1 at the age of 64 and 68 years. The duration of the disease in the described clinical cases was 20 and 15 years, respectively, due to the psychological conditions of patients - cancerophobia, tomophobia, thanatophobia [1, 2, 3, 4, 5, 6, 8, 9, 10].
The features of the presented observations include: slow long-term asymptomatic growth of solitary tumor-like nodes of a mushroom-shaped form of stagnant pink color with a bumpy surface, densely elastic consistency, soldered to the underlying soft tissues, larger than 5 cm in diameter, which corresponds to the clinical signs of the conglomerated form of BCC. The absence of metastasis over a long period of existence of the tumor indicates a low biological potential of nodular GCC [1, 10].
The dermatoscopic picture of the above observations was characterized by structureless areas of pinkish-red and stagnant red color with multiple large tree-like vessels and thick chrysalis-like structures, which corresponds to the typical signs of nodular BCC [15, 16].
The conducted pathomorphological study showed that the tumor in both cases was represented by complexes of basaloid cells with a pronounced "palisade" and was characterized by a complex structure - a solid adenoid histological type with signs of invasion into the reticular dermis and subcutaneous fat by 25 and 35 mm, respectively, which indicates infiltrative nature of the growth of nodular GBCC [1, 2, 4, 5, 9, 19]. It should be noted that the solid-adenoid morphological type is verified most often among non-aggressive forms of giant basaliomas [4, 5, 8].

Thus, nodular GCC is characterized by a long-term course without subjective symptoms and metastasis. The clinical picture of the above neoplasms is represented by a giant conglomerated form of basalioma, which has typical dermatoscopic signs of nodular BCC and pathomorphological features - tumors of a complex structure with an infiltrative growth pattern.
Conclusion. The presented clinical observations indicate late referral of patients with nodular HBCC to doctors, associated with many years of slow asymptomatic growth of the neoplasm and psychological states of fear and anxiety - phobias. Insufficient oncological awareness of patients and low oncological alertness of doctors correlate with the detection of basal cell skin cancer in the late stages of the disease, the treatment of which involves radical reconstructive surgical excision of the tumor.

About the authors

Tatiana G. Sedova

Perm State Medical University named after Academician E. A. Wagner; Perm, Regional Clinical Dermatovenereological Treatment Centre of Perm region, Perm

Email: sedovca-1978@yandex.ru
ORCID iD: 0000-0002-2660-0536
SPIN-code: 9947-9989
Scopus Author ID: 57205361525

MD, Cand. Sci. (Med.)

Russian Federation, 614990, Perm region, Perm, st. Petropavlovskaya, 26; 614000, Perm region, Perm, Kombaynerov street, 28a

Vladimir D. Elkin

Perm State Medical University named after Academician E. A. Wagner

Author for correspondence.
Email: elena.plotnikova@hotmail.com
ORCID iD: 0000-0003-4727-9531
SPIN-code: 1631-8188

MD, Dr. Sci. (Med.), Professor

Russian Federation, 614990, Perm region, Perm, st. Petropavlovskaya, 26

References

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