A Neglected Facial Ulceration

in an Elderly Man

presented by

Henry Foong FRCP, Ipoh, Malaysia (1)

Andrew Carlson MD, FRCPC, Albany, NY, USA (2)

on September 17, 2004

(1) Consultant Dermatologist, Foong Skin Specialist Clinic, Ipoh, Malaysia

(2) Associate Professor, Divisions of Dermatopathology and Dermatology
Albany Medical College, Albany, NY, USA

C.C., 71-year-old Chinese man
4 years

Presented with longstanding massive eroding ulcer on his face for 4 years. According to the patient, the lesion started around the mouth and gradually eroded into surrounding areas. He had no other significant past medical history.

Physical Examination

Physical examination showed an extensive and deep 8x11-cm ulceration on the buccal mucosa extending into the nasal cavity. The ulcer had a raised margin. Cervical adenopathy was present. A biopsy specimen of the ulceration is shown below.


Laboratory Data



The biopsy showed a large, ulcerative basal cell carcinoma that is composed of superficial, nodular and infiltrative components as well as areas of keratinization.

Fig 1. low power view of the lesion

Fig 2 high power view


Invasive Giant Basal Cell Carcinoma

Reasons Presented

Presented for interest and for dermatologic surgical opinions.

Questions and Discussions

“Doctor, I am not keen for surgery yet.” How often does the doctor hear that response in relation to the treatment of skin cancer? This case presentation illustrates the importance of prompt surgical therapy for BCC.

Though skin cancer is rare in Malaysia, BCCs are the most commonly diagnosed skin cancer. First described in 1827 as a rodent ulcer, these lesions arise from the pluripotential epithelial cells of the epidermis and hair follicles. BCC are locally invasive, but rarely metastasize. While the cell cycle of a BCC is about 9 days, these tumors grow slowly, taking years to reach a large size. This apparent discrepancy is explained by the fact that only the outer layer of cells of a tumor nodule is actively dividing, which underscores the importance of adequate excision of peripheral BCC extensions.

Our local plastic surgeon deem this neglected case as inoperable now. He is undergoing radiotherapy instead.

Please share your views on the management of this patient.

  1. Weinstein GD, Frost P. Cell proliferation in human basal cell carcinoma. Cancer Res 1970;30:724-8.
  2. Randle HW, Roenigk RK, Brodland DG. Giant basal cell carcinoma (T3). Who is at risk? Cancer 1993;72:1624-30.
  3. Sherman JE, Talmor M. Slow progression and sequential documentation of a giant basal cell carcinoma of the face. Surgery 2001;130:1:90-92
Comments from Faculty and Members

Yelva Lynfield MD, Cedarhurst, New York, USA on Sept 17, 2004

This photo should be shown to everyone who thinks BCE is a trivial tumor. After he finishes radiation this man will require extensive reconstructive surgery.

Gabriela Frias MD, Mexico City, Mexico on Sept 17, 2004

I've seen some similar cases, although treated by oncologist who have done an extensive surgical resection and then a wonderful made prosthesis was adapted by day, which looked very natural.

David Elpern MD, Williamstown, MA, USA on Sept 18, 2004

My personal opinion is that this man should be left alone. I think that no one has experience with this kind of patient and the surgery will likely kill him. The post op period will be extremely difficult. Radiotherapy will leave him with non-healing radionecrosis. Chemotherapy does not work for BCC. There is a time to "not just do something, but stand there." There may be ENT cancer surgeons who can comment.

Michael Albom MD, Clinical Professor of Dermatology, Ronald O. Perelman Department of Dermatology, New York University Medical Center, New York, NY, USA on Sept 18, 2004

This patient's massive cutaneous facial neoplasm presents a very serious dilemma in terms of management. I would suggest that additional information is needed to evaluate this case. An MRI or CT scan of the head and neck would help to assess the depth and spread of invasion of disease and what critical underlying anatomic structures are invaded by this neoplasm. A needle biopsy would determine if the cervical adenopathy was due to neoplastic or inflammatory cells. Immunochemical histologic stains would be useful if the routine basic histochemical stains showed equivocal histologic findings.

A single biopsy of the main tumor mass may not necessarily be histologically representative of the entire neoplasm which may actually consist of multiple histologic subtypes. In other words, I have seem massive cutaneous tumors, such as this one, that have demonstrated microscopic elements consistent with basal cell carcinoma, squamous cell carcinoma and eccrine carcinoma. In my experience, basal cell carcinomas with multiple types of differentiation are more biologically aggressive in their invasive capabilities as compared to ones that reveal only single histologic patterns of basal cell carcinoma. This is a general comment and not meant to be inclusive since infiltrative and/or morphealike basal cell carcinomas can be extremely biologically aggressive. ( For Full Commentary)

Omid Zargari MD Rasht, Iran on Sept 18 2004

I've seen two similar cases before. Radiotherapy and/or chemotherapy might be palliative in this patient.

Benjamin Barankin MD, Department of Dermatology, University of Alberta, Edmonton, Canada on Sept 19, 2004

I think that radiation therapy is the mainstay of treatment for this gentleman, with guarded prognosis. If affordable/accessible, I think a 3 month trial of imiquimoid would be beneficial.

Tom Rohrer MD, SkinCare Physicians of Chestnut Hill, Boston, MA, USA on Sept 20, 2004

That is unbelievable! Wow, what a case. I think this could only be done in a main Operation Room at a hospital and would need wide excision with margin control followed by extensive reconstructive surgery and radiation. That is really impressive. Thanks for sharing.,

Henry Foong's note on Sept 29, 2004:

This patient underwent palliative radiotherapy without much improvement. He passed away on Sept 27, 2004.

Please Click Here To Comment and Evaluate

Back to July 25, 2004 Case