Giant basal cell carcinoma: 11-year follow-up and seven new cases.

Basal cell carcinoma is the most common malignancy of the body and the most common skin cancer, and is seen most often on the head and neck. Histopathologically, most basal cell carcinomas arise from the epidermis and hair follicles.1 The most common factor involved in the pathogenesis of skin cancer is ultraviolet light,2 which explains why three-quarters of these tumors are in the head and neck.3 Metastasis of basal cell carcinoma is rare, with an incidence as low as 0.0028 percent.4 Regardless of size, all basal cell carcinomas arise in the basal layer of the epidermis and the pilosebaceous follicle units (Figs. 1 and 2). Basal cell carcinoma usually grows solely by local extension in both horizontal and vertical directions; local extension can continue into the deeper tissues, such as cartilage and bone. Perineural extension is often insidious in its development. In 2000, we presented a series of seven patients with giant basal cell carcinoma—tumors larger than 5 cm in diameter—without any clinical evidence of metastases.5 At the time of our original publication, the tumor, node, metastasis system classified these tumors ( 5 cm) as T3.6 The American Joint Committee on Cancer recently released the seventh edition of the Cancer Staging Manual7; this updated manual includes several changes, including a revision of the tumor, node, metastasis staging system for basal cell carcinomas. Until this latest edition, basal cell carcinoma with a diameter greater than 5 cm was classified as a T3 tumor; however, the new T staging has eliminated the 5-cm diameter cutoff. Two-centimeter diameter continues to differentiate T1 and T2 with certain high-risk features that increase the T stage: depth of tumor, anatomical site, perineural invasion, histopathologic grade or differentiation, and bony invasion. We would like to present an additional seven patients with these large tumors, now classified as T2, and reassert the notion that depth of invasion of giant basal cell carcinoma does not have any prognostic implication. This study followed the Declaration of Helsinki guidelines for research involving human individuals. The nature of the study was explained and all patients gave written consent to participate. Treatment for these large basal cell carcinomas is the same for any other size basal cell carcinoma: surgical excision. With a 1-cm margin of normal tissue as part of the resection margin, we found it most expeditious and practical to reconstruct all surgical defects with split-thickness skin grafts. We found that reconstructive options other than split-thickness skin grafts were not necessary or indicated, unlike other authors.8,9 We have not had any experience with Metvix photodynamic therapy as a preoperative means of shrinking the size of the tumor.10 Our practice has accumulated over 5000 specimens of surgically excised basal cell carcinoma over the past 20 years. Regardless of size or any prior treatments, we have yet to see one case of metastasis, which is consistent with the new classification in the seventh edition of the Cancer Staging Manual by the American Joint Committee on From the Division of Plastic Surgery, Ambulatory Surgery Center, Holy Redeemer Hospital. Received for publication March 3, 2011; accepted March 30, 2011. Follow-up to: Manstein CH, Gottlieb N, Manstein ME, Manstein G. Giant basal cell carcinoma: A series of seven T3 tumors without metastasis. Plast Reconstr Surg. 2000; 106:653–656. Copyright ©2011 by the American Society of Plastic Surgeons