JEADV

LETTER TO THE EDITOR

Neglected skin carcinomas: What should not be Editor Basal cell (BCC) and squamous cell (SCC) carcinomas are the two most frequent non-melanoma skin cancers that affect humans.1 Multiple treatment options are now available, and precise guidelines give patients better outcomes. In developing countries like Mexico sanitary systems are not always well employed and patients can fall into a gap between misdiagnosis, wrong treatments and poorly conducted follow-ups. We present five cases of highly invasive, neglected cutaneous carcinomas. Case 1: A 68-year-old male with an ulcerated 10 9 15 cm mass over his right hemi-facial area with complete destruction of the orbit and its content. Skin biopsy revealed a moderately differentiated squamous cell carcinoma (Fig. 1a). (a)

(b)

Figure 1 Time between the initial lesion and the diagnosis: (a) 17 years, (b) 15 years.

(a)

Case 2: An 88-year-old female with a 10 9 7 cm ulcerated mass over her left orbital region. Skin biopsy was consistent with a basosquamous carcinoma (Fig. 1b). Case 3: A 55-year-old male with 10 different lesions on his scalp, forehead and nasal areas; seven of them were exophytic, while the rest were large ulcerated plaques with yellow and haematic crusts. All skin biopsies revealed infiltrative basal cell carcinomas (Fig. 2a). Case 4: A 71-year-old female with an exophytic 7 9 8 cm multilobular mass that replaced her nasal anatomy, with central ulceration and haematic crusts. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2b). Case 5: A 69-year-old male with a 15 9 10 cm ulcerated plaque over the lateral aspect of the left hemi-facial region and complete destruction of the ear. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2c). Giant basal cell carcinomas are defined as a tumour of 5 cm or more in maximum diameter that are locally aggressive, have a greater risk of metastasis and are associated with a poor prognosis.2 Squamous cell carcinomas classified as high risk types are tumours characterized by thickness greater than 4 mm, perineural invasion and poor differentiation.3 Highest cure rates are achieved by complete excisional surgery, but can result in disfigurement and poor acceptance from the patient.4 Alternative therapeutic measures, such as electrosurgery, chemotherapy and radiotherapy as well as newer agents that inhibit the hedgehog pathways are being used as neoadjuvant treatments to reduce tumour size. Patients presenting with horrifying/giant BCC and SCC pose a therapeutic challenge requiring multidisciplinary team efforts. The described cases are a few of the neglected skin carcinomas we still receive annually at our outpatient clinic. Although BCC rarely metastasize, they can be very locally aggressive, causing

(b)

(c)

Figure 2 Time between the initial lesion and the diagnosis: (a) 8 years, (b) 23 years, (c) 20 years.

JEADV 2014

© 2014 European Academy of Dermatology and Venereology

Letter to the Editor

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tissue destruction and alteration of normal facial anatomy and significant morbidity when left untreated.5 These patients share the same history of long periods of time between the appearance of the initial lesion and the time of diagnosis. Interestingly, most had seen multiple physicians and received a long list of topical medications before reaching the right diagnosis. These unfortunate cases of neglected skin carcinomas could have easily been treated at earlier stages with curative excisional surgery or other available means, avoiding this otherwise devastating outcome. The main reasons that led to a delay in consultation and treatment were fear of the diagnosis and an obvious lack of well prepared first contact medical attention. Dermatologists in developing countries like ours need to have closer contact with general practitioners, medical oncologists and surgical oncologists in order to optimize patient follow-ups and early diagnoses and prompt referrals can be made. In this era, where novel treatments for locally advanced and metastatic basal cell carcinomas are emerging, patients such as those presented here, can now have more treatment options and aspire to better outcomes.6

Department of Dermatology, Dermatologic surgery, Hospital Universitario lez UANL, Monterrey, Mexico Jos e Eleuterio Gonza *Correspondence: M. E. Garcia-Melendez. E-mail: megmelendez@live. com

References 1 Madan V, Lear JT, Szeimies RM. “Non-melanoma skin cancer”. Lancet 2010; 375: 673–685. 2 Zoccali G, Pajand R, Papa P, Orsini G, Lomartire N, Giuliani M. Giant basal cell carcinoma of the skin: literature review and personal experience. J Eur Acad Dermatol Venereol 2012; 26: 942–952. 3 Gurney B, Newlands C. “Management of regional metastatic disease in head and neck cutaneous malignancy.1. Cutaneous squamous cell carcinoma”. Br J Oral Maxillofac Surg 2014; 52: 294–300. 4 Sanmartın V, Aguayo R, Baradad M, Casanova JM. “Oral acitretin and topical imiquimod as neoadjuvant treatment for giant basal cell carcinoma”. Actas Dermosifiliogr 2012; 103: 149–152. 5 Chang AL, Solomon JA, Hainsworth JD et al. Expanded access study of patients with advanced basal cell carcinoma treated with the Hedgehog pathway inhibitor, vismodegib. J Am Acad Dermatol 2014; 70: 60–69. 6 McCusker M, Basset-Seguin N, Dummer R et al. Metastatic basal cell carcinoma: prognosis dependent on anatomic site and spread of disease. Eur J Cancer 2014; 50: 774–783. DOI: 10.1111/jdv.12787

s K. Eichelmann, M. E. Garcia-Melendez,* O. Toma zquez-Martınez, J. Ocampo-Candiani Va

JEADV 2014

© 2014 European Academy of Dermatology and Venereology

Neglected skin carcinomas: What should not be.

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