A lobulated mass on the upper back with prominent vasculatur
A 60-year-old male with no personal history of skin cancer, immunosuppression, or radiation exposure presented to the emergency department for assessment of a three-day history of fatigue and orthostatic lightheadedness. The patient had a history of essential hypertension treated with metoprolol but no other known chronic medical conditions. His initial labs were notable for hemoglobin of 7.2, mean corpuscular volume of 73.6, ferritin of 6, and unsaturated iron-binding capacity of 371, consistent with iron deficiency anemia. On exam, he was found to have a 15×10×4 cm firm, fungating, lobulated, violaceous-pink tumor with areas of ulceration leaking serosanguinous fluid on his upper back. Along the surface of the tumor and extending inferolaterally into the peritumoral skin were radiating dilated violaceous vessels. Extending beyond the dominant growth was a rim of violaceous-pink patches.

The total area of skin involvement (combining both the excrescence and rim of involved tissue) was 20×18 cm. Upon further questioning, the patient stated that the mass had been present and slowly enlarging for 18 years. On computerized tomography, the mass was found to be heterogeneously enhancing involving the skin and subcutaneous fat overlying the trapezius muscle with no bony or visceral involvement. The patient’s lesion was excised primarily by surgical oncology leaving exposed left scapula, trapezius, spinous processes, and occipital fascia. Excisional margins were noted as less than 2 mm from the deep margin and greater than 2 cm from all other margins. Microscopic examination of the tumor specimen demonstrated dermal nodules of pleomorphic, hyperchromatic purple cuboidal, and columnar cells with scattered keratin pearls in a background of loose fibrous stroma and a moderate lymphocytic infiltrate, consistent with a diagnosis of BCC. Two weeks later, plastic surgery performed a rotational skin flap from suboccipital region and split thickness skin grafting from lower back to upper back wound. This patient had no additional treatments. This report presents a case of a very large neglected giant basal cell carcinoma, which was discovered upon workup of orthostatic lightheadedness and iron deficiency anemia. Although rare, basal cell carcinoma must be included on the differential of a large cutaneous lesion and may be a source of significant blood loss.