Aggressive and Neglected Basal Cell Carcinoma ALI ASILIAN, MD, AND BANAFSHE TAMIZIFAR, MD Department of Dermatology, Alzahra Hospital, Medical University of Isfahan, Isfahan, Iran BACKGROUND. Basal cell carcinoma (BCC) is the most common cutaneous malignancy and usually has a benign coarse. Rarely, examples of aggressive and neglected types of this tumor are seen. OBJECTIVE. To present an interesting and dramatic example of how some people neglect their tumors and how devastating the sequelae can be. METHODS. We report a 58-year-old man with an extensive BCC and signs of cranial nerve involvement. RESULTS. The patient had a large, infected ulcer on his scalp. He also had skull bone destruction, osteomyelitis, mastoiditis, cra- nial nerve paralysis, and radiographic features of the skull base and upper cervical soft tissue involvement. Pathologic studies revealed an infiltrating form of BCC. CONCLUSIONS. If left untreated and neglected, as in this case, BCC can become inoperable and complicated. © 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc ISSN: 1076–0512 • Dermatol Surg 2005;31:1468–1471. ALI ASILIAN, MD, AND BANAFSHE TAMIZIFAR, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. BASAL CELL carcinoma (BCC) is the most common cuta- neous malignancy. BCC generally has a clinical course char- acterized by slow growth, minimal soft tissue invasiveness, and a high response rate to conventional therapies. Occa- sionally, however, BCC behaves aggressively, with deep invasion, recurrence, and potential regional and distant metastasis. Several factors, including tumor size, duration, histologic subtype, and perineural spread, have been postu- lated as markers of the aggressive BCC phenotype. 1 This report revealed a patient whose cranial nerve paralysis was due to BCC. Case Report A 58-year-old man with a 10-year history of a slowly pro- gressive skin ulcer was referred to our department. His ill- ness began as a small, slowly growing, asymptomatic, pig- mented nodule on his posterior scalp. An incisional biopsy performed on the ulceration in 1999 revealed a BCC, and treatment with Mohs micrographic surgery was recom- mended. The patient was noncompliant with treatment suggestions, and he chose to simply cover the wound with a cap. Two months prior to his most recent presentation, the patient’s family observed that the patient’s face was becoming progressively asymmetric. On reexamination, he also complained of food collection between the cheek and teeth. He denied any history of facial pain, facial trauma, or any parotid gland problem. He also complained of some degree of hearing loss, although he denied tinnitus, headache, vertigo, ear pain, fever, or extraction of a puru- lent discharge from the external auditory canal. He had no history of acute or chronic otitis media or occupational acoustic trauma. The patient provided a history of receiving unknown amounts of radiation to the scalp for the treatment of tinea capitis during childhood, and he also mentioned that he had chronic alopecia within the areas of the scalp that were previously treated with radiation therapy. His med- ical history was otherwise unremarkable. On physical examination, the patient had a very large (about 15  15 cm) depressed ulcer with irregular borders containing purulent and malodorous discharge. Portions of the underlying left parietal, occipital, and temporal bones were visibly destroyed. In a 3  5 cm area in the center of the lesion, the dura mater and its associated pul- sation could be observed. The patient also had a flaccid facial paralysis on the ipsilateral side (Figures 1 and 2). He was unable to close his eye or wrinkle his forehead on the affected side. The mouth drew to the contralateral side, and he could not normally compress or separate his left lips. He could not hear a hair-rubbing sound on the left side, and on ipsilat- eral otoscopic examination, there were calcified areas with irregular borders and related spotted hemorrhages in the entire left external auditory canal. The right ear was nor- mal. There was no palpable regional lymphadenopathy. Address correspondence and reprint requests to: Banafshe Tamizifar, MD, Department of Dermatology, Alzahra Hospital, Medical Uni- versity of Isfahan, Isfahan, Iran 81997, or e-mail: tamizifar@resi- dents.mui.acoir.