giant basal cell carcinomas ( gbccs ) measuring more than 5 cm constitute less than 1% of all basal cell carcinomas ( bccs ) [ 1 , 2 ] . due to their large size and tendency to infiltrate neighboring muscle , nerve , and bone the presence of 2 coexisting gbccs in the same individual is rare , with few reported cases [ 3 , 4 , 5 , 6 ] . here a 71-year - old caucasian man presented to the emergency room with 2 large tumors symmetrically distributed on his dorsal forearms . the patient did not seek medical treatment ; instead he opted for home herbal remedies and salves . the large bleeding lesions were noted when he underwent a routine medical assessment , and he was referred to the hospital for evaluation . on the left dorsal forearm there was a 10  13  4.5 cm exophytic nodular tumor on an ulcerated base . on the right dorsal forearm was a 6  4 cm ulcerated plaque with rolled borders . both tumors were friable with hemorrhagic exudate and sclerotic perilesional skin ( fig 1 ) . magnetic resonance imaging of the left forearm tumor revealed local muscle , nerve , and periosteal invasion . computed tomography scans of the chest , abdomen , and pelvis showed no evidence of nodal involvement or metastatic disease . superficial wound cultures of both tumors grew pseudomonas aeruginosa that was treated with intravenous cefepime . orthopedic and plastic surgery consultants recommended wide local excision of both tumors followed by skin grafting and reconstruction . the patient consented to removal of the lesions but refused subsequent grafts , stating that they were contrary to his beliefs of natural healing . a psychiatry consult was obtained to assess the patient 's ability to make medical decisions , and he was found to have capacity . he was discharged in a stable condition to a rehabilitation facility , with outpatient follow - up arranged to discuss nonsurgical treatment options . while bccs are generally small and slow growing , gbccs are rare , aggressive tumors that often recur and are more likely to metastasize . though many risk factors for gbccs are similar to those for bccs ( e.g. , caucasian race , prior history of bcc , and exposure to ultraviolet radiation ) , a distinct feature of gbcc is a patient 's neglect of the lesion and a resulting delay in effective intervention [ 3 , 5 , 8 , 9 ] . a common trend among cases of gbcc is patients distrust of contemporary western medicine [ 3 , 5 , 8 ] . previous case reports of multiple gbccs also described patients with established beliefs in holistic or religious treatments [ 3 , 5 , 8 ] . in some instances , patients that experienced bcc recurrence after surgical excision were frustrated by the outcome and rejected all further care , leading to progression and death from associated complications . given the markedly increased risk of metastases and death from gbcc , it is particularly important to recognize and openly address patient concerns regarding treatment options . establishing a strong physician - patient therapeutic alliance while excision remains the widely acknowledged gold standard of treatment for gbcc [ 1 , 2 , 7 ] , table 1 summarizes various alternative therapies that have been reported in the medical literature and can be discussed with patients declining first - line surgical modalities [ 11 , 12 , 13 , 14 , 15 ] . most of these medical therapies are affordable and easily dosed and have an acceptable side effect profile . treatment involving radiation has historically been reserved for poor surgical candidates [ 11 , 12 , 13 ] . vismodegib is a targeted chemotherapy agent that has been shown to halt tumor growth , but it has many side effects . finally , imiquimod has been used alone or in combination with cryosurgery or acitretin to successfully shrink gbccs by an unknown mechanism [ 6 , 14 , 15 ] . in each instance , treating physicians were able to negotiate treatment plans that were consistent with patient beliefs , resulting in compliance and tumor regression . in conclusion , gbccs are rare , destructive tumors that are more likely to develop in patients with strong beliefs in complementary and holistic medicine . a discussion and implementation of less invasive alternative therapeutic modalities can be integral to patient survival and improved clinical outcomes . we received verbal consent from the patient to use his data and photographs for publication .
giant basal cell carcinomas ( gbccs ) are large basal cell carcinomas ( bccs ; < 5 cm ) with a greater propensity to invade and metastasize than standard bccs . 
 the presence of 2 gbccs in a single individual is rare . 
 we present the case of a 71-year - old caucasian male with bilateral gbccs on the dorsal forearms , measuring 130 cm2 and 24 cm2 , respectively , that developed over a 21-year period . over this period , 
 the patient treated the tumors with herbal remedies . 
 histologic evaluation showed a conventional nodular bcc for both tumors . computed tomography and magnetic resonance imaging revealed a t4n0m0 stage for the larger lesion . surgical excision and grafting and reconstruction 
 were offered , but he declined . 
 this case highlights a shared belief in holistic treatments and rejection of western medical interventions that are common among many patients with gbcc . 
 studies reporting nonsurgical treatments for gbccs , including radiotherapy , vismodegib , topical imiquimod , and acitretin are reviewed .