#basal cell

Abstract

Gorlin-Goltz syndrome is an inherited dominant autosomal disorder characterized by a predisposition to numerous cancers. The clinical-pathological findings of this syndrome are very diverse. The objective of this report is to present an Ecuadorian patient with Gorlin-Goltz syndrome who underwent surgical resection of basal cell carcinoma compatible lesions.

Conclusion: Gorlin-Goltz syndrome encompasses a variety of clinical signs and symptoms, including important oral manifestations and skin lesions that must be recognized to achieve an early specialty referral, thus reducing the risk of malignancy through a multidisciplinary treatment.

Keywords: Basal Cell Nevus Syndrome, Gorlin-Goltz syndrome, Carcinoma, Basal Cell

Introduction

Gorlin-Goltz (G-G) syndrome or nevoid basal cell carcinoma syndrome (NBCCS) is a dominant autosomal genetic disorder with high penetrance. Fifty percent of patients who suffer from it have a mutation in the long arm of chromosome 9q22.3 in the area of the PTCH gene (protein patched homolog) (1–3), a homologue of the Drosophila patched gene (PTC), which encodes a transmembrane receptor protein (4). This protein binds to a soluble factor of the hedgehog family (Hh), thus activating the Smo (smoothened) receptor, which unblocks the transcription of several growth factors. Therefore, the PTCH gene is an oncosuppressor that is part of the Sonic Hedgehog Homolog (Shh) signaling pathway and is crucial in embryonic development, cell division control, and tumor growth (5).

Its approximate prevalence is 1 in 57000 to 1 in 256000 and the ratio of males to females is 1:1 (6). Binkley and Johnson reported this syndrome for the first time in 1951 (7), then, in 1960, Gorlin and Goltz described the association between multiple basal cell carcinoma, odontogenic keratocysts (OKC) and bifid ribs, which account for the characteristic triad (8). In 1977, Rayner et al. added additional features, including calcification of the falx cerebri and palmar/plantar fossae (9).

According to the criteria of Kimonis et al., the diagnosis of G-G syndrome requires the coexistence of at least two major criteria or one major and two minor (10).

The characteristic that is usually diagnosed first is OKC, because it can be detected during the first decade of life and appears in almost 80% of G-G syndromes.

Other manifestations include palmar and plantar ulcers that appear as shallow pits, caused by partial or complete absence of the corneal layer, which can also appear along the sides of the hands and fingers and even on the tongue; spina bifida (10,11); medulloblastoma (can be an epiphenomenon of G-G, especially in children who are ≤5years-old) (12); cardiac tumors, including fibromas and ventricular histiocytomas, usually congenital (13); hypertelorism, congenital cataract, nystagmus, coloboma and strabismus (14); and ameloblastoma (extremely rare) (15,16).

Early diagnosis of G-G syndrome and its subsequent treatment are very important due to neoplasm susceptibility (2).

The case of a patient with a previous diagnosis of Gorlin-Goltz syndrome who presented multiple lesions compatible with basal cell carcinoma is presented below.

Case Report

A 35-year-old male, living in Quito, Ecuador, without allergies; no history of tobacco or alcohol intake. His mother and his brother presented Gorlin-Goltz syndrome (G-G).

The patient presents hereditary and congenital G-G syndrome (multifocal basal cell carcinoma and maxillary keratocysts), whose manifestations began at the age of 22. He underwent surgery for bilateral keratocysts at the age of 25, and multiple biopsies of the upper left eyelid were taken since 2012. In August 2015, with a positive tumoral activity biopsy report, a wide resection involving 60% of the left upper eyelid plus flap reconstruction was performed.

Physical examination revealed multiple surgical scars on the left upper eyelid with tumoral activity on the eyelid margin, as well as on the outer third of the ipsilateral lower eyelid and on the right side.

In October, a wide resection of the left upper and lower eyelid was planned, plus reconstruction and transoperative study, which are performed without complications.

Subsequently, the patient attended scheduled control, reporting the presence of a left superciliary nodular lesion. Physical examination revealed multiple lesions located in the left superciliary region, left helix, concha, and antihelix, in the inner corner of the left lower eyelid, in the left parieto-temporal and occipito-temporal regions, and other small bilateral genian lesions. There were no alterations in the flap. Left external campimetry was limited. It was decided to perform a facial bone and skull simple and contrasted tomography (CT) and laboratory tests.

Then, resection of the previously mentioned lesions and resection of the lower eyelid with transoperative study, shield-type incision and external canthoplasty of the lower left eyelid was planned. A plastic surgeon was included in the surgical team.

Altogether, 9 skin lesions located in the left superciliary, left frontal, interparietooccipital, posterior occipital, auricular, and left retroauricular regions were resected, which were positive for basal cell carcinoma.

In the subsequent control, the patient's campimetry showed improvement.

DISCUSSION

Reports about Gorlin-Goltz syndrome are scarce in the literature (17). The rarity and phenotypic variability of this syndrome causes a delay in its diagnosis. Syndromicassociated keratocystic odontogenic tumors are often treated in the same way as nonsyndromic cases (18) and associated systemic signs can easily be missed due to lack of understanding of the syndrome. In addition, their characteristics vary globally, so doctors and even dentists must identify them in a timely manner, considering those that are more prevalent in their population or similar populations (19,20).

The pathogenesis of basal cell carcinoma (BCC) is thought to involve increased sensitivity to ultraviolet light and to involve ineffective mechanisms that repair UVinduced DNA damage. In any case, this theory is not accepted by all authors since these lesions can also appear in areas that have not been exposed to sunlight. Especially in children, patients with G-G syndrome who undergo radiotherapy for other cancers have shown to be at increased risk of radiation-induced BCC (21).

In 50% of patients with G-G syndrome, jaw keratocysts appear, characterized by a thin surrounding layer of epithelial cells, which tend to reappear locally after excision in 6 to 60% of cases, therefore, the indication for surgery should be carefully considered, also due to the possibility of intensive clinical and instrumental monitoring (22).

In recent years, new drugs have been developed to inhibit certain components of the sonic hedgehog signaling pathway. In 2013, the FDA approved vismodegib, the first small molecule to target this pathway (11). Although these agents seem promising options for patients with G-G syndrome, their efficacy is limited by adverse effects and the development of resistance (23). Logically, a more aggressive approach is necessary if basal cell carcinoma is suspected; subsequently, depending on the lesion site and the surgery type, a reconstruction can be performed, as in the case presented in this article (24,25).

CONCLUSION

Gorlin-Goltz syndrome encompasses a variety of clinical signs and symptoms, including important oral manifestations and skin lesions that must be recognized to achieve early referral to a specialty, thus reducing the risk of malignancy through multidisciplinary treatment.

Ethical responsibilities

“Do the best you can until you know better. Then, when you know better, do better.”Maya Angelou When I first started using essential oils over twenty years ago it was all about the smell for me. I loved the way that they blended together to make a custom perfume or to use in yoga classes. It wasn’t until many years later that I actually started to learn that the powerful molecules in plants are…

As a family medicine physician, I often encounter patients with different skin conditions. One of the most common types of skin cancer is basal cell carcinoma. In this post, we will discuss the key points that you need to know about this condition. What is Basal Cell Carcinoma? Basal cell carcinoma (BCC) is a type of skin cancer that arises from the basal cells, which are located in the lower…

ABSTRACT

Gorlin-Goltz syndrome is an inherited dominant autosomal disorder characterized by a predisposition to numerous cancers. The clinical-pathological findings of this syndrome are very diverse. The objective of this report is to present an Ecuadorian patient with Gorlin-Goltz syndrome who underwent surgical resection of basal cell carcinoma compatible lesions.

Conclusion: Gorlin-Goltz syndrome encompasses a variety of clinical signs and symptoms, including important oral manifestations and skin lesions that must be recognized to achieve an early specialty referral, thus reducing the risk of malignancy through a multidisciplinary treatment.

Keywords: Basal Cell Nevus Syndrome, Gorlin-Goltz syndrome, Carcinoma, Basal Cell

INTRODUCTION

Gorlin-Goltz (G-G) syndrome or nevoid basal cell carcinoma syndrome (NBCCS) is a dominant autosomal genetic disorder with high penetrance. Fifty percent of patients who suffer from it have a mutation in the long arm of chromosome 9q22.3 in the area of the PTCH gene (protein patched homolog) (1–3), a homologue of the Drosophila patched gene (PTC), which encodes a transmembrane receptor protein (4). This protein binds to a soluble factor of the hedgehog family (Hh), thus activating the Smo (smoothened) receptor, which unblocks the transcription of several growth factors. Therefore, the PTCH gene is an oncosuppressor that is part of the Sonic Hedgehog Homolog (Shh) signaling pathway and is crucial in embryonic development, cell division control, and tumor growth (5).

Its approximate prevalence is 1 in 57000 to 1 in 256000 and the ratio of males to females is 1:1 (6). Binkley and Johnson reported this syndrome for the first time in 1951 (7), then, in 1960, Gorlin and Goltz described the association between multiple basal cell carcinoma, odontogenic keratocysts (OKC) and bifid ribs, which account for the characteristic triad (8). In 1977, Rayner et al. added additional features, including calcification of the falx cerebri and palmar/plantar fossae (9).

According to the criteria of Kimonis et al., the diagnosis of G-G syndrome requires the coexistence of at least two major criteria or one major and two minor (10).

The characteristic that is usually diagnosed first is OKC, because it can be detected during the first decade of life and appears in almost 80% of G-G syndromes.

Other manifestations include palmar and plantar ulcers that appear as shallow pits, caused by partial or complete absence of the corneal layer, which can also appear along the sides of the hands and fingers and even on the tongue; spina bifida (10,11); medulloblastoma (can be an epiphenomenon of G-G, especially in children who are ≤5years-old) (12); cardiac tumors, including fibromas and ventricular histiocytomas, usually congenital (13); hypertelorism, congenital cataract, nystagmus, coloboma and strabismus (14); and ameloblastoma (extremely rare) (15,16).

Early diagnosis of G-G syndrome and its subsequent treatment are very important due to neoplasm susceptibility (2).

The case of a patient with a previous diagnosis of Gorlin-Goltz syndrome who presented multiple lesions compatible with basal cell carcinoma is presented below.

CASE REPORT

A 35-year-old male, living in Quito, Ecuador, without allergies; no history of tobacco or alcohol intake. His mother and his brother presented Gorlin-Goltz syndrome (G-G).

The patient presents hereditary and congenital G-G syndrome (multifocal basal cell carcinoma and maxillary keratocysts), whose manifestations began at the age of 22. He underwent surgery for bilateral keratocysts at the age of 25, and multiple biopsies of the upper left eyelid were taken since 2012. In August 2015, with a positive tumoral activity biopsy report, a wide resection involving 60% of the left upper eyelid plus flap reconstruction was performed.

Figure 1: Facial skin lesions and previous left maxillary keratocyst

Physical examination revealed multiple surgical scars on the left upper eyelid with tumoral activity on the eyelid margin, as well as on the outer third of the ipsilateral lower eyelid and on the right side.

Figure 2: Surgical scars with tumoral activity in the left and right eyelids.

In October, a wide resection of the left upper and lower eyelid was planned, plus reconstruction and transoperative study, which are performed without complications.

Figure 3 : Surgical planning

Figure 4 : Tumor resection involving the upper and lower eyelids with safety margins and surgical piece

Figure 5 : Confection of the left fronto-parietal flap

Figure 6: Immediate reconstruction results

Subsequently, the patient attended scheduled control, reporting the presence of a left superciliary nodular lesion. Physical examination revealed multiple lesions located in the left superciliary region, left helix, concha, and antihelix, in the inner corner of the left lower eyelid, in the left parieto-temporal and occipito-temporal regions, and other small bilateral genian lesions. There were no alterations in the flap. Left external campimetry was limited. It was decided to perform a facial bone and skull simple and contrasted tomography (CT) and laboratory tests.

Then, resection of the previously mentioned lesions and resection of the lower eyelid with transoperative study, shield-type incision and external canthoplasty of the lower left eyelid was planned. A plastic surgeon was included in the surgical team.

Figure 7: Shield-type incision

Altogether, 9 skin lesions located in the left superciliary, left frontal, interparietooccipital, posterior occipital, auricular, and left retroauricular regions were resected, which were positive for basal cell carcinoma.

In the subsequent control, the patient's campimetry showed improvement.

Figure 8 : Final result

DISCUSSION

Reports about Gorlin-Goltz syndrome are scarce in the literature (17). The rarity and phenotypic variability of this syndrome causes a delay in its diagnosis. Syndromicassociated keratocystic odontogenic tumors are often treated in the same way as nonsyndromic cases (18) and associated systemic signs can easily be missed due to lack of understanding of the syndrome. In addition, their characteristics vary globally, so doctors and even dentists must identify them in a timely manner, considering those that are more prevalent in their population or similar populations (19,20).

The pathogenesis of basal cell carcinoma (BCC) is thought to involve increased sensitivity to ultraviolet light and to involve ineffective mechanisms that repair UVinduced DNA damage. In any case, this theory is not accepted by all authors since these lesions can also appear in areas that have not been exposed to sunlight. Especially in children, patients with G-G syndrome who undergo radiotherapy for other cancers have shown to be at increased risk of radiation-induced BCC (21).

In 50% of patients with G-G syndrome, jaw keratocysts appear, characterized by a thin surrounding layer of epithelial cells, which tend to reappear locally after excision in 6 to 60% of cases, therefore, the indication for surgery should be carefully considered, also due to the possibility of intensive clinical and instrumental monitoring (22).

In recent years, new drugs have been developed to inhibit certain components of the sonic hedgehog signaling pathway. In 2013, the FDA approved vismodegib, the first small molecule to target this pathway (11). Although these agents seem promising options for patients with G-G syndrome, their efficacy is limited by adverse effects and the development of resistance (23). Logically, a more aggressive approach is necessary if basal cell carcinoma is suspected; subsequently, depending on the lesion site and the surgery type, a reconstruction can be performed, as in the case presented in this article (24,25).

CONCLUSION

Gorlin-Goltz syndrome encompasses a variety of clinical signs and symptoms, including important oral manifestations and skin lesions that must be recognized to achieve early referral to a specialty, thus reducing the risk of malignancy through multidisciplinary treatment.

Ethical responsibilities

In this case report, the informed consent of the patient was obtained. Its elaboration and all the inherent details were based on the Declaration of Helsinki.

Financing

Self-financed

Conflict of interests

The authors declare the non-existence of conflicts of interest.

For more information: https://jmedcasereportsimages.org/about-us/

Basal cell carcinoma is the most common and easiest-to-treat skin cancer. Because basal cell carcinoma spreads slowly, it occurs mostly in adults. Basal cell tumors can take on many forms, including a pearly white or waxy bump, often with visible blood vessels, on the ears, neck, or face. Tumors can also appear as a flat, scaly, flesh-colored or brown patch on the back or chest, or more rarely, a white, waxy scar.

Symptoms

Basal cell carcinoma appears as a change in the skin, such as a growth or a sore that won’t heal. These changes in the skin (lesions) usually have one of the following characteristics:

A flat, scaly, reddish patch with a raised edge is more common on the back or chest. Over time, these patches can grow quite large.

A white, waxy, scar-like lesion without a clearly defined border, called morphea form basal cell carcinoma, is the least common.

A brown, black or blue lesion — or a lesion with dark spots — with a slightly raised, translucent border.

A pearly white, skin-colored or pink bump that is translucent, meaning you can see a bit through the surface. Tiny blood vessels are often visible. In people with darker skin tones, the lesion may be darker but still somewhat translucent. The most common type of basal cell carcinoma, this lesion often appears on the face and ears. The lesion may rupture, bleed and scab over.

A flat, scaly, reddish patch with a raised edge is more common on the back or chest. Over time, these patches can grow quite large.

Causes Of Basal Cell Carcinoma

Almost all basal cell cancers occur on parts of the body excessively exposed to the sun — especially the face, ears, neck, scalp, shoulders, chest and back. On rare occasions, however, tumors develop on unexposed areas

When To See A Doctor

Make an appointment with your doctor or visit your nearest emergency center if you observe changes in the appearance of your skin, such as a new growth, a change in a previous growth or a recurring sore.

Who’s At Risk?

Anyone with a history of sun exposure can develop a basal cell carcinoma. Exposure to ultraviolet (UV) light is the risk factor most closely linked to this cancer.  However, other factors (such as ionizing radiation, chronic arsenic ingestion, and immune suppression, family history, skin type, and genetic syndromes) also potentially contribute to carcinogenesis.  People who are at highest risk have fair skin, blond or red hair, and blue, green, or grey eyes. Those most often affected are older people, but as the number of new cases has increased sharply each year in the last few decades, the average age of patients has steadily decreased.

This type of skin cancer is rarely seen in children, but occasionally a teenager is affected. More and more people in their twenties and thirties are presenting with basal cell carcinoma.

Treatment

A diagnosis of basal cell carcinoma is confirmed with a biopsy. In this procedure, the skin is first numbed with local anesthesia. A piece of tissue is then removed and sent to our pathologists. If tumor cells are present, treatment is required. Fortunately, there are several effective methods for eradicating basal cell carcinoma. The choice of treatment is based on the type, size, location, and depth of penetration of the tumor, the patient’s age and general health, and the likely cosmetic outcome of specific treatments. Treatment can almost always be performed on an outpatient basis. Any pain or discomfort during the procedure is minimal, and pain afterwards is rare.

I am writing this today before I get stitches removed from my face.  I know I am okay deep in my core, even if I am not actually okay.  I went for a normal skin check, thank you heritage and too much sun exposure, and then I heard Basal and the C word, and we are doing a biopsy right now.  I was stunned, but calm, knowing the "spot" wasn't normal for months and then fearing this moment.  A pinch, burn, sting, and then driving myself home with my left eye half covered with a bandage.  Then, just numb. Let me back up.

I have mentioned before on here and on different social media posts that this last 12 months has been one of the hardest years of my life.  Harder than living with a broken home as a little girl and having no idea that that hard wasn't normal.  Harder than defying my mother and moving out and into a relationship she didn't approve of.  More difficult than that same relationship failing and going through a two-plus year long divorce.  Harder than parenting alone and even more difficult than being abused for years and harder than recovering from the night I was raped.  More difficult than health issues and family drama, mental health crisis's and living on less money than could stretch to feed us, and all of the uncertainty of life on a normal day-to-day.  This last 12 months shook me, changed me, and showed me how all of that suddenly seemed to pale in comparison.

To say I am resilient is a fact.  I have survived things that should have killed me. But this last year, which contains the absolute hardest night of my life to date, also involves others, so some of it I have yet to open up about in an effort to protect them.  In time I will find a way to share but for now, you'll just have to believe me when I say that I felt my life impossible to face under this set of events. 

During all of the same time that my life was turning upside down, I was also faced with the wildly overwhelming idea of being on my own and what that meant for what really was the first time in my life.  I compounded the hardest time in my life with my fake sense and need to control, the need to make clear who I was in what felt like an early midlife crisis.  Good timing eh?

At the lowest point, when I struggled to get through the days I finally hit a place in my life where I could no longer get through alone.  I knew I needed help, the kind that my loving family and friends could not provide.  Not for lack of want to or effort, but simply because they are too close to be objective and also were supporting me no matter what.  (Sidenote, I am eternally for all of your support, y'all know who you are. Whether a passing conversation or those nearest and dearest on this journey, I appreciate you!)  I knew I needed the kind of help that only a professional could direct and finally, finally after all of the hard times and suffering of my life, some even beyond what I touched on above, I decided I was worth it. 

I was worth saving.  I knew I had more work to do and feeling familiar with rock-bottom meant I was tired of being a rock-bottom frequent flyer/visitor.  I knew I could overcome.  I knew that my audacious tenacity would eventually pull me through, that years to come I would put in the work and be better for it, all, again.  But now, this time, the cost to recover sooner, the desire to use my pain to launch me into this next phase of life was bigger than my concern over affording it.  My value was worth every penny I put into getting help, every penny.

After all what good can I do in this world if I allowed this kind of suffering to hold me down? Again, again. 

So, I made the decision to make an appointment with a therapist.  I had seen several before and I knew that there is always the risk of it not being a fit.  I have been to a therapist so bad that the urge to walk out mid-meeting was almost more than I could resist.  I have tried therapists who coddle, downplay, judge and underestimate.  They all gave me just what I needed to give up on relying on a professional for help, furthering my reluctance to ever need anyone for that matter.  They all gave me enough incentive to say, "it is too expensive anyway."  Or in other words, I am not worth it.  But this time I had faith that I would find someone who would not deter me from the real work that needed to be done. I knew my life needed savings and the cost became an after thought.  

Facts are, that I could say out loud in the most monotone way, what I survived.  I had stood in front of over one hundred people and told my story.  And yet, I still had not felt my way through the traumas of my life.  I disconnected feeling and emotion from the happenings of my life in an effort to numb, to survive.  And it had served a purpose at some points.  Unfortunately, it also became a habit.

But now, this night, this situation, was in the heart of my heart something I could no longer numb to. It was blaring in my face, "TRACY JEAN!!!!  You have work to do.  You cannot keep going this way.  You have to get better, learn better, DO BETTER! You cannot give what you do not have!"  And so I found my person to help.  Actually, within a few weeks, I found two.  I found my therapist and my life coach.  And when I say they helped me save my life, I mean it with all of the conviction I can.

My therapist, I came by through local word of mouth, my life coach, well I found him on Instagram funny enough.  Let me say here that in my weakest moments something told me there was more for me in this business of helping others.  So, I needed help but I also knew in order to become like my heroes, to fulfill my desires and passions for giving back, I needed to also learn from them.  It was a faint voice under the tormented days but it was there, none the less.  

Therapy is reparative and helps you heal the past in order to move forward, coaching is the acceptance of the past with the directive of massive forward momentum. Healing and recovery plus goals and direction.  In the overlap is the present and also the action.  I knew I had my team.  My family, my friends and this dynamic duo, completely unknown to each other were and are magnifying my worth and value, helping me, holding my pain in their hearts and encouraging my change.  This unearthing of who I am meant to be.  Besides Josephs mom, besides a broken girl, beyond all of the things that happened to me.

This recipe of humans enabling my ability to succeed. 

I started the work, realizing it is never really done, I became my own accountability partner.  Reading, immersing myself in everything I could to immerse my mind in the fuel that helped direct me, propel me, drive me through the acknowledgment, the facing, the overcoming and into the best me I have been yet. 

It wasn't pretty on a lot of days, in fact, sometimes the monumental tasks kept me in bed, or shut down, or with a feeling of being a spinning top with more questions than answers.  But then other days would bring a breakthrough and I found myself a step ahead of my pain, shoulder to shoulder with all of my experiences rather than them strapping me down as they had previously.  I was working through it.  I was getting up and pushing into all of the dark corners and connecting the dots where there was once only blank space.  This puzzle of all of what makes me, me, was taking shape.  There was no loud bang, no poof, and a cure.  It was in the constant and consistent connection to myself, mediations, journaling, reading, showing up for my appointments and myself.  The day-to-day, one foot in front of the other, one breath at a time AND the grace in which I faced my failures.  My grace allows me to be human, to know it is okay to not have it all together, all the time.  It gifts me with the softness I need to recover and heal. 

Grace.

Throughout these past few months, I have come so far.  My therapist helped me give me back my worth, my validation of events, my heart connected to soul and life.  She helped me give myself back all of the grace I so easily handed out to others, she helped me forgive myself years after letting others off the hook so easily.  My coach, man he exploded my brain so many times and still does.  He helped me undo past damage but sent me forward with new perspectives that have helped me change my life.  He guided me to my own truths and answers without judgment.  He allowed me to shout my truths at the top of my lungs and then say "job well done!"  Together they have empowered me to rewrite my story.  My way.  I cannot change this life up to now but I absolutely can grasp this life by the balls, or boobs to be equally un-PC, and make it mine with audacious resiliency.

Shew all good stuff and liberating, overcoming, strength, resiliency-based brain power!  And then my body went, "Oh hey brain, good job!  Well done, I am so proud of you... but uh we need some love now too."

I realized to the detriment of my health I had neglected really taking care of me.  Not on purpose, not in a malicious way.  But in the simple disregard in making an appointment a year earlier when I first noticed the spot on my face as an example.

I am writing this now, before I know the results because I truly, unwaveringly know and believe that I am okay.  Better than that I am chock full of this life and even if there is another obstacle to face because they are bound to come, I trust myself and feel secure in my ability to get through.  I can face things with all of the strength that has its basin and foundation in the depths of my pains... which is deep Y'all!  I have work to do.

As always, I am not reaching out, also read as spilling my guts, for anything in return.  My only hope is to reach those who need the encouragement today.  To possibly fall into the inbox or be read on a post by someone I can help.  This is not about comparison, just my story.  My story being spoken loud enough so that those it can reach hear it with a compassionate hug of "me too".  Life is tough, but you are worth it.

    UPDATE!

My head is still spinning, the results were not good, BUT I AM STILL OKAY!  I have been diagnosed with Basal Cell Carcinoma, but before your head starts to spin too, it is the best kind of skin cancer to have.  It is very common, slow moving, and once removed it should be gone from my body completely.  The reality of it's outcome, it being super common, it being curable and figure-out-able does bring a little relief.

Am I scared? Of course.  

Has it fully sank in? Not really.  And I am sure there will be emotionally charged moments, questions, and the fogginess I felt as the words from my doctor settled over me.  I will be sure to continue to share and spill my guts here about it all in the future.  

Do I know I will be okay and still mean everything I wrote yesterday? ABSOLUTELY.

I have cancer, I am going to face it with every ounce of strength and resiliency that has grown from within me through all of my experience up to this point.

I am a warrior.  Today, I am okay.

PSA - Stop using your skin as payment to worship the sun.  I spent half of my teens with sun-in and baby oil during my summers and my twenties in a tanning bed.  I love the feeling I get from enjoying the sun and being tan... but if I have to look like Casper to keep doing this life, so be it.  SUNSCREEN is your friend!  Use it!

XO