Giant Morpheaform Basal Cell Carcinoma Mimicking Scarring Alopecia: Exception Prone to Neglect

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article oscillates between a report on alopecia neoplastica (AN), here secondary to a giant basal cell carcinoma (GBCC), and a report on GBCC on the scalp; the second is clearly predominant, and such the title is misleading, since the title leads one to expect an article on alopecia. If you want to emphasize AN, then you need to broaden the differential diagnosis and the considerations on this topic, such as mentioning the look-alikes of crusted cicatricial alopecia (e.g., a crusted ulcerated BCC imitating what seems to be an erosive pustular dermatosis of the scalp with crust). I like the in-depth discussion, but I miss a clear direction.

The introduction needs to be revised (redundancy of lines 28-30 and 34-35).

Author Response

I am grateful for your comments. I have significantly reduced the discussion on  GBBC with the aim to make the discussion more harmonious and fluid.

In figure 1, I have pointed out that the crust visible at the level of the plaque is actually the outcome of the biopsy. Indeed, the surface of the plaque was completely smooth, with no erosions or ulcerations.

The introduction has been revised and redundancy has been eliminated.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript presents an interesting case detailing the clinical misdiagnosis of basal cell carcinoma (BCC) as androgenetic alopecia. The text is well-written and organized. It discusses various aspects including a review of other neoplasias that can present as secondary alopecias, the reasons for the delayed diagnosis, dermatoscopical aspects, treatment, and even a paragraph discussing the molecular background of BCC, although its relevance in this context may not be entirely clear. The paper also includes a brief mention of the histopathological diagnosis of basal cell carcinoma, which in this case can be straightforwardly performed on the hematoxylin and eosin slides. It highlights also the limited utility of immunohistochemistry in its differential diagnosis from certain metastatic tumors.

Author Response

We are grateful for your comments and appreciation. The manuscript has been reduced significantly and the discussion on the molecular background of BCC has been omitted.

Reviewer 3 Report

Comments and Suggestions for Authors

This is an interesting article of a patient with a history of apocrine breast carcinoma presenting with a giant morpheaform BCC on the scalp.

Was EMA performed? A negative EMA and a positive BerEP4 staining would be helpful in supporting a diagnosis of BCC, while excluding other differentials such as a moderately differentiated SCC or basosquamous carcinoma. It would also be another useful IHC to differentiate between the scalp BCC and apocrine breast carcinoma.

It would be clearer if photomicrographs and relevant IHC stains for the scalp BCC are placed in Figure 2, and the apocrine breast carcinoma case (H&E and relevant IHCs) be placed in Figure 3, rather than placing both the in the same figure. Separate figures will be able to highlight the differences to the readers more effectively.

A medium power photomicrograph of the scalp BCC would be helpful, in addition to the low and high-power photomicrographs the authors have provided.

Comments on the Quality of English Language

This article needs to be vetted by a native English speaker.

Author Response

We are grateful for this reviewer comments.  EMA and BER-P4 have been performed and the results have been added in the text and placed in the Figure 2. A medium power photomicrograph of the scalp BCC has been added.

The manuscript has been vetted by a native English speaker

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Now, after revision, the case as such is well presented and worthy of publication somewhere; in my opinion, a purely clinical journal would be more appropriate (e.g., www.jaadcasereports.org), but that is your and the editors' decision.

Reviewer 2 Report

Comments and Suggestions for Authors

This clinical case report is quite extraordinary and will likely be very useful for clinical dermatologists. However, its relevance from a dermatopathological perspective is very limited. Despite this, the paper is well-written and addresses several interesting general topics. While I believe it might be more appropriate for a clinical journal, it could still fit within the scope of Dermatopathology.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the changes made. I do not have any other comments.