Concerned about a lesion between her eyes, a 91-year-old woman sought medical evaluation (A). She had not seen a physician for 23 years. Dr Roy T. Rapp of Quincy, Ill, writes that the patient was strong-willed and alert, with no evidence of Alzheimer disease. A huge goiter was evident. Iodine-deficiency goiter is prevalent in the St Lawrence Valley and in the Great Lakes region of the United States, where this woman spent her life. The patient refused cosmetic operative removal of the goiter and medical therapy; she did, however, accept a box of iodized salt. The facial lesion was excised, and the wound healed uneventfully (B). The pathologic examination of the excised lesion revealed a basal cell carcinoma with clear margins. Because of the possibility of recurrence, follow- up radiation therapy was offered; the patient rejected the treatment. The lesion reappeared 21 months later. To avoid a skin graft, which would likely be necessary with re-excision, radiation therapy was administered. A total tumor dose of 6000 to 6600 cGy was given in about 6 weeks using a 9 million volt electron beam. There has been no recurrence; the patient remains in good health.