Case: “Difficult-to-Operate” Basal Cell Carcinoma

Sanjiv S. Agarwala, MD

Uncategorized

Surgery may not be appropriate in advanced basal cell carcinoma (BCC), such as those in difficult-to-treat locations or when the deformity would be substantial. At the Third Annual World Cutaneous Malignancies Congress, a panel discussed a complex case of advanced BCC, offering their opinions on the need for imaging, surgery, radiation, and new oral agents.

Case: Basal Cell Carcinoma

A 70-year-old widower presents with an enlarging, bleeding mass (approximately 5-6 cm) on the right ear and posterior auricular scalp. This patient has an extensive history of sun exposure secondary to lifelong outdoor construction work, and he hasn’t seen a physician in 25 years.

What Would Be Your Next Step?

• Computed tomography (CT) of the head and neck
  
• Referral to a plastic surgeon
  
• Referral to a radiation oncologist
  
• Initiate cisplatin-based therapy

“Because it’s on the right ear and posterior auricular scalp, you would need CT,” said Reinhard Dummer, MD, Vice Chairman, Department of Dermatology, University Hospital Zurich, Switzerland. “In Switzerland, I would use positron emission tomography-CT.”

Imaging demonstrates involvement of the deeper layers of the fat and muscle. After further consultation with a surgeon and radiation oncologist, the patient is deemed difficult to resect because of the extensive involvement.

“This is straightforward unresectable,” said Sanjiv S. Agarwala, MD, Chief of Oncology and Hematology, St. Luke’s Cancer Center, Bethlehem, PA.

In Germany, the term “inoperable” is not favored, but rather “surgery is not appropriate,” said Axel Hauschild, MD, Professor of Dermatology, Schleswig-Holstein University Hospital, Kiel, Germany. The decision to operate or not must be made in a tumor board. Radiation treatment for difficult-to-operate advanced BCC is an option, with patient preference being a deciding factor, he said.

Depending on the exact location of the mass and the amount of radiation required, “there may be other potential consequences of radiation that would make radiation less optimal,” said Aleksander Sekulic, MD, PhD, dermatologist at the Mayo Clinic Arizona, Scottsdale. “If radiation is thought of as less optimal, I think oral medication would be my next choice.”

Activation of the Hedgehog signaling pathway is the pivotal molecular abnormality in BCC carcinogenesis. Vismodegib (a Smoothened antagonist) is an inhibitor of this pathway that has been approved in the United States for the treatment of locally advanced or metastatic BCC that is not amenable to surgery and radiation.

“Without information of infiltration in bones or cartilage, this is actually not a case for Smoothened inhibitors,” said Dummer. “At least in my tumor board, I would have a very hard time defending it.”

The patient has a recurrence after surgery. Is it now appropriate for an oral agent (ie, Smoothened inhibitor)?

“Yes, after both surgery and radiation,” said Sekulic.

“The new adjuvant story is the most complicated story because I don’t know how to resect a tumor after the patient has been treated with a Hedgehog inhibitor, because the margins are unclear,” said Hauschild. “It could well be that the tumor looks like half of its initial size, but there may be one tumor clone that is invisible in the depths, and this is the relapse. If it’s resected too small, I have a problem. The new adjuvant approach sounds extremely attractive, but this is a most complicated clinical trial.”

Clinical trials of the combination of radiation therapy and Smoothened inhibitors are ongoing in an effort to prolong response in patients with advanced BCC, said Jean Tang, MD, PhD, Associate Professor of Dermatology, Stanford University Medical Center, CA.

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