Treatment of Margin Positive Basal Cell Carcinoma With Vismodegib: Case Report and Consideration of Treatment Options and Their Implications
October 2013 | Volume 12 | Issue 10 | Supplement | s147 | Copyright © 2013
Stephanie Bayers BSBA,a Daniel L. Kapp MD FACS,b
Kenneth R. Beer MD FAAD,b and Benjamin Slavinc
aUniversity of Miami Miller School of Medicine, Miami, FL
bPalm Beach Plastic Surgery Center, West Palm Beach, FL
cUniversity of Miami, Miami, FL
Historically, basal cell carcinomas (BCCs) that are neither surgically resectable nor candidates for radiation therapy have had few treatment options. The hedgehog pathway inhibitor, vismodegib, represents a new opportunity for the treatment of such patients. Vismodegib has approval from the United States Food and Drug Administration for treatment of metastatic BCC, locally advanced BCC recurring after surgery, and BCC that is not treatable via surgery or radiation. We present the case of a patient with a BCC infiltrating the spinal column that was neither possible to fully remove surgically nor a candidate for primary treatment with radiation. Treatment with vismodegib followed by adjuvant radiation therapy resulted in complete disease clearance. Vismodegib represents a promising treatment option for patients with surgically non-resectable BCCs that are not candidates for radiation therapy. Mechanism of action, benefits, and adverse events of vismodegib are reviewed, along with a brief discussion on newer options in the hedgehog inhibitor class.
J Drugs Dermatol. 2013;12(suppl 10):s147-s150.
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Basal cell carcinoma (BCC) is frequently associated with mutations in the s (PTCH) gene leading to dysregulation of the hedgehog (Hh) pathway.1-3 This mutation is seen in more than 90% of BCCs and causes uninhibited tumor growth. Fortunately, the majority of BCCs are easily treated with a variety of modalities including surgery (electrodesiccation and curettage, Mohs), radiation, topical immunomodulation, and cryosurgery. However, for some patients, the removal of a BCC, either using Mohs micrographic surgery or intraoperative frozen sections, may not result in clear pathologic margins. For these patients, subsequent treatment is not standardized, but options usually include additional Mohs, radiation, or, for those unable to undergo further surgery or radiation, topical 5-fluorouracil, topical imiquimod, photodynamic therapy, or cryotherapy.4-7 Lesions that are surgically non-resectable due to their proximity to vital structures or the risk of cosmetic deformation may also not be subject to radiation therapy. Moreover, when surgical extirpation of BCCs is aborted because of their proximity to adjacent sensitive structures, such as peripheral motor nerves or the central nervous system, the possibility of adjunctive radiation therapy is often ruled out too. Until recently, traditional chemotherapy has been ineffective for the treatment of BCCs, and patients with non-resectable BCC have had few treatment options. However, the advent of vismodegib (Erivedge®; Genentech) presents an opportunity to treat patients with partially resected disease.
This population of patients represents an unmet need with historically few treatment options. In this report, we discuss one patient treated with vismodegib following positive surgical margins. In addition to a discussion of vismodegib, therapeutic choices available to control BCC postoperatively when positive margins are obtained will also be discussed.
A 69 year-old man presented to his primary care physician with a large lesion on his back (Figure 1). According to the patient, the lesion had been there for more than 10 years and was not causing him any discomfort. He had been caring for the lesion at home with simple dry dressing changes. However, when it began to bleed on a consistent basis, he sought care from his primary care physician. The patient was ultimately admitted to the hospital for evaluation and management of the lesion.
Examination at presentation revealed a 24 cm x 30 cm lesion on his middle back. There was adhesion to the underlying structures with a friable, hypergranulated surface. Computed tomography (CT) scans revealed a large lesion extending from T5 to T11 that measured approximately 17 cm (Figure 2). A surgical biopsy demonstrated an infiltrative BCC (Figure 3). Based on the physical examination, it was decided that resection of the lesion would be the optimal treatment approach.