Multidisciplinary Management of Advanced Basal Cell Carcinoma: Report of Four Cases

May 2014 | Volume 13 | Issue 5 | Case Report | 601 | Copyright © 2014

Justin Yu BS*,a Bishr Aldabagh MD*,b Jennifer Wang BA,f Sue S. Yom MD,c,d Ivan El-Sayed MD,d
Daniel Knott MD,d Mary H. McGrath MD MPH,e and Sarah Arron MD PhDb
For the UCSF High Risk Skin Cancer Program

aDepartment of Dermatology, St. Louis University, St. Louis, MO
bDepartment of Dermatology, University of California San Francisco, San Francisco, CA
cDepartment of Radiation Oncology, University of California San Francisco, San Francisco, CA
dDepartment of Otolaryngology – Head & Neck Surgery, University of California San Francisco, San Francisco, CA
eDivision of Plastic Surgery, University of California San Francisco, San Francisco, CA
fDepartment of Dermatology, New York Medical College, Valhalla, NY
*Mr. Yu and Dr. Aldabagh contributed equally to this article

Abstract

BACKGROUND: Advanced basal cell carcinomas (BCC) are neoplasms with high-risk clinical characteristics that can develop as locally advanced disease or metastasis. Treatment of advanced BCC may result in significant morbidity due to the technical challenges of size and/or location or in which surgery and radiation therapy may be contraindicated. No standard of care exists for the management of advanced BCC. As such, the difficulty in managing these tumors necessitates a multidisciplinary approach to patient care.
METHODS: We report four cases of advanced BCC that benefited from a multidisciplinary approach, as well as highlight treatment considerations and factors in the development of advanced BCC.
RESULTS: All four complex cases of advanced BCC presented to a multidisciplinary non-melanoma skin cancer tumor board with extensive tumor involvement. Treatment of disease was effective in preventing recurrence while optimizing aesthetic outcomes.
CONCLUSIONS: The multidisciplinary tumor board has a central and important role in the evaluation and management of advanced BCC.

J Drugs Dermatol. 2014;13(5):601-606.

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INTRODUCTION

Basal cell carcinoma (BCC) is the most common neoplasm in the United States. It is slow growing but will cause local destruction over time, leading to disfigurement and even metastasis if left untreated.1,2 BCCs can be categorized as low- or high-risk with certain clinical characteristics predictive of high-risk subtypes (Table 1). Low-risk BCCs may be treated via destruction, surgery, radiation, or topical therapy. Because of increased risk for recurrence or metastasis, high-risk BCCs should be treated according to oncologically oriented management standards. The National Comprehensive Cancer Network (NCCN) recommends Mohs micrographic surgery (MMS) or radiation therapy (RT) for non-surgical candidates as the primary initial treatment. If residual disease remains, the recommendation is to proceed with evaluation by a multidisciplinary tumor board with consideration of clinical trials and vismodegib (GDC-0449, Genentech), a first-in-class hedgehog pathway inhibitor approved in January 2012.3 The paucity of randomized, prospective, comparative studies guiding treatment of complicated cases of BCC presents a challenge in interpreting treatment guidelines.4 In rare cases, BCCs can become so extensive that treatment may result in significant morbidity due to the technical challenges of its size and/or location, or result in the decision that the patient is not a candidate for radiation or surgery. No standard therapeutic algorithm exists for these advanced BCCs, and the challenges of managing these tumors necessitate a multidisciplinary approach to care. UCSF holds a monthly non-melanoma skin cancer tumor board (NMSC-TB) to review cases of rare or complex cutaneous tumors requiring multi-specialty input. Herein, we present four cases of advanced BCC that were managed with a multidisciplinary approach (Table 2).

MATERIALS AND METHODS

Patient 1

A 50-year-old Caucasian male presented with BCC of the left forehead, measuring 3.0 x 3.0 cm in a background of hyperpigmentation surrounded by multiple skin-colored and pearly papules. Recurrence occurred four years prior after MMS and one year prior after MMS followed by RT to a dose of 50 Gy over 20 fractions. Past medical history was significant for a remote history of left tonsillar non-Hodgkin’s lymphoma treated successfully with chemotherapy and radiation. Repeat MMS of biopsy confirmed recurrent, nodular, and infiltrative BCCs with perineural invasion of the supratrochlear and supraorbital nerve. The procedure was aborted after the eighth stage, leaving a 9.0 x 7.0 cm defect (Figure 1) repaired with a split-thickness skin graft. Subsequent MRI revealed no evidence of perineural spread along the supraorbital nerve; however, scout

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