Locally Advanced Basal Cell Carcinoma: Two Severe Case Presentations and Review

Case 1Case 1 is a 56-year-old male with past medical history of hypertension and basal cell carcinoma (BCC) who first presented to Larkin Community Hospital February 2015. Upon presentation, he had extensive ulceration with surgical reconstruction to the left face/orbit secondary to an advanced BCC that was diagnosed 13 years prior in 2002 and was complaining of increasing pain and purulent discharge of the uninvolved right eye with concern that his cancer was spreading (Figure 1).The patient stated the original lesion started in 2002 as a small ulceration under the left orbit, which was biopsied and confirmed to be BCC at that time. The patient was lost to follow-up and finally returned for excision of the lesion in 2007 when the ulceration was >5 cm in size. Due to the vast size of the surgical defect, he was sent to Bascom Palmer Eye Institute/Sylvester cancer center for skin graft closure from the left thigh. In April of 2007, the pathology report of surgical margins returned with positive margins extending deep through subcutaneous fat. At this time, he was referred for radiation treatment of positive margins but did not follow up through multiple attempts to schedule radiation therapy. He admitted to being lost to follow-up due to personal issues and socio-economic difficulties for the following 8 years.Upon admission to Larkin Community Hospital, a multi-specialty team approach was initiated. Dermatology, Plastic Surgery, Ophthalmology, Family Medicine, Pain Management, and Wound Care were involved in care. On examination, the patient had a large ulceration with a skin flap over the left face/orbit with a purulent green discharge from his eyes, bilaterally. CT scan of brain, maxillofacial, and orbits were performed at that time and showed extensive soft tissue thickening of the left face where reconstructive surgery was performed as well as soft tissue thickening of bilateral orbits with erosive osseous changes near the cribriform plate. These changes were believed to be tumor spread as well as cellulitis of affected regions. The patient was placed on Vancomycin and Zosyn IV therapy as well as Ocuflox 0.3% ophthalmic drops Q1 hour while awake for treatment of his cellulitis. Cultures eventually grew Proteus mirabalis bacteria. Blood cultures remained negative and vitals were stable throughout admission. Pain was controlled through multiple opioid pain medications.Dermatology decided that the patient would be a good candidate for treatment with Vismodegib 150mg PO daily for treatment of his locally invasive BCC. Even though he had already suffered from extensive facial deformity, it was believed that this medication would potentially help preserve his vision in the right eye and prevent further maxillofacial and intracranial invasion. Through the patient assistance program, he was approved for therapy. He was eventually discharged to a nursing home and scheduled to follow-up as an outpatient at the dermatology clinic. Per nursing home staff, he refused medications and outpatient follow-up care. He has since been admitted for recurrent cellulitis and extension of tumor five times over the past year, his behavior has become increasingly agitated, and he refuses medications occasionally throughout his admissions. He has been seen by psychiatry and started on anti-depressants to help treat the psychological impact of the deformity. He continues to refuse Vismodegib although it was approved through assistance programs multiple times. His last admission to the community hospital was December 2015 for continued right facial and orbital pain. He was again placed on Zosyn, and Ocuflox 0.3% antibiotic drops for his recurrent Proteus mirabalis cellulitis. Repeat CT scans at this time showed cellulitis as well as possible infiltration of tumor to maxillary sinus cavities. Secondary to non-compliance issues with