INTRODUCTION
Periocular basal cell carcinoma (BCC) is the most common eyelid malignancy concomitant with ocular morbidity and quality of life impact.1,2 Orbital invasion occurs in 2% of cases and poses challenges for management.1,3 We highlight a multidisciplinary approach to the treatment of advanced periocular BCC.
CASE
We discuss a 56-year-old male who presented for Mohs consultation with recurrent progressive BCC of the left lower forehead extending to the orbital rim. Fourteen years prior, the patient sustained a bike trauma to the left lateral forehead. Ten years later, he underwent a biopsy and surgical excision of a nodular and infiltrative BCC at the previous trauma site.
Eight years after surgery, he reported a new ulcerated nodule in the area adjacent to the excised site with involvement of the left temple and upper eyelid causing swelling and inability to fully close the eye (Figure 1A). Symptoms included left-sided blurred vision with disabling headaches. Clinical examination revealed an ulcerating plaque with pink rolled borders on the left forehead extending laterally to the left temple and upper eyelid, with associated eyelid edema and ptosis. Histopathology showed nodular and infiltrative BCC (Figure 2). CT-head with contrast
showed an infiltrative soft tissue mass involving lateral aspects of the left periorbital soft tissue with possible involvement of the superior palpebris muscle. There was swelling of the left upper eyelid and a tumor near the globe without involvement of extraocular muscles. CT-chest, abdomen, and pelvis showed no evidence of distant metastasis.
Worsening blurred vision and headaches signified rapid tumor growth. Given the tumor's effects and location, a multidisciplinary team including dermatologic surgery, ophthalmology, otolaryngology, and oncology was convened to discuss treatment options. Neoadjuvant treatment with vismodegib was initiated, as curative surgical excision at this time could result in eye exenteration and vision loss.4 Within 2 weeks of starting oral vismodegib 150 mg daily, the patient reported resolving cutaneous lesions and complete relief of headaches and blurred vision. Four months after vismodegib initiation, repeat CT-head revealed an interval decrease in the prominence of ill-defined multilobulated pre-septal soft tissue within the left-upper eyelid and periorbital regions, indicating treatment response.
Eight months after vismodegib initiation (Figure 1B), repeat CT-head and MRI of the orbit showed continued tumor resolution. At this time, tumor resection was performed by the dermatologic surgeon, and closure with right radial forearm free flap reconstruction was performed by the otolaryngologist
