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
