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 (ErivedgeÂ®; 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.