INTRODUCTION
Basal cell carcinoma (BCC) is the most common cancer amongst men and women.1 The majority of non-superficial BCCs are treatable either by surgery or radiotherapy. Some BCC’s especially while neglected, become aggressive with potential local destruction, disfiguring and a rare chance of metastases.2 When a BCC becomes locally aggressive the role of surgery and or radiotherapy becomes less efficient. In these cases surgery can result in loss of function of vital structures such as the nose, eyelids, ears and lips and also in severe cosmetic defect. More than 90% of patients with BCC have a mutation in the hedgehog (Hh) signaling pathway.3 Recently, Vismodegib (Erivedge, Roche) was found to be a potent inhibitor of the Hh pathway and was approved for the treatment of locally advanced and metastatic BCC’s that are not amendable for surgery or radiotherapy.4,5 We report 2 patients with three aggressive BCC’s in whom Vismodegib served as a useful neoadjuvant therapy prior to Mohs micrographic surgery.
Patients
Two patients with three locally aggressive BCC’s received Vismodegib for 6 months prior to Mohs surgery.
Patient 1. A 70-year-old woman was referred for Mohs surgery because of growing tumor on the nose for 10 years. A large “bunch of grapes†like tumor was seen on the lower half of the nose. (Figure 1). She also had a large BCC on the forehead (Figure1). An attempt to decrease the size of the tumors prior to Mohs surgery was initiated. Treatment with Vismodegib 150 mg per day was initiated. At the end of 6 months treatment, the tumor on the forehead had completely disappeared clinically, and the tumor of the nose was reduced dramatically more than 60% of its original size (Figure 1). One month after session of the oral treatment the patient underwent Mohs surgery in the forehead and nose. Margins were marked at the clinical border of the atrophic scar in the forehead, and at the clinical border of the tumor on the nose. Despite clinical elimination of the forehead tumor, remnants of tumor were found in the debulking stage (Figure 2). The forehead defect was closed primarily after one stage. The tumor of the nose required 2 stages of Mohs surgery to clean the tumor. The surgical defect was closed by full-thickness graft from the preauicular area (Figure 2). Follow-up for 6 months after surgery revealed no recurrences.
Patient 2. A 70-year-old male had a recurrent nodular BCC on the left upper lip-cheek junction. Two operations were performed before he showed up with a 2cm subcutaneous firm nodule which caused retraction of the left upper lip (Figure 3a, b). Biopsy revealed BCC. We decided to try to shrink the tumor with
