Frontline Forum Part 4: Improving Basal Cell Carcinoma Management

Continued from part 3

Real-World Clinical Cases of BCC Treatment

#1: Man With Large BCC on the Left Temple

For Schlesinger’s patient with a large BCC lesion on his left temple, the panelists said they would likely choose Mohs surgery. Assessing the risk of disease progression is important because the lesion’s raised appearance suggests a high likelihood of deep invasion, microscopic positive margins after surgery, and lymph node involvement, said Schlesinger. Ruiz said that if she chose surgery, she would also counsel the patient about the possibility of losing the temporal nerve.

If the patient opted against surgery, definitive radiation therapy would be preferred by many of the panelists. For these patients, Arron and Zeitouni noted that they book follow-up appointments after the patients meet with the radiation oncologist because patients often become more amenable to surgery after learning that the radiation protocol is several weeks long and there is a possibility of hair loss in the radiated area.

“I make sure that we close the loop, so that they don’t go off to the radiation oncologist and then we have no idea [what happened to them],” said Zeitouni.

#2: Use of Cemiplimab to Treat 50-Year-Old Man With Multiple BCCs

Schlesinger discussed his use of cemiplimab to treat a patient with multiple lesions on his body, including a large (approximately 8 x 10 cm) BCC on his chest. The choice was primarily due to the large size of the tumor, potential morbidity associated with multiple complex surgeries, and concerns about adherence to oral therapies. Additionally, asking the patient to come to the oncologist’s office to receive the infusion allowed for close management of AEs, said Schlesinger.

Arron agreed that she would have chosen a systemic therapy in this case, but she noted that systemic therapies may not be the optimal treatment for all patients with multiple BCCs because of the AEs and morbidity associated with treatment. Depth of invasion is important to consider when deciding between systemic therapy and surgery, said Ruiz; for example, surgical resection of a BCC with involvement of nerves, tendon, or bone could result in functional deficits.

For isolated tumors, definitive radiation could be an option with a durable response, but Ruiz noted that a multidisciplinary discussion is warranted because of the possibility of functional deficits after treatment. The panelists also cautioned that the choice of therapy should be carefully considered for patients who have had or are likely to need an organ transplant, as immunotherapy agents could make a patient ineligible for transplantation or increase the risk of a graft rejection.

#3: Woman Aged 69 Years With a Multiply Recurrent Lesion on the Left Temple

Justine Cohen, DO, said neoadjuvant vismodegib 150 mg daily yielded a remarkable response and was tolerated well by one of her patients, a 69-year-old woman with a painful, bleeding lesion on her left temple. She had undergone multiple surgeries and recurrences for it before 2009, when she lost health insurance. Cohen noted that although surgery may be the most straightforward option with the least effort in terms of adherence, she chose to start with a systemic therapy because this patient’s tumor was initially too extensive for surgery or radiation therapy. Because the vismodegib was well tolerated and was covered financially, the patient has not undergone further surgery; she continues to take vismodegib more than 1 year later.

“There’s a role for giving targeted therapy if you want an up-front, really fast response,” said Cohen. “If you want the durable response and you don’t think this patient is going to go for surgery, you may want to start with immunotherapy.”

Zeitouni added that some of her patients have opted for vismodegib because they are hesitant to make another consultation appointment with an oncologist about immunotherapy, but some of these patients become more willing to try immunotherapy after the AEs of the vismodegib start to affect them more.

“There is a role for being able to start something quickly with your patient who may have had enough of a psychosocial distrust of doctors that they don’t want to go for infusions or they don’t want to meet another doctor yet,” said Zeitouni.

#4: Man Aged 69 Years With a Fixed BCC on His Nose and a Tethered BCC on His Lip

The panelists discussed their treatment strategy for one of Ruiz’s patients, a 69-year-old man with a fixed BCC on his nose and a tethered BCC on his lip that was invading the mandible and involving submandibular lymph nodes. The patient opted for vismodegib over a surgery-only strategy that would have involved multiple flaps, bilateral neck dissections, a mandibulectomy, and multiple skin and bone grafts. After 3 months, the tumor on the nose responded well, but the lip tumor had grown larger. A rebiopsy of the area revealed a PTCH1 mutation that differed from the PTCH1 mutation found in the nose lesion and was not targetable by hedgehog pathway inhibitors. The patient opted for radiation therapy over immunotherapy for the lip tumor, which yielded a relatively good response that has been maintained 3 years later. Ruiz noted that she likely would have offered only immunotherapy if the patient had a tumor with both squamous and basal cell components, given the rapid growth observed while on vismodegib. Although radiation therapy was an option in this case, Arron and Ruiz noted that its application near the mouth may require tooth extraction prior to treatment for patients with poor dentition or may cause dental issues after treatment.

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