Cytoreductive approach with hedgehog inhibitors followed by reflectance confocal microscopy assisted Mohs surgery for morpheiform basal cell carcinoma

Hedgehog pathway inhibitors (HHI) combined with radiotherapy and immunotherapy for advanced basal cell carcinoma: a case report

PURPOSE

Basal cell carcinoma (BCC) is one of the most common skin cancers. Most BCCs can be treated with surgery excision. For advanced BCC unsuitable for curative surgery, the combination of radiotherapy and Hedgehog pathway inhibitors (HHI) are effective systemic treatment options. However, there is a scarcity of evidence-based guidelines for the management of patients with advanced or metastatic BCC, particularly those who develop resistance to HHI therapy.

MATERIALS AND METHODS

We report the case of a patient with advanced BCC of the head and neck, which originated from a nevus sebaceous.

RESULTS

The patient initially responded well to sonidegib, an HHI, but resistance emerged within a month. We then modified the systemic therapy to include a combination of radiotherapy and the anti-PD-1 agent sintilimab.

CONCLUSIONS

This adjusted treatment regimen led to effective long-term clinical responses without significant adverse events.

Current treatment options for locally advanced and metastatic basal cell carcinoma. A narrative review

INTRODUCTION

Although basal cell carcinomas (BCC) are the most common skin cancer and usually considered as 'easy-to-treat,' locally advanced BCC (laBCC) and metastatic BCC (mBCC) are rather exceptional and often more 'difficult-to-treat.' They load a high burden on the quality of life (QoL) of the patients, often elderly and frail individuals. Several management options are possible, varying from supportive therapy without any therapeutic intervention until anti-programmed cell death protein-1 (PD-1) immunotherapy, such as cemiplimab, either administered intravenously or intralesional. In between this spectrum, oral hedgehog inhibitors including vismodegib and sonidegib, electrochemotherapy, different types of radiotherapy, and surgery can be considered. CAR-T cell therapy, anti-LAG therapy, and multiple combination therapies are currently under investigation for laBCC and mBCC.

AREAS COVERED

Current and future treatment options for the management of laBCC and mBCC, limitations of different approaches as well as some practical and financial aspects are presented.

EXPERT OPINION

The management of laBCC and mBCC patients is determined by a multidisciplinary dermato-oncology board, including dermatologists, medical oncologists, radiotherapists, pathologists, and surgeons, as well as the patient's GP. Today, experts recommend keeping as long as possible laBCC and mBCC patients under sequential courses of HHIs, if surgery and/or radiotherapy are not amenable.