Oral Hedgehog Pathway Inhibition as a Means for Ocular Salvage in Locally Advanced Intraorbital Basal Cell Carcinoma

Advanced Periocular Basal Cell Carcinoma with Orbital Invasion: Update on Management and Treatment Advances

Purpose

Basal cell carcinoma (BCC) is the most frequent malignant periocular tumor. It is associated with exposure to ultraviolet radiation, and its incidence is gradually increasing. It may occasionally display more aggressive behavior and result in orbital or intracranial invasion. Mortality from periocular BBC with orbital invasion is very low, but the associated morbidity can be significant, from disfigurement to blindness. Traditionally, these cases have been treated with orbital exenteration or with radiotherapy (RT), but in recent years, hedgehog pathway inhibitors (HPIs) have emerged, are effective in more serious cases, and are used primarily or combined with surgery, changing our perspective on the management of these patients.

Methods

We studied 24 cases of periocular BCC with orbital invasion, some primary and others recurrent, which were treated between 2011 and 2021 in the same hospital. All patients had clinical or radiological evidence of orbital invasion. Orbital exenteration was performed on 9/24 of the patients (1 received vismodegib after surgery), and 12/24 were treated, surgically preserving the eyeball, with 3 of them receiving adjuvant vismodegib. Three of the twenty-four patients were treated exclusively with vismodegib (Erivedge®, Genentech).

Results

One patient died due to poor tumor evolution, but the rest evolved favorably and they have had no recurrences. Vismodegib was generally well tolerated, except for in one patient who discontinued treatment due to the side effects.

Conclusions

In advanced BBC with orbital invasion, mutilating surgical treatments such as exenteration or potentially vision-threatening treatments such as RT remain as options. In recent years, however, very promising new medical therapies have emerged, such as HPI, which can be used effectively instead of surgery or in combination with it, preserving the eye and vision, which implies a new approach to treatment.

The Role of Surgery After Remission of Nonsystemic Extensive Periorbital Basal Cell Carcinoma Treated by Vismodegib: A Systematic Review

BACKGROUND

Eyelid basal cell carcinoma (BCC) is usually cured by surgery. However, for a minority of patients, extensive disease progression and recurrence contraindicate surgery or radiotherapy because of severe ocular morbidity. The hedgehog signaling pathway inhibitor vismodegib is becoming the key treatment for this specific form.

OBJECTIVE

The aim of this review was to define the role of surgery after vismodegib treatment.

MATERIALS AND METHODS

A literature search of the PubMed, Cochrane Library, ScienceDirect, and Embase databases was conducted for all articles published up to March 2021 to identify studies that examined treatment of BCC of the eyelid by vismodegib.

RESULTS

Level 1 evidence was found for the use of vismodegib as neoadjuvant therapy in locally advanced eyelid BCC contraindicated to surgery and/or radiotherapy with a rather good tolerance of treatment. Level 3 evidence was found for the role of surgical excision of residual clinically suspicious lesions as for the indication of eyelid reconstruction after mapping or during residual tumoral resection if frozen sections or Mohs surgery were performed.

CONCLUSION

Vismodegib is a well-tolerated treatment for advanced periorbital BCC. The hedgehog signaling pathway inhibitor vismodegib is a potential treatment option in patients with these challenging tumors.

Treatment of Advanced Basal Cell Carcinoma with Hedgehog Pathway Inhibitors: A Multidisciplinary Expert Meeting

Despite recent progress and the publishing of several clinical guidelines on the management of advanced basal cell carcinoma, there is still no comprehensive set of clinical guidelines addressing the complexity inherent to the use of Hedgehog pathway inhibitors in the treatment of advanced basal cell carcinoma in real-world clinical practice. To develop practical and valuable tools that help specialists improve the clinical management of these patients, we sought the opinion of expert physicians with extensive knowledge and experience in the treatment of advanced basal cell carcinoma.

[Alternative treatment options for periorbital basal cell carcinoma]

BACKGROUND

Latest developments as well as established procedures offer alternative treatment approaches to basal cell carcinoma (BCC) when micrographically controlled surgical removal is not a valid option.

OBJECTIVE

Alternative treatment options for periorbital BCC are presented.

METHODS

A literature search was carried out and a structured display and analysis of the results are given.

RESULTS

Micrographically controlled surgical removal represents the gold standard in treatment of BCC. When for various reasons surgical removal is not a valid option, other procedures are required. The alternative treatment options can be divided into three main groups: treatment options for locally advanced or metastasized BCC, topical approaches for small and superficial BCC and prophylactic measures. While radiotherapy and systemic therapy are suitable for locally advanced BCC and are discussed in a tumor board, small and superficial BCC can be treated by topical medication. In cases of a previous BCC history, a prophylactic treatment can be considered. Combinations of systemic treatment and also neoadjuvant or adjuvant approaches before and after surgery are promising options for a successful outcome, which can further improve the standard treatment for locally advanced BCC.

CONCLUSION

Alternative treatment options for periocular BCC are available; however, the use is only indicated when microscopically controlled excision with subsequent oculoplastic reconstruction is not possible. According to the national guidelines a prior presentation to a suitable tumor board is practically compulsory.

Vismodegib for periocular basal cell carcinoma: an international multicentre case series

INTRODUCTION

Vismodegib (Erivedge, Genentech) is a first-in-class inhibitor of the hedgehog (Hh) pathway, which is licensed for use in locally advanced basal cell carcinoma (BCC) and metastatic BCC. The National Institute for Health and Care Excellence withdrew recommendation for use of vismodegib secondary to a lack of data comparing vismodegib to standard supportive care. The purpose of this multicentre, international case series is to report outcomes of patients with locally advanced periocular BCC who have been treated with vismodegib.

METHODS

The medical records of all patients treated with vismodegib were retrospectively reviewed across seven institutions in the United Kingdom, Australia, and New Zealand.

RESULTS

Thirteen patients were identified. Seven (54%) patients were male. All BCCs were ill-defined, with seven (58%) having orbital involvement at presentation. Median treatment time was 7 months (range 2-36 months). Eleven out of 13 patients developed side effects, the most common being fatigue in six patients (46%). Median follow-up was 24 months (range 12-48 months). Complete response was found in 5/13 patients (38%) and a partial response in 8/13 patients (62%). Six patients had further surgery after vismodegib, with three classed as globe-sparing operations. Three patients developed recurrence (23%). Three patients (23%) ultimately underwent exenteration.

DISCUSSION

This study demonstrates vismodegib to be a well-tolerated treatment which may, in some cases, facilitate globe-sparing surgery and hence avoid disfiguring operations such as exenteration. Uncertainty does remain regarding the long-term outcomes of patients treated with vismodegib.