Successful Management of Basal Cell Carcinoma in a Challenging Location with a Multimodal Approach
Case author Mark Lebwohl, MD, presents a case of a 86-year-old male with a progressively enlarging erythematous nodular mass with overlying telangiectases.
By Mark Lebwohl, MD
Case presentation and medical history summary
An 86-year-old male presented with a progressively enlarging, 2- to 3-cm erythematous nodular mass with overlying telangiectases. Concurrently, the patient reported recurrent bleeding from the left medial canthal region.
The patient's medical history revealed notable cardiovascular conditions, including atrial fibrillation, congestive heart failure, and hyperlipidemia. Additionally, he had a history of moderate chronic kidney disease. Management of psoriasis vulgaris with risankizumab was also noted.
Physical exam and lab results
Histopathological analysis unveiled clusters of basaloid cells exhibiting patterns of peripheral invasion.
Diagnostic review
A diagnosis of basal cell carcinoma was established.
Which of the following accurately describes the mechanism of action of sonidegib in the treatment of basal cell carcinoma?
Before & After Photos
Treatment discussion and outcome
Due to the lesion's location near the nasolacrimal duct and its cosmetically sensitive nature, the patient was hesitant to undergo Mohs surgery and asked for options to reduce the risks of cosmetic deformity and damage to the nasolacrimal duct.
The patient was treated with sonidegib, a hedgehog signaling pathway inhibitor, at a daily dose of 200 mg, accompanied by L-carnitine to mitigate muscle cramps. At week 4, significant flattening and reduction in size of the BCC were noted, with dimensions shrinking to 1 to 2 cm, and the patient reported no hair loss or muscle cramps. By week 8, an 80% reduction in the nodule's size was observed, still without hair loss or muscle cramps.
At week 18, the patient reported mild muscle cramping in his hands but stated that the associated discomfort was manageable. Sonidegib therapy continued until week 25, at which point Mohs surgery was scheduled. At the time of surgery, the basal cell carcinoma measured 1.0 x 0.8 cm, reflecting a nearly 90% reduction from the initial visit.
Following Mohs surgery, successful excision of the basal cell carcinoma was achieved without any intraoperative or postoperative complications and with an excellent cosmetically pleasing result.