In this episode of The Spot Check, Jamie Restivo, PA-C, sits down with Aaron Farberg, MD, dermatologist and Mohs surgeon, to unpack what locally advanced basal cell carcinoma (BCC) really looks like in practice. As Dr Farberg notes, it is not always just about size. It is about location, recurrence, tumor biology, surgical morbidity, and sometimes, a patient who has simply had enough surgery.

Through two real-world cases, the conversation explores how hedgehog pathway inhibitors can be used strategically to reduce tumor burden, including in neoadjuvant settings, and how alternative dosing and proactive management of adverse effects (including early L-carnitine use for muscle cramps) may improve tolerability.

In one case, a large scalp tumor was medically reduced before surgery. In another, systemic therapy helped decrease the number of tumors in a patient with numerous BCCs, allowing for more selective surgical intervention.

The throughline is clinical judgment. When surgery alone may lead to significant morbidity, systemic therapy can create space for tumor shrinkage, shared decision-making, and more thoughtful sequencing of care.