Case 1: Assessing a Surgery-Refractory Patient with Recurrent Temple BCC

"Case 1: Assessing a Surgery-Refractory Patient with Recurrent Temple BCC" presents the first patient case of the program, in which multidisciplinary review steers treatment away from another excision.

Dr. Singh introduces a 71-year-old man with recurrent, locally advanced basal cell carcinoma of the left temple and preauricular region. Over 4 years, he underwent Mohs surgery and several non-Mohs procedures for local recurrences. The current tumor has grown over several months and is now causing pain.

The patient works part-time, is independent in daily activities, and has an excellent ECOG performance status. Comorbidities include controlled hypertension, hyperlipidemia, and mild osteoarthritis. Examination shows a 4.5-cm infiltrative nodule extending into adjacent soft tissue, without lymphadenopathy. Baseline creatine kinase and renal function are normal.

Imaging confirms temporal and preauricular soft tissue involvement without nodal or distant disease. Pathology shows infiltrative features with deep soft tissue involvement. He has not received radiation and does not wish to pursue it, and further surgery would likely cause substantial functional and cosmetic morbidity.

After tumor board review, the multidisciplinary team recommended considering a hedgehog inhibitor. Dr. Singh highlights the supporting features: large size, depth, infiltrative histology, and, most importantly, repeated surgical failure. He urges Mohs surgeons to look beyond another excision when a lesion has recurred after multiple procedures.

He documents goals of care at initiation, distinguishing curative intent from disease control. Given the patient's health and active life, he anticipates that cure is achievable, while emphasizing that shared decision-making ultimately sets the plan.

Dr. Singh also frames therapy as a possible stepping stone. The team can assess clinical response at 3 and 6 months and consider scouting biopsies if the tumor shrinks. Surgery or radiation may then carry less morbidity, an approach he terms neoadjuvant use. He sees patients monthly for laboratory monitoring and adverse effect support. After reviewing all options, the patient began sonidegib 200 mg daily, along with L-carnitine.

The discussion continues in "Sustaining Long-Term Hedgehog Inhibitor Therapy in Surgery-Refractory BCC Patients," where Dr. Singh reviews long-term trial data and his supportive care toolkit for patients on extended therapy.