Case 2: Evaluating a Surgery-Averse Patient With Recurrent Nasal BCC

Our second case unfolds in "Case 2: Evaluating a Surgery-Averse Patient With Recurrent Nasal BCC," where quality-of-life priorities shape the choice of systemic therapy.

Dr. Singh presents a 76-year-old woman with a 6-year history of recurrent basal cell carcinoma involving the nasal sidewall and medial cheek. Despite two prior Mohs procedures, the lesion has enlarged and now wraps around underlying subcutaneous structures. She lives independently, has excellent ECOG status, and cares for her grandchildren.

Her comorbidities include controlled hypertension, mild chronic kidney disease, and well-controlled osteoarthritis. Examination shows infiltrative ulceration extending into facial soft tissue, without lymphadenopathy. Imaging confirms locally invasive disease without nodal or distant spread, and pathology shows infiltrative tumor in the dermis and subcutis without muscle involvement.

She strongly wishes to avoid extensive surgery. She also worries about taste changes, because cooking for her grandchildren is one of her greatest joys. Dr. Singh flags the infiltrative histology, involvement of multiple cosmetic subunits, and prior surgical failure. He calls patient preference the biggest consideration and says a request to avoid surgery immediately prompts him to explore alternatives.

Both agents are reasonable here, and her kidney disease makes a baseline laboratory assessment essential before going further. Dr. Singh explains that both drugs inhibit smoothened rather than hedgehog itself, yet they differ pharmacologically. Sonidegib binds plasma protein independently of concentration, has a volume of distribution above 9,000 L, and a half-life of about 1 month. Vismodegib binds in a concentration-dependent manner, with a volume of distribution near 30 L and a half-life of 4 to 12 days.

He then cites a 2025 real-world analysis by Dr. Lebwohl and colleagues. Sonidegib-treated patients remained on therapy longer and were less likely to experience pharmacologically relevant clinical conditions than vismodegib-treated patients. GI-related conditions were about 33% less likely, taste and smell alterations about 71% less likely, and muscle spasms more than 50% less likely. He emphasizes that these are not head-to-head trial data.

In the following episode, "Selecting a Hedgehog Inhibitor for Surgery-Averse Patients with Nasal BCC," Dr. Singh unpacks pivotal trial response criteria and explains how he sequences therapy after hedgehog inhibitor failure.