91 year old man presented with a recurrent right medial canthus BCC that was previously treated with 45 days of radiation (SRT at Hoag Hospital). Biopsy showed infiltrative sclerosing basal cell carcinoma with focal perineural invasion. MRI in December of 2016 showed the mass was fixed on the lamina papyracea adjacent to the medial rectus. 3 month follow up MRI in March 2017 showed minimal increase in size (from 0.9 x 0.6 x 1 cm to 1 x 0.9 x 1 cm).
This is a 91-year-old man, who presented with recurrence of basal cell carcinoma in the right medial canthal area and anterior orbit. Initially, the patient was treated with superficial radiation of the right lower medial eyelid. Although the patient had complete response in the area of treatment, the cancer recurred in the area of medial canthus deeper and more medial than the area treated with radiation therapy. Unfortunately in these medical scenarios, a preoperative assessment with mapping biopsies is the best way of preventing these recurrences. Clinical evaluation alone is not sufficient in determining true margins of the carcinoma. If deeper biopsies of medial canthus were done, a different radiation plan could have been designed. Alternatively, the patient could have been treated with surgery despite his advanced age. When the patient presented to us, evaluation with an MRI revealed a significant involvement of the tumor in the anterior medial orbit including involvemen t of the lamina papyracea and the medial globe. Surgical resection was not an option for this patient given the nature of resection. This would involve orbital exenteration and likely anterior skull base resection with free flap reconstruction. Radiation again is not an option for this patient, because it would have to be preceded by orbital exenteration first. (The globe does not tolerate radiation).
As a result, the patient was recommended Erivedge (vismodegib) as an alternative. Prior to starting this treatment, we recommended establish the growth rate of the tumor with a serial MRI. You can see on the left are the MRIs on the first assessment, and on the right are the MRIs three months later. The radiologist identified that the tumor has progressed in the three months by 1 mm in one dimension, 3 mm in another dimension, and no growth in the third dimension. With that knowledge, Erivedge treatment could be started. Erivedge dosing would have to depend on the patient’s symptoms. If the symptoms are tolerable he could continue Erivedge given tumor response for many months. Alternatively, if the patient is having difficulty tolerating the medication, then pulse dosing could be considered. Following the tumor with serial MRIs could establish if pulse dosing is controlling the progression of the tumor. The expected side effects of Erivedge would include alteration and possibly loss of taste, cramps of forearms and legs, gastrointestinal issues such as nausea, and alopecia. A theoretical alternative discussed at the conference was the use of itraconazole between pulse dosing of Erivedge. Itraconazole, an antifungal agent, has a weak hedgehog inhibitor activity. Currently, this is not the standard of care, but has been used in some reported cases.