Case and Research Letters
Aggressive Inferior Eyelid Basal Cell Carcinoma: Advantage of Neoadjuvant Vismodegib
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In 2012 the US Food and Drug Administration (FDA) approved Vismodegib, an oral hedgehog pathway inhibitor, for the treatment of locally advanced and metastatic BCCs which are inappropriate for surgery or radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Herein, we report a patient with an infraorbital locally advanced BCC who was offered oral vismodegib before surgery reducing surgery-associated morbidity and allowing the preservation of functional and aesthetic aspect of the affected area.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 81-year-old man presented with a 6-year history of a progressively growing lesion in the left lower eyelid. Examination of the ocular adnexae showed an extensive, infiltrated and centrally erosive lesion, covered by a crust with 6<span class="elsevierStyleHsp" style=""></span>cm of major axis and involving all the left lower eyelid with ectropion and extending onto the left malar cheek (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Biopsy showed a ulcerated BCC and computed tomography (CT) scan of the head did not identify alterations in the facial bones (left maxilla, inferior orbital rim, and base of the nasal bone). Due to the advanced nature of the lesion and involvement of more than two-thirds of the tarsal conjunctiva with a complex location for surgery and radiotherapy, the patient was offered oral vismodegib 150<span class="elsevierStyleHsp" style=""></span>mg PO daily in order to shrink the tumor before surgery and reduce surgery-associated morbidity.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The reassessment was performed at 4, 8 and 16 weeks after initiation of oral therapy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). At 16 weeks the lesion showed a significant clinical improvement with substantial regression and a biopsy of the tarsal conjunctiva was performed. The histopathologic examination of the tarsal conjunctiva was compatible with “absence of neoplasia”. Vismodegib treatment was discontinued at 23 weeks and wide excision of the residual lesion with reconstruction was performed. The pre-surgical clinically visible lesion size was 2,5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0,8<span class="elsevierStyleHsp" style=""></span>cm and the final surgical defect measured 3,2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1,5<span class="elsevierStyleHsp" style=""></span>cm. For the reconstruction of the defect, it was suggested to perform a modified Tripier flap (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). A single pedicle, randomized and lateral, was drawn with a relatively wide base (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The surgical solution was consistent with a good functional result. Histological evaluation of the surgical specimen revealed “absence of neoplasia”. The follow-up 6 months after surgery revealed no recurrences and an excellent functional and aesthetic result (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). The patient tolerated vismodegib very well just reporting a slight muscles spasm, dysgeusia and alopecia of the eyebrows and eyelids. All the side effects were graded as 1 using the Common Terminology Criteria for Adverse Events (CTCAE). No severe adverse events were observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It is established that neoadjuvant treatment with vismodegib for an average of 4 months before surgery reduces tumor area and surgical defect size.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> In literature, a clinical trial with short-term vismodegib showed a reduction of the surgical defect area by 31% if used for at least 3 months in non-recurrent BCCs of functionally sensitive locations.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Furthermore, previous studies revealed that the clinical appearance of tumors after vismodegib was variable and did not predict histologic cure.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> This achievement enhances the importance of performing biopsies or diagnostic techniques such as confocal laser scanning microscopy in order to identify residual tumor nests. The margins performed in this case had the intention to excise the clinical residual lesion with 10<span class="elsevierStyleHsp" style=""></span>mm margin and the reconstruction of the inferior eyelid ectropion. Some studies support the idea that vismodegib “cure” is temporary, as BCCs recur at the same site within a few months of drug discontinuation.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a> We consider that probably the best surgical option after vismodegib would be micrographic Mohs surgery (MMS) as this surgical technique allows to localize residual nests of BCC that can remain during the reduction of the tumor.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our clinical case, a modified Tripier flap was performed as eyelid wound repair must be carefully designed so that eyelid function is maintained and the globe is protected. The original Tripier flap is considered a myocutaneous bipedicular flap originating from the upper eyelid and recommended for the reconstruction of lower lateral eyelid defects.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Usually this technique is time-consuming and requires a second surgical stage for sectioning the lateral pedicles.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Its modification consists in planning a single pedicle, lateral, randomized in one-stage surgery which does not rely on the inclusion of orbicularis muscle or innervation. The surgical solution of our case demonstrates an option of the lower eyelid reconstruction, simple and versatile without ectropion or eyelid distortion.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This case highlights the potential of short-term vismodegib as neoadjuvant to surgery for high-risk locally advanced basal cell carcinomas, especially in functionally sensitive locations as the periocular and orbital areas.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dr. César Martins is a member of the Roche Pharmaceutics Advisory board. The other authors declare no conflicts of interest.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding sources</span><p id="par0045" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "xpalclavsec1177567" "titulo" => "Palabras clave" ] 1 => array:2 [ "identificador" => "xpalclavsec1177568" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding sources" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-08" "fechaAceptado" => "2018-05-23" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1177568" "palabras" => array:3 [ 0 => "basal cell carcinoma" 1 => "neoadjuvant therapy" 2 => "vismodegib" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Monteiro AF, Rato M, Trigo M, Martins C. Carcinoma basocelular agresivo del párpado inferior: ventaja del vismodegib neoadyuvante. Actas Dermo-Sifiliográficas. 2019;110:863–865.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 567 "Ancho" => 1300 "Tamanyo" => 161748 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0185" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical regression of left lower eyelid basal cell carcinoma during vismodegib therapy.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 657 "Ancho" => 1505 "Tamanyo" => 204106 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0190" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative stages with excision of the residual suspected lesion in the lower eyelid and reconstruction with a modified Tripier flap of the upper eyelid (A,B) and 6-month postoperative result (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vismodegib for periocular and orbital basal cell carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 12 | 24 |
| 2024 October | 71 | 44 | 115 |
| 2024 September | 82 | 33 | 115 |
| 2024 August | 92 | 58 | 150 |
| 2024 July | 70 | 29 | 99 |
| 2024 June | 101 | 47 | 148 |
| 2024 May | 77 | 33 | 110 |
| 2024 April | 71 | 20 | 91 |
| 2024 March | 66 | 40 | 106 |
| 2024 February | 62 | 51 | 113 |
| 2024 January | 63 | 39 | 102 |
| 2023 December | 61 | 23 | 84 |
| 2023 November | 82 | 42 | 124 |
| 2023 October | 83 | 38 | 121 |
| 2023 September | 79 | 34 | 113 |
| 2023 August | 45 | 24 | 69 |
| 2023 July | 99 | 49 | 148 |
| 2023 June | 69 | 30 | 99 |
| 2023 May | 77 | 29 | 106 |
| 2023 April | 57 | 26 | 83 |
| 2023 March | 60 | 31 | 91 |
| 2023 February | 71 | 25 | 96 |
| 2023 January | 54 | 30 | 84 |
| 2022 December | 68 | 44 | 112 |
| 2022 November | 91 | 33 | 124 |
| 2022 October | 54 | 37 | 91 |
| 2022 September | 48 | 45 | 93 |
| 2022 August | 45 | 45 | 90 |
| 2022 July | 64 | 39 | 103 |
| 2022 June | 24 | 28 | 52 |
| 2022 May | 79 | 42 | 121 |
| 2022 April | 65 | 36 | 101 |
| 2022 March | 72 | 58 | 130 |
| 2022 February | 97 | 38 | 135 |
| 2022 January | 84 | 38 | 122 |
| 2021 December | 57 | 40 | 97 |
| 2021 November | 55 | 50 | 105 |
| 2021 October | 58 | 51 | 109 |
| 2021 September | 52 | 38 | 90 |
| 2021 August | 51 | 24 | 75 |
| 2021 July | 49 | 27 | 76 |
| 2021 June | 47 | 25 | 72 |
| 2021 May | 53 | 35 | 88 |
| 2021 April | 182 | 96 | 278 |
| 2021 March | 60 | 32 | 92 |
| 2021 February | 47 | 24 | 71 |
| 2021 January | 47 | 23 | 70 |
| 2020 December | 54 | 14 | 68 |
| 2020 November | 32 | 15 | 47 |
| 2020 October | 40 | 19 | 59 |
| 2020 September | 33 | 8 | 41 |
| 2020 August | 22 | 27 | 49 |
| 2020 July | 20 | 10 | 30 |
| 2020 June | 25 | 20 | 45 |
| 2020 May | 33 | 22 | 55 |
| 2020 April | 25 | 18 | 43 |
| 2020 March | 43 | 10 | 53 |
| 2020 February | 8 | 4 | 12 |
| 2020 January | 1 | 2 | 3 |
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