Advanced basal cell carcinoma: when a good drug is not enough

Dear Editor, The introduction of vismodegib is an almost science-fiction evolution in the treatment of advanced basal cell carcinoma (BCC). Vismodegib has changed advanced BCC treatment from an almost exclusively surgical approach with potentially disabling outcomes to a medical treatment that can be extremely effective,with short and medium-scale side effects. A 51-year-old white man with a giant ulcerated lesion on the back (figure 1a) associated with severe anemia and cachexia was referred for evaluation by the oncology department. A biopsy revealed basal cell carcinoma. CT scan showed nodules in the lung and tumor infiltration of the vertebrae Biopsy of the lung nodules confirmed metastatic BCC. Twenty years previously, the patient ignored the onset of a Few 5mm lesionon his back due to a reactive depressive syndrome. Over the years, the lesion increased in size and started to bleed. Despite the size and the permanent discomfort, the patient did not undergo any medical examination until his hospitalization for anemia. At the clinical examination,the lesion appeared ulcerated, was 17x15cm in size, and had multiple nodules on the edges. The ulceration was deep and reached the vertebral spinous processes (Figure 1a). Because curative surgery and radiation therapy would have been inappropriate and unsuccessful for metastases, we decided to treat the patient with vismodegib 150 mg daily (1,2). After three months of treatment, his cutaneous BCCwas smaller, the nodules had disappeared, and the ulceration had begun to heal (Figure 1). The metastatic BCC lesions remained stable in size on the CT scans, indicating no progression of the disease.The vismodegib was well tolerated without significant side effects. During his monthly clinical examination,the patient exhibited euphoric feelings about the successful treatment. However, after eight months, multiple nodules became visible in the former tumor area(figure 1), and the patient appeared to be disorientated. Biopsies of three of the nodules revealed infiltrative BCC. A CTscan showed the lung nodules had enlarged. We were surprised at the sudden lack of responseafter the initial success. Because the patient seemed to be back in a major depressive state, we asked the patient if he regularly took the vismodegib. After a long talk, he admitted that he had stopped the therapy after two months for reasons he could not explain. fter four months the patient died from the progression of the disease. We prescribed the right treatment, but we underestimated the impact of our patient’s severe depression that led him to the clinical condition he was in when he presented to us. Our tragic case is emblematic of many patients with advanced basal cell carcinoma. These patients may have psychological issues which must be addressed at the same time as the skin lesion. Generally,these patients are elderly and have ulcerated, bleeding, or suppurating lesions. They may feel vulnerable, defenseless, and too uncomfortable to attend social events. Because these patients may avoid relationships, their partners and families may not realize the severity of the situation. Moreover, patients with recurrent BCC can feel hopeless due to treatment failures and may feel abandoned by the health system. New miraculous medications may be a huge help, but appropriate and timely psychological and emotional support may be just as important to assure the effectiveness of that treatment.