Dr. Pauline Funchain:
Hello everyone. Welcome to the ASCO Post Roundtable Series on evolving skin cancer management. I'm Dr. Pauline Funchain. I am a medical oncologist at Stanford University. I co-direct the Skin Cancer Genetics Program and the Immunotherapy Toxicity Program, and I have two wonderful dermatology colleagues here, and I will have them introduce themselves. Dr. Vidimos, can you start?
Dr. Allison Vidimos:
Hi, I'm Allison Vidimos. I am the chairman of dermatology at Cleveland Clinic and my practice is dermatologic surgery and Mohs surgery and cutaneous oncology.
Dr. Pauline Funchain:
Dr. Zaba?
Lisa Zaba:
Hi, my name is Lisa Zaba and I am a dermatologist at the Stanford Cancer Center, and I direct the multidisciplinary Merkel cell carcinoma clinic.
Dr. Pauline Funchain:
Wonderful. So today, we will be discussing the treatment of skin cancer with four patient cases. Thank you for joining us. Our first installment will focus on non-surgical approaches to basal cell carcinoma. So let me introduce you to case one.
So case one is Mrs. Miller. She is a 68-year-old woman with a fair complexion. She presents with a 1.5 centimeter nodular lesion on her nose. You can see something similar pictured here. The biopsy is done and shows basal cell carcinoma. There are no signs of aggressive growth or invasion, but she's really concerned about potential scarring. So she asks you two about what kind of non-surgical treatment options are available.
So I'll have the two of you explain to me like a medical oncologist. I know there's a lot of options out there. I have some listed here on the slide. So things like photodynamic therapy, laser therapy, there's oral hedgehog inhibitors, there's topical medications, there's systemic immunotherapy even, and of course, surgery. So there are multiple options here. This is a sensitive spot on the face where people really care what it looks like. So how do you go through these options? Are there things that you favor more than others?
Dr. Allison Vidimos:
So I would start by explaining to her that this is in a high risk location. It's a sizable tumor. And the treatment of choice, as far as optimizing the cure rate, to me would be a surgical intervention, Mohs surgery in particular, which would give us 100% margin check, and then reconstruction would follow tumor extirpation. We do have patients who really shy away from surgery, understandably. And my next option for her would be either radiation therapy or vismodegib or sonidegib, one of the hedgehog inhibitors, which are oral medications. The cure rate for radiation is probably going to sit between 90 and 95%. She will have a scar when the tumor involutes. And with the vismodegib and sonidegib she would see slow tumor involution and she would probably have kind of the ghost of the tumor. It would be kind of whitish and kind of a white plaque, I would guess, once it's involuted.
Topical therapies here are not in general recommended because this is a high-risk site. Low-risk locations like the trunk, we would consider PDT, 5-FU for a superficial basal cell carcinoma, imiquimod, for example. But in this location, I think the cure rate would be unacceptably low with those modalities.
Dr. Pauline Funchain:
Dr. Zaba, what do you think?
Lisa Zaba:
I concur. I think the standard of care here is Mohs. I think it is a little bit unlikely that insurance would actually cover a hedgehog inhibitor for this indication. Radiation can be used, but it is not typical standard of care. So I do recommend Mohs surgery for a nodular basal cell on the nose.
Dr. Pauline Funchain:
And so, I'm hearing you talk about... So you prefer surgery in this case, and there are patients who absolutely won't. If you're talking to patients about non-surgical options in this case, what are the chances that they would still need surgery afterwards?
Dr. Allison Vidimos:
After the hedgehog inhibitor, probably 40% to 50%. Now what I will say is we've started a new protocol where we surgically debulk the tumor before we start the vismodegib, and these are generally large tumors. And what we have found is that our cure rates are higher doing that, so you're taking down the bulk of the tumor so there's less tumor for the hedgehog inhibitor to go after. And secondly, we did a small basic science study, which is soon to be published out of Hershey where we looked at the notch signaling pathway after surgical manipulation of basal cell carcinomas and found that a few of the markers were upregulated making the tumor more responsive to the hedgehog inhibitor just by curetting. So I think it works very well with surgical debulking for those reasons.
Dr. Pauline Funchain:
That's interesting. So would a combination therapy be better cosmetically? Is there any of these options that are the best cosmetically?
Dr. Allison Vidimos:
I think surgically, for a smaller nodular BCC, I don't think that the defect would be very deep or large. I think we talk to patients and try to give them confidence in the repair and make them not be afraid of the repair to say, "This is going to give you the best chance that this is gone, whereas these other treatments may not clear it and you still might need surgery. And these are the repair options." And we have the luxury of having facial plastics and plastic surgeons who help us with some of the more advanced wound repairs, so that is how we really try to make the patient understand what their true options are.
Dr. Pauline Funchain:
For both of you, I guess one of the questions I would have for... Basal cell's pretty common. This is seen all over the place in multiple practices. Is there a situation you think is more appropriate for a referral in this situation to an academic center or a specialist? What kinds of things would make you think about referring out? Or do you think this is something that could be pretty much handled at any dermatology office?
Dr. Allison Vidimos:
I think this case, in particular, could be handled at an outpatient office or a community practice. Tumors that come to our attention are generally large, half the whole nose or an ear or the scalp. Over half the scalp is involved with a basal cell carcinoma. And many of those patients weren't imaging as well just to see the extent of the tumor and really guide the optimal therapy. But as you know, we have a tumor board that meets once a month. We just met yesterday. So these cases are very fresh in my mind and many of them were very large, very aggressive, and warranted imaging and true multidisciplinary management.
Dr. Pauline Funchain:
Any thoughts, Dr. Zaba?
Lisa Zaba:
Metastatic disease obviously would involve an oncologist. It's rare for basal cell carcinoma, but it can happen. And involvement of facial structures such as nerves, that is also a tricky situation. But as Dr. Vidimos points out, this can be handled in an academic center with multidisciplinary care.
Dr. Pauline Funchain:
What I've heard in terms of takeaways here, there are multiple modalities available, topicals not so much, but surgery would be the preferred option. And a hedgehog inhibitor might be something for bigger lesions and PDT laser are other options. But ultimately, it sounds like it really does help to take into account patient's preferences. I think it sounds like surgically, for something in a high-risk location that's at least of a moderate size, surgery is preferred. And larger lesions then might require referral and multidisciplinary care with potential involvement of systemic therapies. But I think that is a great discussion on the basal cell carcinoma.
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