Multidisciplinary Approaches to Managing Challenging Basal and Squamous Cell Carcinomas

At a recent Dermatology Times Case-Based Roundtable custom event, “Advancing Multidisciplinary Strategies for Optimal Management of BCC and CSCC,” John Strasswimmer, MD, PhD, led a discussion about personalized care for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (CSCCs). Strasswimmer, a Mohs surgeon and clinical professor of dermatology and research biochemistry at Florida Atlantic University, spoke on the difficulty of managing adverse effects, the role of interdisciplinary clinical relationships, and the challenges in complex and older patients.

Case 1: A 93-Year-Old with a History of BCC and CSCC

The first case centered on a 93-year-old man with a history of multiple BCCs andCSCCs, previous excisions and radiation, and chronic edema. Even with past treatments, his tumors were persistent, and his health was fragile because of hypertension, early kidney failure, and use of diuretics and antidepressants.

Strasswimmer discussed how to best approach an older, weaker patient, weighing the benefits and risks of aggressive therapies such as vismodegib (Erivedge; Genentech), a hedgehog pathway inhibitor that shrinks tumors but often leads to severe adverse events including cramping. The patient’s tolerability, quality of life, and long-term goals were all considered in this decision-making. After starting vismodegib, the patient’s condition improved significantly, with reduced edema and healed basal cell lesions. However, a squamous cell carcinoma continued to grow, and the patient later developed life-threatening hyponatremia.

“We’re lucky in medicine because we have specific guidance based on class [adverse] effects and so forth, so we have to go by that for testing,” Strasswimmer said. “But this was a great learning case for me; I actually went back and reread the package. I learned a lot from this case.”

Case 2: A 55-Year-Old With Advanced BCC Near the Eye

The next case was that of a 55-year-old man with an advanced 1.5-cm BCC located at the left medial canthus. The clinicians discussed excision using Mohs surgery because of the tumor’s location and size. One participant shared their experience with Mohs in a similar case, where 2 stages of excision were needed, resulting in the loss of the lacrimal duct and other structures. An oculoplastic surgeon was needed for reconstruction.

Despite the clear surgical approach, the panel considered patient preferences, as some may find the idea of surgery daunting. In such cases, the patient’s desire to avoid surgery may lead to exploring nonsurgical options, such as vismodegib or other systemic therapies. However, Mohs surgery is generally favored, and systemic treatments might be considered only if surgery fails or the patient strongly prefers alternatives. In this particular case, the first hedgehog inhibitor was FDA approved after the patient had already undergone surgery. He expressed that he would’ve preferred the nonsurgical option, according to Strasswimmer.

Case 3: A 41-Year-Old with Nodular BCC on Chest

In this case, a 41-year-old woman presented with a 3.5-cm nodular BCC on her chest. The dermatologists discussed their approaches to treatment, weighing both surgical and nonsurgical options. One clinician mentioned using imiquimod to shrink the tumor before excision but suggested referring to Mohs if it doesn’t shrink. Others preferred to send the patient straight to a Mohs surgeon for consultation, emphasizing the importance of specialist input in handling significant tumors.

Strasswimmer and the panel agreed that surgery is the standard of care, especially for younger patients with no history of skin cancer, who tend to prefer aggressive, 1-time treatments. The group generally rejected radiation as a treatment option, with 1 doctor noting that they don’t offer radiation in their practice and refer to oncologists when needed.

The patient, a young woman of childbearing age, was not interested in systemic therapies like hedgehog inhibitors because of their potential impact on pregnancy. At the time, cemiplimab (Libtayo; Regeneron Pharmaceuticals, Inc) was not yet available. After Mohs surgery, she had a successful outcome with a visible scar. 

Case 4: A 65-Year-Old with Large, Bleeding BCC

The next case revolved around a 65-year-old man with large, advanced BCC and significant bleeding from untreated tumors. The clinicians discussed their management approach, with some considering referral to a Mohs surgeon, whereas others emphasized sending the patient directly to a medical oncologist. The group also debated the use of systemic treatments. They acknowledged the limited use of hedgehog inhibitors in more aggressive cases, whereas immunotherapy such as cemiplimab is viewed as a promising option for advanced or metastatic BCC.

“In your mind, you’ve got this feeling that immunotherapy can do incredible things for some cancers. Maybe it could also help this type of cancer,” Strasswimmersaid.

The patient’s condition became more complicated when a PET scan revealed a lung nodule, raising concerns about metastasis. Cemiplimab, which is FDA approved for metastatic BCC, could be the right treatment approach, especially considering the patient’s critical state, including severe anemia from blood loss. Ultimately, the patient is started on cemiplimab with further multidisciplinary collaboration, including consultations with surgical and medical oncologists.

Case 5: A 75-Year-Old with Recurrent BCC and Prior Surgery

The final patient is a 75-year-old woman with recurrent BCC after a prior excision on the nose. The patient was anticoagulated with existing scarring, which complicated Mohs surgical options because of the need for a staged flap reconstruction. However, Strasswimmer and the group agreed that Mohs surgery would be the first option for re-excision.

Following initial surgery by a plastic surgeon, the tumor recurred, and further surgical intervention became more difficult. Some clinicians suggested that radiation therapy or consultation with a multidisciplinary team might be necessary in complex cases like this. The patient was put on vismodegib but could not tolerate it because of constant fatigue and vertigo. She switched to cemiplimab, which is FDA approved for advanced BCC.