What is the recommended line of treatment for an elderly female patient with infiltrative basal cell carcinoma on the nose who is not a good candidate for surgery due to poor general health or significant comorbidities?

Treatment of Infiltrative Basal Cell Carcinoma on the Nose in Patients Unfit for Surgery

For an elderly patient with infiltrative basal cell carcinoma on the nose who is not a surgical candidate due to poor general health, radiation therapy is the primary treatment option, with hedgehog pathway inhibitors (vismodegib or sonidegib) as an alternative if radiation is also contraindicated. 1, 2

Primary Non-Surgical Treatment: Radiation Therapy

• Radiation therapy is an effective option for patients who refuse surgery or have contraindications, though it is generally limited to patients older than 60 years due to long-term toxicity risks 2, 3
• The British Association of Dermatologists explicitly states that aggressive management may be inappropriate for certain patients, especially the very elderly or those in poor general health, when a palliative rather than a curative treatment regimen may be in the best interests of the patient 1
• Radiation represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients 4

Secondary Option: Hedgehog Pathway Inhibitors

• Hedgehog pathway inhibitors (vismodegib or sonidegib) should be considered if surgery and radiation are contraindicated or inappropriate 2, 3
• Vismodegib (ERIVEDGE) is FDA-approved for locally advanced basal cell carcinoma in patients who are not candidates for surgery and who are not candidates for radiation 5
• Sonidegib (ODOMZO) is FDA-approved for locally advanced BCC that has recurred following surgery or radiation therapy, or for those who are not candidates for surgery or radiation therapy 6
• Hedgehog inhibitors should be offered to patients with locally advanced BCC when other modalities are not feasible 4

Critical Contraindications and Warnings

For Hedgehog Inhibitors:

• Vismodegib can cause embryo-fetal death or severe birth defects and requires pregnancy verification within 7 days prior to initiating treatment in females of reproductive potential 5
• Males must use condoms during therapy and for 3 months after the final dose to avoid potential drug exposure in pregnant partners 5
• Patients cannot donate blood or blood products during treatment and for 24 months after the final dose 5

For Radiation Therapy:

• Radiation therapy should not be used in patients with genetic conditions predisposing to skin cancer or connective tissue diseases 3

Treatment Algorithm for Non-Surgical Candidates

1. First, assess fitness for radiation therapy: Consider age >60 years, absence of genetic predisposition to skin cancer, and absence of connective tissue diseases 2, 3
2. If radiation is appropriate: Proceed with radiation therapy as primary treatment 1, 4
3. If radiation is contraindicated or refused: Consider hedgehog pathway inhibitors (vismodegib 150 mg orally once daily or sonidegib) 5, 6, 4
4. If both radiation and systemic therapy are inappropriate: A conservative, palliative approach may be in the best interests of the patient 1

Important Considerations for Infiltrative BCC on the Nose

• Infiltrative histologic subtype is classified as an aggressive histological pattern with higher recurrence risk, and nasal location is a central facial site with the highest risk of recurrence 2
• The presence of these high-risk features (infiltrative histology + nasal location) makes this lesion particularly challenging to manage non-surgically 2
• When deep margins are involved in incompletely treated lesions, there is a 33% risk of recurrence compared to 17% when only lateral margins are involved 2

Common Pitfalls to Avoid

• Do not use topical therapies (imiquimod, 5-fluorouracil) or photodynamic therapy for infiltrative BCC, as these are only appropriate for superficial, low-risk lesions 3, 7
• Do not use curettage and electrodesiccation for infiltrative BCC, as this aggressive histologic subtype requires complete margin assessment 1, 3
• Do not delay treatment indefinitely in patients with reasonable life expectancy, as infiltrative BCC can be locally destructive and disfiguring despite slow growth 7