The current clinical approach to difficult-to-treat basal cell carcinomas

ABSTRACT

Introduction

Basal cell carcinoma (BCC) is the most common malignant tumor in adult white populations. If BCCs are not treated for years, if they cause massive destruction of the surrounding tissues, if they are considered unresectable or not eligible for radiotherapy they become progressively ‘locally advanced’ (laBCC) or metastatic (mBCC). These tumors are defined as ‘difficult-to-treat BCC.’

Areas covered

A comprehensive search on PubMed was conducted to identify relevant literature about the several approved and recommended treatment options for the management of difficult-to-treat BCC published from January 2012 to July 2022. Surgical options, radiotherapy, hedgehog inhibitors, immunotherapy, and combined treatments are discussed. The keywords used were basal cell carcinoma; difficult-to-treat BCC; management of difficult-to-treat BCC; surgical therapy; radiotherapy; hedgehog inhibitors; immunotherapy.

Expert opinion

Identifying the best approach to DTT BCCs is one of the main challenges for the dermato-oncologist. The introduction of HHI for the treatment of advanced BCCs has revolutionized the clinical management of DTT BCCs. The immune checkpoint inhibitor cemiplimab has been approved for the treatment of locally advanced or metastatic BCC refractory to HHI therapy or in patients intolerant to HHI therapy. Multidisciplinary teams (MDTs) play a key role in managing these complex patients.

KEYWORDS:

• Basal cell carcinoma
• difficult-to-treat BCC
• management of difficult-to-treat BCC
• surgical therapy
• radiotherapy
• hedgehog inhibitors
• immunotherapy

Article highlights

• Difficult-to-treat BCCs are those BCCs where there is a technical difficulty in maintaining function and esthetics due to a series of factors, including size or location, the poorly defined borders of the tumor, previous treatment, and the patient’s characteristic. A multidisciplinary approach is the best strategy for the management of these patients.

• Surgery is usually first treatment option.

• Radiation therapy is an alternative option in elderly BCC patients who are not candidates for surgery or in cases where curative surgery may be disfiguring or burdened with poor cosmetic outcome.

• Hedgehog inhibitors are indicated in the treatment of laBCC that are not eligible for surgery or radiotherapy.

• The FDA approved cemiplimab in February 2021 for the treatment of locally advanced or metastatic BCC refractory to HHI therapy or in patient’s intolerant to HHI therapy.

• The combination of different treatments can be considered as part of the multidisciplinary approach

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.