Case Presentation: Cemiplimab for Advanced Basal Cell Carcinoma Ineligible for Surgery or Radiation Case Presentation

An 80-year-old male with a history of hypertension, noticed a small, ulcerated skin lesion by the lateral canthus of his left eye. He first spotted this lesion several months ago, but it had healed by the time he was due for his annual physical, so he did not bring this up to his family physician. He was also busy helping care for his wife who recently started chemotherapy for lymphoma, so he decided to let the skin lesion take care of itself like it had before.

Over the next 2 months, the patient grew concerned that the skin lesion by his left eye was still present and growing. However, he remained preoccupied with his wife’s lymphoma care. He was also worried about the rapid increase in COVID-19 infections due to emergence of the omicron variant. He thought it was best to accompany his wife to her appointments but otherwise stay home. He told himself he would see his family physician once his wife had finished her cancer treatment.

The patient and his wife received the wonderful news that she was in a complete remission 4 months later. Unfortunately, the skin lesion by Mark’s left eye had grown considerably in size to 5 cm and was now involving the lateral canthus. He was not able to close his left eye completely and noticed blurry vision. He saw his family physician who promptly referred him to a head and neck surgeon. A biopsy was performed in clinic that confirmed a diagnosis of an infiltrative basal cell carcinoma.

The patient was referred to a medical oncologist who ordered imaging studies to see how far the tumor had spread. There was no evidence of distant disease, but the tumor had invaded the adjacent muscle and bone. As he had discussed with the head and neck surgeon, the patient made it very clear again that he was not interested in surgery, even if potentially curative, given the associated morbidity at his age. Thus, the decision was made to start systemic treatment with vismodegib, an oral hedgehog inhibitor that is commonly used as first-line therapy for advanced basal cell carcinoma.

The patient was pleased to see his tumor shrink since starting vismodegib, but he soon began to experience terrible muscle cramps in both legs and could no longer walk. He tried taking amlodipine. The patient was switched over to cemiplimab, a PD-1 inhibitor, which showed meaningful clinical responses and durability after disease progression or intolerance to hedgehog inhibitors. He remains on cemiplimab with a partial response and no significant toxicity aside from mild fatigue that is tolerable to him.