Delayed Presentation of Basal Cell Carcinoma: A Case Report

Basal cell carcinoma (BCC) is the most common skin cancer in the United States. Although BCC has a low metastatic potential, it can be locally invasive and destructive, especially when there is a delay in diagnosis or treatment. This can affect not only the surrounding skin, but deeper tissues including muscle, cartilage, and even bone. Primary care physicians often serve as the first line of defense in the recognition, diagnosis, and even treatment of skin lesions suspicious for BCC. Most low-risk BCC can be treated in the primary care office with electro-desiccation and curettage or surgical excision. We present a case of locally invasive BCC with significant soft tissue destruction of the neck, which was incidentally identified during an emergency department presentation for a myocardial infarction. It is the responsibility of primary care physicians to recognize the appearance of skin lesions suspicious for BCC and initiate or arrange for subsequent definitive diagnosis and treatment. Our intent in presenting this case is to illustrate a missed opportunity for earlier recognition and treatment because of lack of access to primary care, as well as to demonstrate the destructive nature of BCC when neglected over time. Comprehensive approaches to diagnosis and treatment are described elsewhere.

The Role of Anti-PD-1/PD-L1 in the Treatment of Skin Cancer

Skin cancers remain the most common group of cancers globally, and the incidence continues to rise. Although localized skin cancers tend to have excellent outcomes following surgical excisions, the less common cases that become surgically unresectable or metastatic have been associated with poor prognosis and suboptimal treatment responses to cytotoxic chemotherapy. Development of monoclonal antibodies to programmed cell death-1 receptor and its ligand (PD-1/PD-L1) have transformed the management of metastatic melanoma, squamous cell carcinoma, and Merkel cell carcinoma. These agents, as monotherapies, are associated with response rates of approximately 40-60%, many of which persist durably. Further efficacy is observed with combination immunotherapy in advanced melanoma. Early reports suggest similar activity in locally advanced or metastatic basal cell carcinoma. In this review, we describe common molecular features of skin cancers that may render them particularly susceptible to anti-PD-1/PD-L1 and detail results from key clinical trials of these agents across skin cancers. Overall, the superior response rates of skin cancer to anti-PD-1/PD-L1 compared with other solid tumor types are likely due, at least in part, to a high mutational burden and, in Merkel cell carcinoma, viral etiology. Although melanoma has been rigorously studied in the setting of anti-PD-1/PD-L1 treatment, more research is needed for the other skin cancer types to establish toxicity profiles, responses, and quality-of-life outcomes.