Combined Vismodegib and Mohs surgery
Reviewed by James Hsuan

This is a report of eight patients with locally advanced periocular basal cell carcinoma who were treated with Vismodegib prior to Mohs micrographic surgery. The rationale for the combined treatment plan was that long-term Vismodegib is poorly tolerated due to side-effects, but a short course may shrink the tumour prior to resection by Mohs surgery. The patients received Vismodegib 150mg/day until no further regression was noted, disease progressed, or there were unacceptable side-effects or toxicity. The average tumour size was 18mm with three involving the conjunctiva. The others were considered locally advanced because a complex reconstruction with a suboptimal functional or cosmetic outcome would be expected following Mohs surgery. One patient progressed on Vismodegib and underwent an orbital exenteration. A complete response, defined as disappearance of the target lesion, was seen in the remaining seven patients after four to six months of treatment. One of these refused surgery, and six underwent Mohs surgery, five of whom had no tumour found on histology. The one with positive histology withdrew from Vismodegib after four months due to side-effects. All patients were disease free at an average follow-up of 14 months. All patients experienced side-effects, but only one had to stop treatment due to the short courses given. This is an interesting report and the authors make a compelling argument for combining neoadjuvant Vismodegib with surgery, even for operable but advanced tumours.

Neoadjuvant Vismodegib and Mohs micrographic surgery for locally advanced periocular basal cell carcinoma.
Gonzalez AR, Etchichury D, Gill ME, Del Aguila R.
OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY
2019;35:56-61.