Dermatology: Practical and Conceptual


Letter  |  Dermatol Pract Concept 2019;9(4):9 295

Dermatology Practical & Conceptual

Introduction

Basal cell carcinoma (BCC) is the most common malignancy 

in Western populations. Metastatic BCC (mBCC), however, is 

extremely rare and occurs in only 0.0028%-0.55% of cases. 

Despite the recent introduction of hedgehog pathway inhibi-

tors, the prognosis for mBCC remains poor [1].

Case Presentation

A 73-year-old previously healthy Caucasian woman was 

admitted to Uddevalla Hospital because of her impaired 

general condition. Her hemoglobin level was 40 g/L and she 

had experienced significant weight loss. Physical examination 

revealed a 37- × 14-cm ulcerated tumor from the cervical 

region vertebra C7 to the level of vertebrae L1-L2 (Figure 

1A). The tumor had been growing on her back for the last 

decade. Biopsies of the tumor showed an infiltrative BCC. 

Three firm subcutaneous nodules could be visualized and 

palpated along the in-transit route toward the right axilla 

with 2 nodules located 1 and 7 cm, respectively, from the 

ulcerated tumor and a third in the right axilla.

MRI showed infiltrative tumor growth into the under-

lying subcutaneous tissues including muscles and spinous 

processes. The presence of metastases was difficult to assess 

with computed tomography (CT) because of the large amount 

of pleural fluid (Figure 2A). Plastic surgeons were consulted, 

but the tumor was considered inoperable. Multidisciplinary 

consultation resulted in a recommendation of systemic ther-

apy with the hedgehog pathway inhibitor vismodegib 150 

mg per os per day.

During the first 3 months of treatment, the tumor shrank 

significantly to 24 × 12 cm. However, a new CT scan revealed 

a suspected metastasis 20 mm in diameter in the inferior lobe 

of the right lung and 4 smaller metastases in the inferior lobe 

of the left lung. Oncologists were consulted, but since the side 

effects of vismodegib were considered moderate (mild muscle 

cramps, diffuse alopecia, and ageusia), it was recommended 

that the patient continue with vismodegib.

After 7 months of treatment, a third CT scan detected 

several new 2- to 3-mm metastases in both lungs, and the 

Neglected Basal Cell Carcinoma  
With Fatal Outcome

Jenna Pakka1, Joanna Holm2, Annika M. Börjesson3, Christina B. Halldin1, John Paoli1

1 Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 

Sweden

2 Department of Dermatology and Venereology, Uddevalla Hospital, Uddevalla, Sweden

3 Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden

Key words: basal cell carcinoma, metastasis, patient delay, hedgehog inhibitor

Citation: Pakka J, Holm J, Börjesson AM, Halldin CB, Paoli J. Neglected basal cell carcinoma with fatal outcome. Dermatol Pract Concept. 
2019;9(4):295-296. DOI: https://doi.org/10.5826/dpc.0904a09

Accepted: March 7, 2019; Published: October 31, 2019

Copyright: ©2019 Pakka et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Jenna Pakka, MD, Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska 
Academy, University of Gothenburg, Gröna stråket 16, 41345 Gothenburg, Sweden. Email: jenna.pakka@vgregion.se



296 Letter  |  Dermatol Pract Concept 2019;9(4):9

ry of published cases from 1981 through 

2011. JAMA Dermatol. 2013;149(5):615-

616.

the management of basal cell carcinoma. J 

Am Acad Dermatol. 2018;78(3):540-559.

2. Wysong A, Aasi SZ, Tang JY. Update on 

metastatic basal cell carcinoma: a summa-

small metastases that were detected in 

previous CT scans had increased in size 

(Figure 2B). Furthermore, the healing 

process of the large BCC on the back 

had ceased (Figure 1B). The decreasing 

effect of vismodegib was suspected to be 

caused by resistance development. The 

treatment was finally discontinued after 

12 months. The patient died 6 months 

later, which was 1 year and 10 months 

after the diagnosis.

Conclusions

This rare case is a reminder of the 

potential of BCCs to metastasize and 

even cause a fatal outcome. mBCC has 

been associated with a high mortality 

rate, with median survival of only 8-10 

months after the diagnosis [2]. The 

tumor size was considered the only risk 

factor for mBCC in this patient. Because 

of the patient’s unwillingness and the 

general palliative approach, biopsies 

were not taken to confirm that the lung 

metastases were from the BCC. How-

ever, the patient had no other known 

cancers or symptoms suggesting other 

origins. Although vismodegib showed 

good effect initially, the response was 

only partial. The response rate of this 

relatively new medicine in patients with 

mBCC has varied between 30.0% and 

37.9% [1].

References

1. Kim JYS, Koslow JH, Mittal B, Moyer J, 

Olencki T, Rodgers P. Guidelines of care for 

Figure 1. Clinical picture showing a massive tumor on the patient’s back (A) before and (B) 

6 months after the initiation of treatment with vismodegib. [Copyright: ©2019 Pakka et al.]

A B

Figure 2. Computed tomography scan showing the progression of the metastases (A) before 

and (B) 6 months after the initiation of treatment with vismodegib. Initially, the lung metas-

tases were difficult to assess because of the large amount of pleural fluid. [Copyright: ©2019 

Pakka et al.]

A B