Node Positive Recurrent Basal Cell Of Trunk

[Mandelin Rain]

0.7 cm skin recurrence (multiple previous recurrences) located on right back resected with negative margins >1cm. Also had 1/2 nodes with a 4 cm axillary node with ECE and +margins in axilla due to involvement of thoracodoral nerve. Sounds like the surgeon suspected some Level III nodes as well via palpation though pre-op PET was negative in this location (no biopsy or dissection).

Treat primary site?
Treat whole axilla or just bed where disease was?
What dose?

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[OTN]

I'd go with 60 Gy in 2 Gy qd fx to axilla

Probably can avoid primary site unless it's close enough to axilla, in which case I'd treat.

 

[Neuronix]

I agree with 60 Gy baseline dose to axilla. I'd be looking to boost high risk areas to 66 Gy, particularly the area with ECE and consider 70 Gy to anything that might be gross disease. That's a tough area to treat to high dose so tolerance might be tough depending on the volumes. Also I'm just inviting the usual debates over plexus tolerance.

Would also treat the primary site to 60 Gy assuming it was a local or marginal recurrence on prior resection. Since it's recurrent there's a high risk of another recurrence, and this is clearly an aggressive tumor.

 

[scarbrtj]

This is a way, way out there really bad basal cell. "Multiple recurrences," so treat the primary area of course and as much nodal site as you can to as high a dose as you can (ie 66-70 Gy where feasible esp in ECE region). Before the 3D planning is undertaken, everything is guesswork beforehand about what is really achievable and/or MD-stomach-able. But these really bad cases I have begun offering concurrent Erivedge (hedgehog inhibitor) along with RT. Concurrent data is not a sockdolager by any means but with such a high-risk case, with nodal mets (again unusual in basal cell as we all know) throw the kitchen sink at it I say.

 

[Radiator20]

This is a way, way out there really bad basal cell. "Multiple recurrences," so treat the primary area of course and as much nodal site as you can to as high a dose as you can (ie 66-70 Gy where feasible esp in ECE region). Before the 3D planning is undertaken, everything is guesswork beforehand about what is really achievable and/or MD-stomach-able. But these really bad cases I have begun offering concurrent Erivedge (hedgehog inhibitor) along with RT. Concurrent data is not a sockdolager by any means but with such a high-risk case, with nodal mets (again unusual in basal cell as we all know) throw the kitchen sink at it I say.

Completely agree this is really bad disease. Concurrent vismodegib is a new one for me--thank you for point out that there is evidence. The paper you linked also cites this prior 2-case series in JAMA Dermatology.

 

[evilbooyaa]

I've seen pretty bad toxicity with head and neck RT + Vismodegib for advanced unresectable BCC in 2 consecutive patients. Might be able to get away with in Axilla however, although I'd consider saving it for salvage.

Agree with 60-66 to post-op axilla, I wouldnt off-trial add in Vismodegib. I think if the back was well resected and is far away from axilla I'd leave it alone. If it recurs there will he be able to get a re-resection if he recurs locally?

Multiply recurrent meaning recurrent in the same location? That's pretty rare even for aggressive BCCs. Was it marginal recurrences, or more likely, separate primaries?

 

[Mandelin Rain]

Multiply recurrent meaning recurrent in the same location? That's pretty rare even for aggressive BCCs. Was it marginal recurrences, or more likely, separate primaries?

Hard to tell after seeing him. History is pretty sketchy. By his report, he's had 4-5 surgeries. and had 3 scars on his back. I thought all surgeries were to the same site previously reading the notes. So I'm guessing this one was perhaps recurrent, but likely not several times.