Ulcerated, inoperable basal cell carcinoma of the face in an elderly patient – expanding therapeutic horizons

Introduction & Objectives: Basal cell carcinoma (BCC) is the most frequent skin cancer, often manageable with surgery or radiotherapy. Nevertheless, in advanced cases—especially among elderly patients—tumors may reach a stage where these conventional modalities are not feasible, due to size, location, or patient comorbidities. Hedgehog pathway inhibitors, such as vismodegib, offer a systemic therapeutic alternative. We aim to present a compelling case of an elderly patient with a large ulcerated facial BCC, successfully treated with vismodegib, and to discuss challenges and insights for management in such high-risk settings. Materials & Methods: An 82-year-old woman was referred in early 2024 with a progressively enlarging ulcerated lesion on the left cheek and chin region, first noted circa 2020. On examination, the lesion measured approximately 10 × 5 cm, with crusting and periodic bleeding. Skin biopsy confirmed ulcerated basal cell carcinoma, G2. Imaging (CT/MRI) excluded distant metastases but showed local soft tissue invasion. In a multidisciplinary tumor board, the lesion was judged inoperable and unsuitable for radiotherapy; systemic vismodegib (150 mg daily) was initiated. Results: Over an 18-month period of close follow-up, the patient exhibited excellent tolerability. Serial laboratory evaluations (CBC, renal and hepatic panels) remained stable, with no high-grade adverse events. Clinically, the lesion's ulceration and bleeding diminished, and its size plateaued without further progression. The patient maintained acceptable quality of life throughout therapy. Conclusion: This case reinforces the role of Hedgehog pathway inhibition in managing advanced, inoperable BCC in elderly patients. Vismodegib allowed disease stabilization with favorable safety, underscoring its value when surgery or radiotherapy are contraindicated. Meticulous multidisciplinary assessment and vigilant monitoring are pivotal in optimizing outcomes in such complex clinical scenarios.