with Michael Wilkerson, MD and Anthony W. Linfante, MD
Case History
A 58-year-old indigent with known untreated hypertension and a remote history of cocaine abuse presented to a free medical-student/resident-run clinic with large, neglected basal cell carcinomas of the cheek and forehead (Figure 1). As a first effort at control, he was placed on vismodegib 150mg daily and once-daily application of 5% imiquimod. While his tumors did shrink, he was reluctant to continue systemic therapy due to a variety of adverse effects, including elevated liver function studies accompanied by overt jaundice, dysgeusia, and severe muscle cramps. Funding for radiation therapy was obtained, but for unknown reasons, the patient adamantly refused this treatment modality. As a consequence, his tumors began to resume their prior shape and size.
At this point, in the hope of minimizing adverse events, the patient was started on sonidegib, along with topical 5% 5 fluorouracil cream. Improvement from sonidegib was transient at best, and the lesions continued to increase in siandbecome progressively more painful (Figures 2 and 3). Intralesional undiluted 5-Fluorouracil replaced topical chemotherapy. Nonetheless, the lesions continued to progress. Significant cumulative blood loss resulted from daily lesional oozing and was felt responsible for the development of unstable angina. Despite repeated suggestions for radiotherapy, the patient remains resistant. The forehead lesion clinically is fixed to bone, likely involving the calvarium.
While chronic anemia and incessant pain are suspected of altering the patient’s mentation, he appears to be entirely rational and capable of making his own medical decisions. It would be medically, logistically, and ethically questionable to somehow force him to receive radiation. Nonetheless, standard and extended medical maneuvers have failed to yield a satisfactory result.
Although the diagnosis, in this case, is not much of a “Zebra,” the situation is truly uncommon and poses challenges on many fronts.
What would you do if confronted with such a case?
