Electrochemotherapy in the treatment of basal cell carcinoma of the head and neck: a case report

Abstract

Background

Skin areas chronically exposed to solar radiation, such as the face, neck, scalp, and upper limbs, are at significantly increased risk of developing basal cell carcinoma. The objective of this case report is to describe the treatment of a basal cell carcinoma located on the chin using electrochemotherapy in a patient with advanced heart disease, a condition that contraindicated invasive surgical intervention.

Case presentation

An 83-year-old Caucasian female patient presented with a persistent nodular lesion on the chin, present for approximately 6 months. The diagnosis of cutaneous basal cell carcinoma was confirmed through histopathological analysis of tissue obtained via punch biopsy of the lesion. A single electrochemotherapy application was sufficient. Monitoring was discontinued at 24 months due to the patient’s death from cardiac causes. Her clinical condition did not allow for further diagnostic procedures such as biopsy or positron emission tomography–computed tomography.

Conclusion

In the present study, the patient successfully underwent a single session of electrochemotherapy, with a favorable outcome and no complications. The therapeutic approach allowed us to avoid general anesthesia while ensuring effective treatment of the neoplastic lesion with excellent aesthetic outcomes.

Introduction

Basal cell carcinoma (BCC) of the face is the most common skin cancer, frequently affecting sun-exposed facial areas; it is particularly common in fair-skinned individuals over the age of 50, and the anatomical location and late treatment increase the risk of aggressive or mutilating disease [1].

Skin areas chronically exposed to solar radiation, such as the face, neck, scalp, and upper limbs, are at significantly increased risk of developing BCC [2]. In fact the main risk factor for the development of BCC is intermittent exposure to ultraviolet radiation, particularly during childhood and adolescence, which explains why approximately 80% of all BCCs are located on the head and neck [3].

Facial basal cell carcinomas generally do not exhibit metastatic potential; however, they can lead to significant physical consequences for patients. Visible lesions in exposed areas may cause social anxiety and depressive symptoms, particularly in anticipation of surgical excision, which can result in aesthetic disfigurement. This is especially relevant when excision involves functionally and anatomically delicate regions. The subsequent reconstructive process can be challenging, particularly when the tumor has deeply infiltrated the skin, bone, or surrounding soft tissues. It typically presents in an asymptomatic form and with low metastatic potential, which allows for effective management through surgical excision or localized therapies [4]. However, some variants exhibit a more aggressive clinical behavior, often associated with delayed diagnosis. In recent years, targeted therapies such as hedgehog pathway inhibitors (HHIs) and immune checkpoint inhibitors (ICIs) have been introduced, yielding promising results [5]. Despite these advances, the emergence of treatment intolerance and resistance, along with limited accessibility to these therapies, highlights the need to develop alternative systemic approaches. The nodular subtype is the most frequently observed on the face; however, more aggressive variants, such as micronodular, infiltrative, and superficial types, are associated with a higher risk of recurrence and require careful therapeutic management [6]. Surgical excision with histopathological margin assessment remains the gold standard, particularly for high-risk or recurrent facial BCC [7]. Mohs micrographic surgery is the preferred technique for primary and high-risk tumors, owing to its high precision in preserving healthy tissue and ensuring complete margin control [8]. Topical therapies, such as imiquimod and 5-fluorouracil, are indicated for superficial spreading BCC [9]. Radiotherapy has shown less success, owing to higher recurrence rates and less favorable aesthetic outcomes compared with surgery. Electrochemotherapy (ECT) is an emerging therapeutic option that is increasingly recognized as an effective and minimally invasive treatment for BCC. It offers promising outcomes both in terms of tumor control and patient quality of life, particularly owing to its ability to preserve aesthetic integrity and reduce procedural morbidity [10].

The objective of this case report is to describe the treatment of a basal cell carcinoma located on the chin using electrochemotherapy in a patient with advanced heart disease, a condition that contraindicated invasive surgical intervention.

Case presentation: an 83-year-old female Caucasian patient presented with a persistent nodular lesion on the chin, present for approximately 6 months. The patient reported localized itching and a tendency to scratch the affected area. Following clinical evaluation, a diagnosis of severe dilated cardiomyopathy was established, which contraindicated invasive surgical intervention. The patient underwent pretreatment clinical assessment and was subsequently monitored through scheduled follow-up visits aimed at evaluating therapeutic response and identifying potential adverse effects. The study was based in the Tor Vergata, Rome in Italy, in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki (https://www.wma.net/ wp con-tent/uploads/2018/07/DoHOct2008.pdf) and the additional requirements of Italian law. The patient signed informed consent on the adopted procedure.

The patient was treated with electrochemotherapy (ECT) at the Department of Maxillo-Facial Surgery, University of Tor Vergata, Rome, between May 2011 and February 2012. Therapeutic decisions were made within a multidisciplinary tumor board, following a comprehensive evaluation involving the surgeon, radiation oncologist, medical oncologist, cardiologist, and the patient. The diagnosis of cutaneous basal cell carcinoma was confirmed through histopathological analysis of tissue obtained via punch biopsy of the lesion.

Prior to the electrochemotherapy (ECT) procedure, local anesthesia was administered using a 4% articaine solution through targeted infiltration around and beneath the lesion, inducing tumescence to ensure patient comfort and procedural tolerability. In one specific case, involving a 2-cm lesion on the right side of the chin, short-term sedation was achieved with an intravenous dose of 5 mg midazolam. Local anesthesia facilitated precise electrode placement and optimal patient cooperation.

Electroporation was performed using the Cliniporator VITAE device (IGEA S.p.A.), designed to deliver rectangular electrical pulses optimized for transient permeabilization of tumor cell membranes. Bleomycin was administered intralesionally at a dose of 10 µg/m² approximately 10 minutes prior to pulse delivery, to maximize intracellular drug uptake.

A ring-shaped electrode worn on the index finger was selected to allow easy access to the treatment site. These high-voltage electric pulses temporarily destabilize the cell membrane, creating pores that increase its permeability and allow the entry of cytotoxic drugs, such as bleomycin, into tumor cells [11] (Fig. 1).

Fig. 1.

Mechanism of electrochemotherapy. On the left, electric pulses delivered through electrodes induce transient electroporation in tumor cells. On the right, schematic representation of the cell membrane: a intact bilayer, b formation of aqueous pores after high-voltage pulses, and c increased permeability allowing cytotoxic drug molecules (e.g., bleomycin) to enter the cell

Tumor response was assessed according to RECIST 1.1 criteria: complete response (CR) was defined as total disappearance of the lesion, while partial response (PR) was defined as a > 30% reduction in the longest diameter [12].

Post-treatment pain was managed with paracetamol and a single dose of tramadol. The patient was informed of the potential risk of necrosis in the treated area, which might require reconstruction with sliding flaps. She was also advised of the possibility of developing post-treatment hyperpigmentation and fibrosis, with increased tissue firmness on palpation.

Results

The patient underwent a punch biopsy of the lesion, which revealed the presence of an infiltrative basal cell carcinoma involving the dermis. Subsequent histopathological analysis of the excised tissue confirmed a nodular BCC, ranging from well to moderately differentiated. The presence of healthy tissue at the base of the biopsy specimen excluded bone infiltration. A comprehensive clinical evaluation was performed, including magnetic resonance imaging (MRI), which demonstrated tumor infiltration into the skin and subcutaneous tissue, without involvement of the underlying bone. Following electrochemotherapy, the patient developed a mild area of necrosis, which gradually decreased in size and resolved completely within approximately 2 months (Fig. 2). A single ECT application was sufficient. The patient did not develop hyperpigmentation in the treated area. The patient was monitored every 6 months, with follow-up visits conducted during hospital admissions related to her cardiac condition. Follow-up continued for 24 months after treatment, with no evidence of local recurrence (Fig. 3). Monitoring was discontinued at 24 months due to the patient’s death from cardiac causes. Her clinical condition did not allow for further diagnostic procedures such as biopsy or positron emission tomography–computed tomography (PET-CT).

Fig. 2.

A Patient with basal cell carcinoma before treatment; an ulcerated area with a tendency to bleed is observed at the chin. B At 1 week after treatment, tissue necrosis and erythema are visible. C At 4 weeks after treatment, erythema persists

Fig. 3.

A The lesion is almost completely healed after 6 weeks. B After 8 weeks, complete healing is observed. No hyperpigmentation or scarring is evident

Discussion

The outcome of this case report shows the high clinical efficacy of ECT in the treatment of BCC of the facial region. Elderly patients are often affected by severe chronic conditions that may contraindicate invasive surgical procedures. In our case, the patient suffered from advanced dilated cardiomyopathy, which contraindicated the use of general anesthesia. Among the various therapeutic options, electrochemotherapy plays a significant role in the treatment of this neoplasm, which often results in substantial scarring.

Facial basal cell carcinomas (BCCs) treated with ECT have shown high rates of complete clinical response, with studies reporting up to 81–100% complete response after one or more sessions, and durable disease-free survival at 5 years [10].

Electrochemotherapy is a well-established therapeutic technique, successfully used in the treatment of various cutaneous and subcutaneous malignancies. In particular, it has demonstrated efficacy in the management of superficial metastatic melanoma, cutaneous head and neck tumors, nonmelanoma skin cancers, Kaposi’s sarcoma, and breast cancer.

In carefully selected patients, ECT can also be employed for symptom control in oropharyngeal tumors, offering a noninvasive and well-tolerated therapeutic option.

Clinical studies confirm that ECT is an effective and safe method for local disease control in patients with basal cell carcinoma and other skin tumors. Specifically, for BCC, an overall response rate of 96% and a complete response rate of 85% have been reported after one or more treatment sessions [13, 14]. Another important finding is that patients treated with ECT report greater satisfaction regarding scarring and aesthetic outcomes compared with surgical excision. This translates into significant improvements in quality of life and body image, making ECT particularly suitable for anatomical areas prone to visible scarring [15]. An important issue to address when treating BCC is its potentially destructive nature. Therefore, skin cancer should be considered a global health concern. The destructive nature of BCC can lead to high rates of physical and psychological morbidity following treatment, as a significant number of lesions occur in both functional and aesthetic areas [16]. Electrochemotherapy is well tolerated, with minimal and transient side effects such as skin ulcerations and hyperpigmentation. It is particularly indicated for elderly patients or those with comorbidities who are not suitable candidates for surgery, including as a palliative treatment option.

ECT has proven especially effective in the management of locally advanced, recurrent, or multiple BCC, including lesions located in anatomically challenging areas such as the periocular and nasal regions. In these locations, surgical intervention may result in significant aesthetic and functional impairment. In such cases, ECT represents a valuable therapeutic alternative, potentially avoiding the need for complex reconstructive procedures [17]. Randomized and multicenter studies have demonstrated that ECT provides local control of BCC comparable to standard surgical excision, with the added advantage of avoiding general anesthesia and offering superior aesthetic outcomes [15, 18].

Indeed, ECT does not require general anesthesia, as sedation/anxiolysis combined with local anesthesia is generally sufficient, making it particularly suitable for elderly patients or those with comorbidities. Electrochemotherapy (ECT) for facial BCC is generally well-tolerated, with most side effects being mild, localized, and transient [19]. The most frequently reported adverse events include erythema, skin ulceration, hyperpigmentation, and persistent pigmentation. These effects are typically mild and resolve within a few days.

Pain at the treatment site is common, often described as moderate and temporary, and is generally manageable with nonopioid analgesics [20]. Local edema and mild irritation or discomfort, sometimes associated with muscle contractions near the electrodes, are also reported, but usually resolve quickly. Systemic reactions such as nausea, vomiting, and flu-like symptoms are rare and generally mild [21].

Serious adverse events are very rare but have included lower eyelid ectropion requiring surgical correction and, in exceptional cases, severe neurological complications such as seizures or ischemic stroke. Most patients tolerate electrochemotherapy well, show high willingness to repeat the procedure if necessary, and benefit from minimal recovery time and a favorable safety profile.

Conclusion

In the present study, the patient successfully underwent a single session of electrochemotherapy, with a favorable outcome and no complications. The therapeutic approach adopted allowed us to avoid general anesthesia while ensuring effective treatment of the neoplastic lesion, with excellent aesthetic outcomes. Future prospective multicenter studies could help strengthen the role of ECT within the oncological therapeutic landscape, including its potential use in combination with other treatment modalities.

Author contributions

Gianluca Nicolai, Francesco Campanella, Sergio Alexandre Geherk: Conceptualisation (lead); methodology (equal); project administration (lead); resources (lead); supervision (lead); writing—review and editing (equal). Gianluca Nicolai, Francesco Campanella, Spinelli Raffaele, Sergio Alexandre Geherk and Antonio Scarano:: Methodology (equal); writing—review and editing (equal). Antonio Scarano, Sergio Tari Rexhep: Visualisation (lead); writing—original draft.

Funding

This research received no external funding.

Data availability

To safeguard the privacy of study participant, we cannot openly share the data. However, the datasets used or analyzed in this study can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Institutional review board statement

The authors confirm that the ethical policies of the journal, as noted on the journal’s author guidelines page, have been adhered to. The study was based in the Tor Vergata, Rome in Italy, in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki (https://www.wma.net/ wp con-tent/uploads/2018/07/DoHOct2008.pdf) and the additional requirements of Italian law. The patient signed informed consent on the adopted procedure.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Conflicts of interest

The authors declare that they have no conflicts of interest.