2022 Beyond Skin Deep: Serious Gastrointestinal Complications Associated With Oral Chemotherapy for a Case of Basal Cell Carcinoma

Abstract

INTRODUCTION: Oral chemotherapy with Vismodegib for locally advanced Basal Cell Carcinoma (BCC) is widely used by dermatologists. In several isolated case reports, rare hepatotoxicity has been reported, but no consumer safety notifications have been issued by the manufacturer or the FDA to date. CASE DESCRIPTION/METHODS: A 62-year-old Caucasian female presented to emergency room with profound jaundice of her skin and scleral icterus that began two weeks after completion of Vismodegib oral chemotherapy for BCC of the left lateral forehead (Figure 1). Her past medical history was only significant for hypertension and pyrosis. The patient reports that she did not take any prescription or over-the-counter medications, herbal supplements, and had no history of alcohol use. Admission labs revealed AST of 37, ALT of 287, alkaline phosphatase of 522, total bilirubin 11.2, direct bilirubin 6.9, and indirect bilirubin of 4.3. A prompt liver biopsy revealed findings consistent with drug-related injury, including bile ductular reaction associated with portal inflammation consisting of lymphocytes, eosinophils, and neutrophils (Figure 2). She was stabilized and discharged with a plan for weekly outpatient monitoring. However, she presented two weeks later with complaints of right upper quadrant pain and melanotic stools for two days. Admission labs revealed a hemoglobin of 8.4, decreased from 12.0 on previous discharge. She was transfused appropriately and an upper endoscopy (EGD) revealed bleeding from the papillary orifice, indicative of hemobilia (Figure 3), warranting selective angiography and coil embolization for successful hemostasis. Jaundice resolved fully in four weeks and hemoglobin and liver function tests (LFTs) normalized in two months at follow-up. DISCUSSION: As noted in our case, gastroenterologists are bound to see an array of iatrogenic life-threatening complications from outpatient oral therapy for cosmetic lesions. Our case involved not only the hepatotoxic effects from Vismodegib, but a rare iatrogenic complication from the biopsy with bleeding requiring further interventions. Fatalities have been reported with this drug. Therefore, heightened awareness in medical community and mandated patient safety notifications by the manufacturer and the FDA are necessary to improve outcomes.