Complete pathologic clearance with vismodegib in advanced basal cell carcinoma of the scalp with cranial invasion.

The management of advanced basal cell carcinoma (BCC) can be challenging and often involves a multi-disciplinary approach with dermatologists, plastic surgeons, and oncologists. Standard therapy for advanced BCCs has historically involved prompt excision and radiation; however, in recent years, management strategies utilizing hedgehog pathway inhibitors as neoadjuvant therapy have gained popularity. While controversy regarding management recommendations still exists, we present a case of advanced BCC with cranial involvement in an immunocompromised patient where the use of neoadjuvant vismodegib led to a favorable outcome and, surprisingly, complete the pathologic clearance of the tumor.

Prognostic value of normal regadenoson stress perfusion cardiovascular magnetic resonance.

BACKGROUND: Regadenoson is a vasodilator stress agent that selectively activates the A2A receptor. Compared to adenosine, regadenoson is easier to administer and results in fewer side effects. Although extensively studied in patients undergoing nuclear perfusion imaging (MPI), its use for perfusion cardiovascular magnetic resonance (CMR) is not well described. The aim of this study was to determine the prognostic value of a normal regadenoson perfusion CMR in patients with known or suspected coronary artery disease. METHODS: Patients with known or suspected coronary artery disease were prospectively enrolled to receive perfusion CMR (Philips 1.5 T) with regadenoson. Three short-axis slices of the left ventricle (LV) were obtained during first pass of contrast using a hybrid GRE-EPI pulse sequence (0.075 mmol/kg Gadolinium-DTPA-BMA at 4 ml/sec). Imaging was performed 1 minute after injection of regadenoson (0.4 mg) and repeated 15 minutes after reversal of hyperemia with aminophylline (125 mg). Perfusion defects were documented if they persisted for ≥ 2 frames after peak enhancement of the LV cavity. CMR was considered abnormal if there was a resting wall motion abnormality, decreased LVEF (<40%), presence of LGE, or the presence of a perfusion defect during hyperemia. All patients were followed for a minimum of 1 year for major adverse cardiovascular event (MACE) defined as coronary revascularization, non-fatal myocardial infarction, and cardiovascular death. RESULTS: 149 patients were included in the final analysis. Perfusion defects were noted in 43/149 (29%) patients; 59/149 (40%) had any abnormality on CMR. During the mean follow-up period of 24 ± 9 months, 17/149 (11.4%) patients experienced MACE. The separation in the survival distributions for those with perfusion defects and those without perfusion defects was highly significant (log-rank p = 0.0001). When the absence of perfusion defects was added to the absence of other resting CMR abnormalities, the negative predictive value improved from 96% to 99%. CONCLUSION: Regadenoson perfusion CMR provides high confidence for excellent prognosis in patients with normal perfusion.