Advanced Basal Cell Carcinoma: Epidemiology and Therapeutic Innovations

Personalized treatment concepts in extraocular cancer

Background

The periocular skin is neoplasms-prone to various benign and malignant. Periocular malignancies are more aggressive and challenging to cure and repair than those in other skin areas. In recent decades, immunotherapy has significantly advanced oncology, allowing the autoimmune system to target and destroy malignant cells. Skin malignancies, especially periocular tumors, are particularly sensitive to immunotherapy. This technique has dramatically impacted the successful treatment of challenging tumors.

Main text

Extraocular cancers, including eyelid (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma), conjunctival tumors (conjunctival melanoma, ocular surface squamous neoplasia) and other rare tumors, are unique and challenging clinical situations. Several genetic alterations associated with the pathogenesis of these diseases have been identified, and molecular mechanism are essential for the development of the immunotherapy agents, such as Hedgehog pathway inhibitors (vismodegib and sonidegib) for basal cell carcinoma, BRAF/MEK inhibitors (vemurafenib, dabrafenib, and encorafenib) for melanoma, and immune checkpoint inhibitors (Avelumab, pembrolizumab) for Merkel cell carcinoma.

Conclusions

The optimal treatment for periocular skin cancer depends on the type and size of the tumor and whether it involves orbital and adnexal structures. Adjuvant and neoadjuvant therapy with chemotherapy-targeted therapies and immune checkpoint inhibitors should be considered based on tumor type, tumor molecular profile, expected response rate, and candidacy for systemic treatment.

Nodular Basal Cell Carcinoma in an Unusual Groin Location: A Rare Presentation

Basal cell carcinoma is the most frequent skin malignancy with a constant rise in its incidence. It affects typically the head and neck of elderly patients. However, the literature in English shows its occurrence in many uncommon locations. In our work, we report a case of basal cell carcinoma occurring in the groin region in a 66-year-old male patient, with no particular medical history. We also discuss through a literature review, the characteristics of this common neoplasm when it occurs in the groin and in other atypical locations.

Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set

BACKGROUND

The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative.

METHODS

Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins.

RESULTS

All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies.

CONCLUSION

The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

Final analysis of phase II results with cemiplimab in metastatic basal cell carcinoma after hedgehog pathway inhibitors

BACKGROUND

Metastatic basal cell carcinoma (mBCC) is a rare condition with no effective second-line treatment options. Cemiplimab is an immune checkpoint inhibitor that blocks the binding of programmed cell death-1 (PD-1) to its ligands, programmed death-ligand 1 (PD-L1) and programmed death-ligand 2 (PD-L2). Here, we present the final analysis of cemiplimab in patients with mBCC after first-line hedgehog pathway inhibitor (HHI) treatment (NCT03132636).

PATIENTS AND METHODS

In this open-label, single-arm, phase II study, adults with mBCC and Eastern Cooperative Oncology Group performance status ≤1, post-HHI treatment, received cemiplimab 350 mg intravenously every 3 weeks for ≤93 weeks or until disease progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) by independent central review (ICR). Duration of response (DOR) was a key secondary endpoint. Other secondary endpoints were ORR per investigator assessment, progression-free survival (PFS), overall survival (OS), complete response rate, safety, and tolerability.

RESULTS

Fifty-four patients were enrolled: 70% were male and the median age of patients was 64 [interquartile range (IQR) 57.0-73.0] years. The median duration of follow-up was 8 months (IQR 4-21 months). The ORR per ICR was 22% [95% confidence interval (CI) 12% to 36%], with 2 complete responses and 10 partial responses. Among responders, the median time to response per ICR was 3 months (IQR 2-7 months). The estimated median DOR per ICR was not reached [95% CI 10 months-not evaluable (NE)]. The disease control rate was 63% (95% CI 49% to 76%) per ICR and 70% (95% CI 56% to 82%) per investigator assessment. The median PFS per ICR was 10 months (95% CI 4-16 months); the median OS was 50 months (95% CI 28 months-NE). The most common treatment-emergent adverse events were fatigue [23 (43%)] and diarrhoea [20 (37%)]. There were no treatment-related deaths.

CONCLUSIONS

Cemiplimab demonstrated clinically meaningful antitumour activity, including durable responses, and an acceptable safety profile in patients with mBCC who had disease progression on or intolerance to HHI therapy.

Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery

PURPOSE

Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms.

METHODS

Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes.

RESULTS

Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups.

CONCLUSIONS

One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Development of thiolated xanthan gum-stearylamine conjugate based mucoadhesive system for the delivery of biochanin-A to melanoma cells

Recently, instead of creating new active compounds, scientists have been working to increase the bioavailability and residence time of existing drugs by modifying the characteristics of the delivery systems. In the present study, a novel mucoadhesive bioconjugate (SN-XG-SH) was synthesized by functionalizing a polysaccharide xanthan gum (XG) with cysteamine hydrochloride (CYS) and a lipid stearylamine (SN). FTIR, CHNS and 1H NMR studies confirmed the successful synthesis of SN-XG-SH. Mucoadhesion of the thiolated XG was enhanced and evaluated by different methods. Disulfide bond formation between thiolated XG and skin mucus enhances mucoadhesive behavior. The mucoadhesive bioconjugate was used to prepare nanoparticles for the delivery of hydrophobic biochanin-A (Bio-A) for the treatment of melanoma. The thiolated xanthan gum nanoparticles also demonstrated high drug entrapment efficiency, sustained drug release, and high storage stability. The drug loaded nanoparticles (Bio-A@TXNPs) significantly improved the cytotoxicity of Bio-A against human epidermoid cancer cells (A431 cells) by inducing apoptosis and changing mitochondrial membrane potential. In conclusion, thiolation of XG improves its mucoadhesive properties and prolongs the release of Bio-A. Thus, thiolated XG conjugate has a high potential for use as a bioadhesive agent in controlled and localised delivery of drugs in different skin diseases including melanoma.

Targeted therapy and immunotherapy for orbital and periorbital tumors: a major review

Traditionally, for patients who are poor candidates for surgery and/or radiotherapy, palliative chemotherapy is often offered but with significant toxic side effects. However, recent advancements in our understanding of tumor biology and molecular genetics have brought new understanding to the molecular pathways of certain tumors and cancers. This has ushered in a new era of precision medicine specific to a tumor or cancer treatment pathway (targeted therapy) or directed to host-tumor responses (immunotherapy). This article will focus on recent updates in the application of available targeted and immunotherapy for managing orbital and periorbital tumors and tumor-like conditions, which include cutaneous basal cell carcinoma, cutaneous squamous cell carcinoma, cutaneous melanoma, Merkel cell carcinoma, sebaceous gland carcinoma, solitary fibrous tumor, dermatofibrosarcoma protuberans, orbital meningioma, neurofibromatosis, Langerhans cell histiocytosis, ocular adnexal lymphoma, orbital lymphatic malformation, and adenoid cystic carcinoma.

Endogenous Photosensitizers in Human Skin

Endogenous photosensitizers play a critical role in both beneficial and harmful light-induced transformations in biological systems. Understanding their mode of action is essential for advancing fields such as photomedicine, photoredox catalysis, environmental science, and the development of sun care products. This review offers a comprehensive analysis of endogenous photosensitizers in human skin, investigating the connections between their electronic excitation and the subsequent activation or damage of organic biomolecules. We gather the physicochemical and photochemical properties of key endogenous photosensitizers and examine the relationships between their chemical reactivity, location within the skin, and the primary biochemical events following solar radiation exposure, along with their influence on skin physiology and pathology. An important take-home message of this review is that photosensitization allows visible light and UV-A radiation to have large effects on skin. The analysis presented here unveils potential causes for the continuous increase in global skin cancer cases and emphasizes the limitations of current sun protection approaches.

Advanced non-melanoma skin cancer in elderly patients: When surgery says NO, interventional radiotherapy (brachytherapy) says YES

Purpose

The prevalence of non-melanoma skin cancer (NMSC) increases, especially in older adults with comorbidities, narrowing radical treatment options. About 5% of skin cancer patients are diagnosed with an advanced stage, which impairs daily functioning. The study was to present a retrospective summary of elderly patients unfit for surgery and treated with various brachytherapy (BT) techniques tailored individually for locally advanced NMSCs in a reference BT department. Clinical case presentations supported the findings.

Material and methods

Inoperable patients older than 75 years presenting with advanced pathologically confirmed NMSCs were retrospectively identified. All cases were individually assessed, and the best suiting radical treatment option was chosen, including contact, interstitial, or hybrid high-dose-rate (HDR) or pulsed-dose-rate (PDR) BT. Doses ranging from 45 to 60 Gy were administered to clinical target volume (CTV) in different time schedules. All patients were closely followed-up until complete remission.

Results

Ten elderly patients (mean age, 84 years) with differently located locally advanced NMSCs (all staged T3) were treated between 2007 and 2022. Six basal and four squamous cell carcinoma cases showed most painful symptoms as well as bleeding and exudation. Six patients underwent HDR-BT and four PDR-BT. Six patients had superficial, and four interstitial or hybrid applications. All patients completed the intended protocols. Median follow-up was 8.5 months (range, 3-35 months). Six out of ten patients died from other reasons before analysis. All case data were presented in the text and respective figures.

Conclusions

Advanced NMSCs in elderly patients are challenging in terms of cure. Inoperable cases may be referred for feasible and locally effective interventional radiotherapy (BT). Individually tailored BT leads to an excellent disease control, function sparing, symptoms release, and quality of life improvement. Large treated volumes are related to prolonged healing. BT should be discussed in a multidisciplinary tumor board regarding older patients with symptomatic functions affecting advanced NMSCs.

Clinical and dermoscopic variation of basal cell carcinoma according to age of onset and anatomic location: a multicenter, retrospective study

Basal cell carcinoma (BCC) is rare in young individuals and reported to possess different pathogenetic, clinical and histological features from late-onset BCC. However, the dermoscopic variability of BCC according to age of onset has not been investigated. Anatomic location was revealed to be associated with dermoscopic variation of BCC in Western population, but whether it applies to Asian population remains unknown. We evaluated the clinical and dermoscopic features of 448 BCCs and compared each feature by age of onset (age < 50/ > 50 years) and anatomic location. Early-onset BCCs occurred more frequently on non-sun-exposed sites (OR 3.28, P = 0.001) and were less pigmented than late-onset BCCs (P = 0.003). Blue-gray globules (OR 1.74, P = 0.037) and no vessels (OR 2.04, P = 0.021) were independently associated with early-onset BCCs, whereas arborizing telangiectasia (OR 0.30, P < 0.001), large blue-gray ovoid nests (OR 0.38, P < 0.001) and ulceration (OR 0.33, P < 0.001) were less common in early-onset BCCs. Scalp BCCs were significantly more pigmented than BCCs located elsewhere (P = 0.022). Superficial subtype (OR 5.90, P < 0.001), spoke-wheel areas (OR 4.78, P = 0.034), superficial erosions (OR 4.69, P = 0.003) and polymorph vessels (OR 6.86, P = 0.001) were independently associated with trunk BCCs, whereas nodular subtype (OR 5.48, P < 0.001) and arborizing telangiectasias (OR 3.64, P < 0.001) with BCCs on face and neck. Our findings suggest that age of onset and anatomic location are independent factors affecting the dermoscopic appearance of BCC.

Sun protective behaviors among adolescents and young adults in the United States

PURPOSE

We described sun protective behaviors in adolescents and young adults (AYA) compared to older adults.

METHODS

We used data from the 2013-2018 National Health and Nutrition Examination Survey, a nationally representative samples of the civilian, noninstitutionalized US population (10,710 respondents aged between 20 and 59 and without a history of skin cancer diagnoses). The primary exposure for the study was age group: aged 20-39 defined as AYA and aged 40-59 as adults. The outcome variable was sun protective behaviors: stay in the shade, wear a long-sleeved shirt, use sunscreen, at least one of the three; and all three measures. Multivariable logistic regression models were used to assess association between age group and sun protective behaviors adjusting for sociodemographic factors.

RESULTS

Overall, 51.3% of respondents were AYA, 76.1% reported staying in the shade, 50.9% using sunscreen, 33.3% wearing long-sleeved clothes, 88.1% engaging in one of the three behaviors, and 17.1% engaging in all three behaviors. In the adjusted models, the odds of engaging in all three behaviors among AYAs was 28% (aOR: 0.72, 95% CI: 0.62-0.83) lower than adult respondents. Compared to adults, AYAs were 22% less likely to wear long sleeved clothes (aOR: 0.78, 95% CI: 0.70-0.87). There were no significant differences in the odds of engaging in at least one sun protective behavior, using sunscreen, and staying in the shade between AYAs and adults.

CONCLUSIONS

More targeted interventions need to be implemented to decrease the risk of skin cancer in the AYA population.

Qualitative Patient Interviews to Characterize the Human Burden of Advanced Basal Cell Carcinoma Following Hedgehog Pathway Inhibitor Treatment

INTRODUCTION

Evidence of patients' experiences of living with advanced basal cell carcinoma (aBCC) are limited, particularly after hedgehog pathway inhibitor (HHI) treatment. We explored the burden of aBCC on symptoms and patients' everyday lives post HHI treatment.

METHODS

In-depth, semi-structured, approximately 1-h qualitative interviews of US patients with aBCC and prior HHI treatment were conducted. Data were assessed using thematic analysis with NVivo 1.0 software. Saturation analysis was performed to ensure all concepts were captured.

RESULTS

Fifteen patients (median age, 63 years; locally advanced BCC, n = 9; metastatic BCC, n = 6) were interviewed. A patient-led conceptual model was developed from the responses using 10 symptoms and 15 impact categories (comprising emotional/psychological, physical, and social domains) identified as most commonly discussed and important to patients. Overall, reported impacts were discussed more commonly than reported symptoms. Impacts most commonly discussed were related to emotions (e.g., anxiety, worry, fear [n = 14; 93%]; low mood, depression [n = 12; 80%]) and physical function (e.g., hobbies or leisure activities [n = 13; 87%]). Symptoms most commonly discussed were fatigue and tiredness (n = 14; 93%) and itch (n = 13; 87%). Out of all reported impacts and symptoms, fatigue and tiredness (n = 7, 47%) and anxiety, worry, and fear (n = 6; 40%) were most bothersome to patients. As a descriptive exercise, participant responses were mapped to commonly used patient-reported outcome scales in aBCC clinical trials. Most expressed concepts were captured across two common measures in oncology/skin conditions (European Organization for Research and Treatment of Cancer Quality of Life-Core 30 [EORTC QLQ-C30] and Skindex-16 questionnaires), but sun avoidance and others' perception of skin cancer were not explicitly mentioned by these instruments.

CONCLUSION

Patients with aBCC experienced a significant disease burden post first-line HHI therapy, including major emotional and lifestyle impacts. Accordingly, through this study, patients with aBCC highlighted a significant unmet need for second-line treatment options post HHI therapy.

Lower lip basal cell and squamous cell carcinomas: a reappraisal of the similarities and differences in clinical presentation and management

Basal cell carcinoma and squamous cell carcinoma are the two most common types of carcinomas, affecting a total of 5.4 million people each year in the United States. Sun-exposed areas, especially the face and nose, are most affected given the strong association between these carcinomas and ultraviolet radiation. Less research has been done surrounding carcinomas of the lip, despite the significant aesthetic and functional importance of this area. Although lip carcinomas tend to follow a classic, unique distribution pattern that favors basal cell carcinoma on the upper lip and squamous cell carcinoma on the lower lip, more cases of lower lip basal cell carcinoma are being reported, warranting further educational awareness to differentiate carcinomas of the lower lip. In this article, we provide an updated overview of the risk factors, presentations, differential diagnoses, metastatic risks, evaluation, management guidelines, and outcomes of lower lip carcinoma. Of note, recent advances in imaging modalities are beginning to show promise as a non-invasive, affordable, and rapid way to detect and stage tumors. We conclude that increased clinical awareness and investigation of lower lip carcinoma is needed to improve early intervention, as a delayed diagnosis can rapidly alter the management and outcomes of lip carcinomas.

Analysis of image-guided superficial radiation therapy (IGSRT) on the treatment of early-stage non-melanoma skin cancer (NMSC) in the outpatient dermatology setting

BACKGROUND

Interest in image-guidance superficial radiation therapy (IGSRT) for the treatment of early-stage non-melanoma skin cancer (NMSC) has resurfaced given its low complication rates, superior cosmesis and local control and cure rates. In addition, it has been recommended by the American Academy of Dermatology (AAD) for early-stage NMSC in patients who are considered poor surgical candidates.

METHODS

1899 NMSC lesions were treated with energies ranging from 50 to 100 kilovoltage (kV), for a mean of 20.2 fractions, and treatment dose of 5364.4 centigray (cGy). Lesions were treated for a mean of 7.5 weeks and followed for 65.5 weeks. SAS studio was used to conduct Kaplan-Meier analysis to calculate local control rates and account for differences in follow-up intervals. A log-rank test was used to calculate statistical differences between histologies.

RESULTS

Absolute lesion control was achieved in 99.7% of the patients after an average of 7.5 weeks of treatment, with a stable control rate of 99.6% when the follow-up duration was over 12 months. 95% of lesions with toxicity scoring received a Radiation Treatment Oncology Group Toxicity (RTOG) score of 1 or 2.

CONCLUSION

IGSRT has a high safety profile, can achieve superior cosmesis and should be considered first-line for treating early-stage NMSC tumors as cure rates have been shown to be effective in all NMSC on early follow-up.

Comparison of the Basal Cell Carcinoma (BCC) Tumour Microenvironment to Other Solid Malignancies

Basal cell carcinoma (BCC) is the most common form of skin cancer, contributing to nearly a third of new cancer cases in Western countries. Most BCCs are considered low risk "routine" lesions that can either be excised through surgery or treated with chemotherapeutic agents. However, around 1-2% of BCC cases are locally aggressive, present a high risk of metastasis, and often develop chemoresistance, termed advanced BCC. There currently exists no animal model or cell line that can recapitulate advanced BCC, let alone intermediate-risk and high-risk early BCC. We previously found that aggressive BCC tumours presented a Th2 cytokine inflammation profile, mesenchymal stem cell properties, and macrophage-induced tumoral inflammation. In this study, we aimed to identify potential BCC "relatives" among solid-organ malignancies who present similar immune cell proportions in their microenvironment compositions. Using immune cell type deconvolution by CIBERSORTx, and cell type enrichment by xCell, we determined three cancers with the most similar tumour microenvironments as compared to BCC. Specifically, chromophobe renal cell carcinoma, sarcoma, and skin cutaneous melanoma presented significance in multiple cell types, namely in CD4+ T lymphocytes, gammadelta T lymphocytes, and NK cell populations. Consequently, further literature analysis was conducted to understand similarities between BCC and its "relatives", as well as investigating novel treatment targets. By identifying cancers most like BCC, we hope to propose prospective druggable pathways, as well as to gain insight on developing a reliable animal or cell line model to represent advanced BCC.

Combined cemiplimab and radiotherapy for advanced basal cell carcinoma: A case report

Advanced basal cell carcinoma may be treated with systemic therapies such as hedgehog pathway inhibitors or programmed cell death protein 1 inhibitors, namely cemiplimab. We report a case of a 70-year-old man with a nodulo-infiltrative advanced basal cell carcinoma over the right posterior neck and scapula. The patient had a partial response to the hedgehog pathway inhibitor, vismodegib. The tumour progressed, and the patient was switched from vismodegib to radiotherapy combined with cemiplimab, which led to a significant reduction in pain, bleeding, and tumour size. A combined treatment approach with radiotherapy and cemiplimab may be beneficial for advanced basal cell carcinoma cases that progress after treatment with hedgehog pathway inhibitors.

Clinical Utility of an AI-powered, Handheld Elastic Scattering Spectroscopy Device on the Diagnosis and Management of Skin Cancer by Primary Care Physicians

BACKGROUND

Patients with lesions suspicious for skin cancer often present to primary care physicians (PCPs), who may have limited training in skin cancer diagnosis.

OBJECTIVE

To measure the impact of an adjunctive handheld device for PCPs that employs elastic scattering spectroscopy (ESS) on the diagnosis and management of skin cancer.

METHODS

Fifty-seven PCPs evaluated 50 clinical images of skin lesions (25 malignant and 25 benign), first without and then with knowledge of the handheld ESS device output, and in each case indicated if a lesion was likely to be benign or malignant.

RESULTS

The diagnostic sensitivity of the PCPs with and without the use of the ESS device was 88% (95% CI, 84%-92%) and 67% (95% CI, 62%-72%), respectively (P < .0001). In contrast, no significant difference was observed in the diagnostic specificity. The management sensitivity of the physicians with and without the use of the ESS device was 94% (95% CI, 91%-96%) and 81% (95% CI, 77%-85%), respectively (P = .0009). Similarly, no significant difference was observed in the management specificity.

CONCLUSION

The use of the ESS device may have the potential to help improve skin cancer diagnosis and confidence in management decision-making in a primary care setting.

Update in the treatment of non-melanoma skin cancers: the use of PD-1 inhibitors in basal cell carcinoma and cutaneous squamous-cell carcinoma

Non-melanoma skin cancer (NMSC) includes a wide range of cutaneous tumors, the most frequent of which are basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (CSCC). Although NMSC is usually cured by surgical resection, in rare cases it can progress to locally advanced and metastatic disease. Risk factors for advanced disease include comorbidities, neglect, and immunosuppression. Advanced NMSC may require systemic treatment if surgery and radiation are not feasible. Chemotherapy, epidermal growth factor receptor (EGFR) inhibitors in CSCC, and hedgehog inhibitors in BCC have been used but are generally of limited benefit, with responses often short-lived and toxicity issues. Given the high mutational burden of NMSC, the use of immunotherapy has been investigated and two anti-PD-1 antibodies, cemiplimab and pembrolizumab, are approved for the treatment of advanced CSCC not curable by surgery or radiation. Both have shown durable responses with good tolerability in patients in phase II trials and anti-PD-1 therapy is now the standard of care for locally advanced and metastatic CSCC. PD-1 blockade is also approved as second-line therapy in advanced BCC, with frequent and durable responses after failure on hedgehog inhibitor therapy. PD-1 checkpoint inhibition is being assessed for NMSC in combination with other modalities, including oncolytic viruses and EGFR inhibitors. Adjuvant and neoadjuvant use of cemiplimab and pembrolizumab is also being investigated with several ongoing trials. Further clinical trials of immunotherapy must be prioritized in NMSC for further improvement in outcomes.

High-fidelity detection, subtyping, and localization of five skin neoplasms using supervised and semi-supervised learning

Background

Skin cancers are the most common malignancies diagnosed worldwide. While the early detection and treatment of pre-cancerous and cancerous skin lesions can dramatically improve outcomes, factors such as a global shortage of pathologists, increased workloads, and high rates of diagnostic discordance underscore the need for techniques that improve pathology workflows. Although AI models are now being used to classify lesions from whole slide images (WSIs), diagnostic performance rarely surpasses that of expert pathologists.

Objectives

The objective of the present study was to create an AI model to detect and classify skin lesions with a higher degree of sensitivity than previously demonstrated, with potential to match and eventually surpass expert pathologists to improve clinical workflows.

Methods

We combined supervised learning (SL) with semi-supervised learning (SSL) to produce an end-to-end multi-level skin detection system that not only detects 5 main types of skin lesions with high sensitivity and specificity, but also subtypes, localizes, and provides margin status to evaluate the proximity of the lesion to non-epidermal margins. The Supervised Training Subset consisted of 2188 random WSIs collected by the PathologyWatch (PW) laboratory between 2013 and 2018, while the Weakly Supervised Subset consisted of 5161 WSIs from daily case specimens. The Validation Set consisted of 250 curated daily case WSIs obtained from the PW tissue archives and included 50 "mimickers". The Testing Set (3821 WSIs) was composed of non-curated daily case specimens collected from July 20, 2021 to August 20, 2021 from PW laboratories.

Results

The performance characteristics of our AI model (i.e., Mihm) were assessed retrospectively by running the Testing Set through the Mihm Evaluation Pipeline. Our results show that the sensitivity of Mihm in classifying melanocytic lesions, basal cell carcinoma, and atypical squamous lesions, verruca vulgaris, and seborrheic keratosis was 98.91% (95% CI: 98.27%, 99.55%), 97.24% (95% CI: 96.15%, 98.33%), 95.26% (95% CI: 93.79%, 96.73%), 93.50% (95% CI: 89.14%, 97.86%), and 86.91% (95% CI: 82.13%, 91.69%), respectively. Additionally, our multi-level (i.e., patch-level, ROI-level, and WSI-level) detection algorithm includes a qualitative feature that subtypes lesions, an AI overlay in the front-end digital display that localizes diagnostic ROIs, and reports on margin status by detecting overlap between lesions and non-epidermal tissue margins.

Conclusions

Our AI model, developed in collaboration with dermatopathologists, detects 5 skin lesion types with higher sensitivity than previously published AI models, and provides end users with information such as subtyping, localization, and margin status in a front-end digital display. Our end-to-end system has the potential to improve pathology workflows by increasing diagnostic accuracy, expediting the course of patient care, and ultimately improving patient outcomes.

Categorization of Common Pigmented Skin Lesions (CPSL) using Multi-Deep Features and Support Vector Machine

The skin is the main organ. It is approximately 8 pounds for the average adult. Our skin is a truly wonderful organ. It isolates us and shields our bodies from hazards. However, the skin is also vulnerable to damage and distracted from its original appearance: brown, black, or blue, or combinations of those colors, known as pigmented skin lesions. These common pigmented skin lesions (CPSL) are the leading factor of skin cancer, or can say these are the primary causes of skin cancer. In the healthcare sector, the categorization of CPSL is the main problem because of inaccurate outputs, overfitting, and higher computational costs. Hence, we proposed a classification model based on multi-deep feature and support vector machine (SVM) for the classification of CPSL. The proposed system comprises two phases: First, evaluate the 11 CNN model's performance in the deep feature extraction approach with SVM, and then, concatenate the top performed three CNN model's deep features and with the help of SVM to categorize the CPSL. In the second step, 8192 and 12,288 features are obtained by combining binary and triple networks of 4096 features from the top performed CNN model. These features are also given to the SVM classifiers. The SVM results are also evaluated with principal component analysis (PCA) algorithm to the combined feature of 8192 and 12,288. The highest results are obtained with 12,288 features. The experimentation results, the combination of the deep feature of Alexnet, VGG16 and VGG19, achieved the highest accuracy of 91.7% using SVM classifier. As a result, the results show that the proposed methods are a useful tool for CPSL classification.

A Novel Approach to Skin Lesion Segmentation: Multipath Fusion Model with Fusion Loss

Segmentation of skin lesions plays a very important role in the early detection of skin cancer. However, indistinguishability due to various artifacts such as hair and contrast between normal skin and lesioned skin is an important challenge for specialist dermatologists. Computer-aided diagnostic systems using deep convolutional neural networks are gaining importance in order to cope with difficulties. This study focuses on deep learning-based fusion networks and fusion loss functions. For the automatic segmentation of skin lesions, U-Net (U-Net + ResNet 2D) with 2D residual blocks and 2D volumetric convolutional neural networks were fused for the first time in this study. Also, a new fusion loss function is proposed by combining Dice Loss (DL) and Focal Tversky Loss (FTL) to make the proposed fused model more robust. Of the 2594 image dataset, 20% is reserved for test data and 80% for training data. In test data training, a Jaccard score of 0.837 and a dice score of 0.918 were obtained. The proposed model was also scored on the ISIC 2018 Task 1 test images, whose ground truths were not shared. The proposed model performed well and achieved a Jaccard index of 0.800 and a dice score of 0.880 in the ISIC 2018 Task 1 test set. In addition, it has been observed that the new fused loss function obtained by fusing Focal Tversky Loss and Dice Loss functions in the proposed model increases the robustness of the model in the tests. The proposed new loss function fusion model has outstripped the cutting-edge approaches in the literature.

Vismodegib in Locally Advanced Basal Cell Carcinoma in Slovenia

BACKGROUND

Vismodegib is a first-in-class inhibitor of the hedgehog pathway for treatment of locally advanced basal cell carcinoma (laBCC) and metastatic BCC.

OBJECTIVES

The purpose of this study is to report outcomes of patients with laBCC, with basal cell carcinoma nevus syndrome (Gorlin Goltz syndrome [G-G Syn]) treated with vismodegib in routine clinical practice in Slovenia in 8.3-year period.

METHODS

In this retrospective cohort study, we analyzed baseline characteristics, outcomes, and treatment-related adverse events from locally advanced BCC. The patients were divided into two cohorts: 39 laBCC or multiple BCC patients and 7 patients with G-G Syn who were treated with vismodegib from November 2012 till January 2021.

RESULTS

During 100-month period, 46 patients were diagnosed with laBCC (26), multiple BCC (13), and G-G Syn (7), all inappropriate for surgery or radiotherapy. Baseline characteristics: median age was 72.8 years in laBCC + multiple BCC cohort and 47.4 years in G-G Syn cohort. The objective response rate was 80% in laBCC + multiple BCC and 86% in G-G Syn cohort. Disease control rate (DCR) was 95% in laBCC + multiple BCC and 100% in G-G Syn cohort. Median duration of treatment was 9.9 months (range: 1.5-43.1) in laBCC and multiple BCC cohort and 19.5 months (range: 3.6-94.1) in G-G Syn cohort. Majority of treatment-emergent adverse events (TEAEs) in laBCC or multiple BCC cohort were grade 1 or 2 (96%), only 4% of AEs were grade 3. Majority of TEAEs in G-G Syn cohort were also grade 1 or 2 (87%), 13% of AEs were grade 3. No grade 4 or 5 vismodegib-related AEs were reported.

CONCLUSION

Vismodegib has shown meaningful efficacy with DCR from 95% to 100% in patients with laBCC, multiple BCC, and G-G Syn in Slovenia. TEAEs were successfully alleviated with multidisciplinary approach and early supportive care.

Real-World Treatment Patterns and Outcomes Among Patients with Basal Cell Carcinoma Following First-Line Hedgehog Inhibitor Discontinuation

INTRODUCTION

Until recently, patients discontinuing first-line (1L) hedgehog inhibitors (HHIs) for basal cell carcinoma (BCC) had few subsequent treatment options. The objective of this study was to describe the treatment journey and prognosis of patients discontinuing 1L HHI for BCC.

METHODS

This was a retrospective cohort study of patients with BCC who discontinued 1L HHI treatment in The US Oncology Network between 1 January 2012 and 1 January 2019 (with follow-up until 1 May 2020). Two cohorts were identified: patients who initiated a second-line (2L) treatment (2L initiators), and patients with 1L progression or toxicity without pathology-confirmed complete response who did not initiate 2L treatment (2L non-initiators). Patient demographics, treatment characteristics, and outcomes are reported for each cohort.

RESULTS

Among 115 patients with BCC who received 1L HHI treatment, 63.5% (n = 73/115) discontinued 1L HHIs. Of those, 50.7% (n = 37/73) discontinued because of documented toxicity or progression, without evidence of a complete response. We identified 4 patients who initiated 2L systemic treatment (median age 68.7 years, 100.0% female) and 15 patients who were eligible for the 2L non-initiator cohort (median age 80.2 years, 20.0% female). Median 1L HHI duration was 6.8 months (range 1.9-20.6 months) for the 2L non-initiator cohort and 8.6 months (range 6.8-42.2 months) for 2L initiators. At the end of follow-up, among 2L non-initiators (median follow-up duration 9.7 months), 40.0% were lost to follow-up, 33.3% had died, 20.0% continued observation, and 6.7% transitioned to an academic medical center or hospital; among 2L initiators (median follow-up duration 6.3 months), 50.0% were lost to follow-up, 25.0% had died, and 25.0% continued observation.

CONCLUSIONS

Following 1L HHI discontinuation, lack of standardized care and suboptimal outcomes were observed, including limited receipt of 2L treatment. Further studies are necessary to evaluate the impact of newer BCC treatment options.

Gorlin Syndrome: Assessing Genotype-Phenotype Correlations and Analysis of Early Clinical Characteristics as Risk Factors for Disease Severity

PURPOSE

Gorlin syndrome (GS) is a rare genetic disorder characterized by lifetime risk of basal cell carcinomas (BCCs), skeletal anomalies (SAs), and other extracutaneous neoplasms. There is great variation in disease severity, and a genotype-phenotype correlation has not been well established. Here, we investigate whether patients' clinical characteristics predict disease severity to inform clinical decision making.

METHODS

Data of 248 patients with GS were collected between 2014 and 2021 from three institutions. Multivariable regression analyses were performed to investigate whether clinical characteristics predicted disease burden. Genotype-phenotype correlations were investigated in 40 patients.

RESULTS

Patients with SAs had a mean increase of 120 lifetime BCCs (95% CI, 27.1 to 213) relative to patients without SAs. Those with ≥ 2 SAs had 2.45 increased odds (95% CI, 1.01 to 5.91) of advanced or metastatic BCCs. Moreover, the presence of multiple SAs was associated with 5.00 increased odds of having a keratocystic odontogenic tumor (95% CI, 2.22 to 11.3) and 2.79 increased odds of an ovarian fibroma (95% CI, 1.05 to 7.40). Genotype-phenotype analyses showed that missense/in-frame mutations were more likely to be hereditary compared with severe deleterious mutation types (100% v 27%; P = .004). In addition, heat map visualization illustrated that those with more deleterious variants, like large deletions, trended toward increased burden of SAs and BCCs per year.

CONCLUSION

GS patients with SAs may be at greater risk for developing more numerous and severe BCCs and other neoplastic growths including keratocystic odontogenic tumors and ovarian fibromas. Current clinical guidelines suggest yearly follow-up in individuals with GS. Since SAs are usually recognized at the time of diagnosis, our results suggest that more vigilant lifetime multidisciplinary surveillance should be considered for these patients starting in childhood.

Real-world assessment and treatment of locally advanced basal cell carcinoma: Findings from the RegiSONIC disease registry

BACKGROUND

Limited information is available regarding real-world treatment patterns and their effectiveness and safety in patients with locally advanced basal cell carcinoma, including patients not typically represented in clinical trials. The purpose of the current study was to describe how clinicians diagnose and treat locally advanced basal cell carcinoma in the United States.

METHODS

This prospective, multicenter, observational registry study included patients with newly diagnosed, Hedgehog pathway inhibitor-naive locally advanced basal cell carcinoma without basal cell carcinoma nevus syndrome (n = 433) treated at 75 US academic and community practices, including dermatology, Mohs surgery, and medical oncology sites. The main outcomes of this study were treatment patterns and associated effectiveness and safety for patients with locally advanced basal cell carcinoma in real-world settings.

RESULTS

Determination of locally advanced basal cell carcinoma was mainly based on lesion size (79.6% of patients), histopathology (54.3%), extent of involvement (49.0%), and location (46.2%). Within 90 days of determination of locally advanced disease, 115 patients (26.6%) received vismodegib, 251 (58.0%) received surgery/other (non-vismodegib) treatment, and 67 (15.5%) had not yet received treatment (observation). Vismodegib-treated patients had a higher prevalence of high-risk clinical features predictive for locoregional recurrence than those with non-vismodegib treatment or observation. Clinical response rate was 85.1% with vismodegib and 94.9% with non-vismodegib treatment (primarily surgery). The most common adverse events with vismodegib were ageusia/dysgeusia, muscle spasms, alopecia, and weight loss. Rates of cutaneous squamous cell cancers were comparable between vismodegib and non-vismodegib treatment.

CONCLUSIONS

This prospective observational study offers insight on real-world practice, treatment selection, and outcomes for a nationally representative sample of US patients with locally advanced basal cell carcinoma. For patients with lesions that were not amenable to surgery, vismodegib treatment was associated with effectiveness and safety that was consistent with that observed in clinical trials.

Content Analysis of Skin Cancer Screenings on Pinterest: An Exploratory Study

Skin cancer rates are rising in the United States, yet screening rates remain low. Meanwhile, social media has evolved to become a primary source of health information, with 40% of daily users of Pinterest reporting the platform as a “go-to” source. The objective of this research paper is to examine how skin cancer screenings were portrayed on Pinterest. Using the search terms “skin cancer screening” and “skin cancer exam”, researchers sampled every fifth pin to collect 274 relevant pins. Two researchers coded the pins, and interrater agreement was established at 94%. The results showed that twenty-two percent of the sample depicted skin cancer screening in a negative way, yet 41.5% noted that early detection leads to better outcomes. The pins were geared toward younger, white women with minimal depiction of people of color. Few pins included comprehensive information about skin cancer risk factors, importance of routine self-screenings, or what to expect with a medical provider. Fifty-eight percent of pins included links to personal blogs. In conclusion, social media has become a powerful source of health information, yet much of the posted information is incomplete. These findings present public health experts with an opportunity to disseminate more comprehensive skin cancer screening information on social media.

Prognostic Value of Evaluating Platelet Role, Count and Indices in Laboratory Diagnosis of Different Types of Solid Malignancies

Platelets are associated with the processes that aid in tumour growth and progression. Platelet Count (PLT) and platelet indices like Mean Platelet Volume (MPV), Platelet Large Cell Ratio (P-LCR), Plateletcrit (PCT) and Platelet Distribution Width (PDW) are markers that are linked with platelet activities in cancer. This review involves the evaluation of PLT, MPV and PCT in different cancers. Platelets actions should be always monitored during several diseases, as their potential exceeds the classical function in preventing bleeding. Vast roles of platelets were discovered in several biological functions. Therefore, studying their indices can be effective in the diagnosis of several disorders including cancer.

Differential expression of programmed cell death ligand 1 (PD-L1) and inflammatory cells in basal cell carcinoma subtypes

Few studies have evaluated programmed cell death ligand (PD-L1) expression and lymphocytic infiltrates in Basal Cell Carcinoma (BCC). The objectives of this study are to assess PD-L1 expression and markers of local immune response in nodular, superficial, and morpheaform BCC, and compare it to normal, sun-exposed skin from the periphery of intradermal nevi. This was a retrospective study that included three histological subtypes of BCCs, and sun-exposed skin from the periphery of dermal nevi as quality controls. Tissue microarrays (TMA) were constructed with subsequent staining of H&E and immunohistochemistry (IHC) for CD4, CD8, FOXP3 and PD-L1. Non-automated quantification of the infiltrate in the intratumoral and stromal compartments on TMAs was performed. A total of 115 BCC (39 nodular, 39 morpheaform, and 37 superficial) and 41 sun-exposed skin samples were included (mean age 65.4 years; 52.6% females). BCC showed higher expression of PD-L1 (5.4 vs 0.7%, p < 0.001), CD8 (29.8 vs 19.7%, p = 0.002), and FOXP3 (0.3 vs 0.06%, p = 0.022) compared to sun-exposed skin. There was a higher PD-L1 expression in nodular BCC compared with other subtypes. Low-risk BCC subtypes (superficial and nodular) exhibited more PD-L1 expression in intratumoral and stromal immune infiltrates as compared to high-risk BCC subtypes. As a limitation, no immune cells function was evaluated in this study, only the presence/absence of T-lymphocyte sub-populations was recorded. Substantial differences in both PD-L1 expression and lymphocytic infiltrates were found amongst the histological subtypes of BCC and sun-exposed skin. Highest PD-L1 expression was found in nodular BCCs which suggests a potentially targetable strategy in the treatment of this most common BCC subtype.

Key Clinical Adverse Events in Patients with Advanced Basal Cell Carcinoma Treated with Sonidegib or Vismodegib: A Post Hoc Analysis

INTRODUCTION

Sonidegib is approved to treat locally advanced basal cell carcinoma (laBCC) in the USA, EU, Switzerland, and Australia and metastatic basal cell carcinoma (mBCC) in Switzerland and Australia in patients not amenable to surgery or radiotherapy. Vismodegib is approved to treat patients with mBCC, recurrent laBCC, or those not candidates for surgery or radiation. There is no head-to-head trial comparing Hedgehog inhibitors. We describe time to onset and severity of adverse events (AEs) in two studies reporting cumulative AE incidence every treatment cycle: the sonidegib phase 2 BOLT study and the expanded-access, open-label vismodegib study.

METHODS

This analysis included patients with histologically confirmed laBCC or mBCC from BOLT who received sonidegib 200 mg once daily (QD) and patients from the vismodegib study who received vismodegib 150 mg QD. Cumulative occurrence of AEs and median time to AE onset were calculated on 30-day cycles for sonidegib and 28-day cycles for vismodegib. AEs were graded for severity using the Common Terminology Criteria for Adverse Events. Only common (at least 15% incidence) AEs were analyzed in this study.

RESULTS

Over 18 treatment cycles, the most common all-grade AEs for sonidegib and vismodegib were muscle spasm (54.4% vs 70.6%; P = 0.0236), alopecia (49.4% vs 58.0%; no significant difference [NS]), and dysgeusia (43.0% vs 70.6%; P = 0.0003); incidences of diarrhea, nausea, fatigue, and weight decrease were 31.6% vs 25.2% (NS), 39.2% vs 19.3% (P = 0.0032), 32.9% vs 19.3% (P = 0.0429), and 30.4% vs 16.0% (P = 0.0217), respectively. Sonidegib-treated patients had more delayed median time to onset for all AEs than vismodegib-treated patients, except fatigue and weight decrease (NS). Most AEs reported were grade ≤ 2.

CONCLUSION

This post hoc analysis suggests lower overall incidence and slower onset of certain AEs in patients treated with sonidegib compared with vismodegib. In the absence of head-to-head comparisons, the relevance of these findings needs further studies to provide conclusive evidence.

Efficacy and tolerability of vismodegib treatment in locally advanced and metastatic basal cell carcinoma: Retrospective real-life data

The study aims to evaluate the vismodegib treatment in local advanced (laBCC) and metastatic (mBCC) basal cell carcinoma. The data of 29 patients were retrospectively reviewed. The clinical and histopathological features of the patients and adverse events of vismodegib were recorded. Overall survival (OS) and progression-free survival (PFS) were evaluated with Kaplan-Meier analysis. The median follow-up period was 17 months (range: 1.6-57.3), and the median age at diagnosis 73 years (range: 39-88). The most common disease location was head and neck (86.2%), and the most common non-skin sites of disease were lymph nodes (13.8%), bone (13.8%), lung (6.9%), and brain (6.9%). Three (10.3%) patients had Gorlin's syndrome. The number of metastatic patients was 5 (17.2%). With vismodegib treatment, the complete response rate was 27.6%, partial response 55.2%, and stable response 10.3%. Treatment responses were most frequently seen within 2 months from the beginning of vismodegib. The median OS was 43.3 ± 9.0 months (25.6-61.1) for all patients. The median PFS in the laBCC was 15.7 ± 1.8 months (12.2-19.3), and 12.1 ± 4.6 months (2.9-21.2) in the mBCC. In the univariable analysis for the OS, only the treatment after the vismodegib was statistically significant, showing chemotherapy was better comparing to no treatment or surgery. The most common adverse events were fatigue-58.6%, muscle spasms-48.3%, alopecia-13.8%, and weight loss-13.8%. This real-life data study shows that vismodegib treatment in locally advanced and metastatic BCC was well tolerated and effective.

Hedgehog inhibitors with and without adjunctive therapy in treatment of locally advanced basal cell carcinoma

BACKGROUND

Hedgehog inhibitor therapy (HHIT) is considered first-line treatment for locally advanced, unresectable basal cell carcinoma (laBCC). HHIT often results in a partial response, which requires adjunctive therapy (AT) post HHIT. We present real-world data for laBCCs undergoing HHIT ± AT.

METHODS

Retrospective review at Duke University from 11/01/2007 through 5/20/2020 revealed 13 patients treated with systemic HHIT (sonidegib or vismodegib) for laBCC.

RESULTS

Fourteen laBCCs were identified in 13 patients. LaBCCs were treated with sonidegib (n = 10, 71%) or vismodegib (n = 4, 29%) for a median (IQR) of 9.4 (9.3) or 9.8 (8.5) months, respectively. The median (IQR) follow-up time from HHIT initiation was 15.5 (8.7) months. Tumors were most often located on the trunk (43%), followed by head and neck (29%), extremities (21%), and orbit/periorbital area (7%). Nine laBCCs (64%) were treated with HHIT alone, of which five (36%) achieved complete response (CR), four (29%) achieved partial response (PR), and five (36%) achieved CR with combined HHIT and AT post-HHIT. Duration of HHIT treatment (IQR) was 7.5 (3.5) months in the 10 CR patients, versus 15.1 (6.3) months in the four PR patients (P = 0.024). Nine patients (69%) experienced adverse events from HHIT, most commonly ageusia/dysgeusia, muscle spasms, and alopecia.

CONCLUSION

As a single institutional experience, we report 10/14 laBCCs (71%) with CRs without recurrence and 4/14 laBCCs (29%) with PRs with HHIT ± AT over median follow-up of 15.5 months. Longer follow-up and larger cohorts evaluating responses with HHIT followed by AT are needed to substantiate our findings.

Citrus Consumption and Risk of Non-Melanoma Skin Cancer in the UK Biobank

Background: Non-melanoma skin cancer (NMSC) incidence has been dramatically increasing worldwide. Psoralen, a known photocarcinogen, is naturally abundant in citrus products, leading to the hypothesis that high citrus consumption may increase NMSC risk.Methods: We fitted age- and multivariable-adjusted logistic regression models to evaluate the association between citrus consumption and NMSC risk among 197,372 UKBB participants. A total of 9,613 NMSC cases were identified using International Classification of Disease 10 codes. Citrus consumption data were collected via five rounds of 24-hour recall questionnaires.Results: We found no association between high total citrus consumption and NMSC risk, although a slightly elevated NMSC risk was observed among participants who consumed >0 to half a serving of total citrus per day (OR [95% CI] = 1.08 [1.01-1.16]). There was no association between individual citrus products and NMSC risk.Conclusion: High citrus consumption was not associated with an increased risk of NMSC in our UKBB sample. Further studies are needed to clarify these associations.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2021.1952439 .

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection

SUMMARY

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Does reduction of the oncologic safety margin for facial basal cell carcinoma result in higher recurrence rates?

Background

Wide surgical excision is the gold standard for basal cell carcinoma (BCC) treatment. Typically, resection requires a safety margin ≥ 4 mm. We aimed to confirm BCC excisions’ cancer recurrence rate and safety on the facial region with new safety margins.

Methods

We included patients with primary BCC on the facial region who underwent wide excision with 2- or 3-mm safety margins at our institution between January 2010 and December 2018. Medical records were reviewed to confirm the epidemiology and surgical information. Recurrence was confirmed by physical examination through regular 6-month follow-up.

Results

We included 184 out of 233 patients in this study after applying the exclusion criteria. The mean age and follow-up period were 71.2±10.2 years and 29.3±13.5 months, respectively. The predominantly affected area was the nose (95 cases); a V-Y advancement flap was the most commonly used surgical method. There were two cases of recurrence in the 2 mm margin group and one recurrence in the group resected with 3 mm margins.

Conclusion

In this large cohort study, we found 2–3 mm excision margins can yield enough safety in facial BCCs. The recurrence rates were found to be comparable with those reported after wider margins.

Effectiveness, safety and utilization of vismodegib in locally advanced basal cell carcinoma under real-world conditions in Germany - The non-interventional study NIELS

BACKGROUND

Basal cell carcinoma (BCC) can arise by the uncontrolled proliferation of cells from multiple epidermal compartments due to aberrant activation of the Hedgehog (Hh) signalling pathway. Vismodegib, a small-molecule inhibitor of this pathway, is approved for treatment of patients with locally advanced (la) BCC inappropriate for surgery or radiotherapy or patients with symptomatic metastatic (m) BCC.

OBJECTIVES

The aim of this non-interventional study was to assess effectiveness with a special focus on duration of response (DOR), safety and utilization of vismodegib for treatment of laBCC in daily practice in Germany.

METHODS

This non-interventional study (NIS) observed treatment of laBCC with vismodegib according to the German label in clinical practice. All available patients who had received at least one dose of vismodegib between commercial availability of vismodegib in Germany (02 August 2013) and 3 years before end of study (31 March 2016) could be included and were documented retrospectively and/or prospectively for up to 3 years. Primary effectiveness variable was DOR. Assessment of tumour response was carried out by the treating physicians. Exploratory variables included utilization of vismodegib, decision makers for therapy and method of tumour response evaluation. All statistical analyses were descriptive.

RESULTS

Between September 2015 and March 2019, 66 patients were observed at 26 German centres. The objective response rate (ORR) was 74.2% and the disease control rate (DCR) was 90.9%. The median DOR was 15.9 months (95% CI: 9.2; 25.7; n = 49 patients with response). The median progression-free survival (PFS) was 19.1 months and the median time to response (TTR) 2.7 months. A total of 340 adverse events were reported in 63 (95.5%) patients; no new safety signals were identified.

CONCLUSIONS

The NIS NIELS shows effectiveness and safety of vismodegib in patients with laBCC. It confirms the transferability of the results of the pivotal trial into routine clinical practice.

Efficacy and Safety of Simultaneous Application of HIFEM and Synchronized Radiofrequency for Abdominal Fat Reduction and Muscle Toning: A Multicenter Magnetic Resonance Imaging Evaluation Study

BACKGROUND

Radiofrequency and high-Intensity Focused Electromagnetic (HIFEM) field procedure are well-known, stand-alone, body-shaping modalities, yet their simultaneous application has not been investigated.

OBJECTIVE

The aim is to evaluate the efficacy of a novel device simultaneously delivering HIFEM and radiofrequency for subcutaneous fat reduction and muscle toning.

MATERIALS AND METHODS

Forty-one subjects with an average age of 39.7 ± 11.5 years were recruited. The subjects received 3 abdominal treatments (one per week). Magnetic resonance imaging images of the treated area were evaluated at baseline and at 1-, 3-, and 6-month visits for changes in subcutaneous fat, muscle thickness, and abdominal separation (AS). Anthropometric data and digital photographs were collected. Subject satisfaction and therapy comfort were evaluated.

RESULTS

The muscle mass increase peaked at 3 months, showing 26.1% thickening. The fat thickness reduction was most prominent at 3 months, showing a 30.8% reduction. The AS decreased by 18.8% at 3 months after treatment. The waist circumference reduced by 5.87 ± 3.64 cm at a 3-month follow-up. Six-month data showed maintenance of these outcomes. The treatment was considered as comfortable with high patient satisfaction.

CONCLUSION

The analysis of magnetic resonance imaging images and waist measurements showed that the therapy combining HIFEM and radiofrequency is highly effective in reducing subcutaneous fat and muscle thickening.

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection

SUMMARY

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Reflectance Confocal Microscopy Identification of Subclinical Basal Cell Carcinoma after Vismodegib Treatment: Report of a Case

Although surgery represents the treatment of choice for the majority of basal cell carcinomas, different therapies are required to treat the advanced ones. Vismodegib and sonidegib are the two oral Smoothened (Smo) inhibitors approved for the treatment of advanced basal cell carcinoma. Clinical detection of subclinical basal cell carcinoma during and after vismodegib treatment could be difficult, requiring the use of dermoscopy and reflectance confocal microscopy as noninvasive diagnostic methods. We report the case of a 62-year-old woman with a locally advanced basal cell carcinoma successfully treated with vismodegib in which dermoscopy and reflectance confocal microscopy showed their superiority in detecting subclinical recurrent basal cell carcinoma developed on scar tissue after complete regression of the tumor.

Epidemiology and Prevention of Cutaneous Cancer

Cutaneous malignancy is becoming an increasing public health burden in terms of morbidity and cost, associated with changing environmental exposures and increased longevity of the general and the immunosuppressed population. Yet the understanding of the scope of this problem is hindered by lack of robust registries for nonmelanoma skin cancer. The risk factor responsible for most of these cancers, exposure to ultraviolet radiation, can be mitigated. However, greater consensus is necessary to enact effective prevention and screening programs. New developments, including identification of biomarkers and use of artificial intelligence, show promise for targeting screening efforts.

Differentiation of Basal Cell Carcinoma and Trichoepithelioma: An Immunohistochemical Study

ABSTRACT

Basal cell carcinoma (BCC) is the most common malignancy of the skin. It is an epithelial neoplasm with origin in the precursor cells of the interfollicular epidermis. Even though it has low metastatic potential, delay in management may lead to local destruction and morbidity. In contrast, trichoepithelioma (TE) is a benign tumor originating from the outer root sheath of the hair follicle. Similar to BCC, TE tends to affect the head and neck region. Both neoplasms may exhibit clinical and histopathological similarities, making them prone to misdiagnosis. Multiple immunomarkers have been used to distinguish among these entities, but so far, no single agent or combination of agents appear to be neither sensitive nor specific enough to differentiate between them. This study was divided into 2 parts. First, 17 cases of BCC and 14 cases of TE were stained with androgen receptor and bcl-2. Then, 27 cases of borderline/equivocal of BCC and 13 cases of borderline/equivocal TE were stained with the same protocol. Sensitivity and specificity were calculated for each individual immunomarker and for the combination of them. Androgen receptor positivity was 100% specific for BCC and borderline/equivocal BCC, whereas bcl-2 diffuse staining pattern demonstrated a sensitivity of 82.4% for BCC and 88.9% borderline/equivocal BCC. When both immunomarkers were combined, the sensitivity for BCC decreased (70.6%) but the specificity remained high (100%). Similarly, the sensitivity for borderline/equivocal BCC was 55.6%, whereas the specificity was 100%. Although moderately sensitive, combining both immunomarkers showed an excellent specificity to discriminate between BCC and TE.

Hair Loss in Patients Treated with Vismodegib: A Single-Center Retrospective Study

Locally advanced basal cell carcinoma had always represented a form of skin cancer which had been difficult to treat until the hedgehog inhibitor vismodegib was approved. This small molecule acts by inhibiting the hedgehog signaling pathway that plays a critical role in the process of tumorigenesis. Although several trials have demonstrated the high efficacy of this drug, different adverse events have been described. Muscle spasms, dysgeusia, weight loss, and alopecia are the adverse events most frequently reported. The objective of this study was to report the incidence of alopecia arising in patients treated with vismodegib, assessing its characteristics, grade of severity, and time of onset.

Hedgehog inhibitors in the treatment of advanced basal cell carcinoma: risks and benefits

INTRODUCTION

Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer (NMSC). Although surgery is the first-line therapy for BCC, some cases can progress to an advanced or, rarely, a metastatic state and targeted therapy are required. The main pathway involved in BCC tumorigenesis is the Hedgehog (Hh) signaling pathway and its inhibition is among the few treatment options available for patients with advanced BCCs. Recent advances in targeting this pathway have led to the development of two small-molecule oral Hh inhibitors, vismodegib and sonidegib.

AREAS COVERED

The aim of this article is to provide a complete overview on the use of HPI for the treatment of advanced BCCs describing the efficacy, the benefits, and risks related to these small molecules.

EXPERT OPINION

To date, the class of Hh inhibitors has revolutionized the management of patients with advanced BCCs, even though they are usually related to a toxicity profile that may represent the major cause of treatment discontinuation; an accurate study of the Hh signaling pathway and the development of other small molecules could be useful to enlarge the armamentarium of treatment in order to assure patients a personalized approach to the choice of treatment.