British Association of Dermatologists' guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014

Bowen's disease revealing a penile invasive squamous cell carcinoma: Case report and review of literature

INTRODUCTION

Bowen's disease (BD) represents an in situ squamous cell carcinoma that can progress to an invasive one without treatment. Various options for Bowen's disease have been delineated, each with its set of advantages and disadvantages.

CASE PRESENTATION

We report the case of a 60-year-old patient with a history of chronic smoking and a background of multiple partners and recurrent urethritis. The patient presented with a maculopapular lesion on the lateral aspect of the penis, evolving for 5 years. A biopsy confirmed the diagnosis of Bowen's disease. The patient underwent an excision of the lesion which the histology showed an infiltrating basosquamous cell carcinoma.

DISCUSSION

The diagnosis of Bowen's disease requires a biopsy and is based on histological examination. Only surgical treatment allows for the identification, through histological analysis of the excised specimen, of any potential invasive area that may not have been identified in the biopsy. Nonsurgical therapies are also an option with high recurrence rates.

CONCLUSION

Bowen's disease management requires a personalized approach, considering factors like lesion characteristics, patient-related variables and treatment efficacy. An adapted follow-up is recommended due to the recurrence risk associated with various treatments.

Multiple Bowen's disease due to long-term narrow-band ultraviolet B phototherapy: A case report and literature review

OBJECTIVE

By presenting a case study on multiple instances of Bowen's disease and the consistent use of narrow-band ultraviolet B (NB-UVB) phototherapy over a three-year period, our aim is to enhance the comprehension of domestic clinicians regarding the disease. Additionally, we seek to review existing literature, encouraging dermatologists to consider clinical secondary primary lesion diagnoses.

METHOD

Our approach involves analyzing a diagnosed case of multiple Bowen's disease, examining clinical manifestations, histopathology, imaging results, and treatment methods related to NB-UVB phototherapy. We aim to facilitate discussion and understanding through a comprehensive literature analysis.

RESULTS

An elderly male with a 30-year history of psoriasis vulgaris initiated continuous NB-UVB therapy three years ago. A year later, he developed red patches and plaques with distinct borders and scaly surfaces on his face, trunk, lower extremities, and scrotum. Histopathological examination confirmed Bowen's disease. Treatment involved liquid nitrogen cryotherapy, with no recurrence observed during the one-year follow-up.

CONCLUSION

This case highlights that Bowen's disease, typically solitary, can manifest as multiple instances, especially in individuals with a history of psoriasis vulgaris. While NB-UVB stands as the primary treatment for psoriasis vulgaris, caution is warranted due to the potential risk of skin tumor induction with prolonged high-dose usage. Clinicians should be vigilant in monitoring and assessing the long-term implications of such therapies.

Photodynamic Therapy for the Treatment of Bowen's Disease: A Review on Efficacy, Non-Invasive Treatment Monitoring, Tolerability, and Cosmetic Outcome

Bowen's disease represents the in situ form of cutaneous squamous cell carcinoma; although it has an excellent prognosis, 3-5% of lesions progress to invasive cutaneous squamous cell carcinoma, with a higher risk in immunocompromised patients. Treatment is therefore always necessary, and conventional photodynamic therapy is a first-line option. The aim of this review is to provide an overview of the clinical response, recurrence rates, safety, and cosmetic outcome of photodynamic therapy in the treatment of Bowen's disease, considering different protocols in terms of photosensitizers, light source, and combination treatments. Photodynamic therapy is a valuable option for tumors at sites where wound healing is poor/delayed, in the case of multiple and/or large tumors, and where surgery would be difficult or invasive. Dermoscopy and reflectance confocal microscopy can be used as valuable tools for monitoring the therapeutic response. The treatment is generally well tolerated, with mild side effects, and is associated with a good/excellent cosmetic outcome. Periodic follow-up after photodynamic therapy is essential because of the risk of recurrence and progression to cSCC. As the incidence of keratinocyte tumors increases, the therapeutic space for photodynamic therapy will further increase.

Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in treatment of Bowen's disease: A multicenter randomized controlled trial

BACKGROUND

Randomized controlled trials comparing the effectiveness of 5-fluorouracil cream, methylaminolevulinate photodynamic therapy (MAL-PDT) and surgical excision in patients with Bowen's disease are lacking.

METHODS

In this multicenter noninferiority trial, patients with a histologically proven Bowen's disease of 4-40 mm were randomly assigned to excision with 5 mm margin, 5% 5-fluorouracil cream twice daily for 4 weeks, or 2 sessions of MAL-PDT with 1 week interval. The primary outcome was the proportion of patients with sustained clearance at 12 months after treatment. A noninferiority margin of 22% was used.

RESULTS

Between May 2019 and January 2021, 250 patients were randomized. The proportion of patients with sustained clearance was 97.4% (75/77) after excision, 85.7% (66/77) after 5-fluorouracil, and 82.1% (64/78) after MAL-PDT. Absolute differences were -11.7% (95% CI -18.9 to -4.5; P = .0049) for 5-fluorouracil versus excision and -15.4% (95% CI -23.1 to -7.6; P = .00078) for MAL-PDT versus excision. Both noninvasive treatments significantly more often led to good or excellent cosmetic outcome.

CONCLUSIONS

Based on our predefined noninferiority margin of 22%, 5-fluorourcail is noninferior to excision and associated with better cosmetic outcome. For MAL-PDT noninferiority to excision cannot be concluded. Therefore, 5-fluorouracil should be preferred over excision and MAL-PDT in treatment of Bowen's disease.

Shedding new light on actinic keratoses and squamous cell carcinoma in situ

ABSTRACT

Cutaneous squamous cell carcinoma can arise from various premalignant lesions such as actinic keratosis, Bowen disease, and premalignant genital squamous cell lesions. Identification and treatment can prevent malignant transformation and death. This article describes the causes, epidemiology, and characteristics of suspicious premalignant squamous cell lesions so that clinicians can identify these lesions and refer patients for specialist treatment as appropriate.

Cryosurgery versus curettage for intraepidermal carcinoma: A randomized controlled trial

BACKGROUND

Cryosurgery is a common destructive treatment method for intraepidermal carcinoma (IEC) above the knee. Curettage alone is a simple, non-aggressive and inexpensive treatment method commonly used on benign skin lesions. However, only one study has assessed curettage for treatment of IEC.

OBJECTIVE

We aimed to (1) compare the effectiveness of cryosurgery (standard method) to curettage (experimental method) for treatment of IEC in regard to overall clearance rates at 1-year follow-up, and (2) investigate whether wound healing times differed between the treatment groups.

METHODS

In this randomized and controlled, non-inferiority trial, adult patients with one or more IEC with a diameter of 5-20 mm, located above the knee and suitable for destructive treatment were recruited from Sahlgrenska University Hospital (Gothenburg, Sweden). Lesions were randomized to treatment with either cryosurgery or curettage. Wound healing was assessed by a nurse after 4-6 weeks and through self-report forms. Overall clearance was assessed by a dermatologist after 1 year.

RESULTS

In total, 183 lesions in 147 patients were included, with 93 lesions randomized to cryosurgery and 90 to curettage. Eighty-eight (94.6%) of the lesions in the cryosurgery group and 71 (78.9%) in the curettage group showed an overall clearance at the 1-year follow-up visit (p = 0.002). The non-inferiority analysis was inconclusive. Curettage resulted in both shorter self-reported wound healing times (mean time 3.1 vs. 4.8 weeks, p < 0.001) and a larger proportion of healed wounds after 4-6 weeks (p < 0.001).

CONCLUSIONS

Cryosurgery and curettage both result in high clearance rates for treatment of IEC, but cryosurgery is significantly more effective. On the other hand, curettage may result in shorter wound healing times.

Annular skin tumors and lymphoproliferative diseases

Determining the shape of a skin lesion may provide a diagnostic clue in dermatology practice, more commonly for inflammatory diseases but also for skin tumors. The annular formation may develop by diverse mechanisms in skin tumors. Annular lesions may occur from the onset of the tumor as sparing the central area or depression and/or ulceration in the center of the tumor or outward expansion of the primary lesion. Clustering of multiple papulonodular lesions sparing the central area or relatively independent processes acting on the central and peripheral components of the tumor may also result in an annular appearance. We have explored a wide variety of benign and malignant skin tumors and lymphoproliferative diseases forming an annular shape.

Experience analysis of a combined photodynamic/electrodesiccation therapy in the treatment of 11 cases of large patches of Bowen's disease

BACKGROUND

Bowen's disease (BD), also known as squamous cell carcinoma (SCC) in situ, should be treated actively. One of the therapy options, photodynamic (PDT) therapy, although an effective measure for the treatment, has a poor patient prognosis if not combined with other treatment options. Therefore, we propose the combination of electrodesiccation (ED) therapy and PTD in the treatment of large BD patches.

METHOD

A retrospective study, comprising 11 cases of BD with large tumor areas, was conducted to analyze various aspects, such as curative effects, cosmetic effects, patient satisfaction, improvement in the quality of life, and adverse reactions, by combining ED with PTD.

RESULT

The recurrence rate of BD patients treated with a combination of ED and PTD was 0% after one year with a satisfactory cosmetic degree (scar score was 1.91) and a high patient satisfaction (7.91). After treatment, the patients' quality of life was significantly improved (DLQI average was 20.08 and 4) and the difference was statistically significantly different. Also, the average healing time was 13.33 days. Adverse reactions were mainly pain and the incidence of infection was extremely low.

CONCLUSION

ET combined with PDT is effective in the treatment of BD with large patches and has the advantages of fast healing, less scar formation, and a good cosmetic effect.

Annular skin tumors and lymphoproliferative diseases

Determining the shape of the skin lesion may provide a diagnostic clue in dermatology practice, more commonly for inflammatory diseases but also for skin tumors. The annular formation may develop by diverse mechanisms in skin tumors. Annular lesions may occur from the onset of the tumor as sparing the central area or depression and/or ulceration in the center of the tumor or outward expansion of the primary lesion. Clustering of multiple papulonodular lesions sparing the central area or relatively independent processes acting on the central and peripheral components of the tumor may also result in an annular appearance. We have explored a wide variety of benign and malignant skin tumors and lymphoproliferative diseases forming an annular shape.

2022 European guideline for the management of balanoposthitis

BACKGROUND

This guideline is an update to the 2014 edition of the European guideline for the management of balanoposthitis. Balanoposthitis describes inflammation of the glans penis and prepuce and is caused by a range of disparate conditions including infection, dermatoses and premalignancy.

OBJECTIVE

The main objectives of this guideline are to aid recognition of the symptoms and signs and complications of penile skin conditions and to offer recommendations on the diagnostic tests and treatment for a selected group of these conditions.

METHODS

The previous guideline was updated following a literature review and priority was given to randomized controlled trial and systematic review evidence.

RESULTS

The updated guideline includes amended management for infective balanitis to provide clear guidance for Group A streptococcal infections, management of on going Lichen sclerosus (to include circumcision and supportive management to reduce the recurrence of genital herpes and warts), additional regimens for Zoonoid change, use of calcineurin inhibitors in management and risk of premalignancy and change of nomenclaturefrom Premalignant conditions to Penile Intraepithelial neoplasia (PeIN).

CONCLUSION

Balanoposthitis has a widerange of causes high quality evidence specific to the management of penile disease is not available for all the conditions described.

Genomic landscape of multiple Bowen's disease using whole-exome sequencing

The genomic landscape of Bowen's disease (BD), with multiple manifestations, has not yet been determined. This study aimed to investigate the genomic alterations in multiple BD. We performed whole-exome sequencing of BD lesions (n = 9) and matched germlines collected from three patients with multiple (≥3) BD to detect somatic and germline mutations. We found a median of 64 somatic mutations in each sample (range 20-267). UV-signature mutations accounted for 64.9% (median, range 26.0%-82.1%) of point mutations. Putative driver mutations were found in five BDs (RB1 p.R445*, ARID2 p.R274*, TP53 p.Y163D/p.Y205D/p.R342*, KMT2C p.R4549C) but not in the other four lesions. Somatic mutations were not shared between multiple BD lesions collected from the same patient, indicating a different clonal origin. We also found no known pathogenic germline mutations in cancer-related genes. The mutational signature analysis revealed that UV signatures (SBS7a/7b) and age-related signatures (SBS1/5) were the main active signatures. Copy number alterations (CNAs) were found in two BDs: one with extensive CNA regions (21.7% of the genome), including driver genes (PIK3CA/SOX2/TP63 and MYC gain, and CDKN2A loss), and the other with 1q gain. Our study revealed that multiple BD lesions harbor distinct genomic landscapes, suggesting that they have different risks of malignant progression.

Update on the management of Bowen disease with a focus on patients' needs

Invited Editorial on the update of the British guidelines on SCC in situ.

Perianal Bowen's disease treated with radiotherapy preserving anal function with a unique skin reaction considered as 'tumoritis'

Bowen's disease (BD) is a form of intraepidermal squamous cell carcinoma (SCC), and it occasionally occurs on the perianal site. BD is often treated with surgical excision; however, sometimes surgical excision for perianal BD cannot preserve anal function. We report the case of a 72-year-old man presenting with perianal pain and BD. He was treated with Radiotherapy (RT) and preserved his normal anal sphincter function without any recurrence or late adverse event. Moreover, we observed the unique skin reaction called 'tumoritis', which is characterized by mucosal inflammation. Tumoritis indicates the true extent of the tumor and evaluating the tumor or lesion size based on the extent of tumoritis when performing RT is important.

Squamous Cell Carcinoma in Situ of the Nail Unit: Current Evidence and Recommendations for Patient Centered Treatment

Squamous cell carcinoma in situ of the hand and nail is an infrequent tumor but represents the majority of hand and nail malignancies. While the conventional treatments of invasive nail unit squamous cell carcinoma include Mohs micrographic surgery, wide local excision, or distal digit amputation, no standardized management paradigm for in situ disease exists and the necessity of surgical options is debated. This review aims to discuss the most commonly reported treatment methods and critically assess relevant management considerations in order to facilitate appropriate treatment decisions for nail unit SCCis across dermatologic practice settings. Assessment of the current literature reveals insufficient evidence to determine a standardized treatment for nail unit squamous cell carcinoma in situ. Rather, management is greatly impacted by multiple factors including the presence of subungual involvement, surgical candidacy, importance of curative treatment, and patient preferences regarding cosmesis and function versus cure. When cure is desired, Mohs micrographic surgery is the treatment of choice in most cases. In the setting of desired curative intent, but poor surgical candidacy, radiotherapy may be effective and provide a reasonable chance of functional and cosmetic preservation. Other methods including photodynamic therapy, electrodesiccation and curettage, cryotherapy, and intralesional chemotherapeutics may be appropriate in specific circumstances, but are generally limited by lack of evidence or impracticalities. Lastly, observation with palliation may be appropriate when considering exceedingly rare disease-related mortality.

Successful treatment of giant Bowen's disease with photodynamic therapy and subsequent imiquimod in a case with chronic arsenic exposure

Multiple large lesions of Bowen's disease (BD) often appear in patients who have been under chronic exposure to arsenic. The treatment of such lesions is very challenging. Photodynamic therapy (PDT) has been considered a first-line effective treatment for BD. However, lesions larger than 2 cm are less responsive to PDT. We reported two giant BD lesions (> 10 cm in diameter), that were on a chronic arsenicosis patient's back, to be successfully treated with PDT and subsequent imiquimod occlusion overnight twice a week on the week after PDT. No recurrence was noted during the 12-month follow-up.

Successful treatment of extremely large Bowen's disease lesion by topical photodynamic therapy and imiquimod: Using optical coherence tomography to detect early recurrence loci and validate the cure

Bowen's disease, a form of skin cancer, is an intraepithelial carcinoma involving keratinocytes. It is associated with a risk of developing invasive squamous cell carcinoma in 3-5% of cases. Ultraviolet exposure, arsenic, human papillomavirus infection, immunosuppression, and genetic factors have been reported to be the causes. Clinically, it presents as symptomless and slowly growing, well-demarcated, irregular erythematous patches or plaques with scaly or crusted surfaces. Surgical excision remains common; however, for large (>20 mm) or multiple Bowen's disease lesions, alternative therapies need to be considered. Here, we present a case of extremely large Bowen's disease lesions in the lower extremities successfully treated with combination therapy using topical aminolevulinic acid-based photodynamic therapy followed by topical 5% imiquimod cream. Optical coherence tomography revealed disorganized and uneven nuclei of keratinocytes in the recurrent lesions, which became relatively small and uniform upon resolution. We demonstrated that photodynamic therapy provides a generally safe and effective strategy for treating large Bowen's disease lesions and optical coherence tomography provides a useful and noninvasive diagnosis of early Bowen's disease recurrence.

From Bowen disease to cutaneous squamous cell carcinoma: eight markers were verified from transcriptomic and proteomic analyses

Background

Bowen's disease is a cutaneous squamous cell carcinoma (CSCC) in situ. If left untreated, BD may progress to invasive CSCC. CSCC is one of the most common cutaneous carcinoma in the elderly and the advanced, metastasis CSCC usually have a poor outcomes. However, the mechanisms of invasion and metastasis from Bowen’s disease to CSCC is complicated and still unclear.

Objectives

The aim of this study was to explore the biomarkers and molecular alterations in Bowen’s disease development process via analyzing the proteomics changes in tissues of CSCC, Bowen disease and healthy skin.

Methods

A total of 7 individuals with CSCC (5 for proteomics study and 2 for validation), 7 individuals with Bowen disease (5 for proteomics study and 2 for validation) and 7 healthy controls (5 for proteomics study and 2 for validation) presented to the Department of Dermatology, Yijishan Hospital, the First Affiliated Hospital of Wannan Medical College between January 2021 and December 2021 were enrolled. The proteomics analysis was performed to screen differentially expressed proteins/gens (DEPs/DEGs) in the lesions of CSCC, Bowen disease and healthy skin tissues. The transcriptomic data (GSE32628) of CSCC was selected and downloaded from the GEO database. The common DEGs in our proteomics results and GSE32628 between CSCC and healthy skin tissues were selected. And then, the common DEGs which significantly up or down-regulated between CSCC and Bowen disease in our proteomics results were further screened to identify using Western blot methods in the validation group. CSCC A431 cells were transfected with SERPINB1 small interfering RNA (si-SERPINB1) or small interfering RNA negative control (si-NC). To explore the effect of SERPINB1 silencing on migration and invasion ability of A431 cells.

Results

A total of 501 proteins were differentially expressed between the CSCC and healthy skin tissues, with 332 up-regulated and 169 down-regulated at least 1.5-fold with a P value < 0.05. These DEPs involved multiple biological functions such as protein binding process, immune, inflammation, ribosome, protein digestion and absorption, ECM-receptor interaction, focal adhesion, PI3K-Akt signaling pathway and others. A total of 20 common DEGs (COL3A1, LUM, TNC, COL1A1, ALDH3A2, FSCN1, SERPINB4, SERPINB1, CD36, COL4A1, CSTB, GPX3, S100A7, ACTN1, SERPINB3, S100A8, RAB31, STAT1, SPRR1B, S100A9) between CSCC and healthy skin tissues in GSE32628 and our proteomics results were found. Besides, the proteins of TNC, FSCN1, SERPINB1, ACTN1 and RAB31 in CSCC were significantly up-regulated, while COL3A1, COL1A1 and CD36 were significantly down-regulated relative to Bowen disease in proteomics results. These proteins were mainly involved in multiple pathways, including Focal adhesion, ECM-receptor interaction, Human papillomavirus infection, PI3K-Akt signaling pathway, PPAR signaling pathway, AMPK signaling pathway and others. These eight proteins were selected for further validation. According to the Western blotting analysis, when compared with the Bowen disease and healthy skin tissues, we found that the relative expression levels of TNC, FSCN1, SERPINB1, ACTN1 and RAB31 in the CSCC were significantly increased, while COL1A1 and CD36 were significantly decreased, and the differences were statistically significant (P < 0.05). Furthermore, the relative expression levels of TNC, FSCN1, SERPINB1 in the Bowen disease were also significantly increased, while the COL3A1 were also significantly decreased relative to the healthy control. SERPINB1 siRNA inhibited the expression of SERPINB1 at mRNA and protein levels in the A431 cells. After interfering with the expression of SERPINB1, the migration and invasion ability in the A431 cells were significantly decreased (P < 0.05).

Conclusions

This study highlights that eight proteins, TNC, FSCN1, SERPINB1, ACTN1, RAB31, COL3A1, COL1A1, CD36, were significantly associated with the mechanisms of invasion and metastasis in Bowen’s disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03622-1.

Durable Clearance Rate of Photodynamic Therapy for Bowen Disease and Cutaneous Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Although surgery is the treatment of choice for Bowen disease (BD) and cutaneous squamous cell carcinoma (cSCC), nonsurgical treatments such as photodynamic therapy (PDT) may be preferred for select tumors. Previous meta-analysis have failed to gather strong evidence to recommend PDT.

OBJECTIVE

This study evaluates the effectiveness of PDT in the treatment of cSCC and BD for clearance rate (CR) after 1 year.

METHODS

A literature search of studies of biopsy-proven BD and cSCC treated with PDT was performed. Pooled CRs were estimated. Subgroup analyses were performed based on follow-up, treatment regimen, lesion size, and site.

RESULTS

Forty-three studies were included, enrolling 1943 BD lesions and 282 SCC lesions. Pooled CRs for BD and SCC were 76% (95% CI: 71%-80%; I2 = 78.9%) and 51% (95% CI: 35%-66%; I2 = 85.7%), respectively.

CONCLUSION

Our findings support the selective use of PDT for BD; however, patients should be advised of potential for recurrence. Although PDT can be used for certain cases of cSCC, the high rate of treatment failure necessitates close surveillance for residual or recurrent disease. Further studies are needed to justify the usage of PDT in the treatment of BD and cSCC.

A combination of laser-assisted ALA-PDT for squamous cell carcinoma in situ and field-directed ALA-PDT for actinic keratosis

Actinic keratosis (AK) is a chronic and recurrent disease caused by long-term sun exposure. Grade 3 AK is considered early squamous cell carcinoma in situ (SCCis). Field- and lesion-directed therapeutic approaches can improve the efficacy and reduce treatment time and cost. It is particularly suitable for AK patients with lesions of differing grades. Herein, we present a case of multiple AK lesions with local SCCis on the face. This patient achieved complete remission after one session of CO₂ laser and three sessions of 5-Aminolevulinic acid photodynamic therapy (ALA-PDT). There was no recurrence as of 1 year into follow-up.

Incidence and treatment strategies of Penile Intraepithelial Neoplasia in Sweden 2000‐2019

Objectives

Materials and methods

Results

Conclusions

[Penile intraepithelial neoplasia]

Penile carcinogenesis can be superposed on vulvar carcinogenesis, with two pathways : with or without a link to HPV. Penile squamous cell carcinomas arise from precursor lesions: penile intraepithelial neoplasia (PeIN) defined by the presence of intraepithelial atypia, which can progress to invasive squamous cell carcinoma. Differentiated PeINs not linked to HPV, affect elderly men with inflammatory lesions, most often lichen sclerosus. PeINs linked to HPV, basaloid, condylomatous or condylomatous-basaloid growth affect younger men. Although clinically similar, their distinction is important, because the treatment differs with a greater risk of invasion for forms unrelated to HPV.

Efficacy of Photodynamic Therapy for the Treatment of Bowen's Disease: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Photodynamic therapy is an established treatment option for Bowen's disease. Our meta-analysis was aimed at evaluating the efficacy and recurrence of photodynamic therapy or other topical treatments (5-fluorouracil, cryotherapy) and of photodynamic therapy alone or in combination with other therapies (ablative fractional CO2 laser or plum-blossom needle) for the treatment of Bowen's disease.

METHODS

Trials that met our inclusion criteria were identified from PubMed, EMBASE, Web of Science, and Cochrane Library databases, and meta-analyses were conducted with RevMan V.5.4. The risk of bias was estimated with the Cochrane Collaboration's risk of bias tools. Complete response rate, recurrence, pain/visual analogue scale score, cosmetic outcome, and adverse events were considered as outcomes.

RESULTS

Of the 2,439 records initially retrieved, 8 randomized controlled trials were included in this meta-analysis. According to our analyses, photodynamic therapy exhibited a significantly higher complete response rate (RR = 1.36, 95% CI [1.01, 1.84], I2 = 86%, p = 0.04), less recurrence (RR = 0.53, 95% CI [0.30, 0.95], I2 = 0%, p = 0.03), and better cosmetic outcome (RR = 1.34, 95% CI [1.15, 1.56], I2 = 0%, p = 0.0002) compared with other treatments. Moreover, there was a significant difference between the complete response rate of photodynamic therapy combined with ablative fractional CO2 laser and that of photodynamic therapy (RR = 1.85, 95% CI [1.38, 2.49], I2 = 0%, p < 0.0001). Photodynamic therapy combined with ablative fractional CO2 laser or plum-blossom needle also showed significantly less recurrence (RR = 0.21, 95% CI [0.09, 0.51], I2 = 0%, p = 0.0005) and a lower visual analogue scale score (RR = 0.51, 95% CI [0.06, 0.96], I2 = 0%, p = 0.03) than photodynamic therapy alone. However, there was no significant difference in the complete response rate between photodynamic therapy combined with ablative continuous CO2 laser and photodynamic therapy combined with ablative fractional CO2 laser (RR = 1.00, 95% CI [0.54, 1.86], I2 not applicable, p = 1.00).

CONCLUSIONS

This meta-analysis shows that photodynamic therapy can be used in the treatment of Bowen's disease with better efficacy, less recurrence, and better cosmetic outcomes than cryotherapy and 5-FU. Some methods, including ablative fractional CO2 laser, can be applied in combination with photodynamic therapy to improve efficacy. However, which laser-assisted photodynamic therapy scheme has the most advantages in the treatment of Bowen's disease warrants further exploration.

Case Report: Treatment of Penile Intraepithelial Neoplasia in an Asian Male With Reconstructive Plastic Surgery

Intraepithelial neoplasia is a special type of squamous cell carcinoma occurring in the skin epidermis. The incidence of penile intraepithelial neoplasia in Asian males is rare. We report the clinical characteristics and treatment process of a case of penile intraepithelial neoplasia in a Chinese man. We treated the disease of this patient by surgical excision of the penile lesion and scrotal flap plastic surgery. After surgery, the shape of the penis was satisfactory, and there was no adverse effect on erection. The pathological results confirmed the diagnosis of penile intraepithelial neoplasia. The pathological features showed that the lesion tissue was covered with squamous epithelium and that there was severe atypical hyperplasia of the lesion epithelium, disordered arrangement of polarity, and an intact basement membrane. The removal of the lesions of penile intraepithelial neoplasia through a wider surgical resection range, combined with the stretchability of a scrotal flap, can achieve a good healing effect of the surgical wound and reduce the possibility of recurrence of penile intraepithelial neoplasia.

Photodynamic therapy utilizing 10% ALA nano-emulsion gel and red-light for the treatment of squamous cell carcinoma in-situ on the trunk and extremities: Pilot study and literature update

BACKGROUND

Data evaluating the effectiveness of photodynamic therapy (PDT) with aminolevulinic acid (ALA) 10% nanoemulsion gel and red-light LED lamp for the treatment of squamous cell carcinoma in situ (SCCis) on the trunk and extremities is limited. Our study sought to investigate the safety and efficacy of utilizing ALA 10% gel with red-light lamp for the treatment of SCCis on the trunk and extremities.

METHODS

A single center prospective study of 12 patients with biopsy proven SCCis underwent one or two cycles of red-light PDT with ALA 10 % gel and 3 hours incubation period. Each cycle consisted of two treatments approximately 10 days apart. All participants had a biopsy for histologic evaluation 4 weeks following the last treatment.

RESULTS

All patients achieved clinical and histologic clearance following either one or two cycles at the 4-week post treatment follow up period. The majority of lesions were located on the extremities (n=10) with the remainder located on the trunk (n=2). The mean diameter of the lesions was 1.83 cm. Mild pain was noted in patients, with no interruption of treatment.

CONCLUSIONS

Our study indicates that ALA 10% gel with a red-light lamp is a safe and effective treatment option for SCCis on the trunk and extremities.

Japanese Dermatological Association Guidelines: Outlines of Guidelines for Cutaneous Squamous Cell Carcinoma 2020

In consideration of the development of treatment options for squamous cell carcinoma (SCC), the Japanese Skin Cancer Society issued the first guidelines of SCC in 2007 and revised them in 2015. Here, we report the English version of the 2020 edition of the Japanese SCC guidelines. The first half of this article is an overview of SCC including actinic keratosis and Bowen's disease, and the second half discusses three clinical questions: (i) treatment of actinic keratosis; (ii) determination of the resection margin of the primary lesion; and (iii) treatment of radically incurable cases, as contemporary problems encountered in treating SCC. In these evaluations, all processes were implemented according to the Grading of Recommendations, Assessment, Development, Evaluation system. Also, items of recommendation concerning each clinical question were determined by a multidisciplinary expert panel consisting of dermatologists, plastic/reconstructive surgeons, radiologists, and oncologists through a comprehensive literature search and systematic reviews.

Systemic acitretin in the management of periocular squamous cell carcinoma

We report a case of periocular squamous cell carcinoma invading the anterior orbit that significantly reduced in size and regressed from invasive to in situ following treatment with oral acitretin, a second-generation retinoid. The residual in situ disease was then successfully treated with cryotherapy and the patient remains in remission 12 months following cessation of systemic acitretin.

Surgery for Bowen Disease: Clinicopathological Factors Associated With Incomplete Excision

Background

One common treatment for Bowen disease (BD) is surgical excision, but there is no international consensus on the appropriate surgical margins.

Objectives

This study examined what factors affect the rate of incomplete excision of BD.

Methods

Clinicopathological data potentially linked to surgical outcome (complete or incomplete excision) were retrospectively collected from medical and histopathological records on all surgically excised BD lesions diagnosed at Sahlgrenska University Hospital in Gothenburg, Sweden during 2014-2015. Data were analyzed with two definitions of incomplete excision: less strict (ie, BD present at the surgical margin) and strict (ie, dysplasia present at the surgical margin).

Results

In total, 463 BD lesions among 408 patients were included. With the less strict definition, 3 factors were associated with significantly higher rates of incomplete excision: surgical margins <3 mm, a less experienced surgeon, and use of punch biopsy excision. The same factors plus a tumor location on the head and neck area or upper extremities were associated with significantly higher rates of incomplete excision using the strict definition. After adjustment for confounders, less experience was independently associated with incomplete excision using the less strict definition, whereas less experience and location on the head and neck area or upper extremities were independently associated with incomplete excision using the strict definition. Surgeon specialty was not associated with incomplete excision regardless of the definition.

Conclusions

When removing BD surgically, an elliptical excision with surgical margins ≥3 mm carried out by an experienced surgeon should be recommended. Surgical margins may need to be adjusted depending on body site.

High-frequency ultrasound in the diagnosis of the spectrum of cutaneous squamous cell carcinoma: Noninvasively distinguishing actinic keratosis, Bowen's Disease, and invasive squamous cell carcinoma

OBJECTIVE

To evaluate high-frequency ultrasound (HFUS) features for diagnosing cutaneous squamous cell carcinoma (cSCC) as a spectrum of progressively advanced malignancies, including precursor actinic keratosis (AK), Bowen's disease (BD), and invasive squamous cell carcinoma (iSCC).

METHOD

In this retrospective study, 160 skin lesions diagnosed histopathologically (54 AK, 54 BD, and 52 iSCC) in 160 patients were included. The HFUS features of AK, BD, and iSCC were analyzed. The obtained data were evaluated using univariate and forward multivariate logistic regression analyses.

RESULTS

The most significant HFUS features in AK were regular surface (odds ratio [OR], 8.42) and irregular basal border (OR, 6.36). The most significant HFUS features in BD were crumpled surface (OR, 19.62) and layer involvement confined to the epidermis (OR, 3.96). The most significant HFUS features in iSCC were concave surface (OR, 27.06), stratum corneum (SC) detachment (OR, 14.41), irregular basal border (OR, 4.01), and convex surface (OR, 3.73). The characteristics of surface features, basal border, and layer involvement could be valuable HFUS clues in the discrimination of AK, BD, and iSCC.

CONCLUSION

High-frequency ultrasound is valuable for the differentiation of AK, BD, and iSCC, which may allow dynamic and noninvasive monitoring in the spectrum of cSCC.

Assessment of Cutaneous Squamous Cell Carcinoma (cSCC) In situ Incidence and the Risk of Developing Invasive cSCC in Patients With Prior cSCC In situ vs the General Population in the Netherlands, 1989-2017

Importance

The incidence rates of keratinocyte cancer are increasing globally; however, the incidence rates of cutaneous squamous cell carcinoma (cSCC) in situ and the risk of developing subsequent invasive cSCC remain unknown.

Objective

To estimate annual population-based age-standardized incidence rates of histopathologically confirmed cSCC in situ stratified by sex, age, and body site and to assess the risk of developing invasive cSCC among patients with cSCC in situ compared with the general population.

Design, Setting, and Participants

This nationwide epidemiological population-based cohort study used cancer registry data to identify all patients with a first incident of histopathologically confirmed cSCC in situ between January 1, 1989, and December 31, 2017. In addition, all patients with cSCC in situ who subsequently had a first incident of invasive cSCC were identified up to June 11, 2019. Data were analyzed between March 18 and November 12, 2019.

Main Outcomes and Measures

Age-standardized incidence rates per year for cSCC in situ, standardized to the 2013 edition of the European Standard Population, were calculated by sex, age, and body site. Cumulative risks, standardized incidence ratios, and absolute excess risks were calculated to assess the risk of invasive cSCC in patients with cSCC in situ compared with the general population.

Results

In this population-based cohort study of 88 754 patients with a first incident of cSCC in situ between January 1, 1989, and December 31, 2017, 58.8% were women; the median age was 75 years (interquartile range [IQR], 67-82 years) for women and 73 years (IQR, 65-80 years) for men. Increasing incidence rates were observed, with the highest incidence rates in 2017 among women in general (71.7 cases per 100 000 person-years) and among men 80 years and older (540.9 cases per 100 000 person-years). The most common body site among women was the face (15.9 cases per 100 000 person-years) and among men was the scalp and/or neck (12.3 cases per 100 000 person-years). After 5 years of follow-up, among patients with cSCC in situ, the cumulative risk of developing an invasive cSCC at any anatomic location was 11.7% (95% CI, 11.6%-11.9%) in men and 6.9% (95% CI, 6.8%-7.0%) in women (P < .001). The standardized incidence ratio was highest in the first year of follow-up among both men (16.6; 95% CI, 15.7-17.5) and women (15.1; 95% CI, 14.2-16.1).

Conclusions and Relevance

This study reports the first nationwide incidence rates of cSCC in situ to date. The increasing incidence rates of cSCC in situ and the high risk of developing invasive cSCC among patients with cSCC in situ may increase the health care burden associated with precursors of keratinocyte cancer and highlight the need to include cutaneous skin cancer precursor lesions when exploring policies to address skin cancer care.

Treatment of Cutaneous Squamous Cell Carcinoma In Situ With Curettage Followed by Topical Imiquimod 5% Cream

BACKGROUND

Treatment strategies for cutaneous squamous cell carcinoma in situ (cSCCIS) are many but reported cure rates are variable and few studies report 5-year follow-up data.

OBJECTIVE

To evaluate the treatment of cSCCIS by curettage followed by topical imiquimod 5% cream (C&I).

METHODS

We evaluated all immunocompetent patients with biopsy proven cSCCIS treated by C&I between January 2008 and December 2012.

RESULTS

A total of 861 patients with 1,198 cSCCIS were treated, with median follow-up of 71 months. The mean tumor diameter was 10.2 mm. The average duration of treatment with imiquimod 5% cream was 21 days. Kaplan-Meier estimated recurrence-free survival at 5-year follow-up was 99.71% with 95% CI (99.38%, 100.00%). A follow-up questionnaire returned by 45% of patients revealed that 94% were satisfied with their treatment. Six hundred eleven patients developed a new nonmelanoma skin cancer (NMSC) during the follow-up period, and 91% (556/611) of patients chose this combination treatment for at least one new NMSC.

CONCLUSION

The combination treatment for cSCCIS of C&I had less than 1% cumulative probability of treatment failure at 5 years. Patients tolerated the treatment well, with the majority choosing this method of treatment for at least one new NMSC.

The application of physical pretreatment in photodynamic therapy for skin diseases

Photodynamic therapy (PDT) is widely used in skin diseases; the response rate of PDT treatment varies widely. The limited penetration in the tissue of photosensitizers influenced the penetration depth of PDT, which obviously impacts the therapeutic effect. The studies have improved the efficacy of PDT through various pretreatment applications; especially, the physical pretreatment had achieved significant outcomes. We will review the physical pretreatment to optimize the efficacy of PDT in skin diseases by searching the literature on this topic. The types of physical pretreatment commonly used in the clinical practice are discussed: curettage, superficial shaving, laser, surgical resection, plum-blossom needles, and microneedles. Compared with PDT alone, the physical pretreatment before PDT application was generally improved the efficacy and reduced the recurrence, especially in actinic keratoses (AK), Bowen disease (BD), basal cell carcinoma (BCC), and viral warts. The application of the physical pretreatments before PDT may improve the efficacy of PDT in various skin diseases. However, each kind of physical pretreatment has the benefit and shortcoming, and the applicable situation is different.

Concurrent Bowen's Disease of the Nipple and Breast Cancer

Bowen's disease is a squamous cell carcinoma in situ that commonly develops on the trunk, arms, or legs and has not spread beyond the top layer of skin. It seldom develops on the nipple. We report a patient who presented with Bowen's disease of the nipple and had a concurrent breast cancer identified in the ipsilateral breast after careful examination. Histopathological examination of the surgical specimen after mastectomy confirmed the diagnoses.

Photodynamic Therapy for Basal Cell Carcinoma: The Clinical Context for Future Research Priorities

Photodynamic therapy (PDT) is an established treatment option for low-risk basal cell carcinoma (BCC). BCC is the most common human cancer and also a convenient cancer in which to study PDT treatment. This review clarifies challenges to researchers evident from the clinical use of PDT in BCC treatment. It outlines the context of PDT and how PDT treatments for BCC have been developed hitherto. The sections examine the development of systemic and subsequently topical photosensitizers, light delivery regimens, and the use of PDT in different patient populations and subtypes of BCC. The outcomes of topical PDT are discussed in comparison with alternative treatments, and topical PDT applications in combination and adjuvant therapy are considered. The intention is to summarize the clinical relevance and expose areas of research need in the BCC context, ultimately to facilitate improvements in PDT treatment.

Optimizing the spray parameters of a cryospray process

Smaller spray zone of single-hole nozzle (SHN) constrains cryospray as a treatment method suitable for lesions having diameter larger than 15 mm on the skin surface. The present study is an attempt to resolve this issue, through the improvement in conventional technique of spraying liquid nitrogen on cancerous lesion. A multi-hole nozzle (MHN) with 5 holes is fabricated to demarcate the variation in outcome when cryogen is sprayed through customised MHN instead of conventional SHN. Special emphasis is placed on reducing the number of sitting required for completion of treatment and increasing the feasibility of cryospray process for larger lesions. Commercial SHN having a hole diameter of 0.8 mm is selected to compare results with the customised MHN having 5 holes of 0.8 mm diameter (4 holes are arranged in a circle of radius 2 mm around the central hole). Single freeze-thaw cycle is carried out to spray liquid nitrogen on tissue mimicking gel. Temperature profile accessed through infrared images advocates that lethal area formed through application of MHN is twice larger than the lethal area formed through the application of SHN on the surface of gel for same spraying distance (z). Thermocouples placed at various locations strengthen the fact that higher cooling rate (CR) corresponding to MHN ensures 15 mm spread of necrotic zone from the centre of spray (CS) and up to a depth of 2 mm from the gel surface while in case of SHN, it is limited to the vicinity of CS. On the basis of observations made through thermal images and digital images, it can be said that the ratio of lateral spread to penetration depth of ice ball remains almost same for SHN and MHN. However, the lateral spread of ice ball formed through the application of MHN is twice larger than SHN while the axial depth of ice ball does not record such increment. This reflects that MHN provides more destruction to superficial skin than SHN. Among the three spraying distances selected (i.e. z = 13 mm, 18 mm and 23 mm), the most optimised spraying distance (z) for MHN is also explored in this study. It has been found that cryoablation is not inversely proportional to the spraying distance. Spraying distance of z = 18 mm provided the most optimised result in terms of cryoablation.

A retrospective study comparing different injection approaches of 5-aminolevulinic acid in patients with non-melanoma skin cancer

BACKGROUND

5-aminolevulinic acid through a needle-free, plum-blossom needle or conventional needle followed by photodynamic therapy are available options for non-melanoma skin cancer treatment.

AIM

To compare these three techniques of injection of 5-aminolevulinic, regarding treatment response and adverse effects in patients with non-melanoma skin cancer.

PATIENTS AND METHODS

Non-melanoma skin cancer patients have received six cycles of 0.5 mL intralesional 20% w/v 5-aminolevulinic acid through a conventional needle (CPT cohort, n = 158), or plum-blossom needle (BPT cohort, n = 118), or needle-free injection (NPT cohort, n = 105) followed by irradiation with a red light. Data regarding treatment response and adverse effects were collected and analyzed.

RESULTS

The treatment response was higher among patients of NPT cohort than those of CPT (p = .012, q = 3.981) and BPT (p = .012, q = 3.472) cohorts. Conventional and plum-blossom needle injections therapies were reported scar, local redness, and worse cosmetic appearance in the follow-up period.

CONCLUSIONS

Needle-free injection of intralesional 5-aminolevulinic acid followed by irradiation with red light therapy were reported high treatment response with manageable adverse effects for non-melanoma skin cancer patients than that of conventional and plum-blossom needle injections.

LEVEL OF EVIDENCE

III.

Penile intraepithelial neoplasia, penile cancer precursors and human papillomavirus prevalence in symptomatic preputium: a cross-sectional study of 351 circumcised men in Sweden

Objectives

To investigate the prevalence of pathological disease and spectrum of human papillomavirus (HPV) types among symptomatic foreskin tissue.

Patients and Methods

Consecutively excised symptomatic foreskins from 351 men were sent for histopathological evaluation. During the surgical procedure, a fresh biopsy was taken for HPV analysis by modified general primer polymerase chain reaction. A medical questionnaire regarding medication, smoking habits, number of lifetime sexual partners, former diseases and surgery performed on penis was completed by all participants.

Results

The most common clinical diagnosis and cause for circumcision was phimosis, seen in 85.2%. Histopathologically inflammatory dermatological conditions were present in 87% of the men. The most common histopathological diagnosis was lichen sclerosus (LS) observed among 58.7%. Notably, penile intraepithelial neoplasia (PeIN) was present in 2% without former clinical suspicion. Overall, HPV was detected in 17.1% of the men and 28 different HPV types were found. High‐risk (HR) HPV types were identified in 9.1% and HPV16 was present in 2.3%. Current smoking increased the risk of HPV (crude odds ratio [OR] 2.8, confidence interval [CI] 1.4–5.6; P = 0.005). Having >15 lifetime sexual partners increased the risk of HPV (crude OR 2.6, 95% CI 1.4–5.1; P = 0.003) and when adjusted for current smoking the OR was substantially increased (OR 6.0, 95% CI CI 2.2–16.8; P < 0001).

Conclusions

Histopathological evaluation of circumcised symptomatic foreskin revealed PeIN in 2% of the men without any clinical suspicion of malignancy and that treatable dermatological conditions were present in 87%, LS being the most common. HR‐HPV types were present in 9%. Due to risk of malignant development both in PeIN and in inflammatory skin diseases we recommend sending all excised foreskins from patients with symptoms for histopathological evaluation as guidance for further clinical management.