The important role of radiotherapy in patients with non-melanoma skin cancer and other cutaneous entities

Effect of Liquid Blood Concentrates on Cell Proliferation and Cell Cycle- and Apoptosis-Related Gene Expressions in Nonmelanoma Skin Cancer Cells: A Comparative In Vitro Study

Nonmelanoma skin cancer (NMSC) presents a significant challenge to global healthcare due to its rising incidence, prompting the search for innovative treatments to overcome the limitations of current therapies. Our study aims to explore the potential effects of the liquid blood concentrate platelet-rich fibrin (PRF) on basal cell carcinoma cells (BCCs) and squamous cell carcinoma cells (SCCs) in order to obtain results that may lead to new possible adjunctive therapies for managing localized skin cancers, particularly NMSC. Basal cell carcinoma (BCC) cells and squamous cell carcinoma (SCC) cells were indirectly treated with PRF generated via different relative centrifugation forces, namely high and low RCF PRF, for 7 days. PRF-treated cells were comparatively analyzed for cell viability, proliferation and cell cycle- and apoptosis-related gene expression. Analysis of MTS assay results revealed a significant decrease in cell viability in both BCC and SCC cells following PRF treatment for 7 days. Ki-67 staining showed a decreased percentage of Ki-67-positive cells in both BCC and SCC cells after 2 days of treatment compared to the control group. The downregulation of CCND1 gene expression in both cell types at 2 days along with the upregulation of p21 and p53 gene expression in SCC cells demonstrated the effect of PRF in inhibiting cell proliferation and inducing cell cycle arrest, especially during the initial phases of treatment. Increased expression of caspase-8 and caspase-9 was observed, indicating the activation of both extrinsic and intrinsic apoptotic pathways by PRF treatment. Although the exact immunomodulatory properties of PRF require further investigation, the results of our basic in vitro studies are promising and might provide a basis for future investigations of PRF as an adjunctive therapy for managing localized skin cancers, particularly NMSC.

Management of unilateral neck irradiation in elderly patients with head and neck cancer: Which place for hypofractionation? A single-centre experience of 43 patients

PURPOSE OF THE STUDY

The purpose of the study was to evaluate retrospectively the acute toxicity and efficacy in terms of locoregional control of a cervical lymph node irradiation using a hypofractionated regimen in frail elderly patients.

MATERIAL AND METHODS

Patients receiving unilateral hypofractionated cervical lymph node irradiation at the Institut de cancérologie de Lorraine (France) were retrospectively included. The treatment regimen consisted of delivering 54Gy in 18 fractions to the high-risk tumour or lymph node volume and 45Gy to the prophylactic volume using the technique of simultaneous integrated-boost without concomitant systemic treatment. Toxicity data according to the Common Terminology Criteria for Adverse Events version 4 and survival data were collected.

RESULTS

Forty-three patients were treated between January 2013 and July 2021. The median age was 83 years (range: 78-86.5 years), 32 patients (74.4 %) were male and 25.6 % had WHO status ≥ 2. Histological types were cutaneous squamous cell carcinoma (39 patients), salivary gland carcinoma (three patients) and Merkel cell carcinoma (one patient). The mean duration of treatment was 27 days. Seventeen patients (39.5 %) received radiotherapy alone. Acute toxicity events of grade ≥ 2 at the end of radiotherapy in the 43 patients were described as follows: 58.1 % radiodermatitis (25 patients), 24.6 % mucositis (11 patients), and 18.1 % xerostomia (eight patients). Seven patients (16.3 %) experienced grade ≥ 2 odynodysphagia, with four patients (9.3 %) requiring enteral nutrition. No grade 3 toxicity events were reported at 3 months, 6 months or 1 year. After a median follow-up of 9.2 months (range: 6-18.5 months), 11 patients (25.6 %) of those treated by exclusive irradiation had a complete locoregional response as assessed by CT-scan 3 months. At 6 months, two of 20 patients retained grade 2 xerostomia and only four of 20 patients reported residual grade 1 pain.

CONCLUSION

Moderately hypofractionated unilateral cervical lymph node radiotherapy appears to be well tolerated in frail elderly patients with an acceptable locoregional control rate, potentially providing an alternative to palliative strategies.

Recommendations of the International Society of Geriatric Oncology on skin cancer management in older patients

INTRODUCTION

Non-melanoma skin cancer (NMSC) is becoming ever more prevalent among older adults. However, older adults with NMSC are often underrepresented in clinical trials and guidelines on effective management is still unclear. The International Society of Geriatric Oncology (SIOG) created a multi-disciplinary task force to explore the potential in developing practical guidelines for the treatment of older patients with basal cell carcinoma (BCC) and skin (cutaneous) squamous cell carcinoma (cSCC).

MATERIALS AND METHODS

A systematic literature search to identify relevant and up-to-date literature on treatment of NMSC in older adults was conducted on various databases including MEDLINE, Embase, CINAHL, Cochrane, and PubMed. The resulting papers were discussed by an expert panel, leading to a consensus recommendation.

RESULTS

A total of 154 articles were identified for the expert panel to utilise in generating consensus recommendations. A major focus on geriatric assessment and management options including surgery, radiotherapy, systemic therapy, clinical monitoring, and medical/medicophysical therapy were reviewed for recommendations.

DISCUSSION

Patient age should not be the sole deciding factor in the management of patients with NMSC. Assessment from a multidisciplinary team (MDT) is crucial, and the decision-making process should consider the patient's lifestyle, needs, and expectations. A comprehensive geriatric assessment should also be considered. Patients should feel empowered to advocate for themselves and have their views considered a part of the MDT discussion.

A SHort course Accelerated RadiatiON therapy (SHARON) dose-escalation trial in older adults head and neck non-melanoma skin cancer

OBJECTIVES

To assess feasibility and safety of a SHort-course Accelerated RadiatiON therapy (SHARON) regimen, in the treatment of non-melanoma skin cancers (NMSC) in older patients.

METHODS

Old patients (age ≥ 80 years) with histological confirmed non-melanoma skin cancers were enrolled. The primary endpoint was to determine the maximum tolerated dose (MTD). Radiotherapy regimen was based on the delivery of four radiotherapy fractions (5 Gy per fraction) with a twice daily fractionation in two consecutive days. Three different level of dose were administered: 20 Gy (one cycle), 40 Gy (two cycles) and 60 Gy (three cycles).

RESULTS

Thirty patients (median age: 91 years; range: 80-96) were included in this analysis. Among fourteen patients who completed the one cycle, only one (7%) experimented acute G4 skin toxicity. Twelve patients reported an improvement or resolution of baseline symptoms (overall palliative response rate: 85.8%). Nine and seven patients underwent to two and three RT cycles, respectively: of these, no G3 toxicities were recorded. The overall response rate was 100% when three cycles were delivered. The overall six-month symptom-free survival was 78.7% and 77.8% in patients treated with one course and more courses, respectively.

CONCLUSIONS

Short-course accelerated radiotherapy in older patients with non-melanoma skin cancers is well tolerated. High doses seem to be more effective in terms of response rate.

ADVANCES IN KNOWLEDGE

This approach could represent an option for older adults with NMSC, being both palliative (one course) or potentially curative (more courses) in the aim, accordingly to the patient's condition.

Electronic brachytherapy for treatment of non-melanoma skin cancers: clinical results and toxicities

Purpose

Although surgical approaches are standard for most non-melanomatous skin cancers, some patients are not candidates due to medical co-morbidities or functional or cosmetic or lesion location. High-dose-rate electronic brachytherapy (HDR-EBT) may be an alternative treatment modality.

Material and methods

A retrospective chart review was conducted from April 2011 to April 2013. All lesions were pathologically confirmed as malignant basal cell or squamous cell carcinoma. A HDR-EBT system delivered a median biological equivalent dose of 50 Gy total to a depth of 0.1-0.5 cm using various sizes of applicators. Treatment feasibility, acute and late toxicity, cosmetic outcomes, and local recurrence were assessed.

Results

Thirty-three patients with a mean age of 76 years with 50 cutaneous lesions were treated. Locations included 17 extremity lesions and 33 head and neck lesions. After treatments, acute grade 3 moist desquamation developed in 9 of the lesions (18%). Acute grade 4 ulceration developed in 3 lesions in the lower extremity (6%) and 1 upper lip lesion (2%). These toxicities were improved after a median of 20 days. Amongst the 4 lesions with grade 4 toxicities, a greater proportion were in lower extremity lesions compared to head and neck lesions (75% vs. 25%). There was no difference in the rate of grade 3 and 4 toxicities between patients aged ≤ 75 years and aged > 75 years (p = 0.082). With a mean long-term follow-up of 45.6 months, there was 1 local recurrence treated with surgery and no reported late toxicities.

Conclusions

Our experience with HDR-EBT for non-melanomatous skin cancers is encouraging in terms of efficacy and convenience for patients. Our long-term follow-up shows a good response in all treated sites. Caution should be used for extremity sites, and more fractionated regimens should be considered to avoid severe acute toxicities.

Curative Radiotherapy for Locally Advanced Scalp Squamous Cell Carcinoma

A 73-year-old man presented to his primary physician with an ulcerative growth on his scalp vertex. Biopsy of the lesion confirmed the growth to be a moderately differentiated squamous cell carcinoma, but the patient declined medical intervention. The lesion increased in size over six months, measuring 12 cm in diameter and 3 cm thickness with erosion of the skull of the vertex. CT and MRI scans showed a large fungating mass with erosion of the skull of vertex without intra-cranial extension, meningeal enhancement, or distant metastatic disease. The patient declined surgical intervention. The patient received radiotherapy using volumetric-modulated arc therapy (VMAT) to a total dose of 60 Gy over six weeks. No evidence of clinical invasive disease apart from a 15 cm * 12 cm skin defect detected three months after completion of radiotherapy. At three years of follow-up, the patient is clinically disease-free. This case report provides evidence that high-dose radiotherapy is a potential effective definitive treatment for locally advanced (T4) squamous cell carcinoma for patients who are unwilling to undergo surgery.

Metastatic and locally aggressive BCC: Current treatment options

The treatment of locally advanced and metastatic BCC presents a significant clinical challenge. Treatment options have evolved recently to include the use of hedgehog inhibitors Vismodigib and Sonidigib and immunotherapy with Cemiplimab.

Palliative Radiotherapy for Cutaneous Squamous Cell Carcinoma of the Head-and-Neck Region

BACKGROUND/AIM

Cutaneous squamous cell carcinoma (cSCC) is a common type of skin cancer. Options for palliative treatment include systemic agents and radiotherapy. Selection of a radiation regimen should consider the patient's survival prognosis. This study aimed to identify prognostic factors of survival after palliative radiotherapy for cSCC of the head-and-neck.

PATIENTS AND METHODS

Ten factors were analyzed for survival in 12 patients including age, gender, tumor site, histological grade, primary tumor stage, lymph node involvement, distant metastases, upfront surgery, radiation dose and completion of radiotherapy.

RESULTS

On univariate analysis, improved survival was significantly associated with lower histological grade (better differentiation) (p=0.022), no distant metastases (p=0.040) and completion of radiotherapy (p=0.014). In the multivariate analysis, lower histological grade (risk ratio=6.05, p=0.100) and completion of radiotherapy (risk ratio=4.87, p=0.115) showed trends.

CONCLUSION

Predictors of survival were identified that can help design individual treatments. Patients require optimal supportive care as completion of radiotherapy was associated with better survival.

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.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Effectiveness of radiotherapy for head and neck skin cancers: a single-institution study

Purpose

External beam radiotherapy (EBRT) is a useful option to treat head and neck skin cancer patients who are not indicated for surgery. In this study, we evaluated the treatment outcomes of EBRT in an Asian population.

Materials and Methods

The records from 19 head and neck skin cancer patients (10 with squamous cell carcinoma and 9 with basal cell carcinoma) who were treated with definitive or adjuvant EBRT from 2009 to 2017 were retrospectively reviewed. The radiotherapy doses administered ranged from 50 to 66 Gy (median, 55 Gy) with 2.0–2.75 Gy per daily fraction (median, 2.5 Gy). The T stage at presentation was as follows: Tis (1 patient), T1 (11 patients), T2 (6 patients), and T3 (1 patient). None had regional lymph node disease or distant metastasis at presentation. The local failure-free survival (LFFS) rates, toxicity, and cosmetic results were analyzed.

Results

The median age was 75.5 years (range, 52.6 to 92.5 years). The median follow-up duration from the completion of radiotherapy was 44.9 months (range, 5.8 to 82.6 months). One local failure occurred in a patient with a 2.1-cm posterior neck squamous cell carcinoma at 32.5 months after radiotherapy (1/19, 5.3%). The 3-year LFFS rate was 91.7%. No patients died from skin cancer during follow-up, and no grade 3 complications occurred. The cosmetic outcomes were excellent for 16 (84.2%) and good for 3 (15.8%) of the 19 patients.

Conclusion

EBRT offers good local control and cosmetic outcomes in patients with head and neck skin cancer, with no grade 3 complications.

Complex Reconstruction of a Pelvic Marjolin's Ulcer Arising from Hidradenitis Suppurativa

The chronic inflammation of hidradenitis suppurativa can cause painful nodules, draining abscesses, sinus tracts, and fibrous scars. This long-term cutaneous inflammation in rare circumstances can lead to malignant transformation producing an aggressive cutaneous malignancy referred to as a Marjolin’s ulcer. Particularly when a Marjolin’s ulcer involves the sacral region, resection and reconstruction can be challenging. We present the case of a patient with a recurrent Marjolin’s ulcer originating from a hidradenitis wound bed overlying and involving the sacrum. Previous radiation, large defect size, and sacral and perianal involvement necessitated the use of a multiflap approach. An extended transpelvic vertical rectus abdominis myocutaneous flap, bilateral gluteal advancement flaps, and a delayed transverse back flap were used to reconstruct the defect after abdominoperineal resection and nerve-sparing partial sacrectomy. Flap choice was derived by dividing the defect into anatomic subunits and considering intrapelvic defect volume, creating a systematic approach that led to successful reconstruction and functional restoration.

A Review of the Literature of Surgical and Nonsurgical Treatments of Invasive Squamous Cells Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is an increasing public health problem. It is a primary malignant skin tumor with Malpighian differentiation and together with basal cell carcinoma is classified among nonmelanoma skin cancers (NMSCs). cSCC usually occurs on photoexposed areas, such as the head, the neck, and the extremities, and its incidence increases with age. Invasive forms of this skin tumor tend to be more aggressive showing a higher metastatic potential, usually regarding regional lymph nodes. Treatment options for invasive cSCCs include both surgical and nonsurgical options. The therapeutic choice depends on several factors, such as anatomic location, risk factors for tumor recurrence, age, and health status of the patient. This review aims to provide an overview of the current evidence on therapeutic surgical and nonsurgical management of invasive cSCC.

Efficacy of hypofractionated radiotherapy in patients with non-melanoma skin cancer: Results of a systematic review

Radiation oncologists are increasingly tasked with the management of elderly patients with non-melanoma skin cancer, unsuitable for surgical intervention due to inoperable lesions and/or poor performance status. In this cohort, hypofractionated radiotherapy, delivered either daily, alternative daily or once weekly is highly effective. A systematic literature search was conducted of PUBMED, MEDLINE and EMBASE databases using the algorithm ('radiotherapy' OR 'radiation therapy' OR 'brachytherapy') AND ('hypofraction' OR 'hypofractionated' OR 'hypofractionation') AND ('skin neoplasms' OR 'carcinoma' OR 'malignancy') AND ('skin' OR 'epidermis' OR 'epidermal' OR 'cutaneous'). Forty relevant publications (1983-2017) encompassing 12,337 irradiated lesions were retrieved. Studies documented a mean age of 71.73 years and male predilection (54.5%). Both external beam radiotherapy and brachytherapy were utilized. Tumour subtype was squamous cell carcinoma (23.5%), basal cell carcinoma (75.2%) or others (1.3%). Irradiated lesions were primary (or denovo) (92.6%), located on the head and neck (95.7%) and received definitive therapy (96.5%). Analysis demonstrated a mean weighted total radiotherapy dose (38.15 Gy), dose per fraction (7.95 Gy) and treatments per week (2.98). Despite significant heterogeneity in the study population, the radiotherapy delivered and follow-up, local recurrence rate (crude or Kaplan-Meier analysis) did not exceed 7.9% in all but three of the 36 publications providing these data. Twenty-nine publications documented local control exceeding 90%. There is a body of evidence documenting the efficacy of hypofractionated radiotherapy as an option that confers no obvious disadvantage in local control when compared to traditional more protracted radiotherapy schedules.

Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology

Skin cancer is a worldwide, emerging clinical need in the elderly white population, with a steady increase in incidence rates, morbidity and related medical costs. Skin cancer is a heterogeneous group of cancers comprising cutaneous melanoma and non-melanoma skin cancers (NMSC), which predominantly affect elderly patients, aged older than 65 years. Melanoma has distinct clinical presentations in the elderly patient and represents a challenging question in terms of clinical management. NMSC includes the basal cell carcinoma and cutaneous squamous cell carcinoma and presents a wide disease spectrum in the elderly population, ranging from low-risk to high-risk tumours, advanced and inoperable disease. Treatment decisions for NMSC are preferentially based on tumour characteristics, patient’s chronological age and physician’s preferences and operational settings. Several treatment options are available for NMSC, from surgery to non-invasive/medical therapies, but patient-based factors, such as geriatric comorbidities and patient’s life expectancy, do not frequently modulate treatment goals. In melanoma, age-related variations in clinical management are significant and may frequently lead to under-treatment, limiting access to advanced surgical and medical treatments. Clinical decision-making in the care of elderly skin cancer patient should ideally implement a geriatric assessment, prioritizing patient-based factors and efficiently differentiating fit from frail cancer patients. Current clinical practice guidelines for NMSC and melanoma only partially address geriatric aspects of cancer care, such as frailty, limited life-expectancy, geriatric comorbidities and treatment compliance. We review the recent evidence on the scope and problem of skin cancer in the elderly population as well as age-related variations in its clinical management, highlighting the potential role of a geriatric approach in optimizing dermato-oncological care.

Hypofractionated radiotherapy in older patients with non-melanoma skin cancer: Less is better

Radiotherapy is a non-surgical option for patients with non-melanoma skin cancer. Lesions in middle-aged to older patients with good performance status are typically prescribed 4-5 weeks of outpatient weekday treatment. Daily radiotherapy fraction sizes of 2-3 Gy are recommended to decrease the late cutaneous consequences such as in-field hypopigmentation and telangiectasia. In elderly, often unwell patients, these concerns are less of an issue and larger fraction sizes (5-7 Gy), referred to as hypofractionation, can be delivered over a shorter time yet still achieve excellent in-field control and improve a patient's quality of life and avoid the need for surgery. The three case studies presented illustrate this approach along with a review of the evidence to support this.

Cutaneous Squamous Cell Carcinoma: A Review of High-Risk and Metastatic Disease

Non-melanoma skin cancer represents one-third of all malignancies and its incidence is expected to rise until the year 2040. Cutaneous squamous cell carcinoma (cSCC) represents 20 % of all non-melanoma skin cancer and is a deadly threat owing to its ability to metastasize to any organ in the body. Therefore, a better understanding of cSCC is essential to strengthen preventative measures and curable treatment options. Currently, research demonstrates that cSCC is diagnosed at a rate of 15-35 per 100,000 people and is expected to increase 2-4 % per year. With respect to metastatic cSCC, this disease is more common in men; people over the age of 75 years; and inhabitants of the south and mid-west USA. In 2010, the American Joint Committee on Cancer updated the Cancer Staging Manual's primary tumor designation to now include high-risk factors; however, factors such as immunosuppression and tumor recurrence were not included. Other staging systems such as Brigham and Women's Hospital have allowed for increased stratification of cSCC. High-risk cSCC is defined as a cSCC that is staged as N0, extends beyond basement membrane, and has high-risk features associated with sub-clinical metastasis. High-risk features are depth of invasion (>2 mm), poor histological differentiation, high-risk anatomic location (face, ear, pre/post auricular, genitalia, hands, and feet), perineural involvement, recurrence, multiple cSCC tumors, and immunosuppression. Epidermal growth factor receptor and nuclear active IκB kinase (IKK) expression are also predictive of metastatic capabilities. Clinically, the initial lesions of a cSCC tumor can present as a painless plaque-like or verrucous tumor that can ultimately progress to being large, necrotic, and infected. Tumors can also present with paresthesias or lymphadenopathy depending on the location involved. With respect to prognosis, metastatic cSCC is lethal, with several large studies demonstrating a mortality rate of >70 %. Therefore, treatment of metastatic cSCC is difficult and depends on the location involved and extent of metastasis. Treatment options include surgery, radiation therapy, chemotherapy, and any combination of the above. Surgery alone can be used for metastatic cSCC treatment, but is not as effective as surgery in conjunction with radiation therapy. Radiation therapy has some success as a monotherapy in low-risk or cosmetically sensitive areas such as the external ear, eyelid or nose. According to the 2013 National Comprehensive Cancer Network Guidelines, cisplatin as a single agent or combined with 5-fluorouracil hold the strongest support for the treatment of metastatic cSCC; however, the supporting evidence is inconsistent and a curative chemotherapeutic approach is still lacking. Epidermal growth factor receptor inhibitors are a newer class of agents being used in metastatic cSCC and hold some promise as a therapy for this disease. Other areas of interest in finding curative treatments for metastatic cSCC include p53, hypermethylation of specific genes, chromatin remodeling genes, and the RAS/RTK/PI3K pathway. This review addresses the epidemiology, staging, risk factors, clinical presentation, management, and new trends in the treatment of high-risk and metastatic cSCC.

Use of Protoporphyrin Fluorescence to Determine Clinical Target Volume for Non-melanotic Skin Cancers Treated with Primary Radiotherapy

PURPOSE 

Non-melanotic skin cancers remain the most commonly diagnosed cancers. Radiotherapy and surgery are the most common treatment options. Radiotherapy has a recurrence rate of up to 20% for basal or squamous cell cancers. One of the difficulties is to determine the extent of disease for poorly demarcated tumors. This study utilizes protoporphyrin (PpIX) fluorescence to provide information on the extent of subclinical disease for poorly demarcated tumors treated with radiotherapy.

MATERIALS AND METHODS 

For 33 patients, PpIX photo-delineation was used to determine the clinical target volume (CTV2), which was compared to current conventional margins used to account for microscopic disease.

RESULTS 

The use of PpIX photo-delineation demonstrated a significantly larger CTV of 15 mm compared to the conventional 10 mm (p = 0.03) for poorly demarcated lesions. A larger CTV was also demonstrated with PpIX photo-delineation for all basal cell carcinomas (13 mm, p = 0.03) as well as for non-nasal lesions (14 mm, p = 0.04). A trend towards an increased CTV was also noted for squamous cell carcinomas (16 mm, p = 0.19) and nasal primary sites (14 mm, p = 0.11). Nasal primary malignancies had multifocal PpIX uptake in 94% of cases. There was one case of local recurrence and one case of distant recurrence, with an average follow-up time of 22 months.

CONCLUSIONS 

The margins currently used to account for subclinical disease may underestimate the extent of microscopic spread for poorly demarcated tumors. Longer follow-up with larger pools of patients are necessary to determine if using PpIX photo-delineation translates into significantly improved clinical outcomes.

Consensus for Nonmelanoma Skin Cancer Treatment, Part II: Squamous Cell Carcinoma, Including a Cost Analysis of Treatment Methods

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis.

OBJECTIVE

To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors.

MATERIALS AND METHODS

The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures.

RESULTS

Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower.

CONCLUSION

The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patient's general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

Advanced basal cell carcinoma, the hedgehog pathway, and treatment options - role of smoothened inhibitors

Cutaneous basal cell carcinoma (BCC) is the most common human cancer and its incidence is rising worldwide. Ultraviolet radiation exposure, including tanning bed use, as well as host factors play a role in its development. The majority of cases are treated and cured with local therapies including surgery. Yet, the health care costs of diagnosis and treatment of BCCs in the US is substantial. In the United States, the cost of nonmelanoma skin cancer care in the Medicare population is estimated to be US$426 million per year. While rare, locally advanced BCCs that can no longer be controlled with surgery and/or radiation, and metastatic BCCs do occur and can be associated with significant morbidity and mortality. Vismodegib (GDC-0449), a smoothened inhibitor targeted at the hedgehog pathway, is the first US Food and Drug Association (FDA)-approved agent in the treatment of locally advanced, unresectable, and metastatic BCCs. This class of agents appears to be changing the survival rates in advanced BCC patients, but appropriate patient selection and monitoring are important. Multidisciplinary assessments are essential for the optimal care and management of these patients. For some patients with locally advanced BCC, treatment with a hedgehog inhibitor may eliminate the need for an excessively disfiguring or morbid surgery.

Nonmelanoma Cutaneous Head and Neck Cancer and Merkel Cell Carcinoma: Current Concepts, Advances, and Controversies

Nonmelanoma skin cancer (NMSC) is the most common cancer worldwide and the most frequently observed malignancy in whites. Approximately 75% to 80% are basal cell carcinomas and 20% to 25% are squamous cell carcinomas. Incidence is increasing, partly reflecting an ageing population, and NMSC is more commonly seen in men. The predominant causative agent is ultraviolet solar radiation exposure, with the majority of cases occurring on the head and neck. Surgical excision is typically the treatment of choice, providing histopathologic information, high cure rates, and acceptable cosmetic and functional outcomes. Radiation therapy is reserved for cases where surgery is not the preferred choice or for high-risk cases where adjuvant therapy is recommended. Although overall mortality rates are low, patients with complex cases such as those with immunosuppression should be considered for management within multidisciplinary tumor boards. In contrast, Merkel cell carcinoma is a rare and aggressive malignancy, frequently arising on the head and neck in older whites, with a poorer prognosis. This article focuses on the current evidence guiding practice, recent advances, and areas of controversy in NMSC and Merkel cell carcinoma of the head and neck.

Radiotherapy treatment for nonmelanoma skin cancer

Non-melanoma skin cancer is the most common malignancy in the USA, with an estimated 3.5 million cases per year. Treatment options include surgical excision, radiation therapy (RT), photodynamic therapy and topical agents. Although surgical excision remains the mainstay of therapy, RT offers an effective alternative. RT can be used as an adjunct to surgery in high-risk situations, or in cases where surgical excision would lead to impaired cosmesis and/or functional outcomes. Radiation treatment modalities for non-melanoma skin cancers are diverse. Studies in the literature have examined the clinical effects of a wide variety of modalities, areas of the body and dosages. The most common modalities include superficial or orthovoltage RT, electron beam therapy and high dose-rate brachytherapy. This article aims to review the diverse radiotherapy treatment modalities for non-melanoma skin cancers, focusing on tumor control and toxicity.

Squamous cell carcinoma of the lip in Australian patients: definitive radiotherapy is an efficacious option to surgery in select patients

BACKGROUND

In Australia, squamous cell carcinoma (SCC) of the lip is a consequence of chronic sun exposure and treated as a nonmelanoma skin cancer. Patients may be recommended radiotherapy (RT) as a treatment modality.

OBJECTIVE

To analyze the outcome of patients with early-stage SCC of the lip treated with definitive RT at Westmead Hospital, Sydney, Australia, between 1980 and 2012.

METHODS AND MATERIALS

Ninety-three patients with early-stage SCC of the lip underwent RT. All patients were clinically node negative based on examination and/or relevant investigations. Retrospective chart review was performed. Patients treated since 2000 had data collected and entered prospectively.

RESULTS

The most frequently involved site was the lower lip (93%). Fifty-six patients (60%) had T1N0 and 37 patients (40%) had T2N0 disease. Most patients were treated with superficial or orthovoltage RT, with the median RT dose delivered 55 Gy (range, 40 to 70 Gy). Local recurrence occurred in 5 patients (5%), whereas regional metastases developed in 5 patients (5%). One patient developed concurrent local and regional relapse. No patient developed distant metastases. The 5-year recurrence-free survival was 90%.

CONCLUSION

The findings confirm the efficacy of RT as an efficacious treatment option in early-stage lip SCC.

Short-course radiotherapy in elderly patients with early stage non-melanoma skin cancer: a phase II study

AIM

To evaluate outcome of an accelerated radiotherapy (RT) regimen in elderly patients with an early stage non-melanoma skin cancer (NMSC).

METHODS

Total RT dose was 30 Gy in 5 Gy fractions in six consecutive days.

RESULTS

Thirty-one patients were enrolled. Fourteen were aged ≥80 years. Acute skin and observed late toxicity were exclusively of grade 1. Thirty patients showed a complete response (median follow-up 30 months). Two-year actuarial local control was 93.2%. The cosmetic result was mostly judged as good or excellent.

CONCLUSIONS

Short-course RT in elderly NMSC patients produces >90% local control of disease.

Identifying locally advanced basal cell carcinoma eligible for treatment with vismodegib: an expert panel consensus

ABSTRACT 

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. Most occur on the head and neck, where cosmetic and functional outcomes are critical. BCC can be locally destructive if not diagnosed early and treated appropriately. Surgery is the treatment of choice for the majority of high-risk lesions. Aggressive, recurrent or unresectable tumors can be difficult to manage. Until recently, no approved systemic therapy was available for locally advanced or metastatic BCC inappropriate for surgery or radiotherapy. Vismodegib provides a systemic treatment option. However, a consensus definition of advanced BCC is lacking. A multidisciplinary panel with expertise in oncology, dermatology, dermatologic surgery and radiation oncology proposes a consensus definition based on published evidence and clinical experience.

10th International Symposium on Head And Neck Skin Cancer

Since 1993, ten multidisciplinary symposia were organized at The Netherlands Cancer Institute on the diagnosis and treatment of malignancies of the head and neck. The symposia are meant to provide up-to-date teaching for physicians by world-renowned speakers. The previous symposia dealt with sarcomas, reconstruction, cancer in young patients, salivary glands, melanoma, unknown primaries, as well as several other topics. This 10th symposium focused on skin cancer of the head and neck. There are many types of skin cancer and the differential diagnosis can often be difficult. In this symposium, diagnosis, molecular biology, epidemiology, staging and the treatment of various skin cancers were discussed by leaders in the field. There were over 200 participants from many different countries in Europe and overseas, representing specialties in the fields of dermatology, maxillofacial surgery, otolaryngology, head and neck surgery, general surgery, plastic and reconstructive surgery, and radiotherapy.

5-Year Review of a Unique Multidisciplinary Nonmelanoma Skin Cancer Clinic

Background:

A multidisciplinary nonmelanoma skin cancer (NMSC) clinic is held weekly at our center, where all new patients are jointly assessed by dermatology/dermatopathology, radiation oncology, and plastic surgery. A new patient database was established in 2004. The purpose of this study was to provide a preliminary report on the patients seen in the NMSC clinic and the treatment recommendations rendered.

Methods:

The new patient database was reviewed from January 2004 to December 2008, and patient demographics, tumor characteristics, and treatment recommendations were extracted. Cochran-Mantel-Harnszel (CMH) testing and chi-square analysis were used to detect any associations or relationships between variables within the database. A p value of less than .05 was considered significant.

Results:

During the 5-year study period, 2,146 new patients were seen in the NMSC clinic. The majority of patients presented with basal cell carcinoma (64%) or squamous cell carcinoma (22%), with a median tumor size of 1 to 2 cm (range 0 to #x003E; 9 cm). Tumors were located in the head and neck region (80%), extremities (14%), and torso (6%). Previous treatment included biopsy only (62%), surgery (20%), electrodesiccation and curettage (11%), topical imiquimod (3%), and radiotherapy (1%). Treatment recommendations included surgery (55%) (with either simple excision [31%] or excision with margin control under frozen-section guidance [24%]), radiotherapy (19%), topical imiquimod (10%), observation (7%), and electrodesiccation and curettage (4%).

Conclusions:

The NMSC clinic at our center sees a high volume of patients who benefit from the multidisciplinary assessment provided. Treatment recommendations were based on patient and disease characteristics as well as patient preference.

Non-melanoma skin cancer

The rising incidence and morbidity of non-melanoma skin cancers has generated great interest in unravelling of their pathogenesis and in the search for new non-invasive treatments. Whereas the role of cumulative sun exposure in pathogenesis of squamous-cell carcinoma seems clear, the relation between sun-exposure patterns and subtypes of basal-cell carcinoma remains undetermined. Several complex genotypic, phenotypic, and environmental factors contribute to pathogenesis of non-melanoma skin cancers. Unlike basal-cell carcinoma, squamous-cell carcinomas can arise from precursor lesions. Diagnosis of non-melanoma skin cancer is made clinically and confirmed by histological testing. Prognosis depends on lesion and host characteristics, which also dictate choice of treatment. Prevention strategies aim at reduction of sun exposure, but are of unproven benefit, especially for basal-cell carcinoma. Surgical excision with predetermined margins is the mainstay of treatment for squamous-cell carcinoma and for most basal-cell carcinomas. Of the new non-invasive treatments, only photodynamic therapy and topical imiquimod have become established treatments for specific subtypes of basal-cell carcinoma, and the search for more effective and tissue-salvaging therapies continues.