Tumor regrowth and development of keratinocytic neoplasms in patients under smoothened inhibition: in vivo assessment with reflectance confocal microscopy

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

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

Ultrasound and Infrared-Based Imaging Modalities for Diagnosis and Management of Cutaneous Diseases

Non-invasive bedside imaging tools are becoming more prevalent for assessing cutaneous lesions. Ultrasound used at specific frequencies allows us to assess margins of lesions to minimize the extent of the biopsy that is performed and improve cosmetic outcomes. Vascularity, seen on Doppler ultrasound and contrast-enhanced ultrasound, and stiffness, assessed on tissue elastography, can help differentiate between benign and malignant lesions for clinicians to be more judicious in deciding whether to biopsy. Moreover, research has shown the efficacy in using ultrasound in monitoring flares of hidradenitis suppurativa, a disease affecting apocrine gland-rich areas of the body, for which the current gold standard involves examining and scoring inflammatory lesions with the naked eye. Infrared-based modalities have also been on the uptrend to aid in clinical decision-making regarding suspiciousness of lesions. Reflectance confocal microscopy has lateral resolution that is comparable to histopathology and it has been shown to be an appropriate adjunctive tool to dermoscopy, specifically when evaluating melanomas. Optical coherence tomography has utility in determining lesion thickness because of its depth penetration, and spectrophotometric intracutaneous analysis is becoming more popular as a tool that can be used by general practitioners to know when to refer to dermatology regarding worrisome pigmented lesions. Strides have been made to incorporate electrical impedance spectroscopy alongside dermoscopy in decision-making regarding excision, although the evidence for its use in the clincial setting remains inconclusive. This paper reviews the efficacy and drawbacks of these techniques in the field of dermatology and suggests future directions.

Reflectance confocal microscopy identification of subclinical basal cell carcinomas during and after vismodegib treatment

BACKGROUND

Recently, it has been shown that reflectance confocal microscopy (RCM) could identify subclinical basal cell carcinoma (BCC) during vismodegib treatment of locally advanced BCC.

OBJECTIVES

To evaluate specificity and sensitivity of clinical, dermoscopic and RCM examination for BCC in patients with multiple BCCs treated by vismodegib.

METHODS

Ninety four BCCs had 710 clinical, dermoscopic and RCM examinations during 72 weeks of vismodegib treatment. Thirty-eight were biopsied at the end of the treatment. Sensitivity and specificity for these 38 lesions were calculated. BCC diagnoses of clinical, dermoscopic and RCM examination on all the 710 investigations were compared using chi-square test.

RESULTS

Reflectance confocal microscopy was extremely more sensitive than dermoscopy and clinical examination and slightly less specific (sensitivity of 95%, 35% and 33% and specificity of 81%, 88% and 86% for RCM, dermoscopy and clinical examination, respectively) for the identification of residual BCC in the 38 biopsied cases. Considering all the 710 observations, RCM correctly diagnosed more BCCs than dermoscopy and clinical examination.

CONCLUSION

Reflectance confocal microscopy is a non-invasive technique that can detect subclinical residual BCC during and after vismodegib treatment helping the clinician to identify incomplete tumour regression.

Updates on the Management of Non-Melanoma Skin Cancer (NMSC)

Non-melanoma skin cancers (NMSCs) are the most common malignancy worldwide, of which 99% are basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) of skin. NMSCs are generally considered a curable diseases, yet they currently pose an increasing global healthcare problem due to rising incidence. This has led to a shift in emphasis on prevention of NMSCs with development of various skin cancer prevention programs worldwide. This article aims to summarize the most recent changes and advances made in NMSC management with a focus on prevention, screening, diagnosis, and staging.

Spotlight on vismodegib in the treatment of basal cell carcinoma: an evidence-based review of its place in therapy

Vismodegib is approved for the treatment of adult patients with metastatic (mBCC) or locally advanced basal cell carcinoma (laBCC) that have recurred following surgery or for those who are not good candidates for surgery (risk/benefit ratio is against patient's benefit, either because of the general condition or because of the expected morbidity from the surgery) or radiation therapy. This article provides an evidence-based review of its current place in therapy. Analytically, the clinical implications in the management of laBCCs and mBCCs and possible new indications, including the neoadjuvant use before surgical excision, are discussed, while in the end, the challenges regarding class-related adverse events and their optimal management are highlighted.