Nonsurgical Options for the Treatment of Basal Cell Carcinoma

Photodynamic Therapy in Pigmented Basal Cell Carcinoma-A Review

This review summarizes the effectiveness of photodynamic therapy (PDT) in the treatment of the pigmented subtype of basal cell carcinoma (BCC) based on the current literature. PDT is a light-activated treatment, non-invasive, that selectively destroys tumor cells and tissues via the interaction of a photosensitizer, light, and molecular oxygen. It can induce cancer cell death through direct tumor vascular damage or via the induction of immune response. However, human skin is also an absorption and scattering medium since it contains hemoglobin and melanin that act as chromophores. Eumelanin can be considered a light-absorber and an intracellular antioxidant that can neutralize PDT-induced ROS and, therefore, decrease PDT success. Various factors, including tumor depth, the degree of pigmentation in malignant cells, and the individual's skin phototype, can impact the outcome of this intricate biochemical process. It has been widely recognized that PDT exhibits limited efficacy in the treatment of pigmented lesions. However, new combination techniques such as curettage or debulking before PDT show promising results in the treatment of pigmented BCC.

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma

BACKGROUND

Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning.

OBJECTIVE

We present an approach to the management of BCC when cost reduction is a priority.

METHODS

A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment.

RESULTS

The cost of treating a primary superficial BCC < 0.5 cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2 cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10 cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc.

CONCLUSIONS

For a primary superficial BCC < 0.5 cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2 cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

Topical Treatments for Basal Cell Carcinoma and Actinic Keratosis in the United States

Skin cancer is an overarching label used to classify a variety of cutaneous malignancies. Surgical excision procedures are the commonly used treatments for these lesions; however, the choice to perform operative intervention may be influenced by other factors. Established research and literature suggest that topical treatments limit the need for surgical intervention and its commonly associated adverse effects, including infection and scarring. In addition, the growing indications for the usage of topical therapies in BCC treatment, as well as their increased availability and therapeutic options, allow for their greater applicability in the dermatology clinic. Certain topical therapies have been highlighted in research, especially those targeting basal cell carcinoma (BCC) and actinic keratosis (AK). There is also a clear correlation between cost and treatment outcomes, considering BCC's ever-growing prevalence and the proportion of excised lesions being reported as malignant. This review will discuss BCC and AK lesion criteria that result in the most successful outcomes using topical treatments, then highlight the various topical treatment options, and finally address their clinical significance moving forward.

Early clinical experience with a degraded 4 MeV electron beam in radiotherapy of superficial basal cell carcinoma

The most common non-melanoma skin cancer is basal cell carcinoma (BCC). Surgery is the gold standard treatment but also non-surgical alternatives are needed. The purpose of this work was to present the early clinical experiences of degraded 4 MeV electron beam as a treatment method for superficial BCC. Twelve patients underwent two weeks radiation therapy treatment with either 5 × 7 Gy or 2 × 12 Gy. There were no significant differences in treatment outcome with different fractionations or lesion locations. The degraded beam method is a safe and valid non-surgical solution for suitable patients with superficial lesions.

Basal Cell Carcinoma Perineural Invasion and Suggestive Signs of Perineural Invasion-Findings and Perspectives

Basal cell carcinoma (BCC) is a malignant tumor with a rising incidence and is the beneficiary of several innovative evaluation techniques. Histopathology remains the gold standard for assessment, having the possibility of addressing multiple high-risk factors such as perineural invasion (PNI). The current study included a number of 244 BCC patients and targeted the identification of positive PNI and its suggestive signs, and whether they correlated or not with other high-risk tumor signs. PNI was found in 20.1% of patients, with 30.7% of patients having perineural chronic inflammation (PCI), which is a suggestive sign of PNI. PNI was also found in larger tumors, with deeper Clark levels, in high-risk BCCs and high-grade tumors. PNI and PCI are both important for pathology reporting, aiding in treatment choice and further patient management, with possibly positive outcomes concerning morbidity and mortality.

Years of dermatology experience and geographic region are associated with outlier performance of excision or destruction for nonmelanoma skin cancer

INTRODUCTION

Treatments for nonmelanoma skin cancer (NMSC) include excision (surgical removal) and destruction (cryotherapy or curettage with or without electrodesiccation) in addition to other methods. Although cure rates are similar between excision and destruction for low-risk NMSCs, excision is substantially more expensive. Performing destruction when appropriate can reduce costs while providing comparable cure rate and cosmesis.

OBJECTIVE

To identify characteristics associated with exclusive (outlier) performance of excision or destruction for NMSC.

METHODS

The study consisted of malignant excision and destruction procedures submitted by dermatologists to Medicare in 2019. Proportions of services for each method were analyzed with respect to geographic region, years of dermatology experience, median income of the practice zip code, and rural-urban commuting area code.

RESULTS

Fewer years of experience predicted a higher proportion of excisions (R²=.7, p<.001) and higher odds of outlier excision performance. Outlier performance of excision was associated with practicing in the South, Midwest, and West, whereas outlier performance of destruction was associated with practicing in the Northeast and Midwest.

CONCLUSIONS

Dermatologists with less experience or in certain geographic regions performed more malignant excision relative to destruction. As the older population of dermatologists retires, the cost of care for NMSC may increase.

Pulsed Dye Laser for Treatment of Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common malignancy worldwide. The incidence of BCC is increasing up to 10% per year worldwide. Surgical excision and Mohs surgery are the gold standard treatment modalities. However, patients may not be candidates for surgery. Pulsed dye laser (PDL) is a novel technique for treating BCC.

Methods

Patients with biopsy-proven BCC underwent two treatments with PDL at 6-week intervals at Berkshire Cosmetic and Reconstructive Surgery Center. Patients returned 6 weeks after the second treatment for evaluation for response to treatment. Follow-up examinations were conducted at 6, 12, and 18 months after treatment with PDL.

Results

Twenty patients with 21 biopsy-proven BCCs were treated with PDL at Berkshire Cosmetic and Reconstructive Surgery Center between 2019 and 2021. Nineteen BCCs had a complete response after two treatments, for a clearance rate of 90%. Two of the 21 lesions did not respond for an incomplete response rate of 10%.

Conclusion

PDL is an effective nonsurgical treatment option in the management of BCC.

Modern aspects of photodynamic therapy of basal cell skin cancer

Photodynamic therapy (PDT) is one of the most effective treatments for basal cell skin cancer (BCC). As the incidence rate of BCC is increasing worldwide, interest in developing new methods for diagnosing and treating this disease, taking into account long-term cosmetic results, is growing. The review article presents the results of domestic and foreign studies on the treatment of BCC with PDT. The presented results of studies from various domestic and foreign clinics indicate the high efficiency of independent PDT and a combination of PDT with other treatment methods. PDT is proposed to be used in combination with surgical methods and radiation therapy, immunomodulating and chemotherapeutic agents, and inhibitors of molecules involved in the carcinogenic process. These new strategies open the way to increasing the effectiveness of treatment and prevention of BCC. Moreover, in all studies, the safety of this non-invasive treatment, a low level of adverse reactions during therapy, good tolerance for the patient and excellent cosmetic treatment results are noted. The guidelines currently being developed in Europe and the United States provide consistent expert advice that reflects current published evidence of treatment outcomes for BCC using PDT. Moreover, the recommendations emphasize that the treatment plan for patients with “difficult to treat” BCC should be discussed at an interdisciplinary oncological council.

Nonsurgical treatment options for basal cell carcinoma

ABSTRACT

Basal cell carcinoma (BCC) is the most common form of nonmelanoma skin cancer. Surgery, including Mohs micrographic surgery, is considered the gold standard for the management of BCC, yet some patients may be unable to undergo surgery. This article describes effective nonsurgical options for treating superficial BCCs as well as some nodular and infiltrative BCCs.

A systematic review of observational management of cutaneous basal cell carcinoma

BACKGROUND

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom and United States. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of cutaneous BCC.

METHODS

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

RESULTS

We identified 2529 titles, from which 4 full-text articles were eligible, reporting on 2298 individuals. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6-12 weeks. Clearance rates ranged from 52-100% for imiquimod and 2-19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

CONCLUSION

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility-adjusted survival following interventional or observational management of BCC.

Non-surgical treatments for basal cell skin cancer

Basal cell carcinoma is the most common nonmelanoma skin cancer. It originates from undifferentiated cells in the basal cell layer of the epidermis or from the outer root sheath of the hair follicle. The most important factor in development of basalioma is ultraviolet radiation. Surgery is considered the gold standard of treatment for basal cell cancer. However, nonsurgical options are available for individuals who are unsuitable for surgery. The purpose of this review is to summarize the efficacy and indications of alternative, nonsurgical treatments that can be used in the management of basal cell cancer Effective nonsurgical treatments include destructive methods (eg, curettage and electrodessication, cryosurgery, laser), photodynamic therapy, topical medications, hedgehog pathway inhibitors. Nonsurgical therapeutic alternatives are safe and effective for the treatment of BCC. Factors such as tumor location, size, and histopathological subtype should be taken into consideration when selecting optimal treatment, cosmetic results and patient preference should be considered too. To search for the necessary literature, the PubMed, MedLine, Web of Science and RSCI databases were used.

Dissolving microneedles containing aminolevulinic acid improves protoporphyrin IX distribution

One important limitation of topical photodynamic therapy (PDT) is the limited tissue penetration of precursors. Microneedles (MNs) are minimally invasive devices used to promote intradermal drug delivery. Dissolving MNs contain drug-associated to polymer blends, dissolving after insertion into skin, allowing drug release. This study comprises development and characterization of a pyramidal model of dissolving MNs (500 μm) prepared with 5% wt/wt aminolevulinic acid and 20% wt/wt Gantrez AN-139 in aqueous blend. Protoporphyrin IX formation and distribution were evaluated in tumor mice model by using fluorescence widefield imaging, spectroscopy, and confocal microscopy. MNs demonstrated excellent mechanical resistance penetrating about 250 μm with minor size alteration in vitro, and fluorescence intensity was 5-times higher at 0.5 mm on average compared to cream in vivo (being 10 ± 5 a.u. for MNs and 2.4 ± 0.8 a.u. for cream). Dissolving MNs have overcome topical cream application, being extremely promising especially for thicker skin lesions treatment using PDT.

Basal Cell Carcinoma Surgery in general practice: Is there a role for the local General Practitioner?

Basal cell carcinoma (BCC) is a common disease of the skin caused principally by prolonged solar radiation exposure. It is normally a malignancy with favorable prognostic features and is potentially curable by standard excision. In White populations with high disease incidence, general practitioners (GPs) play a vital role in diagnosing and managing BCC, including surgical excision. Dedicated care at the primary care level by adequately trained GPs is conceivably cost effective for the health system and more convenient for the patient. In Asia and other parts of the world with low incidence, this valuable role of GPs may appear to be inconsequential. In this regard, any justification for the involvement of local GPs in BCC surgery is debatable. This article aims to provide a clinical update on essential information relevant to BCC surgery and advance understanding of the intricate issues of making a treatment decision at the primary care level.

CASE REPORT

Madam Tan, a 71-year-old Malaysian Chinese lady, otherwise healthy, presented to her local GP with a complaint of a nodule over the left cheek that had been there for more than a decade. Her concern was that the lesion was growing and had become conspicuous. She had spent most of her life as a farmer working in her orchard.Upon examination, she had an obvious dome-shaped nodule over the left cheek measuring approximately 1.8 cm in diameter. The lesion was firm, pigmented, well-demarcated, and slightly ulcerated at the top. Clinically, she was diagnosed with a pigmented nodular basal cell carcinoma of the left cheek. Examination of the systems was unremarkable.She requested that the consulting GP remove the growth. The cost for specialist treatment and waiting time at the local hospital were her concerns.

CLINICAL QUESTIONS

Can the basal cell skin cancer be excised safely and effectively in the local primary care setting? What are the crucial preoperative concerns?

Beyond Mohs surgery and excisions: A focused review of treatment options for subtypes of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer. It originates from undifferentiated cells in the basal cell layer of the epidermis or from the outer root sheath of the hair follicle. The most important factor in development of BCC is ultraviolet radiation. Surgery is considered the gold standard of treatment for BCC. However, nonsurgical options are available for individuals who are unsuitable for surgery. The purpose of this review is to summarize the efficacy and indications of alternative, nonsurgical treatments that can be used in the management of BCC. An extensive literature review was performed for the nonsurgical options for the treatment of BCC. Resources searched included PubMed and Google Scholars, limited to the years 1995 to 2020. Key words searched included BCC, destructive methods, photodynamic therapy (PDT), radiotherapy, topical medication, laser, hedgehog pathway inhibitors (HPIs). The most relevant results such as systematic reviews, randomized controlled trials, or comparative studies were selected to provide a summary for the most common nonsurgical methods used for treating BCC. Effective nonsurgical treatments for BCC include destructive methods (eg, curettage alone, cryosurgery, or electrodessication), PDT, topical medications, radiotherapy, laser, and HPIs. Nonsurgical therapeutic alternatives are safe and effective for the treatment of BCC. Factors such as tumor location, size, and histopathological subtype should be taken into consideration when selecting optimal treatment. In addition to clinical factors, cosmetic results and patient preference should be considered.

Superficial Basal Cell Carcinoma of the Face Successfully Treated with Ingenol Mebutate 0.05% Gel: Case Report and a Review of the Literature

A 64 year-old Caucasian male patient with a long history of ultraviolet light exposure and multiple actinic keratoses presented with a large, erythematous, and scaly plaque on his forehead. Biopsies revealed superficial basal cell carcinoma (sBCC). Because the patient wanted the shortest possible topical regimen, his sBCC was treated with two overnight ingenol mebutate (IM) 0.05% gel applications. He tolerated the local skin reaction (LSR) well, and at approximately six weeks post-treatment, biopsies showed no evidence of sBCC. The patient was happy with the cosmetic outcome and has remained free of clinical recurrence for 18 months. Although IM gel is only FDA approved for the treatment of actinic keratosis, it has also been used off-label to treat other epithelial lesions, including basal cell carcinoma (BCC), anogenital warts, and Bowen's disease. One clinical trial, multiple case series and case reports, and now this report, have demonstrated IM's utility in treating BCC. IM treatment is therefore a promising alternative to surgery for select BCC, with major advantages, including a short treatment duration and generally favorable cosmetic outcome.

Imiquimod does not elicit inflammatory responses in the skin of the naked mole rat (Heterocephalus glaber)

Objective

Naked mole rat (Heterocephalus glaber) has recently attracted interest in biomedical research due to its exceptional longevity, cancer resistance and tolerance to potentially harmful conditions or stimuli. Given its unique attributes, this study was designed to characterize inflammatory skin reactions of this animal to topical application of imiquimod, a toll-like receptor 7 and 8 agonist that triggers psoriasis-like skin reaction.

Results

Imiquimod did not cause the expected psoriasis-like skin changes. There was no epidermal thickening and a straight epidermo-dermal boundary was maintained. There was no parakeratosis and the granular layer of epidermis was well formed. In the dermis, there was no leukocyte infiltration. This points to an exceptional nature of inflammatory/immune responses of this animal, but the mechanism could not be explained by our results. Naked mole rat could be a valuable negative model for studying psoriasis and other inflammatory skin conditions but as a prerequisite, there is need for further investigations to establish the mechanisms behind its lack of response to imiquimod.

Prospective Clinical Trial Comparing Curettage and Cryosurgery to Curettage and Electrodesiccation in the Management of Minimally Invasive Basal and Squamous Cell Carcinomas [Formula: see text]

BACKGROUND

Basal and squamous cell carcinomas represent the most common cancers in North America. Their management is an important issue.

OBJECTIVES

The evaluation of cure rates of minimally invasive cutaneous carcinomas with curettage-cryosurgery compared to curettage-electrodesiccation, as well as the assessment of the aesthetic appearance of scars.

METHODS

This prospective trial randomized 117 patients 1:1 to treatments of curettage-cryosurgery or curettage-electrodesiccation. They were then followed at 6, 12, 18, and 24 months.

RESULTS

At 12-month follow-up, only one (1/49) patient had a recurrence of cutaneous carcinoma in the curettage-cryosurgery group and none (0/43) in the curettage-electrodesiccation group. Farrington-Manning analysis with a 5% margin of error showed the non-inferiority of the first method (P = .04). For the aesthetic appearance of scars after 12 months, better results with curettage-cryosurgery procedure has been observed, but this was not statistically significant (P = .80 and P = .27 for evaluations of patients and clinicians respectively).

LIMITATIONS

This study was mainly limited by its small sample size.

CONCLUSION

We have demonstrated that curettage-cryosurgery compared to curettage-electrodesiccation for the treatment of minimally invasive carcinomas is noninferior (comparable) with regards to cure rates at 12-month follow-up. No significant difference has been demonstrated for the appearance of scars.

Ingenol mebutate therapy in erythroplasia of Queyrat: a new approach

BACKGROUND

Erythroplasia of Queyrat (EQ) is a rare squamous cell carcinoma in situ, usually occurring on the glans penis, the prepuce, or the urethral meatus. Therapy is mandatory because it can progress to invasive carcinoma in up to 30% of cases. Treatment options include 5-fluorouracil, curettage, cryotherapy, radiotherapy, laser, partial or total penectomy, and microsurgery, as also with imiquimod and photodynamic therapies.

METHODS

Between 2015 to 2018 we treated five patients, with histologically confirmed EQ, with ingenol mebutate (IM) 0.015% gel applied for 3 days consecutively.

RESULTS

Three patients showed complete response at one year follow up. Two patients showed partial response after two months, so they received a second course of therapy with IM. At one-year follow-up, one of them showed complete response, the other partial response.

CONCLUSIONS

Our experience demonstrated that IM may be considered as an effective and safe treatment option in EQ. IM offers various advantages such as easy and fast application, rapid complete remission, better compliance, few side effects and excellent cosmetical results. The authors call for further exploitation in bigger trials.