Delayed Presentation of Basal Cell Carcinoma: A Case Report

Basal cell carcinoma (BCC) is the most common skin cancer in the United States. Although BCC has a low metastatic potential, it can be locally invasive and destructive, especially when there is a delay in diagnosis or treatment. This can affect not only the surrounding skin, but deeper tissues including muscle, cartilage, and even bone. Primary care physicians often serve as the first line of defense in the recognition, diagnosis, and even treatment of skin lesions suspicious for BCC. Most low-risk BCC can be treated in the primary care office with electro-desiccation and curettage or surgical excision. We present a case of locally invasive BCC with significant soft tissue destruction of the neck, which was incidentally identified during an emergency department presentation for a myocardial infarction. It is the responsibility of primary care physicians to recognize the appearance of skin lesions suspicious for BCC and initiate or arrange for subsequent definitive diagnosis and treatment. Our intent in presenting this case is to illustrate a missed opportunity for earlier recognition and treatment because of lack of access to primary care, as well as to demonstrate the destructive nature of BCC when neglected over time. Comprehensive approaches to diagnosis and treatment are described elsewhere.

Resolution of Keratoacanthoma Type Squamous Cell Carcinoma Following Intralesional Therapy With Methotrexate

Keratoacanthoma is considered a variant of squamous cell carcinoma prone to spontaneous involution, but it may also rapidly grow and invade surrounding tissues. Herein, we report a case of keratoacanthoma-type squamous cell carcinoma that resolved after intralesional therapy with methotrexate.

Two intermittent vismodegib dosing regimens in patients with multiple basal-cell carcinomas (MIKIE): a randomised, regimen-controlled, double-blind, phase 2 trial

BACKGROUND

Vismodegib, a first-in-class Hedgehog-pathway inhibitor, is approved for use in adults with advanced basal-cell carcinoma. Patients with multiple basal-cell carcinomas, including those with basal-cell nevus (Gorlin) syndrome, need extended treatment. We assessed the safety and activity of two long-term intermittent vismodegib dosing regimens in patients with multiple basal-cell carcinomas.

METHODS

In this randomised, regimen-controlled, double-blind, phase 2 trial, we enrolled adult patients with multiple basal-cell carcinomas, including those with basal-cell nevus syndrome, who had one or more histopathologically confirmed and at least six clinically evident basal-cell carcinomas. From a centralised randomisation schedule accessed via an interactive voice or web-based response system, patients were randomly assigned (1:1) to treatment group A (150 mg oral vismodegib per day for 12 weeks, then three rounds of 8 weeks of placebo daily followed by 12 weeks of 150 mg vismodegib daily) or treatment group B (150 mg oral vismodegib per day for 24 weeks, then three rounds of 8 weeks of placebo daily followed by 8 weeks of 150 mg vismodegib daily). Treatment assignment was stratified by diagnosis of basal-cell nevus syndrome, geographical region, and immunosuppression status. The primary endpoint was percentage reduction from baseline in the number of clinically evident basal-cell carcinomas at week 73. The primary analysis was by intention to treat. The safety population included all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT01815840, and the study is ongoing.

FINDINGS

Between April 30, 2013, and April 9, 2014, 229 patients were randomly assigned treatment, 116 in treatment group A and 113 in treatment group B. The mean number of basal-cell carcinoma lesions at week 73 was reduced from baseline by 62·7% (95% CI 53·0-72·3) in treatment group A and 54·0% (43·6-64·4) in treatment group B. 216 (95%) of 227 patients included in the safety analysis had at least one treatment-emergent adverse event deemed to be related to study treatment (107 [94%] of 114 in treatment group A and 109 [97%] of 113 in treatment group B). The most common grade 3 or worse treatment-related adverse events were muscle spasms (four [4%] patients in treatment group A vs 12 [11%] in treatment group B), increased blood creatine phosphokinase (one [1%] vs four [4%]), and hypophosphataemia (zero vs three [3%]). Serious treatment-emergent events were noted in 22 (19%) patients in treatment group A and 19 (17%) patients in treatment group B. Four (2%) patients died from adverse events; one (pulmonary embolism in treatment group A) was possibly related to treatment.

INTERPRETATION

Both intermittent dosing schedules of vismodegib seemed to show good activity in long-term regimens in patients with multiple basal-cell carcinomas. Further study is warranted.

FUNDING

F Hoffmann-La Roche.

Maintenance interleukin-2 (IL-2) and sargramostim (GM-CSF) following high-dose IL-2 (HD IL-2) therapy for metastatic melanoma

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Background: At our institution, patients with metastatic melanoma who achieve partial response (PR) to HD IL-2 therapy undergo monthly maintenance treatment with IL-2 and GM-CSF with the thought that the continuous stimulation of the immune system may improve response. Our aim was to describe our experience with maintenance treatment following HD IL-2 therapy. Methods: A retrospective chart review was performed on patients with metastatic melanoma seen at Saint Louis University from January 1999-June 2011 who were partial responders to HD IL-2 therapy (720,000 IU/kg per dose intravenously; 14 doses, 2 cycles per course, maximum 2 courses) that received maintenance IL-2 therapy (continuous 42 hour infusion of three consecutive doses of 18,000,000 IU/m2 over 6, 12 hours, then 24 hours) and GM-CSF (daily subcutaneous injection of 125 mcg/m2 for 3 days) every 4 weeks for 13 cycles or until disease progression. Duration of response for this cohort was compared to established data for partial responders using the Mann-Whitney test. Results: Five patients were included in the analysis. Median duration of response was 9 months (3.9-53.4 months). Median overall survival was 20.6 months (15-53.4+ months). One patient who initially showed PR to HD IL-2 therapy converted to complete response during maintenance IL-2 and has the longest duration of response in the study dataset. Duration of response for the maintenance group (9 months) was longer than a benchmark of 5.9 months as reported in the literature and package insert for partial responders to HD IL-2 without maintenance therapy, p = 0.068. Conclusions: Subjects who received maintenance IL-2 and GM-CSF therapy had a longer duration of response compared to previous reports, which trended toward statistical significance in this small sample. Maintenance IL-2 and GM-CSF after HD IL-2 therapy may help to prolong partial response, possibly lead to conversion to complete response and is worthy of additional study.

Nausea and vomiting during high-dose interleukin-2 (HD IL-2) therapy

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Background: Nausea and vomiting (N/V) are two common side effects during HD IL-2 therapy. They may be severe enough to cause electrolyte imbalances or lead to missed doses, which may compromise response. Our aim was to describe the incidence of N/V during HD IL-2 therapy at our institution. Methods: A retrospective chart review of patients treated with HD IL-2 therapy (720,000 IU/kg per dose intravenously; 14 doses, 2 cycles per course, maximum 2 courses) from January 1999 to June 2011 at Saint Louis University was performed. Patients received scheduled PO ondansetron 24 mg daily and prochlorperazine 10 mg IV or PO every 4 hours as needed per standard protocol. Additional antiemetics were ordered at the clinician’s discretion. Data regarding incidence of N/V and use and type of rescue medication for N/V were recorded. Results: 104 patients were identified (68 melanoma and 36 renal cell carcinoma). Median age was 53.7 years (17.7-77.7 years) and there were 66 men and 38 women. Only 3.8% of patients (4 out of 104) were able to complete HD IL-2 therapy without rescue medication. All patients (n = 100) who needed rescue therapy received prochlorperazine on day 1 of treatment (acute phase) and at least 1 additional day during days 2-6 of each admission (delayed phase). Metoclopramide (n = 23) was the most common supplemental antiemetic ordered followed by promethazine (n = 16), meclizine (n = 5), and palonsetron (n = 3). Conclusions: Almost all patients who underwent HD IL-2 therapy had N/V that necessitated rescue therapy during both the acute phase and the delayed phase. Decreasing the incidence and severity of N/V may increase patients’ quality of life during this demanding regimen. Current protocols are single-institution based, but generally include daily 5HT-3 antagonists and prochlorperazine as needed. Our data suggests that this regimen is inadequate. One challenge to management is that steroids, which are commonly used as adjuncts, are contraindicated during immunotherapy. Additional therapeutic options are still needed. Recently new drug targets, including neurokinin-1 receptor (NK1R) inhibitors, have been approved to treat N/V during chemotherapy. NK1R inhibitors may be of assistance during immunotherapy with HD IL-2 in the future.

Quality of life and depression assessment in nevoid basal cell carcinoma syndrome

BACKGROUND

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare genetic disease which causes a variety of dermatological lesions, especially basal cell carcinomas (BCCs), often on the face, neck, and head.

METHODS

Persons attending a national NBCCS support group meeting were asked to participate in survey-based assessments of quality of life and depressive symptoms. Inclusion criteria required a self-reported NBCCS diagnosis, voluntary agreement to participate, and age over 18 years. Exclusion criteria included cognitive impairment. Skin-related quality of life was assessed with Skindex-29, completed by 32 participants. Depressive symptomatology was determined with the Center for Epidemiological Studies Depression Scale (CES-D), completed by 18 participants. Sociodemographic, medical, and social variables were also analyzed.

RESULTS

Median Skindex-29 scores for the emotions, symptoms, and functioning scales were 42.50, 32.14, and 28.13, respectively (means: 41.17, 37.05, and 29.30, respectively). These scores were slightly higher than those observed in patients with neurofibromatosis type 1, a similar genetic disease with skin symptoms. The CES-D scores (median = 15.50, mean = 17.50) suggested that 50% of participants had significant depressive symptomatology. Variables showing moderate associations with the scores included diet, number of affected family members, and treatment type. Interestingly, the number of BCCs had no effect.

CONCLUSIONS

Nevoid basal cell carcinoma syndrome impacts the quality of life of its subjects in a similar manner to other genodermatoses. Depressive symptoms are particularly prevalent. Several demographic, medical, and social characteristics affect these outcomes. Thus, the psychological impact of this disorder should be evaluated in the course of considering the care of persons with NBCCS.

Nasal trumpet orthosis to maintain nares opening during a melolabial interpolation flap

BACKGROUND

The nasal trumpet has been used in emergency resuscitation, anesthesia, and facial burns to maintain nares openings. The dermatologic surgery literature is not as familiar with this device to improve respiratory function during the postoperative period after reconstruction of large defects on the nose.

OBJECTIVE

To present a novel way of using a modified nasal trumpet orthosis to maintain nasal valve patency and improve nasal valve respiratory function postoperatively following a melolabial interpolation flap.

MATERIALS

A sterile nasal trumpet orthosis.

CONCLUSION

We present a novel way of using a modified nasal trumpet orthosis after a melolabial interpolation flap procedure. For large defects involving the nares and/or nasal valve of the nose, the nasal trumpet is well tolerated by the patient and can lead to increased postoperative respiratory function while acting as a "bolster" for the closure.

The use of lymphoscintigraphy and PET in the management of head and neck melanoma

OBJECTIVES

Lymphoscintigraphy with sentinel node dissection and 18 fluoro-2-deoxyglucose positron emission tomography (PET) are being used independently in the management of many intermediate and thick melanomas of the head and neck. We report a series of patients with melanoma of the head and neck with Breslow depths greater than 1.0 mm and clinically negative regional nodes that were evaluated prospectively with PET and lymphoscintigraphy.

STUDY DESIGN AND SETTING

Between July 1, 1998 and December 30, 2000 PET scans were obtained preoperatively on 18 patients undergoing resection of head and neck melanoma. Lymphoscintigraphy and sentinel node dissection was performed. Resection of the primary lesion was then carried out with adequate margins and the defects were reconstructed.

RESULTS

Sentinel node(s) were found in 17/18 patients (94.4%); 5/18 (27.8%) of cases had metastases. PET detected nodal metastasis preoperatively in 3 patients (16.7%), one of which had a positive sentinel node dissection.

CONCLUSION

PET and lymphoscintigraphy offer complimentary ways of evaluation for metastatic melanoma.