Intralesional Treatments for Invasive Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most frequent cancer in humans and has the potential to progress locally, metastasize, and cause death in a subset of patients. cSCC is especially common in the elderly, and it will probably represent a major health concern in the near future. Surgery is the standard treatment for cSCC, but intralesional therapies can sometimes be considered for certain patients and under certain circumstances. The choice of intralesional treatment depends on the patient's characteristics and the clinician's previous experience and expertise. Here we are reviewing intralesional treatments for cSCC and keratoacanthoma (KA). We have started with some classic drugs, such as methotrexate and 5-fluorouracil, bleomycin, interferon, and cryosurgery, but also comment on electrochemotherapy. Finally, we have focused on novel therapies, some of which are under development, and future perspectives, including intralesional immunotherapy and oncolytic viruses.

Efficacy of Intralesional Vitamin D3 for Treatment of Verruca Vulgaris: A Randomized Control Study

Cutaneous warts are benign epithelial lesions caused by human papillomavirus and are common entities, affecting nearly 10 percent of the United States population. While most warts spontaneously resolve, the immunocompromised are susceptible to recalcitrant warts which often require medical treatment. Most current therapies use either physical or chemical destruction for wart removal, but these treatments are associated with adverse effects. Intralesional vitamin D3 has the potential to demonstrate a stronger treatment response due to its ability to stimulate the immune system at the injection site via cell-mediated immunity. We sought to test the efficacy of intralesional vitamin D3 for wart treatment in a sample size of 70 patients over a three-month period. Efficacy was determined as "excellent" if there was greater than a 90-percent reduction in both size and number of lesions, "good" if there was a 60 to 89-percent reduction, and "fair" if there was less than a 60-percent reduction. Treatment efficacy was excellent in 20 (28.6%) patients, good in 29 (41.4%) patients, fair in 18 (25.7%) patients, and poor in three (4.3%) patients. Patients in the younger age group had a higher treatment efficacy compared to other treatment groups. Thus, intralesional vitamin D3 has promising qualities as a treatment for cutaneous warts and should be considered at the clinician's disposal. Vitamin D is an innovative approach for treating warts without the various side effects posed by other commonly used agents. The unique features of this treatment modality including its simplicity, safety, and efficiency make it a promising option for a very common cutaneous condition.

A Study of Comparison and Evaluation of Various Intralesional Therapies in Cutaneous Warts

Background

The study compares the efficacy of four immunotherapeutic agents, measles mumps and rubella (MMR), purified protein derivative (PPD), Candida extract, and vitamin D3, in the treatment of multiple cutaneous warts.

Aim and Objectives

To observe the clinical responses and safety of different intralesional immunotherapeutic agents and compare their efficacy.

Materials and Methods

Hundred patients with multiple (>5) cutaneous warts were enrolled in the study and randomized into four groups: Group A: MMR, Group B: PPD, Group C: Candida extract, and Group D: Vitamin D. Target wart was selected, and the intralesional injections were given at three weekly intervals for a maximum of three doses. Response was observed in target and distant warts three months after the last injection.

Results

Intralesional vitamin D3 had the highest efficacy, while MMR had the lowest efficacy in clearance of target wart. Intralesional Candida extract had the highest efficacy, while vitamin D3 had the lowest efficacy in clearance of distant warts. Intralesional Candida extract was the most effective treatment for both local and distant warts. Side effects were minimal and transitory in nature.

Conclusion

Intralesional immunotherapy is a safe, affordable, and efficacious treatment for warts.

A comparative clinico-dermoscopic study of intralesional injection of combined digoxin and furosemide, Candida antigen, and vitamin D3 for multiple warts

BACKGROUND

Immunostimulatory and antiproliferative therapies have been widely used for the treatment of multiple warts. Recently, anti-HPV activity of ionic contra viral therapy (ICVT) which is comprised of combined digoxin and furosemide has been demonstrated.

AIM

To evaluate and compare the effectiveness and safety of intralesional injection of Candida antigen, vitamin D3, and combined digoxin and furosemide in the treatment of multiple warts.

PATIENTS AND METHODS

Seventy-five patients with numerous warts were randomly assigned to one of three equal groups: Candida antigen, vitamin D3, or a combination of digoxin and furosemide. In the Candida antigen group, injections into the biggest wart were done. In the vitamin D3 and combined digoxin/furosemide groups, the agent was injected into each wart with a maximum of five injected warts. Injections were repeated every 2 weeks until clearance or for a total of five sessions.

RESULTS

There was a statistically significant difference in the overall therapeutic response among the studied groups in favor of the intralesional Candida antigen group (60%), followed by the vitamin D3 group (48%) and the ionic contraviral therapy group (28%) (p = 0.02). However, the difference between both Candida antigen and vitamin D groups was not significant (p = 0.59).

CONCLUSIONS

Intralesional Candida antigen immunotherapy and vitamin D3 antiproliferative therapy are significantly more effective than ICVT.

LIMITATIONS

Short follow-up period and relatively small sample size.

Cutaneous Breast Cancer Metastasis Is Effectively Treated With Intralesional Interleukin-2 and Imiquimod: A Case Report and Brief Literature Review

Breast cancer is the most common non-cutaneous cancer affecting women worldwide and is a major cause of cancer-related morbidity and mortality in females. While many women are diagnosed with early-stage disease, a subset of women may present with isolated cutaneous metastases or recurrent locoregional cutaneous metastatic disease. There is a paucity of evidence for effective treatments for cutaneous breast cancer metastases. Herein, we present a case of hormone receptor negative, HER2 positive cutaneous breast cancer metastasis treated with intralesional IL-2 and topical imiquimod, which was well tolerated with only minor low grade side effects. We also present a brief literature review of immunotherapy for cutaneous breast cancer metastasis to frame the discussion around using minimally invasive local therapies for this disease. Together, this limited data suggests that intralesional IL-2 and imiquimod may be considered as a safe option when treating a patient with cutaneous breast cancer metastases.

Case Report: Combined Intra-Lesional IL-2 and Topical Imiquimod Safely and Effectively Clears Multi-Focal, High Grade Cutaneous Squamous Cell Cancer in a Combined Liver and Kidney Transplant Patient

Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer worldwide, with ever increasing incidence and mortality. While most patients can be treated successfully with surgical excision, cryotherapy, or radiation therapy, there exist a subset of patients with aggressive cSCC who lack adequate therapies. Among these patients are solid organ transplant recipients who due to their immunosuppression, develop cSCC at a dramatically increased rate compared to the normal population. The enhanced ability of the tumor to effectively undergo immune escape in these patients leads to more aggressive tumors with a propensity to recur and metastasize. Herein, we present a case of aggressive, multi-focal cSCC in a double organ transplant recipient to frame our discussion and current understanding of the immunobiology of cSCC. We consider factors that contribute to the significantly increased incidence of cSCC in the context of immunosuppression in this patient population. Finally, we briefly review current literature describing experience with localized therapies for cSCC and present a strong argument and rationale for consideration of an IL-2 based intra-lesional treatment strategy for cSCC, particularly in this immunosuppressed patient population.

Evaluation of intralesional Candida antigen in diabetic patients with multiple warts

BACKGROUND

Treatment of warts in diabetic patients with ablative modalities poses a significant risk owing to increased possibility of secondary infection, slow healing, and recurrence. Intralesional immunotherapy has gained popularity in the treatment of warts due to its proven efficacy and good tolerability compared with destructive methods.

AIM

To evaluate the intralesional Candida antigen injection for the treatment of multiple warts in diabetic patients.

PATIENTS/METHODS

Fifty diabetic patients with multiple genital/nongenital warts were divided into two groups. The first group (30 patients) received intralesional Candida antigen, and the second group (20 patients) had intralesional saline as control. The treatments were injected into the largest wart every 2 weeks until complete clearance of warts or for a maximum of five sessions.

RESULTS

Complete clearance of warts was observed in 80% of the diabetic patients in the Candida antigen group compared with 15% in the control group (P < .001). Side effects to Candida antigen included pain during injection in all patients, flu-like symptoms, and localized reaction at the injection site in few patients.

CONCLUSION

Intralesional Candida antigen injection can be a promising effective and safe therapeutic option for the treatment of warts in diabetic patients.

Efficacy and safety of intralesional injection of vitamin D3 versus tuberculin PPD in the treatment of plantar warts: A comparative controlled study

BACKGROUND

Several destructive and immunotherapeutic methods are used in treatment of plantar warts, but an effective method with no or reduced recurrence has not been found till now.

OBJECTIVES

To evaluate the efficacy and safety of intralesional (IL) vitamin D₃ (Vit.D₃ ) injection vs IL tuberculin purified protein derivative (PPD) injection in the treatment of plantar warts.

METHODS

Sixty patients with plantar warts were randomized into 3 equal groups: group I treated using IL tuberculin PPD every 2 weeks, group II treated using IL Vit.D₃ every 4 weeks, and group III treated with IL saline every 2 weeks till complete clearance or for a maximum of 3 sessions. The follow-up period was 6 months.

RESULTS

There was a statistically significant improvement in therapeutic groups than control with more significant improvement in group II than I. Regarding number of sessions required for complete response, there was a positive significant correlation in both groups, but more significant in group I. There was a negative correlation between the number of lesions and the response to treatment in both groups. Group II showed significantly better response to treatment in male patients. Both modalities were well tolerated, with no remarkable side effects and no recurrence in cured patients of both groups.

CONCLUSIONS

Both IL PPD and Vit.D₃ injection are safe and effective for treatment of plantar warts even recalcitrant or multiple, with no postprocedural downtime, better results, and patient satisfaction. IL Vit.D₃ injection has a superior advantage than PPD.

Armed antibodies for cancer treatment: a promising tool in a changing era

Advances in the understanding of tumor immunology and molecular biology of melanoma cells have favored a larger application of immunotherapy and targeted therapies in the clinic. Several selective mutant gene inhibitors and immunomodulating antibodies have been reported to improve overall survival or progression-free survival in metastatic melanoma patients. However, despite impressive initial responses, patients treated with selective inhibitors relapse quickly, and toxicities associated to the use of immunomodulating antibodies are not easily manageable. In this sense, the concept of using antibodies as delivery vehicles for the preferential in vivo localization of the drug at the site of disease with reduction of side effects has raised particular interest. Antibody-cytokine fusion proteins (termed immunocytokines) represent a new simple and effective way to deliver the immunomodulatory payload at the tumor site, with the aim of inducing both local and systemic antitumoral immune responses and limiting systemic toxicities. Several clinical trials have been conducted and are actually ongoing with different immunocytokines, in several tumor histotypes. In metastatic melanoma patients, different drug delivery modalities such as systemic, loco-regional and intratumoral are under investigation. In this review, the rationale for the use of L19-IL2 and L19-TNF, two clinical stage immunocytokines produced by the Philogen group, as well as opportunities for their future development will be discussed.