Management of actinic keratosis: a practical report and treatment algorithm from AKTeam™ expert clinicians

BACKGROUND

Actinic keratoses (AK) are common photo-induced cutaneous lesions that may progress to invasive squamous-cell carcinoma and serve as a risk marker for skin cancer. Although numerous studies present the various therapeutic options for AK, publications that can be used to pragmatically guide dermatologists in their daily practice are limited. National and international guidelines have been published, however, they are based on clinical trials with highly selected patient populations and do not always capture the range of patients seen in everyday practice.

OBJECTIVE

The objective of this expert panel of French dermatologists was to present an analysis of AK geared towards everyday practice, to express an informed opinion about most recent treatments, and to propose a treatment algorithm for AK for daily practice in France.

METHODS

Over a 12 month period, six expert dermatologists in the field of AK (AKTeam(TM) expert panel) met regularly to formulate an opinion about treatment in everyday practice compared with the analysis of the literature and guidelines published since 1990.

RESULTS

Definitions, terminology, diagnosis and risk factors were summarized. Data from the literature and current practices related to the initial evaluation, indications for biopsy, therapeutic indications, therapeutic options and effectiveness, monitoring and prevention were discussed. A pragmatic treatment algorithm was formalized according to current data available. This practical algorithm distinguishes between different clinical situations depending on the number of AK, their hyperkeratotic or suspicious nature, and includes cryotherapy, curettage-electrocoagulation, 5% 5-fluorouracil, 3% diclofenac sodium, 5% imiquimod, 150 and 500 μg/g ingenol mebutate, lasers, photodynamic therapy and surgery.

CONCLUSION

This up-to-date expert opinions about AK and its treatment provide a management strategy and practical treatment algorithm for AK for French dermatologists to use.

Metastatic basal cell carcinoma: prognosis dependent on anatomic site and spread of disease

PURPOSE

This review provides a description of the epidemiology and survival outcomes for cases with metastatic basal cell carcinoma (mBCC) based on published reports (1981-2011).

METHODS

A literature search (MEDLINE via PubMed) was conducted for mBCC case reports published in English: 1981-2011. There were 172 cases that met the following criteria: primary BCC located on skin, metastasis confirmed by pathology and metastasis not resulting from direct tumour spread. From these, 100 mBCC cases with explicit information on follow-up time were selected for analysis. Survival analysis was conducted using Kaplan-Meier methods.

RESULTS

Among 100 mBCC cases selected for analysis, including one case with Gorlin syndrome, 50% had regional metastases (RM) and 50% had distant metastases (DM). Cases with DM were younger at mBCC diagnosis (mean age, 58.0 versus 66.3 years for RM; P=0.0013). Among 93 (of 100) cases with treatment information for metastatic disease, more DM cases received chemotherapy (36.2% versus 6.5% for RM), but more RM cases underwent surgery (87.0% versus 40.4% for DM). Among all 100 cases, median survival after mBCC diagnosis was 54 months (95% confidence interval (CI), 24-72), with shorter survival in DM (24 months; 95% CI, 12-35) versus RM cases (87 months; 95% CI, 63-not evaluable).

CONCLUSION

Cases with RM and DM mBCC may have different clinical courses and outcomes. Based on published reports, DM cases were younger at mBCC diagnosis, with shorter median survival than RM cases. This study provides a historical context for emerging mBCC treatments.

[Basal cell carcinomas]

Basal cell carcinomas (BCC) are the most common cancers and represent 80% of non-melanoma skin cancer and one third of cancers diagnosed per year. The main risk factor for these carcinomas is represented by excessive sun exposure compared to the phototype of the patient, which explains their location mainly on sun-exposed areas (head and neck). This location makes it necessary to consider the aesthetic and functional aspect of their care in addition to oncological treatment. The standard treatment for BCC is based on their surgical excision with histological healthy margins, done in most cases as an outpatient under local anaesthesia. However, the BCC are causing very heterogeneous situations because of their many clinicopathologic forms. New therapeutic options are increasingly available. Prevention is based on sun protection and early detection of lesions in patients at risk (light phototype).

Long-term safety and efficacy of vismodegib in patients with advanced basal cell carcinoma (aBCC): 18-month update of the pivotal ERIVANCE BCC study

9037

Background: Therapies for aBCC, which includes metastatic (m) and locally advanced (la) BCC, are limited. Abnormal Hedgehog pathway signaling is a key driver in BCC pathogenesis. Primary analysis of the pivotal ERIVANCE BCC trial of vismodegib, an oral hedgehog pathway inhibitor (HPI), demonstrated an objective response rate (ORR) of 30% and 43%, in mBCC and laBCC patients, respectively, with a median duration of response (DOR) of 7.6 months. We present safety and investigator (INV) assessed efficacy results 18 months (29 May 2012) after primary analysis (26 Nov 2010). Methods: Multicenter, international, nonrandomized study in patients (N=104) with radiographically measurable mBCC or laBCC (surgery inappropriate due to multiple recurrence, or substantial morbidity or deformity anticipated) receiving 150 mg oral vismodegib daily until disease progression or intolerable toxicity. Key secondary endpoints included INV-assessed ORR, progression-free survival (PFS), DOR, overall survival (OS), and safety. Results: At data cutoff, 21 patients continued to undergo protocol-specified assessments and 56 patients were in survival follow-up. The median dose intensity was comparable with primary analysis. ORR was 48.5%, mBCC; 60.3%, laBCC, comparable with primary analysis. However, median DOR improved (mBCC=14.7; laBCC=20.3 months). The median OS for mBCC was 30.9 months but not estimable in laBCC. Adverse events remained consistent, with muscle spasm, alopecia, dysgeusia, weight decrease, and fatigue most frequently reported. Eleven more deaths were reported in the update period after primary analysis; these occurred in survival follow-up and were not drug-related. Conclusions: Vismodegib is the first FDA-approved HPI; thus, long-term efficacy and safety data are particularly relevant. 18-month update data confirmed prolonged responses and consistent safety in vismodegib-treated aBCC patients. Clinical trial information: NCT00833417.

Vismodegib, a Hedgehog pathway inhibitor (HPI), in advanced basal cell carcinoma (aBCC): STEVIE study interim analysis in 300 patients

9036

Background: Therapy options are limited for locally advanced (la) and metastatic (m) BCC. Aberrant Hedgehog (Hh) signaling is the key driver in BCC pathogenesis. Vismodegib, a first-in-class HPI, is approved in the US for use in adults with aBCC. STEVIE is an ongoing study focusing on safety of vismodegib therapy in patients with aBCC. We present data from the third interim analysis (data cutoff: 19 October 2012), which also permits a preliminary assessment of efficacy of vismodegib in the largest study ever conducted in patients with aBCC. Methods: Adult patients with laBCC or mBCC received oral vismodegib 150 mg QD until progressive disease, unacceptable toxicity, or withdrawal. Safety is the primary objective of STEVIE (Common Terminology Criteria for Adverse Events 4.0). Secondary endpoints include efficacy variables. Recruitment is ongoing. Results: This analysis included 300 patients with locally advanced (n=278) or metastatic (n=22) BCC from 11 countries with potential for ≥3-month follow-up. Median treatment duration, including vismodegib interruption, was 176.5 days (range 1-455 days). Common treatment-emergent AEs (TEAEs), typically ≤ grade 2, included muscle spasm (59.3%), alopecia (49.3%), and dysgeusia (41.0%) and were comparable to prior analysis. Serious TEAEs occurred in 53 patients (17.7%). 131 (43.7%) discontinued from the study, mainly due to patient or investigator request (n=41), AEs (n=35), disease progression (n=18) or death (n=13; 7 due to AEs assessed by the investigator as unrelated to study drug, 3 due to AEs not possible to be assessed, 3 due to disease progression). Preliminary best overall response in patients with available tumor assessments (n=251) included complete response (17.5%), partial response (39.8%), stable disease (39.0%) and progressive disease (2.8%). Patient recruitment and monitoring is ongoing. Conclusions: This third interim analysis of STEVIE confirms the previously observed vismodegib safety profile but can also provide further information about the high rate of tumor control with vismodegib in a large series of patients with aBCC. Clinical trial information: 2011-000195-34.

Consensus recommendations for the treatment of basal cell carcinomas in Gorlin syndrome with topical methylaminolaevulinate-photodynamic therapy

BACKGROUND

Patients with Gorlin syndrome develop multiple basal cell carcinomas (BCC), for which treatment is often difficult. Methylaminolevulinate-photodynamic therapy (MAL-PDT) is approved for the treatment of superficial and nodular BCCs in Canada and several European countries.

OBJECTIVES

To establish consensus recommendations for the use of MAL-PDT in patients with Gorlin syndrome.

METHODS

The Gorlin consensus panel was comprised of 7 dermatologists who had treated a total of 83 patients with Gorlin syndrome using MAL-PDT. Consensus was developed based on the personal experience of the expert and results of literature review (on PUBMED using the keywords 'MAL' and 'PDT' and 'Gorlin' or 'naevoid basal cell carcinoma syndrome').

RESULTS

Consensus was reached among the experts and the literature review identified 9 relevant reports. The experts considered MAL-PDT a generally effective and safe therapy for treatment of BCC in Gorlin syndrome. For superficial BCC (sBCC), all sizes can be treated, and in nodular BCC (nBCC), better efficacy can be achieved in thinner lesions (<2 mm in thickness). MAL-PDT treatment schedule should be performed according to labelling although in individual cases, it may be adapted and performed on a monthly basis based on clinical assessment. Follow-up should be related to frequency of recurrence, and severity, number and location of lesions. Multiple lesions and large areas may be treated during the same session; however, adequate pain management should be considered.

CONCLUSIONS

MAL-PDT is safe and effective in patients with Gorlin syndrome. Utilization of these recommendations may improve efficacy and clearance rates in this population.

Genetic variation at KIT locus may predispose to melanoma

As loss of KIT frequently occurs in melanoma progression, we hypothesized that KIT is implicated in predisposition to melanoma (MM). Thus, we sequenced the KIT coding region in 112 familial MM cases and 143 matched controls and genotyped tag single-nucleotide polymorphisms (SNPs) in two cohorts of melanoma patients and matched controls. Five rare KIT substitutions, all predicted possibly or probably deleterious, were identified in five patients, but none in controls [RR = 2.26 (1.26-2.26)]. Expressed in melanocyte lines, three substitutions inhibited KIT signaling. Comparison with exomes database (7020 alleles) confirmed a significant excess of rare deleterious KIT substitutions in patients. Additionally, a common SNP, rs2237028, was associated with MM risk, and 6 KIT variants were associated with nevus count. Our data strongly suggest that rare KIT substitutions predispose to melanoma and that common variants at KIT locus may also impact nevus count and melanoma risk.

MC1R, SLC45A2 and TYR genetic variants involved in melanoma susceptibility in southern European populations: results from a meta-analysis

BACKGROUND AND METHODS

Seven genetic biomarkers previously associated with melanoma were analysed in a meta-analysis conducted in three South European populations: five red hair colour (RHC) MC1R alleles, one SLC45A2 variant (p.Phe374Leu) and one thermosensitive TYR variant (p.Arg402Gln). The study included 1639 melanoma patients and 1342 control subjects.

RESULTS

The estimated odds ratio (OR) associated with carrying at least one MC1R RHC variant was 2.18 (95% confidence interval (CI): 1.86-2.55; p-value=1.02×10(-21)), with an additive effect for carrying two RHC variants (OR: 5.02, 95% CI: 2.88-8.94, p-value=3.91×10(-8)). The SLC45A2 variant, p.Phe374Leu, was significantly and strongly protective for melanoma in the three South European populations studied, with an overall OR value of 0.41 (95% CI: 0.33-0.50; p-value=3.50×10(-17)). The association with melanoma of the TYR variant p.Arg402Gln was also statistically significant (OR: 1.50; 95% CI: 1.11-2.04; p-value=0.0089). Adjustment for all clinical potential confounders showed that melanoma risks attributable to MC1R and SLC45A2 variants strongly persisted (OR: 2.01 95% CI: 1.49-2.72 and OR: 0.50, 95% CI: 0.31-0.80, respectively), while the association of TYR p.Arg402Gln was no longer significant. In addition, stratification of clinical melanoma risk factors showed that the risk of melanoma was strong in those individuals who did not have clinical risk factors.

CONCLUSION

In conclusion, our results show without ambiguity that in South European populations, MC1R RHC and SCL45A2 p.Phe374Leu variants are strong melanoma risk predictors, notably in those individuals who would not be identified as high risk based on their phenotypes or exposures alone. The use of these biomarkers in clinical practice could be promising and warrants further discussion.

A reliable method for the selection of exploitable melanoma archival paraffin embedded tissues for transcript biomarker profiling

The source tissue for biomarkers mRNA expression profiling of tumors has traditionally been fresh-frozen tissue. The adaptation of formalin-fixed, paraffin-embedded (FFPE) tissues for routine mRNA profiling would however be invaluable in view of their abundance and the clinical information related to them. However, their use in the clinic remains a challenge due to the poor quality of RNA extracted from such tissues. Here, we developed a method for the selection of melanoma archival paraffin-embedded tissues that can be reliably used for transcript biomarker profiling. For that, we used qRT-PCR to conduct a comparative study in matched pairs of frozen and FFPE melanoma tissues of the expression of 25 genes involved in angiogenesis/tumor invasion and 15 housekeeping genes. A classification method was developed that can select the samples with a good frozen/FFPE correlation and identify those that should be discarded on the basis of paraffin data for four reference genes only. We propose therefore a simple and inexpensive assay which improves reliability of mRNA profiling in FFPE samples by allowing the identification and analysis of “good” samples only. This assay which can be extended to other genes would however need validation at the clinical level and on independent tumor series.

Photodynamic therapy for skin field cancerization: an international consensus. International Society for Photodynamic Therapy in Dermatology

Field cancerization is a term that describes the presence of genetic abnormalities in a tissue chronically exposed to a carcinogen. These abnormalities are responsible for the presence of multilocular clinical and sub-clinical cancerous lesions that explains the increased risks of multiple cancers in this area. With respect to the skin, this term is used to define the presence of multiple non-melanoma skin cancer, its precursors, actinic keratoses and dysplastic keratinocytes in sun exposed areas. The multiplicity of the lesions and the extent of the area influence the treatment decision. Providing at least equivalent efficacy and tolerability, field directed therapies are therefore often more worthwhile than lesion targeted approaches. Photodynamic therapy (PDT) with its selective sensitization and destruction of diseased tissue is one ideal form of therapy for this indication. In the following paper the use of PDT for the treatment of field cancerized skin is reviewed and recommendations are given for its use.

Photodynamic therapy for actinic keratosis in organ transplant patients

BACKGROUND

The incidence of actinic keratoses (AK) and non-melanoma skin cancer (NMSC) in organ transplant recipients (OTRs) is significantly higher than in immunocompetent patients. Rates of progression and recurrence following treatment are higher too, in part due to the effects of the immunosuppressant drugs. Conventional therapies for AK, using curettage, cryotherapy, surgical excision, topical therapies and photodynamic therapy (PDT), are often less effective, and may be inappropriate, for treating the greater numbers and extent of lesions in OTRs. Moreover, there are no specific protocols for treating this patient population that take into account the need for more frequent treatment and the increased pain associated with treating larger areas.

OBJECTIVES

Recently, a pan-European group of dermatologists with expertise in this area met to share current best practice in PDT for the treatment of AK in OTRs.

METHODS

The group identified areas where PDT currently is not meeting the needs of these patients and discussed how these gaps might be addressed.

RESULTS/CONCLUSIONS

This position article summarizes those discussions and makes recommendations concerning a standardized protocol for treating OTRs, for a large randomized controlled trial to provide robust data on safety, efficacy and optimal pain control, and to provide pharmaco-economics data that can be used to support extended reimbursement in this patient group. The authors also recommend a second clinical trial to further investigate induced immunosuppression with PDT in healthy volunteers.