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Aggarwal I, Puyana C, Chandan N, Jetter N, Tsoukas M. Field Cancerization Therapies for the Management of Actinic Keratosis: An Updated Review. Am J Clin Dermatol 2024; 25:391-405. [PMID: 38351246 DOI: 10.1007/s40257-023-00839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 05/07/2024]
Abstract
Field cancerization theory highlights that the skin surrounding actinic keratoses (AK) is also at increased risk for possible malignant transformation; thus, field-directed treatments may both reduce the risk of AK recurrence and potentially reduce the risk of development of cutaneous squamous cell carcinoma (cSCC). Photodynamic therapy (PDT) with either aminolevulinic acid (ALA) or methylaminolevulinate (MAL), as well as topical treatments such as 5-fluorouracil (5-FU), diclofenac gel, piroxicam, imiquimod, and ingenol mebutate, have all shown higher efficacy than vehicle treatments. PDT is widely recognized for its high efficacy; however, concerns for associated pain have driven new studies to begin using alternative illumination and pretreatment techniques, including lasers. Among topical treatments, a combination of 5-FU and salicylic acid (5-FU-SA) has shown to be the most effective but also causes the most adverse reactions. Tirbanibulin, a new topical agent approved for use in 2020, boasts a favorable safety profile in comparison with imiquimod, 5-FU, and diclofenac. Meanwhile, ingenol mebutate is no longer recommended for the treatment of AKs due to concerns for increased risk of cSCC development. Moving forward, an increasing number of studies push for standardization of outcome measures to better predict risk of future cSCC and use of more effective measures of cost to better guide patients. Here, we present an updated and comprehensive narrative review both confirming the efficacy of previously mentioned therapies as well as highlighting new approaches to PDT and discussing the use of lasers and novel topical treatments for treatment of AK.
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Affiliation(s)
- Ishita Aggarwal
- Department of Dermatology, University of Illinois College of Medicine, 808 S. Wood St., Suite 380, Chicago, IL, 60612, USA
| | - Carolina Puyana
- Department of Dermatology, University of Illinois College of Medicine, 808 S. Wood St., Suite 380, Chicago, IL, 60612, USA
| | - Neha Chandan
- Department of Dermatology, University of Illinois College of Medicine, 808 S. Wood St., Suite 380, Chicago, IL, 60612, USA
| | - Nathan Jetter
- Department of Dermatology, University of Illinois College of Medicine, 808 S. Wood St., Suite 380, Chicago, IL, 60612, USA
| | - Maria Tsoukas
- Department of Dermatology, University of Illinois College of Medicine, 808 S. Wood St., Suite 380, Chicago, IL, 60612, USA.
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Anand S, Heusinkveld LE, Cheng CE, Lefatshe L, De Silva P, Hasan T, Maytin EV. Combination of 5-Fluorouracil with Photodynamic Therapy: Enhancement of Innate and Adaptive Immune Responses in a Murine Model of Actinic Keratosis. Photochem Photobiol 2022; 99:437-447. [PMID: 36039609 DOI: 10.1111/php.13706] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/19/2022] [Indexed: 11/29/2022]
Abstract
We previously showed that a combination of differentiation-inducing agents (5-fluorouracil, vitamin D3, or methotrexate) and aminolevulinate-based photodynamic therapy (PDT) improves clinical responses by enhancing protoporphyrin IX (PpIX) photosensitizer levels and cell death. Here, we show that in addition to its previously known effects, 5-fluorouracil (5FU) enhances PDT-induced tumor-regressing immunity. Murine actinic keratoses (AK) were treated with topical 5FU or vehicle for three days prior to ALA application, followed by blue light illumination (~417 nm). Lesions were harvested for time-course analyses of innate immune cell recruitment into lesions, i.e., neutrophils (Ly6G+) and macrophages (F4/80+), which peaked at 72 hours and 1 week post PDT, respectively, and was greater in 5FU treated lesions. Enhanced infiltration of activated T cells (CD3+) throughout the time course, and of cytotoxic T cells (CD8+) at 1 - 2 weeks post PDT, also occurred in 5FU treated lesions. 5FU pretreatment reduced the presence of cells expressing the immune checkpoint marker PD-1 at ~72 hours post PDT, favoring cytotoxic T cell activity. A combination of 5FU and PDT, each individually known to induce long-term tumor-targeting immune responses in addition to their more immediate effects on cancer cells, may synergize to provide better management of squamous precancers.
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Affiliation(s)
- Sanjay Anand
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Dermatology and Plastic Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Lauren E Heusinkveld
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cheng-En Cheng
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Lefatshe Lefatshe
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Pushpamali De Silva
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Tayyaba Hasan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Edward V Maytin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Dermatology and Plastic Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, 02114, USA
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Romero MP, Posso V, Ureña V, Inada N, Bagnato V, Cabrera F. Clinical and histopathologycal study of actinic keratosis treatment with photodynamic therapy VS 5-fluorouracil in face cancerization field. Photodiagnosis Photodyn Ther 2022; 39:102967. [PMID: 35716996 DOI: 10.1016/j.pdpdt.2022.102967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
Actinic keratosis (AK) is one of the most frequent pathologies in clinical practice. The prevalence varies according to the area of incidence and age. Approximately 10% of the prevalence of AK occurs at 30 years of age and rises to 80% at 70 years of life. This study conducted a split-face analysis based on Photodynamic Therapy (MALA-PDT) and 5-fluorouracil (5-FU) treatments in patients with AK. Clinical and histopathological studies evaluated each treatment's efficiency and side effects. Six patients were recruited between 50 and 70 years of age for this. MALA-PDT was applied on the right side of the face. A biodistribution time of 2 hours, a dose of light of 36 J / cm2 (20 min irradiation), a spot for photoirradiation with a total area of 100 cm2, and a wavelength of 635 nm were used. (LINCE equipment MMOPTICS-Brazil). By fluorescence diagnosis, clinical and subclinical AK lesions were evidenced in the area called the "cancerization field." Two cycles of MALA-PDT were performed on each patient, and 5-FU was applied twice daily for 15 days. A 2-month follow-up post-MALA-PDT and post-5-FU was carried out. The treatment based on 5-Flu and MALA-PDT clinically shows the same response, but MALA-PDT is less aggressive than 5-FU. The treatment of AK based on MALA-PDT is a practical, cheap, and easy-to-use technique.
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Affiliation(s)
| | - Verónica Posso
- Servicio de Anatomía Patológica. Hospital Carlos Andrade Marín. Quito, Ecuador.
| | - Valeria Ureña
- Postgrado de Dermatología. Facultad de Medicina Eugenio Espejo, Universidad UTE. Quito, Ecuador.
| | - Natalia Inada
- Instituto de Física. Universidade de São Paulo. São Carlos SP-Brasil.
| | - Vanderlei Bagnato
- Instituto de Física. Universidade de São Paulo. São Carlos SP-Brasil.
| | - Franklin Cabrera
- Servicio de Dermatología. Hospital Carlos Andrade Marín. Quito, Ecuador.
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Huang A, Nguyen JK, Austin E, Mamalis A, Jagdeo J. Updates on Treatment Approaches for Cutaneous Field Cancerization. CURRENT DERMATOLOGY REPORTS 2019; 8:122-132. [PMID: 31475077 DOI: 10.1007/s13671-019-00265-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Purpose of Review Field cancerization describes the phenomenon that multiple heterogenous mutations may arise in an area exposed to chronic carcinogenic stimuli. Advances in the understanding of cutaneous field cancerization have led to novel therapeutic approaches to the management of actinic keratoses (AKs). Herein, we review the literature on the pathophysiology and emerging research of field cancerization in dermatology. Recent Findings The classification systems for grading AK lesions are being refined with investigations focusing on their clinical utility. There is a growing shift towards field-directed treatment for AKs as the importance of field cancerization becomes clearer. Current field-directed therapies are being optimized and novel therapeutic modalities are being studied. Summary Field cancerization underlies the transformation of photodamaged skin into AKs and potentially cutaneous SCC (cSCC). Clinically meaningful classification systems for AKs are needed to better inform decisions regarding treatment. As we learn more about the role of field characterization in photodamage, AKs and cSCCs, therapeutic strategies are becoming more field-directed rather than lesion-directed.
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Affiliation(s)
- Alisen Huang
- Department of Dermatology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Julie K Nguyen
- Department of Dermatology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Evan Austin
- Department of Dermatology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Andrew Mamalis
- Department of Dermatology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jared Jagdeo
- Department of Dermatology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
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Modern aspects of photodynamic therapy of actinic keratoses. BIOMEDICAL PHOTONICS 2019. [DOI: 10.24931/2413-9432-2019-8-2-25-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Currently, photodynamic therapy (PDT) remains the most effective treatment for actinic keratosis (AK). With the increase in the incidence of AK, mainly due to the popularization of recreation in countries with increased insolation, there is an increasing interest in developing new methods of diagnostics and treatment and improving the existing ones. Studies that are aimed at determining the final efficacy of PDT, taking into account the resulting adverse reactions and long-term cosmetic results, are becoming increasingly popular. The nature of the light needed to excite a photosensitizer (PS) opens up new possibilities in the field of experimental studies that are aimed at reducing adverse reactions with similar efficacy of the applied therapy. In the review article, we presented the results of our own and foreign studies on the diagnosis and treatment of AK for 2017–2019, namely: we determined the possibilities of using sources with natural and short-wave radiation at different depths of skin lesions; presented a classification of the growth of AK in the basal layer of the epidermis, which increases the possibility of predicting the outcomes of the disease; showed the prevailing efficiency of fluorescent diagnostics compared with traditional diagnostic methods; evaluated the advantages of PDT using natural light and artificial sources of radiation; described the possibility of using a combination of drugs to increase the effectiveness of PDT in difficult to treat areas and in AK foci with a high degree of damage to the basal layer of the epidermis.
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de Oliveira ECV, da Motta VRV, Pantoja PC, Ilha CSDO, Magalhães RF, Galadari H, Leonardi GR. Actinic keratosis - review for clinical practice. Int J Dermatol 2018; 58:400-407. [PMID: 30070357 DOI: 10.1111/ijd.14147] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 06/17/2018] [Accepted: 06/20/2018] [Indexed: 12/18/2022]
Abstract
Actinic keratosis (AK) is a lesion that arises as a result of excessive exposure to solar radiation and appearing predominantly on Fitzpatrick phototype I and II skin. Given that some AKs evolve into squamous cell carcinoma, these lesions are considered premalignant in nature, occurring mostly in elderly men and immunosuppressed individuals chronically exposed to ultraviolet (UV) radiation. There are several mechanisms for the formation of AKs; among them are oxidative stress, immunosuppression, inflammation, altered proliferation and dysregulation of cell growth, impaired apoptosis, mutagenesis, and human papillomavirus (HPV). Through the understanding of these mechanisms, several treatments have emerged. Among the options for AK treatment, the most commonly used include 5-fluorouracil (5-FU), cryotherapy, diclofenac, photodynamic therapy (PDT), imiquimod (IQ), retinoids, and ingenol mebutate (IM). There have been recent advances in the treatment options that have seen the emergent use of newer agents such as resiquimod, betulinic acid, piroxicam, and dobesilate. The combination between therapies has presented relevant results with intention to reduce duration of therapy and side effects. All AK cases must be treated because of their propensity to transform into malignancy and further complicate treatment. In addition to medical or surgical care, education about sun exposure prevention remains the best and most cost-effective method for AK prevention. The objective of this article is to conduct a literature review of the clinical presentation of AK including advances in treatment options available.
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Affiliation(s)
- Erika C V de Oliveira
- Medical Clinic Post Graduation Program of the Medical Sciences Faculty, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
| | - Valéria R V da Motta
- Medical Clinic Post Graduation Program of the Medical Sciences Faculty, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
| | - Paola C Pantoja
- Faculty of Pharmaceutical Sciences, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
| | - Carolina S de O Ilha
- Dermatology Medical Residence Program of the Medical Sciences Faculty, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
| | - Renata F Magalhães
- Dermatology Department in the Medical Sciences Faculty, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
| | - Hassan Galadari
- Department of Dermatology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Gislaine R Leonardi
- Faculty of Pharmaceutical Sciences, University of Campinas - UNICAMP- Brazil, Campinas, Brazil
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