Long-term management of basal cell nevus syndrome with topical tretinoin and 5-fluorouracil

An Institutional Experience of a Tertiary Referral Center in Surgically Managing Patients With Gorlin Syndrome

BACKGROUND

The lifetime risk for basal carcinoma (BCC) is 90% in patients with Gorlin syndrome, also known as basal cell nevus syndrome. Compared with non-Gorlin patients, Gorlin patients often develop BCCs at a younger age and in greater numbers up to 500 BCCs in a lifetime.

OBJECTIVE

To review the options available for Gorlin patients and highlight existing knowledge gaps where future studies are indicated to optimize the care of this unique population.

METHODS

We review the current literature on managing patients with Gorlin syndrome from the lens of a dermatologic surgeon.

RESULTS

Although Mohs surgery is still the gold standard for large and aggressive BCCs, other less-invasive approaches may be considered for smaller, more numerous lesions. As dermatologic surgeons, we must be open to the full spectrum of surgical and nonsurgical options to individualize treatment and optimize patients' quality of life. Without maintaining a balance between optimal cure rate and volume management, Gorlin patients become at risk for surgical burn out and loss to follow-up.

CONCLUSION

Gorlin patients undergo numerous surgeries especially on the central face which can lead to disfigurement and reduce the quality of life. Identifying gaps in the current literature, continuing ongoing research, and eventually establishing appropriate guidelines that help to guide the formation of an individualized treatment plan is crucial in developing a balance between conservative and complex treatments for this population.

Gorlin Syndrome

Gorlin syndrome is a rare autosomal dominant disease caused by mutations in the sonic hedgehog signaling pathway. Of particular importance is the PTCH1 gene. The disease is characterized by the development of multiple basal cell carcinomas at young ages. These tumors may present with other skin manifestations such as palmoplantar pits and with extracutaneous manifestations such as odontogenic keratocysts and medulloblastoma. Although the dermatologist may be key for recognizing clinical suspicion of the syndrome, a multidisciplinary team is usually necessary for diagnosis, treatment, and follow-up. Skin treatment may be complicated due to the large number of basal cell carcinomas and the extent of involvement. In recent years, new drugs that inhibit targets in the sonic hedgehog pathway have been developed. Although these agents appear promising options for patients with Gorlin syndrome, their efficacy is limited by adverse effects and the development of resistance.

Topical Treatment of Bowen's Disease with 5-Fluorouracil

Background:

Bowen's disease is a common skin cancer. There are many different therapeutic approaches to treatment. Topical 5-Fluorouracil (5-FU) cream has been used for many years and there are many published papers attesting to its effectiveness. However, no papers have presented long-term followup results with biopsy confirmation of cure.

Objectives:

The purpose of this article is to present the long-term findings following the use of this cream in the treatment of Bowen's disease.

Methods:

Twenty-four patients with 26 biopsy-confirmed lesions of Bowen's disease were treated with topical 5-Fluorouracil cream and were followed for periods of up to 10 years. Posttreatment biopsies were performed in most cases.

Results:

Two of the 26 lesions treated topically recurred at some point. The rest were apparently cured.

Conclusion:

The results presented in this article confirm that treatment of Bowen's disease with topical 5-Fluorouracil cream is safe and effective treatment.

"PTCH"-ing it together: a basal cell nevus syndrome review

BACKGROUND

Basal cell nevus syndrome (BCNS) has existed at least since Dynastic Egyptian times. In 1960, Gorlin and Goltz first described the classic clinical triad: multiple basal cell carcinomas (BCCs), jaw keratocysts, and bifid ribs. As an autosomal-dominant disorder, it is characterized by tumorigenesis and developmental defects.

OBJECTIVE

To review the current literature on BCNS, including reports on epidemiology, pathogenesis, clinical presentation, diagnostic criteria, management, treatment, and prognosis.

METHODS

A literature review of currently available articles related to BCNS.

RESULTS

Individuals with a mutation in the tumor suppressor gene PTCH1 are predisposed to tumorigenesis and developmental defects. Clinical features include BCCs, often with onset in adolescence, jaw keratocysts, bifid ribs, craniofacial defects, palmar-plantar pits, and ectopic intracranial calcification. Despite high cure rates for individual lesions and various treatment modalities including excision, Mohs micrographic surgery, photodynamic therapy, and topical imiquimod, management of BCCs is challenging. The development of an oral hedgehog pathway inhibitor, vismodegib, has added a new dimension to current treatment algorithms.

CONCLUSIONS

Adolescents and young adults with BCC should be evaluated for BCNS. Early diagnosis of BCNS is critical for possible prevention of the devastating effects of BCCs and establishment of multidisciplinary care.

Gorlin's syndrome: An interesting case study and literature review

Gorlin's syndrome, or basal cell nevus syndrome, is a relatively rare disease. It consists of a classic pentad of features comprised of multiple basal cell carcinomas, jaw cysts, calcification of the falx cerebri, pitting of the palmar and plantar surfaces and rib anomalies. A review of the clinical features, differential diagnosis, clinical work-up and current treatment is presented.

Dermatologic therapy: 1992

This article reviews therapeutic studies reported in the English-language literature during 1992. Readers should review the original article in full before attempting any experimental or controversial therapy.