Nonmelanoma skin cancer of the head and neck I: histopathology and clinical behavior

Epidemiology of facial skin cancers managed in a French ambulatory surgical center

INTRODUCTION

Approximately 80,000 cases of skin cancer are diagnosed annually in France. The management of these cancers can occur in both university hospital centers and ambulatory surgery centers. Limited data exist regarding the epidemiology of cutaneous cancers treated through ambulatory surgery centers. The objective of our study is to describe the epidemiological characteristics of cutaneous cancers managed in a tertiary ambulatory surgery center.

METHODS

This is a retrospective, single-center observational study. The included patients were those who underwent surgical excision of one or more skin cancers within the maxillofacial department of a tertiary ambulatory surgery center. Clinical, therapeutic, histopathological, and follow-up data (additional surgery if margins were not clear, progression, recurrence, second cancer…) were collected.

RESULTS

Among the n = 1931 patients operated for a head and neck skin tumor from September 2018 to July 2022, n = 426 (22 %) were diagnosed with cancer upon histological analysis. The median age was 76 years (31-100), with a male-to-female ratio of 1/1. The most frequent locations were the nose (23 %) and cheek (20 %). Ten percent of patients had dual-site skin cancer at initial diagnosis. The most common histological types were basal cell carcinoma (77 %) and squamous cell carcinoma (18 %). Surgical treatment primarily consisted of "excision-reconstruction with local flap" (51 %) or "excision-suture" (34 %). Resection margins were mostly clear (65 %), and only six patients (2 %) experienced local recurrence or progression during follow-up.

CONCLUSIONS

Skin cancers are prevalent in ambulatory practice. Surgical treatment allows for effective control of the cancer. Photoprotection, particularly in immunocompromised patients, remains crucial for prevention.

Antioxidant and photoprotective role of latex C-serum from Hevea brasiliensis during 15-week UVB irradiation in male hairless SKH-1 mice

It is known that UVB radiation induces several adverse skin alterations starting from simple photoaging to skin cancer. In addition, it was demonstrated that reactive oxygen species (ROS) were found to be related to cancer development and progression. The aim of study was to examine whether male hairless (SKH-1) mice (Mus musculus) that were subchronically exposed to UVB radiation presented with actinic keratosis (AK) and squamous cell carcinoma lesions, and that treatment with latex C-serum cream significantly prevented abnormal skin development. Data demonstrated for the first time the photoprotective activity of latex C-serum extracted from the rubber tree Hevea brasiliensis var. subconcolor Ducke. Latex C-serum prevented the progression of AK to squamous cell carcinoma in SKH-1 mice, indicating that mice topically treated with latex C-serum presented only AK lesions and treatment with the highest concentration (10%) significantly reduced epidermal thickness, suggesting diminished cell proliferation. Latex C-serum protected the skin of mice against oxidative stress damage, increasing catalase (CAT) activity, regenerating glutathione (GSH) levels, lowering thiobarbituric acid-reactive species (TBARS) production and regenerating the total antioxidant capacity (TAC) of the skin. Evidence that UV radiation in skin induced systemic alterations and erythrocytic analysis indicated that latex C-serum increased CAT activity and GSH levels. Taken together these data indicate that latex C-serum plays an important antioxidant and photoprotective role, preventing serious damage to the skin following exposure to UVB radiation.

Non-melanoma skin cancers: physio-pathology and role of lipid delivery systems in new chemotherapeutic treatments

Non-melanoma carcinoma has high incidence rates and has two most common subtypes: basal cell carcinoma and squamous cell carcinoma. This type of carcinoma is usually not fatal; however, it can destroy sensory organs such as the nose, ears, and lips. The treatment of these injuries using non-invasive methods is thus strongly recommended. Some treatments for non-melanoma carcinoma are already well defined, such as surgery, cryosurgery, curettage and electrode section, and radiotherapy; however, these conventional treatments cause inflammation and scarring. In the non-surgical treatment of non-melanoma carcinoma, the topical administration of chemotherapeutic drugs contributes for an effective treatment with reduced side effects. However, the penetration of anticancer drugs in the deeper layers of the skin is required. Lipid delivery systems (liposomes, solid lipid nanoparticles, nanostructured lipid carriers) have been developed to overcome epidermal barrier of the skin and to allow the drugs to reach tumor cells. These lipid nanoparticles contribute to control the release profile of the loaded chemotherapeutic drugs, maintaining their stability and increasing death of tumor cells. In this review, the characteristics of non-melanoma carcinoma will be discussed, describing the main existing treatments, together with the contribution of lipid delivery systems as an innovative approach to increase the effectiveness of topical therapies for non-melanoma carcinomas.

When is a surgical multidisciplinary approach required in the management of head and neck non-melanoma skin cancer and in advanced head and neck pathologies involving skin?

Non-melanoma Skin cancer, including cutaneous squamous cell carcinoma and basal cell carcinoma, is the most common form of malignancy in the Caucasian population, and the skin of the head and neck is the site most involved. They should not be underestimated; in particular, high-risk lesions and advanced skin cancers require accurate diagnostic work up, aggressive surgical treatment and should be managed by the head and neck surgeon, the dermatologist and the plastic surgeon. Cutaneous head-neck malignancies are often overlooked or not routinely treated with a multidisciplinary surgical approach. Similarly, for primary head and neck cancers with involvement of surrounding skin, the involvement of the dermatologist and the plastic surgeon could better define an adequate diagnosis and treatment planning. The management of these patients presents both therapeutic and ethical problems, because the poor prognosis is burdened by facial disfigurement, open malodorous wounds and intractable pain. Therefore, in patients with advanced disease that is not candidate to radical surgery, palliative surgery with flap reconstruction could take place and could be proposed to improve quality of life.

Decreased TMEM40 expression is associated with malignant behavior of cutaneous squamous cell carcinoma and inhibits tumor progression

Cutaneous squamous cell carcinoma (CSCC) is one of the most common types of skin cancer in humans worldwide. The identification and characterization of cancer-associated transmembrane proteins are important for understanding the molecular biology of CSCC. The aim of the present study was to evaluate the expression pattern of transmembrane protein 40 (TMEM40) in CSCC and its clinical significance. The underlying mechanisms were also examined. Reverse transcription-quantitative PCR, western blot and immunohistochemistry analysis were used to determine the relative expression of TMEM40 in CSCC cell lines and clinical tissue samples. The effect of TMEM40 gene silencing on cell proliferation was also evaluated using Cell Counting Kit-8 assays. Wound healing assays, flow cytometry and Transwell assays were used to explore the migration, cell cycle distribution/apoptosis and invasion of CSCC cells following TMEM40 silencing, respectively. In the present study, increased TMEM40 expression was observed in CSCC tissue samples, compared with normal skin, and TMEM40 expression was associated with large tumor size in patients with CSCC. In vitro functional assays indicated that TMEM40 was involved in the regulation of A431 and SCL1 cell growth through its effects on the cell cycle and apoptosis. Silencing TMEM40 in A431 and SCL1 cells resulted in cell cycle arrest at the G₀/G₁ phase and promoted apoptosis. In addition, migration and invasion were significantly inhibited following silencing of TMEM40 expression in CSCC cells. Taken together, the results of the present study indicated that reduced TMEM40 expression could inhibit CSCC development and that TMEM40 may represent a therapeutic target in CSCC.

Radiation therapy of non-melanoma skin cancer of the pinna: an Italian 35-years experience

BACKGROUND

Radiation therapy (RT) is a well known alternative to surgery for the treatment of non-melanoma skin cancer (NMSC), especially in elderly people or in patients who can not undergo or refuse surgical procedure. It has also a pivotal role in those areas, as pinna, where both function and cosmesis must be preserved. We report our experience in treating cutaneous carcinoma of the auricle with radiation therapy.

METHODS

We conducted a retrospective monocentric study on 363 NMSC of the auricle treated by conventional energy radiation therapy as a primary treatment or with adjuvant and salvage purpose. Tumors involving the external canal of the ear or regional lymph node at diagnosis were excluded.

RESULTS

A complete response has been obtained in 95.5% with a 2- and 5-years cure rate respectively of 84% and 76%. Fifty-two tumors developed a central or marginal relapse. Aesthetic result was good or acceptable in the majority of the cases. No cartilage necrosis has been registered.

CONCLUSIONS

Our experience confirms safety and effectiveness of RT on selected auricle carcinoma, affording good cosmetic and functional results.

Treatment and Outcomes for Cutaneous Periauricular Basal Cell Carcinoma: A 16-Year Institutional Experience

Objective

To report a single institutional experience with the surgical management of cutaneous periauricular basal cell carcinoma.

Study Design

Retrospective chart review.

Setting

Tertiary academic center.

Methods

Retrospective chart review of 71 patients diagnosed with periauricular basal cell carcinoma managed surgically from 2000 to 2016. Data were analyzed with descriptive statistics.

Results

The median age at diagnosis was 73.0 years (interquartile range, 13.0). Of all lesions, 2.8% (n = 2) were preauricular, 80.3% (n = 57) auricular, and 16.9% (n=12) postauricular. Auricular subsites included conchal bowl (36.6%, n = 26), helix (21.1%, n = 15), antihelix (1.4%, n = 1), peritragus (5.6%, n = 4), triangular fossa (1.4%, n = 1), external auditory canal (2.8%, n = 2), and lobule skin (1.4%, n = 1). Surgical approach included wide local excision (80.3%, n = 57), partial auriculectomy (8.5%, n = 6), and total auriculectomy or other combinations of surgical methods (11.3%, n = 8). Due to aggressive pathology, 3 cases required concurrent parotidectomy, neck dissection, ear canal sleeve resection, or mastoidectomy. In sum, 52.1% (n = 37) of cases had clear margins on first pass in the operating room; 25.4% (n = 18) required further resection; and 12.7% (n = 9) demonstrated final positive/overturned margins read as negative from the frozen sections. Reconstruction included full-thickness (25.4%, n = 18) or superficial-thickness (29.6%, n = 21) skin grafts and local flap reconstruction (25.4%, n = 18), while 5.6% (n = 4) required combinations of free flap and/or other reconstruction techniques; 14.1% (n = 10) did not undergo formal reconstruction.

Conclusion

Periauricular basal cell carcinoma occurs in anatomically diverse locations in and around the ear, and multiple surgical methods are required for successful treatment.

Skin Cancers of the Auricle: A Retrospective Analysis of 41 Patients

Objective

Skin cancers of the auricle usually present with challenges because of the unique anatomy and topography of the auricle and the behavior of the tumor. The purpose of this study was to evaluate the clinical and histopathological characteristics and the surgical outcomes in patients with skin cancer of the auricle.

Methods

Medical records of patients who underwent surgery for a skin cancer of the auricle at two different tertiary medical centers during 2010 to 2020 were reviewed retrospectively. Sociodemographic data of patients, tumor location and size, histopathological type and subtype, T-stage, recurrence, and reconstructive technique were evaluated.

Results

The study included 41 patients with skin cancers of the auricle. Thirty-six (87.8%) were male and five (12.2%) were female; with a male-to-female ratio of 7.2:1. The mean age of the patients was 71.4 (46-92) years. Eighteen (43.9%) tumors were basal cell carcinoma (BCC) and 17 (41.5%) tumors were cutaneous squamous cell carcinoma (cSCC). The most common subunit for tumor location was the helix (n=17, 41.5%). Wedge resection plus primary closure was the most common surgical technique (58.5%). Recurrent disease was detected in five patients (12.1%).

Conclusion

The frequency of the skin cancers of the auricle was remarkably high in men, and the helix was the most common subunit. Both BCC and cSCC were the most common histopathological types. Poor prognostic factors such as lymph node metastasis, perineural invasion, and recurrence were relatively common in patients with cSCC of the auricle.

Metastatic Basal Cell Carcinoma of the Skin: A Comprehensive Literature Review, Including Advances in Molecular Therapeutics

Basal cell carcinoma (BCC) of the skin is the most common type of malignant human tumor. In Europe, the incidence of BCC ranges from 44.6 to 128 cases per 100,000 inhabitants annually, whereas in the United States, the yearly incidence rate ranges between 500 and 1500. The global incidence has been calculated to be as high as 10 million cases of BCC per year. There are 2 main clinical patterns of BCC-the familial BCC in basal cell nevus syndrome and sporadic BCC. The etiology of cutaneous BCC is usually the result of the interaction between solar ultraviolet radiation and genetic factors. Somatic or germline mutations in the effector components of the hedgehog signaling pathway (ie, PTCH1, PTCH2, SMO or SUFU genes) are responsible for ∼90% of the cases of both sporadic and familial BCC, all causing a constitutive activation of the hedgehog pathway. Cutaneous BCC very rarely metastasizes, and diagnosis in metastatic sites can be very difficult. Metastatic BCC has weakly effective therapeutic options with a poor prognosis until few years ago. In 2012, small-molecule therapies, involving inactivation of the hedgehog signaling pathway, and capable of reducing tumor growth and progression have been introduced into clinical practice for advanced (locally advanced or metastatic) BCC. We performed a comprehensive literature review on metastatic BCC and found at least 915 cases reported to date. In addition, we extensively discussed the differential diagnosis of metastatic BCC, and outlined the advances in clinical therapeutics involving these small molecules.

Surgical management of recurrent cutaneous squamous cell carcinoma of the head and neck after definitive surgery and radiotherapy

BACKGROUND

Surgery is the primary treatment for patients with recurrent head and neck cutaneous squamous cell carcinoma (cSCC) who have previously been treated by definitive surgery and radiotherapy. There are limited published data to direct management and the role of immunotherapy is currently under evaluation.

METHODS

This was a retrospective study of patients with at least stage III recurrent head and neck cSCC previously managed by definitive surgery and radiotherapy.

RESULTS

A total of 30 patients met the inclusion criteria. Eighty-seven percent were male and the median age at the time of surgery was 79 years. After salvage surgery, 7% developed local recurrence and 43% regional or distant failure. The 2-year overall survival and disease-free survival were 45% (95% confidence interval 24-64) and 11% (95% confidence interval 1-34), respectively. Advanced age was associated with a higher risk of overall mortality (P < 0.05).

CONCLUSION

Patients with recurrent head and neck cSCC in the setting of previous radiotherapy have high recurrence rates with poor survival justifying consideration for treatment with anti-PD-1 immunotherapy strategies.

Sex-specific differences in patients with nonmelanoma skin cancer of the pinna

Background

Generally, it is known that men are affected more frequently by nonmelanoma skin cancer (NMSC) than women. The aim of our study was to investigate the effect of sex on the characteristics of NMSCs of the pinna at the population that our center serves and to compare it with the international data.

Methods

We analyzed retrospectively the data of 225 patients with NMSC of the pinna. Sex‐specific differences were investigated for basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) subgroups.

Results

The ratio of BCC to cSCC was determined in male patients at 1:1.3, in contrast in females it was identified at 4:1 (P = .001).

Conclusion

In our study, a new aspect of the sex‐dependent distribution of cSCC and BCC of the pinna was demonstrated. Women are affected four times more frequently by BCC than by cSCC, whereas in men this ratio is approximately equal.

Metastatic Cutaneous Basal Cell Carcinoma: Report of 2 Cases Preceding the Hedgehog Pathway Antagonists Era

Basal cell carcinoma (BCC) of the skin is the most common type of malignant human tumor. However, metastatic BCC is a very rare event with weakly effective therapeutic options and a poor prognosis, until a few years ago. In 2012, small-molecule therapies, capable of inactivating the hedgehog signaling pathway and thus reducing tumor growth and progression, were introduced into clinical practice for the treatment of patients with advanced BCC. We present retrospectively 2 personal cases of metastatic BCC of the skin, from the premolecular therapy era, from primary tumors that arose years before in the head and neck area. The former case occurred in a 45-year-old woman with a history of recurrent BCC of the retroauricular skin who eventually died due to diffuse metastatic spread. The latter case concerned a 70-year-old man also with a history of recurrent BCC of the nasal-perinasal skin who developed multiple subcutaneous and lymph node metastases in the neck. In both cases, the diagnoses were based on biopsies of the metastatic sites. The first patient died 5 months after the diagnosis of metastatic disease, while the second was alive and disease-free 2 years after neck lymph node dissection and external radiation therapy, and then lost to follow-up. We extensively discuss several tumor entities with basal or basaloid features that may enter the differential diagnosis with BCC in metastatic sites. In addition, we briefly summarize the advances in clinical therapeutics using small molecules, which are now an integral part of the treatment of such advanced BCC cases.

Avicularin inhibits cell proliferation and induces cell apoptosis in cutaneous squamous cell carcinoma

Avicularin (AL), quercetin-3-α-L-arabinofuranoside, has various pharmacological properties such as anticancer and anti-infective effects. However, the potential molecular mechanism via which AL exerts its anticancer activity is not fully understood. Cutaneous squamous cell carcinoma (CSCC) is the second most common skin cancer, where metastasis has resulted in in effective clinical treatments. The aim of the present in vitro study was to investigate the anticancer effects and underlying mechanism of AL on human CSCC. The present results suggested that AL dose-dependently inhibited SCC13 cell viability and induced apoptosis. In addition, the present results suggested that AL induced apoptosis via repression of the mitogen-activated protein kinase kinase (MEK)/NF-κB signal pathway, thereby affecting the expression of apoptosis-related genes. Bax expression level was increased, while Bcl-2 expression level was decreased in SCC13 cells following AL treatment. In addition, the MEK/NF-κB signaling pathway-related genes p-MEK and phosphorylated-p65 were also decreased. The present results suggested that AL treatment increased the expression level of E-cadherin, but decreased the expression levels of N-cadherin, matrix metalloproteinase (MMP)-9 and vimentin in SCC13 cells. Collectively, the present results suggested that AL may have an anti-CSCC effect by inhibiting cell viability, inducing apoptosis and inhibiting epithelial-mesenchymal transition (EMT) of CSCC cells. The mechanism of these anti-CSCC effects was suggested to be via the regulation of apoptosis-related genes and EMT-related genes, and the inhibition of the MEK/NF-κB signaling pathway.

Looking beyond the skin: Cutaneous and systemic oxidative stress in UVB-induced squamous cell carcinoma in hairless mice

Cumulative ultraviolet (UV) exposure is associated with squamous skin cell carcinoma. UV radiation induces oxidative modifications in biomolecules of the skin leading to photocarcinogenesis. Indeed, the cyclobutene pyrimidine dimers and other dimers formed by photoaddition between carbon-carbon bonds also have an important role in the initiation process. However, information on the systemic redox status during these processes is scarce. Thus, we investigated the systemic redox profile in UVB-induced squamous cell carcinoma in mice. Female hairless mice were exposed to UVB radiation (cumulative dose = 17.1 J/cm²). The dorsal skin of these mice developed actinic keratosis (AK) and squamous cell carcinoma (SCC) and presented increased levels of oxidative and nitrosative stress biomarkers (4-hydroxy-2-nonenal and 3-nitrotyrosine), and decreased antioxidant defenses. Systemically, we observed the consumption of plasmatic antioxidant defenses and increased levels of advanced oxidized protein products (AOPP), an oxidative stress product derived from systemic inflammatory response. Taken together, our results indicate that UVB chronic irradiation leads not only to adjacent and tumoral oxidative stress in the skin, but it systemically is reflected through the blood. These new findings clarify some aspects of the pathogenesis of SCC and should assist in formulating better chemoprevention strategies, while avoiding additional primary SCC development and metastasis.

Essential oils: from prevention to treatment of skin cancer

The increasing incidence of cutaneous malignancies signifies the need for multiple treatment options. Several available reviews have emphasized the potential role of various botanical extracts and naturally occurring compounds as anti-skin-cancer agents. Few studies relate to the role of chemoprevention and therapeutic activity of essential oils (EOs) and EO components. The present review summarizes an overview of chemopreventive, anti-melanoma and anti-nonmelanoma activities of EOs from various plants and EO components in in vitro and in vivo models with special emphasis on skin cancer. Also, the mechanisms by which EOs and EO components exert their effects to induce cell death are presented.

Outdoor work as a risk factor for high-grade cutaneous squamous cell carcinoma of the head and neck

INTRODUCTION

While it is clear that individuals with outdoor occupations are at a significantly greater risk of developing cutaneous squamous cell carcinoma (cSCC), no previous studies have investigated the potential association between the tumour grade and occupation in this patient population.

AIM

To assess occupation as a risk factor for the development of high-grade cSCC. Secondarily, to determine the association between the tumour grade and other clinical characteristics.

MATERIAL AND METHODS

Retrospective analysis of 256 patients treated for head and neck cSCC at our institution in 2007-2016. The following patient characteristics and variables were assessed: age; sex; tumour location and grade; profession; and education level. A univariate analysis was performed to assess the association between each study variable and grade 3 tumour differentiation.

RESULTS

The following variables were significantly associated (p < 0.05) with grade 3 (G3) cSCC tumours: outdoor work vs. indoor work; primary school vs. high school education; and age. Additionally, patients with low-grade (G1) tumours were significantly younger (mean age: 72) than patients with high-grade (G3) tumours (mean age: 79) (p = 0.046).

CONCLUSIONS

To our knowledge, this is the first study to assess the variables associated with the tumour grade among outdoor workers. These findings suggest that outdoor workers who develop cSCC are at a greater risk of developing more aggressive cancers. These findings provide additional support for classifying cSCC as an occupational disease. Early education about the dangers of sun exposure during the first years of school is essential to minimize the risks of developing high-grade skin cancer.

Synergistic interaction of β-caryophyllene with aromadendrene oxide 2 and phytol induces apoptosis on skin epidermoid cancer cells

BACKGROUND

Pamburus missionis (Wight) Swingle (Rutaceae) is traditionally used in the treatment of swellings, chronic rheumatism, paralysis and puerperal diseases. In a previous study the authors demonstrated apoptotic activity of Pamburus missionis essential oil (EO) on A431 and HaCaT cells. The major components of EO were β-caryophyllene (25.40%), 4(14),11- eudesmadiene (7.17%), aromadendrene oxide 2 (14.01%) (AO-(2) and phytol (6.88%).

PURPOSE OF STUDY

To investigate the role as well as the interactions among EO components inducing apoptosis in A431 and HaCaT cells.

METHODS

Isobolographic analysis and combination index methods were used to detect the type of interactions among the essential oil (EO) components. Cell viability was used to detect cytotoxic activity. Mechanism of cell death was studied using Annexin V-FITC/PI binding assay, cell cycle analysis, measurement of MMP and ROS generation by flow cytometry. Expression of apoptosis associated proteins was investigated by western blot.

RESULTS

Combination of P. missionis EO components: β-caryophyllene/ aromadendrene oxide 2 (β-C/AO-(2)), β-caryophyllene/phytol (β-C/P) and aromadendrene oxide 2 /phytol (AO-(2)/P) inhibited growth and colony formation ability of skin epidermoid A431 and precancerous HaCaT cells. Synergistic interaction was observed between β-C/AO-(2) and β-C/P combination while AO-(2)/P exhibited an additive effect. Combination of components induced chromatin condensation, phosphatidylserine externalisation, increase in sub-G1 DNA content, cell cycle arrest at G0/G1 phase and intracellular ROS accumulation. Inhibition of intracellular ROS by N-acetyl cysteine treatment blocked apoptosis induced by the combinations. The combinations induced apoptosis in A431 and HaCaT cells mediated by loss of mitochondrial membrane potential (ΔΨm), increase in Bax/Bcl-2 ratio, release of cytosolic cytochrome c and activation of caspases (cleaved form of caspase-3, caspase-8, caspase-9) and by PARP cleavage.

CONCLUSION

The present study demonstrates interactions among β-C, AO-(2) and P in the induction of apoptosis on A431 and HaCaT cells. These data suggest the combination of β-caryophyllene with aromadendrene oxide 2 and phytol could be potential therapeutics for the treatment of skin epidermoid cancer and precancerous cells.

WW domain-containing E3 ubiquitin protein ligase 1 depletion evokes antitumor effect in cutaneous squamous cell carcinoma by inhibiting signal transducer and activator of transcription 3 signaling pathway

Objectives

WW domain-containing E3 ubiquitin protein ligase 1 (WWP1) has been implicated in tumor progression. We aimed to investigate the role of WWP1 in cutaneous squamous cell carcinoma (CSCC).

Methods

WWP1 gene and protein levels were detected using semi-quantitative reverse transcription-polymerase chain reaction, immunohistochemistry and western blotting. The effects of WWP1 on cell cycle, apoptosis, cell migration and invasion were examined by flow cytometry, wound healing and Transwell assays, respectively. The antitumor efficacy of WWP1 small interfering RNA was determined in CSCC tumor xenografts in mice.

Results

WWP1 expression was significantly higher in CSCC tissues and cells than in normal skin and cells, respectively. WWP1 expression was significantly associated with histological grade, invasion depth and lymph node metastasis in patients with CSCC. High expression predicted metastatic potential and an unfavorable prognosis. WWP1 downregulation suppressed tumor growth in vitro and in vivo, reduced cell migration and invasion, arrested the cell cycle in G0/G1 and induced apoptosis in A431 cells. WWP1 depletion also decreased phosphorylated signal transducer and activator of transcription 3 (STAT3), matrix metalloproteinase-2, cyclin D1 and Bcl-2, but did not affect total STAT3.

Conclusions

WWP1 is a potential target for the diagnosis, prognosis and therapy of patients with CSCC.

Cutaneous Head and Neck Malignancies in the Elderly

Cutaneous malignancy of the head and neck affects a large proportion of elderly patients. The severity ranges from small, easily treatable lesions to large, invasive, potentially metastatic tumors. Surgical treatment is the primary treatment of most skin cancers; however, geriatric patients are more likely to have multiple comorbidities that increase the risk of surgery. Multiple treatment modalities exist, including surgical, radiation, and medical therapy. Recommendations and treatment options for basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and melanoma are outlined and reviewed.

Surgical Pearl on Reconstructing Surgical Defects of the Nasal Tip

Repairing surgical defects of the nasal tip is challenging, mainly because of the lack of freely mobile skin available peripherally. The Peng flap is a one-stage cutaneous flap that circumvents this difficulty by recruiting skin from the nasal dorsum and sidewall regions. The design produces a tridimensional shape perfectly adapted to the configuration of the nasal tip and allows for an inconspicuous closure of the defect. We present three examples of full-thickness skin defects involving the nasal tip, reconstructed using a modified version of the Peng flap, and present the experience at our department with this surgical technique.

Topical Colchicine Gel versus Diclofenac Sodium Gel for the Treatment of Actinic Keratoses: A Randomized, Double-Blind Study

Introduction. Actinic keratoses (AKs), a premalignant skin lesion, are a common lesion in fair skin. Although destructive treatment remains the gold standard for AKs, medical therapies may be preferable due to the comfort and reliability .This study aims to compare the effects of topical 1% colchicine gel and 3% diclofenac sodium gel in AKs. Materials and Methods. In this randomized double-blind study, 70 lesions were selected. Patients were randomized before receiving either 1% colchicine gel or 3% diclofenac sodium cream twice a day for 6 weeks. Patients were evaluated in terms of their lesion size, treatment complications, and recurrence at 7, 30, 60, and 120 days after treatment. Results. The mean of changes in the size was significant in both groups both before and after treatment (<0.001). The mean lesion size before treatment and at 30, 60, and 120 days was not different between the two groups (p > 0.05). No case of erythema was seen in the colchicine group, while erythema was seen in 22.9% (eight cases) of patients in the diclofenac sodium group (p = 0.005). Conclusions. 1% colchicine gel was a safe and effective medication with fewer side effects and lack of recurrence of the lesion.

Effect of Hath1 on the proliferation and apoptosis of cutaneous squamous cell carcinoma in vitro

Increasing evidence has demonstrated that the tumor suppressor gene Hath1 is implicated in the development and progression of tumors and is verified to be downregulated in several types of tumor. However, the roles and precise molecular mechanisms of Hath1 in cutaneous squamous cell carcinoma (SCC) remain to be elucidated. In the present study, two approaches were used to investigate the tumor-suppressing effect of Hath1 in cutaneous SCC. Firstly, the effect of inhibiting Hath1 expression with short hairpin RNA (shRNA) on tumor growth and apoptosis was investigated. KUMA5 cells were stably transfected with a plasmid expressing Hath1 shRNA (pGenesil-1-Hath1). Secondly, the anti-tumor effect of Hath1 was investigated in KUMA5 cells following transfection with pcDNA3.1-Hath1. The mRNA and protein expression of Hath1 was detected by reverse transcription quantitative polymerase chain reaction and western blot analysis, respectively. Cell proliferation in vitro was assessed using an MTT assay. Flow cytometry was used to detect cell apoptosis. The results demonstrated that compared with the control groups, the expression of Hath1 was significantly reduced in the KUMA5/pGenesil-1-Hath1 cells and markedly increased in the KUMA5/pcDNA3.1-Hath1 cells. Cell proliferation was markedly increased in the KUMA5/pGen-esil-1-Hath1 cells in a time-dependent manner; however, it was markedly inhibited in the KUMA5/pcDNA3.1-Hath1 cells. Flow cytometry revealed that apoptosis decreased in KUMA5/pGenesil-1-Hath1 cells and increased in KUMA5/pcDNA3.1-Hath1 cells. Downregulation of Hath1 expression promoted the proliferation and reduced the apoptosis of KUMA5 cells. By contrast, overexpression of Hath1 inhibited proliferation and induced the apoptosis of KUMA5 cells. These findings provide possible new strategies and therapeutic targets for the treatment and diagnosis of cutaneous SCC.

Physician specialty cost differences of treating nonmelanoma skin cancer

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.

[Basal cell carcinoma in a Congolese (DRC) albinos: about one observation]

Les auteurs rapportent un cas d'un carcinome basocellulaire non décris dans la littérature de notre pays chez un adulte jeune congolais âgé de 25 ans, de sexe masculin présentant une récidive probable de la tumeur. Cette observation permet de décrire le carcinome basocellulaire chez un sujet noir albinos, et de souligner les particularités thérapeutiques.

Topical therapies for skin cancer and actinic keratosis

The global incidence of skin cancer and actinic keratosis (AK) has increased dramatically in recent years. Although many tumours are treated with surgery or radiotherapy topical therapy has a place in the management of certain superficial skin neoplasms and AK. This review considers skin physiology, non-melanoma skin cancer (NMSC), the relationship between AK and skin cancer and drugs administered topically for these conditions. The dermal preparations for management of NMSC and AK are discussed in detail. Notably few studies have examined drug disposition in cancerous skin or in AK. Finally, recent novel approaches for targeting of drugs to skin neoplasms and AK are discussed.

Omental transplantation improves surgical outcome of large squamous cell carcinoma: A case report

Cutaneous squamous cell carcinoma (SCC) is an major health issue due to the significant health costs and marked disfigurement following surgical excision. The conventional reconstructive options may not be suitable for patients with large SCCs of the lower part of the leg, due to the regional tissue damage and ischemic environment. The omental transposition flap is a highly vascularized tissue that is resistant to infection and provides a recipient bed for skin grafts. This is the case report of a male patient with a large SCC in the lower part of his right leg, which was treated with extensive resection. The patient subsequently underwent reconstruction using a free omental flap, followed by transplantation of a secondary skin graft. The patient did not experience recurrence or metastasis during the 2 years of follow-up, indicating that, when dealing with postoperative skin cancer defects in an ischemic environment, omental transplantation may be a viable treatment option.

Imiquimod cream efficacy in the treatment of periocular nodular basal cell carcinoma: a non-randomized trial

Background

The recurrence rate of periocular nodular basal cell carcinoma (PNBCC) following treatment with imiquimod (IMQ) has not yet been established. Previous studies did not include histological follow-up. The aim of this analysis was to evaluate the efficacy of topical immunotherapy with 5% IMQ cream for the treatment of PNBCC.

Methods

Study design: A prospective, non-randomized, and uncontrolled longitudinal case series study. No participants were blinded. Punch biopsy confirmed PNBCC patients were included at the Ophthalmology Clinic of São Paulo University Medicine School Hospital (from 2008 to 2012). Patients were treated with 5% IMQ cream once a day, 5 days per week, for 8–16 weeks. Standard lesion photographic documentation was done during the study. Three months after treatment ended, an image-guided biopsy was performed. Patients were followed at 6-month intervals and annually for control biopsies. Main outcome measures were clinical and histological clearance rates. Data were analysed by frequency distribution for qualitative group characteristics and central tendency measures for quantitative data.

Results

Twenty-four patients met the inclusion criteria, 19 of whom remained until the end of treatment. The histological clearance rate was 89.5% and 84.2%, respectively, at 3 and 39.5 months. The 3-year histological clearance rate was 81.8% (9/11) for lesions >10 mm, and 100% (8/8) for lesions <10 mm. Three patients did not tolerate the side effects of the medication and left the study. Two patients were excluded for treatment interruption related to comorbidities.

Conclusions

Our results indicated that 5% IMQ cream was a useful alternative treatment for NBBCC, especially for lesions <10 mm. IMQ also showed a significant neoadjuvant effect on lesions >10 mm.

Trial registration

ClinicalTrial.gov Registration Dec 3, 2008: #NCT 00803907.

Identifying locally advanced basal cell carcinoma eligible for treatment with vismodegib: an expert panel consensus

ABSTRACT 

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. Most occur on the head and neck, where cosmetic and functional outcomes are critical. BCC can be locally destructive if not diagnosed early and treated appropriately. Surgery is the treatment of choice for the majority of high-risk lesions. Aggressive, recurrent or unresectable tumors can be difficult to manage. Until recently, no approved systemic therapy was available for locally advanced or metastatic BCC inappropriate for surgery or radiotherapy. Vismodegib provides a systemic treatment option. However, a consensus definition of advanced BCC is lacking. A multidisciplinary panel with expertise in oncology, dermatology, dermatologic surgery and radiation oncology proposes a consensus definition based on published evidence and clinical experience.

The effect of pulsed dye laser on high-risk basal cell carcinomas with response control by Mohs micrographic surgery

Several reports have shown the effectiveness of pulsed dye laser (PDL) for the treatment of basal cell carcinoma (BCC). Most studies have focused on low-risk BCCs, but an important limitation has been the lack of histologic confirmation of the treatment results. The aim of this study was to assess the effectiveness of PDL in high-risk BCCs with complete histologic evaluation with Mohs micrographic surgery (MMS). Seven patients with high-risk BCCs located on the face were included. All tumors were treated with three sessions of PDL (595 nm) at 4-week intervals. The tumor and 4 mm of peripheral skin were treated with two stacked pulses with a 1-s delay, a fluence of 15 J/cm(2), a pulse duration of 2 ms, and a spot size of 7 mm. MMS was performed at least 1 month after the last PDL session including excisional tumor debulking prior to the first stage of MMS for standard histologic evaluation. Apparent complete clinical response was achieved in five of seven patients. MMS was finally performed in six patients, and clear margins were achieved after one stage of MMS. The histologic evaluation of the tumor debulking specimens showed complete clearance in four of six cases. One patient who did not undergo MMS showed a recurrence after 14 months. This is the first pilot study that demonstrates that PDL can be effective for the treatment of high-risk BCCs. Until further scientific evidence is available, treatment of high-risk BCCs should include histologic confirmation of clearance.

Molecular pathology of skin neoplasms of the head and neck

CONTEXT

Skin neoplasms include the most common malignancies affecting humans. Many show an ultraviolet (UV)-induced pathogenesis and often affect the head and neck region.

OBJECTIVE

To review literature on cutaneous neoplasms that show a predilection for the head and neck region and that are associated with molecular alterations.

DATA SOURCES

Literature review.

CONCLUSIONS

Common nonmelanoma skin cancers, such as basal and squamous cell carcinomas, show a UV-induced pathogenesis. Basal cell carcinomas are characterized by molecular alterations of the Hedgehog pathway, affecting patched and smoothened genes. While squamous cell carcinomas show UV-induced mutations in several genes, driver mutations are only beginning to be identified. In addition, certain adnexal neoplasms also predominantly affect the head and neck region and show interesting, recently discovered molecular abnormalities, or are associated with hereditary conditions whose molecular genetic pathogenesis is well understood. Furthermore, recent advances have led to an increased understanding of the molecular pathogenesis of melanoma. Certain melanoma subtypes, such as lentigo maligna melanoma and desmoplastic melanoma, which are more often seen on the chronically sun-damaged skin of the head and neck, show differences in their molecular signature when compared to the other more common subtypes, such as superficial spreading melanoma, which are more prone to occur at sites with acute intermittent sun damage. In summary, molecular alterations in cutaneous neoplasms of the head and neck are often related to UV exposure. Their molecular footprint often reflects the histologic tumor type, and familiarity with these changes will be increasingly necessary for diagnostic and therapeutic considerations.

Topical pharmacotherapy for skin cancer: part II. Clinical applications

The purpose of the paper is to provide an in-depth, evidence-based analysis of the clinical use of topical treatments for skin cancer. A comprehensive review of topical drugs has been performed, including 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, retinoids, resiquimod, piroxicam, dobesilate, and betulinic acid. The evaluated studies were rated according to their level of evidence level (I-V), as indicated by recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence. Therapeutic response is generally related to tumor type, extent, and localization, and also to patient compliance. Careful patient selection is required in order to achieve the desired goal of complete tumor clearance.

[Squamous cell carcinomas of the ear: factors of gravity and surgical treatment, about 30 cases]

INTRODUCTION

Squamous cell carcinomas (SCC) of the ear are known for their aggressiveness. The aim of this study was to investigate factors of gravity while freeing the therapeutic requirements.

PATIENTS AND METHODS

This is a retrospective study of 28 patients (30 ears) operated for SCC. The characteristics of the lesion, the presence of metastasis, treatment modalities and histologic findings were collected. Local recurrences and metastasis are identified with a mean follow-up time of 37months (17-110months).

RESULTS

The lesion size was less than 2cm in 19 cases (63.3%) and greater than or equal to 2cm in 11 cases (36.7%). Macroscopic resection margins were 5, 7 or 10mm. The resections were histologically incomplete in 4 cases (13%) requiring further surgery. Six cases had local recurrence (20%): three with pulmonary or lymph node metastases (10%) and one death (3.3%). In these 6 cases of recurrence, the surgical margins were 6.3mm on average, the initial lesion measured always greater than 2cm (100%). Three quarters of incomplete resections have recurrent despite a surgical revision in healthy margin.

CONCLUSION

Our study confirms the data of literature, namely the pejorative character of a lesion greater than 2cm and incomplete resection. The HAS recommendations seem minimal regarding the ear. In case of injury by more than 2cm and with a proximal location on the ear pinna, only amputation of the ear allows satisfactory cancer control.

Paradigm change in the treatment of non-melanoma skin cancer of the auricle: reconstruction with full thickness skin grafting instead of wedge excision

Non-melanoma skin cancer (NMSC) has become an epidemic disease and is predominantly located in the head and neck area. While historically auricular NMSCs are treated by means of a wedge excision, we describe a more elegant technique with excellent esthetical results. We conducted a retrospective cohort study of 43 consecutive patients with NMSC of the auricle who underwent reconstruction with a full thickness skin graft (FTSG). All grafts survived. Two patients (5%) showed crust formation, but fully recovered. One patient had an irradical resection for which he required a limited re-excision. All patients showed excellent esthetical results. When treating NMSC of the auricle, reconstruction with a FTSG demonstrates several important advantages. It is a relatively simple but oncological safe technique; it leads to excellent esthetical and functional outcomes, and shows high patient and surgeon satisfaction.

On the application of Nafion membrane for the preparation of (90)Y skin patches, quality control, and biological evaluation for treatment of superficial tumors

This article describes the preparation, quality control, and biological evaluation of (90)Y-skin patches based on Nafion(®) membrane as a viable treatment modality for superficial skin tumors such as melanoma. To arrive at the conditions for optimum uptake of (90)Y on the membrane, influence of various experimental parameters, such as pH of the feed solution, inactive yttrium carrier concentration, reaction volume, contact time, and temperature, was systematically investigated. Under the optimized conditions, >95% of the (90)Y activity (37-185 MBq) could be incorporated in the Nafion membranes to prepare (90)Y-skin patches. Quality control tests were carried out to ensure nonleachability, uniform distribution of activity, and stability of the (90)Y-patches. Mice bearing transplanted melanoma tumors that were treated with two doses of 74 MBq (90)Y-Nafion membrane sources showed complete tumor regression. Histopathological examination of the treated area showed absence of tumor. The results of the study indicate the potential of (90)Y-Nafion membrane sources for treatment of superficial skin tumors.

Surface anatomy of the ear

Expert diagnosis of cutaneous pathology requires precise anatomic description. This brief report will review the clinically relevant surface anatomy of the ear.

Basal cell carcinomas of the ear are more aggressive than on other head and neck locations

BACKGROUND

On pathology review, basal cell carcinomas (BCCs) on the ear more commonly present as aggressive subtypes. It is unclear if this histologic observation translates into more clinically aggressive tumors.

OBJECTIVE

We sought to determine the clinical aggressiveness of ear BCCs compared with BCCs elsewhere on the head and neck.

METHODS

We conducted a retrospective chart review of all BCCs treated at an academic center from 2005 through 2012. Subjects were divided into ear and non-ear groups. Subtypes classified as "aggressive" included morpheaform, infiltrative, micronodular, adenoid, metatypical, and mixed histology.

RESULTS

Of the 7732 head and neck BCCs, 758 (9.8%) were on the ear. Ear BCCs presented as larger lesions (1.28 vs 0.98 cm(2)), required more Mohs layers (16.5% vs 10.7%), and produced a larger final defect (4.29 vs 3.49 cm(2)) than non-ear lesions. When comparing only aggressive subtypes, ear BCCs also presented as larger lesions (1.42 vs 1.23 cm(2)), more frequently required 3 or more layers for clearance (22.3% vs 14.2%), and produced a larger final defect (4.92 vs 4.21 cm(2)) than non-ear lesions.

LIMITATIONS

Limitations include single-center design and lack of long-term follow-up.

CONCLUSION

Ear BCCs appear to exhibit greater subclinical extension compared with non-ear head and neck BCCs. Therefore, the ear should be considered a high-risk location for BCCs.

Imaging findings of head and neck dermatofibrosarcoma protuberans

BACKGROUND AND PURPOSE

Dermatofibrosarcoma protuberans is a rare, locally aggressive sarcoma of the skin in children and adults, usually involving the trunk and extremities and less commonly the head and neck. Despite clinical reports in the literature on the management of dermatofibrosarcoma protuberans, there are limited articles describing its imaging features.

MATERIALS AND METHODS

We retrospectively reviewed the demographics and imaging findings in all 24 patients with pathologically proven dermatofibrosarcoma protuberans of the head and neck seen at a tertiary cancer center between 2001 and 2010.

RESULTS

Twenty-two of the 24 lesions were nodular and well circumscribed; 19 of the 24 were located on the scalp. On imaging, all 24 lesions involved subcutaneous tissues. The lesions ranged in size from 0.6-9.5 cm (mean, 3.7 cm; standard deviation, 2.3 cm). Twelve lesions involved the soft tissues either at or extending directly to the midline. Thirteen lesions were associated with bulging of the skin surface. Fourteen lesions were imaged with CT and 14 with MR imaging. Whereas variable enhancement patterns were noted on CT and MR imaging, dermatofibrosarcoma protuberans was usually T2-hyperintense and demonstrated marked enhancement. None of the lesions was associated with bone invasion, perineural spread, or nodal/distant metastasis.

CONCLUSIONS

Knowledge of the imaging characteristics of dermatofibrosarcoma protuberans may alert neuroradiologists to include dermatofibrosarcoma protuberans in the differential diagnosis of lesions about the head and neck with similar imaging characteristics.

DLC1 as a regulator of proliferation, invasion, cell cycle, and apoptosis in cutaneous squamous cell carcinoma

Increasing evidence has demonstrated that the tumor suppressor gene deleted in liver cancer-1 (DLC1) is tightly implicated in the development and progression of tumors and is verified to be downregulated in a variety of tumors. However, the roles and precise molecular mechanisms of DLC1 in cutaneous squamous cell carcinoma (cutaneous SCC) remain to be elucidated. In the present study, we confirmed the reduced level in cutaneous SCC tissues and cells, and DLC1 mRNA relative level in cutaneous SCC tissues with lymph node metastasis (0.801 ± 0.079) was markedly lower than those without lymph node metastasis (1.245 ± 0.071) (P < 0.0001). Importantly, the survival rates of patients with low DLC1 level were lower than those with high DLC1 level (P = 0.0051). Further investigation revealed that DLC1 overexpression inhibited proliferation and arrested cell cycle at G0/G1 phase in A431 cells, which may be tightly associated with upregulation of p21 protein and downregulation of cyclin D1 and cdk2 proteins. Moreover, the decreases of FAK and p-FAK as well as the increase of E-cadherin level mediated by elevated DLC1 level suppressed invasion in A431 cells. Additionally, DLC1 overexpression induced apoptosis coupled with elevations of Bax level and caspase-3 activity and decrease of Bcl-2 level in A431 cells. Taken altogether, our data presented herein suggest that DLC1 plays a pivotal role in the development and progression of cutaneous SCC, which may be in part achieved by regulating the signaling pathway related to proliferation, invasion, cell cycle, and apoptosis in cutaneous SCC cells.

Nonmelanoma skin cancer of the head and neck: surgical treatment

This article focuses on the surgical treatment of nonmelanoma skin cancers of the head and neck. The risk factors of nonmelanoma skin cancers for recurrence and metastases that are important for choosing the best treatment option are summarized. Surgical treatment options including surgical excision with standard margins, frozen section, staged surgery, and Mohs micrographic surgery are described. Indications, techniques, outcomes, and advantages and disadvantages of each approach are reviewed. Finally, management of incomplete excisions is discussed.

Radiation-related risk of basal cell carcinoma: a report from the Childhood Cancer Survivor Study

BACKGROUND

Basal cell carcinoma (BCC) is the most common malignancy in the United States. Ionizing radiation is an established risk factor in certain populations, including cancer survivors. We quantified the association between ionizing radiation dose and the risk of BCC in childhood cancer survivors.

METHODS

Participants in the Childhood Cancer Survivor Study who reported a BCC (case subjects, n = 199) were matched on age and length of follow-up to three study participants who had not developed a BCC (control subjects, n = 597). The radiation-absorbed dose (in Gy) to the BCC location was calculated based on individual radiotherapy records using a custom-designed dosimetry program. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between demographic and treatment factors, therapeutic radiation dose, and surrogate markers of sun sensitivity (skin and hair color) and the risk of BCC. A linear dose-response model was fitted to evaluate the excess odds ratio per Gy of radiation dose.

RESULTS

Among case subjects, 83% developed BCC between the ages of 20 and 39 years. Radiation therapy, either alone or in combination with chemotherapy, was associated with an increased risk of BCC compared with no chemotherapy or radiation. The odds ratio for subjects who received 35 Gy or more to the skin site vs no radiation therapy was 39.8 (95% CI = 8.6 to 185). Results were consistent with a linear dose-response relationship, with an excess odds ratio per Gy of 1.09 (95% CI = 0.49 to 2.64). No other treatment variables were statistically significantly associated with an increased risk of BCC.

CONCLUSIONS

Radiation doses to the skin of more than 1 Gy are associated with an increased risk of BCC.

Metastatic basal cell carcinoma in the era of hedgehog signaling pathway inhibitors

BACKGROUND

Inhibition of the hedgehog signaling pathway (HHSP) for the treatment of locally advanced basal cell carcinoma (BCC) and metastatic BCC (mBCC) has produced promising results. Typically, mBCC is not taken into consideration during the workup of a patient with multifocal metastatic disease who has a history of BCC. The objective of the current review, in which the authors evaluated the time from the first BCC diagnosis to metastasis, location of disease, and radiographic features, was to contribute to the general knowledge and awareness among providers, patients, and support groups about mBCC and to provide an outlook for the future of treatments for mBCC. A literature review on mBCC and a review of records from patients with mBCC who presented to Virginia G. Piper Cancer Center Clinical Trials (an oncology clinical trials center) were conducted. The clinical and radiographic findings of 22 patients with mBCC who were evaluated at that center from the initiation of smoothened (SMO) antagonist trials were analyzed along with a review of BCC epidemiology and pathogenesis, the HHSP, and current and future treatments for this rare presentation of the most common malignancy. The results indicated that, in the last 5 years, there has been a plethora of new agents targeting SMO, a key component of the HHSP that, for the majority of patients with mBCC, may be a good match for targeting tumor genetic vulnerability. Like with other targeted therapy for uncommon malignancies, such as chronic myelogenous leukemia and gastrointestinal stromal tumors, the authors anticipate that there will be clinical development of next-generation HHSP inhibitors to combat mBCCs that are nonresponsive to or progress on current SMO antagonists.

Epidemiology of basal cell carcinoma

Basal cell carcinoma is the most common malignant neoplasm in humans and its incidence has increased over the last decades. Its high frequency significantly burdens the health system, making the disease a public health issue. Despite the low mortality rates and the rare occurrence of metastases, the tumor may be locally invasive and relapse after treatment, causing significant morbidity. Exposure to ultraviolet radiation is the main environmental risk factor associated with its cause. However, other elements of risk are described, such as light skin phototypes, advanced age, family history of skin carcinoma, light eyes and blond hair, freckles in childhood and immunosuppression. Behavioral aspects such as occupational sun exposure, rural labor and sunburns at a young age also play a role. Between 30% and 75% of the sporadic cases are associated with patched hedgehog gene mutation, but other genetic changes are also described. The tumor is commonly found in concomitance with skin lesions related to chronic sun exposure, such as actinic keratoses, solar lentigines and facial telangiectasia. The prevention of basal cell carcinoma is based on the knowledge of risk factors, early diagnosis and treatment, as well as on the adoption of specific measures, particularly in susceptible populations. The authors present a review of the epidemiology of basal cell carcinoma.

The influence of anti-TNF therapy upon incidence of keratinocyte skin cancer in patients with rheumatoid arthritis: longitudinal results from the British Society for Rheumatology Biologics Register

Objectives

To compare the risk of keratinoctye skin cancer (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)) in patients treated for rheumatoid arthritis (RA) compared with the general population, and to determine whether anti-tumour necrosis factor (TNF) therapy exacerbates this risk.

Methods

Patients with RA enrolled in the British Society for Rheumatology Biologics Register, a prospective national cohort established in 2001 to monitor the safety of anti-TNF, were followed until 2008. 11 881 patients treated with anti-TNF were compared with 3629 patients receiving non-biological disease-modifying antirheumatic drugs (nbDMARD). Standardised incidence ratios (SIR) were calculated for each cohort and rates between cohorts were compared using Cox proportional HR, adjusted using inverse probability of treatment weighting.

Results

SIR for skin cancer was increased in both cohorts compared with the English population: SIR 1.72 (95% CI 1.43 to 2.04) anti-TNF; 1.83 (95% CI 1.30 to 2.50) nbDMARD only. In patients without previous skin cancer, BCC incidence per 100 000 patient-years was 342 (95% CI 290 to 402) after anti-TNF and 407 (95% CI 288 to 558) after nbDMARD. HR after anti-TNF adjusted for treatment weighting was 0.95 (95% CI 0.53 to 1.71). SCC incidence per 100 000 patient-years: anti-TNF 53 (95% CI 33 to 79); nbDMARD 43 (95% CI 12 to 110); adjusted HR 1.16 (95% CI 0.35 to 3.84).

Conclusions

Skin cancers were increased among treated patients with RA. No evidence was found that anti-TNF therapy exacerbates the risk of BCC or SCC but this cannot be excluded. Patients with RA should use sun protection and be monitored for skin cancer.

Management of high-risk squamous cell carcinoma of the skin

Cutaneous squamous cell cancer (SCC) is the second most common skin cancer, accounting for one-fifth of all cutaneous malignancies. The majority arise on the head and neck skin, and cumulative UV exposure is thought to be the most likely etiological factor. The majority of deaths from SCC occur in a high-risk subgroup of patients. This high-risk subgroup of patients can be identified as those with tumors greater than 2 cm in diameter; tumor thickness over 4 mm; moderately/poorly differentiated or desmoplastic histological SCC subtype; ear, lip, hand, feet or genital tumor site; presence of perineural or lymphovascular invasion; nodal metastasis at presentation; recurrent SCC; SCC arising from scars or chronic skin disease, for example, chronic ulcers; and SCC arising in immunosuppressed patients. It is important to identify and aggressively treat these patients, as high-risk SCC are associated with a greater mortality and morbidity. This article reviews the diagnosis and management of such high-risk SCC.