Aging and the treatment of basal cell carcinoma

Nanotechnology as a Promising Method in the Treatment of Skin Cancer

The incidence of skin cancer continues to grow. There are an estimated 1.5 million new cases each year, of which nearly 350,000 are melanoma, which is often fatal. Treatment is challenging and often ineffective, with conventional chemotherapy playing a limited role in this context. These disadvantages can be overcome by the use of nanoparticles and may allow for the early detection and monitoring of neoplastic changes and determining the effectiveness of treatment. This article briefly reviews the present understanding of the characteristics of skin cancers, their epidemiology, and risk factors. It also outlines the possibilities of using nanotechnology, especially nanoparticles, for the transport of medicinal substances. Research over the previous decade on carriers of active substances indicates that drugs can be delivered more accurately to the tumor site, resulting in higher therapeutic efficacy. The article describes the application of liposomes, carbon nanotubes, metal nanoparticles, and polymer nanoparticles in existing therapies. It discusses the challenges encountered in nanoparticle therapy and the possibilities of improving their performance. Undoubtedly, the use of nanoparticles is a promising method that can help in the fight against skin cancer.

Recent Advances in Melanoma Diagnosis and Prognosis Using Machine Learning Methods

PURPOSE OF REVIEW

The purpose was to summarize the current role and state of artificial intelligence and machine learning in the diagnosis and management of melanoma.

RECENT FINDINGS

Deep learning algorithms can identify melanoma from clinical, dermoscopic, and whole slide pathology images with increasing accuracy. Efforts to provide more granular annotation to datasets and to identify new predictors are ongoing. There have been many incremental advances in both melanoma diagnostics and prognostic tools using artificial intelligence and machine learning. Higher quality input data will further improve these models' capabilities.

An Analysis of Lidocaine Usage in the Treatment of Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) is a form of skin cancer that can be treated using a procedure known as Mohs surgery. Mohs surgery is a safe and effective procedure for eliminating SCC. This surgery requires the usage of an analgesic known as lidocaine. Additional anesthetics were also reported to be necessary for this procedure to be conducted in a manner that significantly minimizes patient harm. According to the review, it was found that SCC was treated with lidocaine as a topical analgesic outside of Mohs surgery. This review analyzes the usage of lidocaine in the treatment of SCC. It was also discovered that lidocaine, as an agent, has the potential to slow the progression of SCC, but more research is needed to see if this is truly the case. On average, it was reported that the concentration of lidocaine used in the in vivo studies was significantly higher than that in the in vitro investigations. Further exploration may be needed to verify the conclusions that were based on the analysis of the papers within the review.

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.

Characteristics and management of skin cancers in very elderly patients: A real-world challenge for clinicians

The increase life expectancy led to an expected increase in skin cancer incidence in older patients. Their treatment can require a complex decision-making process. Limited data are available on characteristics, management and outcome of skin tumours in nonagenarian and centenarian patients. The aim of our study was to describe epidemiology, clinical-pathological features and treatment strategies of skin cancers in a cohort of patients aged ≧95 years. A total of 116 patients ≧95 years of age presented for the evaluation of 225 skin lesions (mean of 1.94 lesions per patient). The mean age was 97.4 years, 57.8% were women. Most patients had an ECOG score of 3 (49.3%) or 4 (32%). Lesions were mainly located on the head and neck area (74.2%), upper (7.1%) and lower (6,2%) limbs. The majority of patients presented with non-melanoma skin cancers (183/225; 81.3%), 25/225 (11.1%) had actinic keratosis, 5 (2.2%) melanoma and 2 (0.9%) atypical fibroxanthoma. Forty-eight lesions (21.3%) were treated with surgery, 58 (25.8%) with radiotherapy. The management of 73 lesion (32.4%) was discussed at the multidisciplinary tumour board meeting. One patient died for the progression of a squamous cell carcinoma; 74 patients died for causes unrelated to skin tumours, 36 are still alive after a mean follow-up of 27.27 months. This cohort study confirms that age is not per se a contraindication for treatment of skin cancers in elderly patients. Our results support the importance of a patient-centred care approach that should take into consideration patient's preferences, comorbidities, compliance and possible adverse events.

A systematic review of observational management of cutaneous basal cell carcinoma

BACKGROUND

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom and United States. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of cutaneous BCC.

METHODS

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

RESULTS

We identified 2529 titles, from which 4 full-text articles were eligible, reporting on 2298 individuals. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6-12 weeks. Clearance rates ranged from 52-100% for imiquimod and 2-19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

CONCLUSION

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility-adjusted survival following interventional or observational management of BCC.

Topical hedgehog inhibitors for basal cell carcinoma: how far away are we?

INTRODUCTION

The standard treatment of basal cell carcinoma (BCC) consists of conventional excision or Mohs micrographic surgery. However, surgical excision is not feasible in specific cases, particularly in patients with several BCCs such as those with Gorlin syndrome or individuals receiving immunosuppression after solid-organ transplantation. Additionally, the geriatric population may not be appropriate candidates for surgery. Thus, alternative therapies are needed for these populations.

AREAS COVERED

Hedgehog (Hh) inhibitors are approved and effective but are currently available only in oral formulations. These agents such as vismodegib and sonidegib are associated with short-lived responses as well as significant adverse effects including myalgias, dysgeusia, and alopecia. Patidegib and itraconazole are two topical Hh inhibitors agents emerging as alternatives to oral Hh inhibiton for difficult-to-treat BCCs. These agents exhibit limited systemic absorption, leading to improved tolerability; however, an optimal formulation is needed to maximize efficacy and is currently being investigated.

EXPERT OPINION

Ongoing and recent clinical studies on topical Hedgehog inhibitors show great promise for the development of an agent with a high therapeutic index and limited adverse effects. If patidegib continues to show clinical efficacy in randomized controlled trials, it may become a universal therapy for all subtypes of difficult-to-treat BCC.

Does experience affect surgical margins in head and neck basal cell carcinoma?

Purpose: The aim of our study was to evaluate the impact of surgical experience in a high volume head and neck surgery department on basal cell carcinoma margin status. Methods: A retrospective analysis of 546 patients surgically treated for primary basal cell carcinoma of the head and neck region was done. Resections were performed by 4 specialists with equal experience in head and neck surgery and 4 ENT residents at the same level of surgical training. A margin of 3-5mm was chosen, according to guidelines. Results: The study consisted of 304 males and 242 females, mean age of 69 (range 26 – 100). Most of the tumors were located on the nose (165 pts; 30,2%) and auricle (119; 21,7%). The most common histological subtype was nodular (119; 21,7%). Tumor size was up to 20mm in 394 cases (72%). Positive surgical margins were found in 112 cases (20,5%). There was no difference in terms of positive surgical margins between residents (19/119 cases; 15,9%) and specialists (93/426; 21,8%; p=0.161). Conclusions: The results of our study have shown that adequate surgical training in dedicated head and neck surgery department is an efficient factor in obtaining free surgical margins in head and neck basal cell carcinoma.

Evolution of Disease Modifying Therapy Benefits and Risks: An Argument for De-escalation as a Treatment Paradigm for Patients With Multiple Sclerosis

Background

Strategies for sequencing disease modifying therapies (DMTs) in multiple sclerosis (MS) patients include escalation, high efficacy early, induction, and de-escalation.

Objective

To provide a perspective on de-escalation, which aims to match the ratio of DMT benefit/risk in aging patients.

Methods

We reanalyzed data from a retrospective, real-world cohort of MS patients to model disease activity for oral (dimethyl fumarate and fingolimod) and higher efficacy infusible (natalizumab and rituximab) DMTs by age. For patients with relapsing MS, we conducted a controlled, stratified analysis examining odds of disease activity for oral vs. infusible DMTs in patients <45 or ≥45 years. We reviewed the literature to identify DMT risks and predictors of safe discontinuation.

Results

Younger patients had lower probability of disease activity on infusible vs. oral DMTs. There was no statistical difference after age 54.2 years. When dichotomized, patients <45 years on oral DMTs had greater odds of disease activity compared to patients on infusible DMTs, while among those ≥45 years, there was no difference. Literature review noted that adverse events increase with aging, notably infections in patients with higher disability and longer DMT duration. Additionally, we identified factors predictive of disease reactivation including age, clinical stability, and MRI activity.

Conclusion

In a real-world cohort of relapsing MS patients, high efficacy DMTs had less benefit with aging but were associated with increased risks. This cohort helps overcome some limitations of trials where older patients were excluded. To better balance benefits/risks, we propose a DMT de-escalation approach for aging MS patients.

Modern understanding of the pathogenesis of basal cell skin cancer

The incidence of basal cell skin cancer is increasing worldwide. The initiation and progression of basal cell skin cancer is due to the interaction of environmental factors and the patient's genetic characteristics. Aberrant activation of the transmission of the Hedgehog signaling pathway is the main pathogenetic pathway of carcinogenesis. Since basal cell skin cancer is manifested by significant variability of morphological structure, aggressiveness and response to treatment, the disclosure of the molecular genetics of pathogenesis will become the basis for developing new approaches and increasing the effectiveness of treatment, as well as overcoming tumor resistance to treatment. To search for the necessary literature, the PubMed, MedLine, Web of Science and RSCI databases were used.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Introduction

The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person.

Methods

We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18.

Results

Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies.

Conclusions

We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

Skin Cancers and the Contribution of Rho GTPase Signaling Networks to Their Progression

Skin cancers are the most common cancers worldwide. Among them, melanoma, basal cell carcinoma of the skin and cutaneous squamous cell carcinoma are the three major subtypes. These cancers are characterized by different genetic perturbations even though they are similarly caused by a lifelong exposure to the sun. The main oncogenic drivers of skin cancer initiation have been known for a while, yet it remains unclear what are the molecular events that mediate their oncogenic functions and that contribute to their progression. Moreover, patients with aggressive skin cancers have been known to develop resistance to currently available treatment, which is urging us to identify new therapeutic opportunities based on a better understanding of skin cancer biology. More recently, the contribution of cytoskeletal dynamics and Rho GTPase signaling networks to the progression of skin cancers has been highlighted by several studies. In this review, we underline the various perturbations in the activity and regulation of Rho GTPase network components that contribute to skin cancer development, and we explore the emerging therapeutic opportunities that are surfacing from these studies.

Geriatric conditions and treatment burden following diagnosis of non-muscle- invasive bladder cancer in older adults: A population-based analysis

INTRODUCTION

Treatment burden is emerging as an important patient-centered outcome for older adults with cancer who concurrently manage geriatric conditions. Our objective was to evaluate the contribution of geriatric conditions to treatment burden in older adults with non-muscle invasive bladder cancer (NMIBC).

METHODS

We identified 73,395 Medicare beneficiaries age 66+ diagnosed with NMIBC (Stage <II) in SEER-Medicare (2001-2014). The primary outcome was treatment burden, defined as health system contact days in the year following NMIBC diagnosis. Explanatory variables were the following geriatric conditions: multimorbidity (≥ 2 chronic conditions), functional dependency, falls, depression, cognitive impairment, weight loss, and urinary incontinence. We used negative binomial regression to model the association between individual geriatric conditions and treatment burden while adjusting for covariates.

RESULTS

At baseline, 64% had multimorbidity and median 3 conditions (IQR 0-5). Prevalence of other geriatric conditions ranged from 5.9%-15.2%. Adjusted mean health system contact was 8.9 days (95% CI 8.6-9.2). Multimorbidity had the largest effect size (adjusted mean 11.8 contact days (95% CI 8.3-8.8)). Each additional chronic condition conferred a 13% increased average number of health system contact (adjusted IRR 1.132, 95% CI 1.129-1.135). Regardless of number of chronic conditions, rural patients consistently had more treatment burden than urban counterparts.

DISCUSSION

In this population-based cohort of older NMIBC patients, multimorbidity and rurality were strongly associated with treatment burden in the year following NMIBC diagnosis. These findings highlight the need for interventions that reduce treatment burden due to geriatric conditions among the growing population of older adults with cancer, particularly in rural areas.

Programmed cell death 1 (PDCD1) gene haplotypes and susceptibility of patients to basal cell carcinoma

Programmed death-1 (PD-1), as an immunoinhibitory receptor encoded by programmed cell death-1 (PDCD1) gene, has a pivotal role in tolerance to self-antigens. Mutations of PDCD1 may participate in susceptibility to basal cell carcinoma (BCC) as the most common of skin cancer. We studied the impacts of two single nucleotide polymorphisms (SNPs) within PDCD1 and their haplotypes in BCC susceptibility in an Iranian population. The blood samples were collected from 210 BCC and 220 healthy individuals. After the extraction of genomic DNA, the genotypes and alleles of PD1.1 G/A (rs36084323) and PD1.6 G/A (rs10204525) SNPs were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Four haplotypes were estimated by these SNPs. Our data revealed that genotype and allele frequencies of PD1.1 and PD1.6 polymorphisms in BCC patients were similar to those in healthy individuals. The results of estimated haplotypes for PDCD1 indicated that GG and AA haplotypes of PDCD1 had protective effects on BCC susceptibility (OR = 0.7, 95% CI = 0.51-0.96, p = 0.03 and OR = 0.57, 95% CI = 0.35-0.91, p = 0.02, respectively), while GA and AG haplotypes served as the risk factors for developing BCC (OR = 1.76, 95% CI = 1.09-2.84, p = 0.02 and OR = 3.87, 95% CI = 1.95-7.69, p = <0.001, respectively). Based on these findings, frequency distributions of PDCD1 haplotypes have important roles in the determination of BCC development in the Iranian population. However, larger multicenter studies are required to confirm this conclusion.

A Vismodegib Experience in Elderly Patients with Basal Cell Carcinoma: Case Reports and Review of the Literature

Cutaneous basal cell carcinoma (BCC) is the most common type of human tumor, and its incidence rate is increasing worldwide. Up until a few years ago, therapeutic options have been limited for patients with advanced BCC (including metastatic and locally-advanced BCC). Over the last few years, promising systemic therapies have been investigated for the treatment of advanced BCC. In particular, the Hedgehog signaling inhibition has shown remarkable results for this population. Hedgehog inhibitors, represented by vismodegib and sonidegib, have been approved by the Food and Drug Administration and the European Medicines Agency for the treatment of both locally advanced and metastatic BCC, with, generally, a good safety profile. Notwithstanding the late onset of BCC in the global population, associated with life expectancy increase, only a few clinical trials have evaluated the efficacy and safety profile of Hedgehog inhibitors in this complex and neglected population. Herein, we review the major mechanisms implicated in the pathogenesis of BCC focusing on the Hedgehog signaling pathway and its therapeutic role in the elderly population. Finally, we report two case reports of BCC elderly patients in order to demonstrate both efficacy and safety of the Hedgehog inhibitors.

Basal Cell Carcinoma: From Pathophysiology to Novel Therapeutic Approaches

Basal cell carcinoma (BCC) is the most common human cancer worldwide, and is a subtype of nonmelanoma skin cancer, characterized by a constantly increasing incidence due to an aging population and widespread sun exposure. Although the mortality from BCC is negligible, this tumor can be associated with significant morbidity and cost. This review presents a literature overview of BCC from pathophysiology to novel therapeutic approaches. Several histopathological BCC subtypes with different prognostic values have been described. Dermoscopy and, more recently, reflectance confocal microscopy have largely improved BCC diagnosis. Although surgery is the first-line treatment for localized BCC, other nonsurgical local treatment options are available. BCC pathogenesis depends on the interaction between environmental and genetic characteristics of the patient. Specifically, an aberrant activation of Hedgehog signaling pathway is implicated in its pathogenesis. Notably, Hedgehog signaling inhibitors, such as vismodegib and sonidegib, are successfully used as targeted treatment for advanced or metastatic BCC. Furthermore, the implementation of prevention measures has demonstrated to be useful in the patient management.