Intralesional chemotherapy for nonmelanoma skin cancer: a practical review

Intralesional methotrexate versus 5-flurouracil in the treatment of keratoacanthoma

BACKGROUND

Keratoacanthoma (KA) is a benign neoplasm that affects mainly photodamaged skin. It is locally destructive and may rarely spread. Surgery is not always suitable and usually disfiguring. Thus, non-operative modalities represent good alternatives.

OBJECTIVE

To assess and compare the efficacy of intralesional methotrexate (MTX) and 5-flurouracil (5-FU) in the treatment of KA.

PATIENTS AND METHODS

Randomized controlled trial included 20 patients with biopsy proven KA divided into 2 equal groups; group (A) received intralesional MTX, 25 mg/ml and group (B) received intralesional 5-FU, 50 mg/ml every 2 weeks till complete clearance or for a maximum 5 sessions.

RESULTS

In the MTX group, complete clearance was observed in 7 patients (70%) compared to 8 patients (80%) in the 5- FU group with no statistically significant difference. However, the median number of injections needed to achieve complete response in the MTX group was 3 sessions versus only 2 sessions in the 5-FU group.

LIMITATIONS

the small sample size due to the relatively low incidence of KAs in our population.

CONCLUSION

Intralesional therapy is a good alternative to surgery in selected cases of KA. Both drugs showed comparable efficacy, but 5-FU may give faster results, hence increasing patient satisfaction and compliance.

Intralesional 5-Fluorouracil in the Treatment of Squamous Cell Carcinoma in an Elderly Patient

Squamous cell carcinoma (SCC) is the second leading form of skin cancer. In the elderly population, surgery may carry more risk and significant morbidity in comparison to less invasive forms of treatment. This case report describes the successful use of intralesional 5-fluorouracil (IL5-FU) to treat cutaneous squamous cell carcinoma (cSCC). A 98-year-old white woman presented in early May 2017 with a 3.5-cm rapidly growing crusted nodule on her left proximal-lateral arm. She had a past medical history of chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The patient also had a frail body habitus and weighed 80 pounds. Physical examination revealed a large, ulcerated, crateriform mass on the left proximal-lateral arm. A shave biopsy was performed, which revealed a well-differentiated SCC, composed of nodular masses of neoplastic squamous cells with atypical nuclei, keratin pearl formation, and scattered mitotic figures with surrounding fibrosis and inflammation. The patient was wheelchair-bound and oxygen-dependent and, thus, not considered a good surgical or radiation candidate. Treatment was decided with 5-fluorouracil. At a four-week follow-up appointment, there was no visible or palpable evidence of the tumor. There was no sign of recurrence at three months, indicating treatment success. The patient later died due to cardiac arrest in September 2017. The elderly population with cSCC can benefit from intervention and treatment with IL5-FU when surgery is not an option due to patient comorbidities. IL5-FU can potentially be used in areas where access to a dermatologist, surgeon, or surgical services is limited.

Common Skin Cancers in Older Adults Approach to Diagnosis and Management

Skin cancers are the most common malignancies to affect older adults. The most common skin cancers, basal and squamous cell carcinoma, can usually be cured with surgery. Although less common, melanoma can be deadly when not caught in its earliest stages.

Solitary Keratoacanthoma of the Scalp: A Case Report

Keratoacanthoma (KA) is a pruritic, rapidly growing cutaneous neoplasm originating from the infundibulum of the hair follicle on the sun-exposed area. Usually presents as a dome-shape with a centralized keratinous plug. Whether KA is benign or malignant is challenging due to its similarity to squamous cell carcinoma (SCC). In this case study, we present a 57-year-old patient who came to the surgery clinic with a rapidly growing ellipse-shaped nodule on her scalp for two years, which was diagnosed and treated as solitary KA by excisional biopsy. This case represents the first reported KA on the scalp of an elderly patient in Saudi Arabia.

Chemotherapeutical treatment of basal cell carcinoma with bleomycin via microinfusion of the drug into the skin (MMP®)

BACKGROUND

Bleomycin is a chemotherapeutical drug used to treat several neoplasias, including non-melanoma skin cancer; it is effective in the treatment of basal cell carcinoma (BCC) via intralesional infiltration. Transdermal drug delivery, which includes technologies such as CO2 Laser, Dermapen, Dermaroller and MMP®, delivers the desired medication to treat skin neoplasias and also acts in skin rejuvenation.

OBJECTIVE

To treat BCC lesions using bleomycin via MMP®.

METHODS

Ninety-eight BCC lesions in different anatomical areas were treated using MMP® technology to administer and uniformly distribute bleomycin throughout the lesion and in the established safety margin.

RESULTS

The cure rate after six months was 96.94%; and recurrences were not associated with lesion size and/or depth. Adverse effects were the expected ones.

STUDY LIMITATIONS

The follow-up time was only six months.

CONCLUSION

This therapeutic route showed to be promising and effective.

Exploring Nanocarriers as Treatment Modalities for Skin Cancer

Cancer is a progressive disease of multi-factorial origin that has risen worldwide, probably due to changes in lifestyle, food intake, and environmental changes as some of the reasons. Skin cancer can be classified into melanomas from melanocytes and nonmelanoma skin cancer (NMSC) from the epidermally-derived cell. Together it constitutes about 95% of skin cancer. Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (CSCC) are creditworthy of 99% of NMSC due to the limited accessibility of conventional formulations in skin cancer cells of having multiple obstacles in treatment reply to this therapeutic regime. Despite this, it often encounters erratic bioavailability and absorption to the target. Nanoparticles developed through nanotechnology platforms could be the better topical skin cancer therapy option. To improve the topical delivery, the nano-sized delivery system is appropriate as it fuses with the cutaneous layer and fluidized membrane; thus, the deeper penetration of therapeutics could be possible to reach the target spot. This review briefly outlooks the various nanoparticle preparations, i.e., liposomes, niosomes, ethosomes, transferosomes, transethosomes, nanoemulsions, and nanoparticles technologies tested into skin cancer and impede their progress tend to concentrate in the skin layers. Nanocarriers have proved that they can considerably boost medication bioavailability, lowering the frequency of dosage and reducing the toxicity associated with high doses of the medication.

The Immunotherapeutic Role of Type I and III Interferons in Melanoma and Non-Melanoma Skin Cancers

Interferons (IFNs) have demonstrated therapeutic potential in various skin cancers, specifically squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and melanoma. The precise mechanism through which type I IFNs exert their antitumor effects in skin cancers is still being studied. However, intralesional type I IFN can be used as an alternative to surgery for select patient populations, and high-dose systemic IFN therapy has been shown to be promising in patients with operable high-risk or metastatic melanoma. Despite the therapeutic potential of IFNs in skin cancer treatment, the toxicity profile often prevents the completion of treatment and further expansion of its clinical application. Type I and III IFNs use the same Janus Kinases (JAKs) for signal transduction, which are pathways initiated at a cell surface receptor that mediates the activation of target genes in the nucleus, based on this shared signaling pathway. Due to selective tumor targeting and the ability to generate both innate and adaptive immune responses, we concluded that type III IFNs have minimal side effects compared with established treatments due to selective tumor targeting. While IFN-λ, a type III IFN, shows therapeutic potential as stand-alone or in combination with another IFN, further studies need to be conducted to explore the therapeutic potential of IFN-λ in skin cancer and the underlying physiological roles and mechanisms of action. In this review, we evaluate whether treatment of skin cancer with type III IFN will have minimal side effects compared with established treatments.

Squamous Cell Carcinoma in Situ of the Nail Unit: Current Evidence and Recommendations for Patient Centered Treatment

Squamous cell carcinoma in situ of the hand and nail is an infrequent tumor but represents the majority of hand and nail malignancies. While the conventional treatments of invasive nail unit squamous cell carcinoma include Mohs micrographic surgery, wide local excision, or distal digit amputation, no standardized management paradigm for in situ disease exists and the necessity of surgical options is debated. This review aims to discuss the most commonly reported treatment methods and critically assess relevant management considerations in order to facilitate appropriate treatment decisions for nail unit SCCis across dermatologic practice settings. Assessment of the current literature reveals insufficient evidence to determine a standardized treatment for nail unit squamous cell carcinoma in situ. Rather, management is greatly impacted by multiple factors including the presence of subungual involvement, surgical candidacy, importance of curative treatment, and patient preferences regarding cosmesis and function versus cure. When cure is desired, Mohs micrographic surgery is the treatment of choice in most cases. In the setting of desired curative intent, but poor surgical candidacy, radiotherapy may be effective and provide a reasonable chance of functional and cosmetic preservation. Other methods including photodynamic therapy, electrodesiccation and curettage, cryotherapy, and intralesional chemotherapeutics may be appropriate in specific circumstances, but are generally limited by lack of evidence or impracticalities. Lastly, observation with palliation may be appropriate when considering exceedingly rare disease-related mortality.

Role of Cerium Oxide Nanoparticles and Doxorubicin in Improving Cancer Management: A Mini Review

Cancer is one of the significant issues with public health and the second leading cause of death worldwide. The three most lethal cancers in the general population are stomach, lung, and liver cancers, in which lung and breast cancers cause the majority of cancer-associated deaths among men and women, respectively. CeO2 nanoparticles have a cytoprotectant effect in normal cells and a cytotoxic effect in cancer cells that enables them to induce the reactive oxygen species (ROS) production within cancer cells, which in turn develops reactive nitrogen species (RNS) that interfere with intracellular activities, and this property makes them an excellent anticancer agent. Because of its biofilm suppression, free radical scavenging ability, redox activity, and other unique properties, attention has been bestowed on cerium oxide nanoparticles as a potential alternative to solve many biomedical issues in the future. This review mainly focuses on the combinatorial effect of cerium dioxide nanoparticles and Doxorubicin in cancer management.

Numerical Study on Death of Squamous Cell Carcinoma Based on Various Shapes of Gold Nanoparticles Using Photothermal Therapy

Due to increased exposure to ultraviolet radiation caused by increased outdoor activities, the incidence of skin cancer is increasing. Incision is the most typical method for treating skin cancer, and various treatments that can minimize the risks of incision surgery are being investigated. Among them, photothermal therapy is garnering attention because it does not cause bleeding and affords rapid recovery. In photothermal therapy, tumor death is induced via temperature increase. In this study, a numerical study based on heat transfer theory was conducted to investigate the death of squamous cell carcinoma located in the skin layer based on various shapes of gold nanoparticles (AuNPs) used in photothermal therapy. The quantitative correlation between the conditions of various AuNPs and the laser intensity that yields the optimal photothermal treatment effect was derived using the effective apoptosis ratio. It was confirmed that optimal conditions exist for maximizing apoptosis within a tumor tissue and minimizing the thermal damage to surrounding normal tissues when using AuNPs under various conditions. Furthermore, it is envisioned that research result will be utilized as a standard for photothermal treatment in the future.

Clinicopathological evaluation of intralesional methotrexate in different subtypes of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common malignant skin tumor. While slowly growing, it can cause major skin disfigurement. Therefore, novel cosmetically acceptable treatment options, other than surgery require investigation. to evaluate efficacy and safety of intralesional methotrexate (MTX) as a convenient modality for BCC treatment clinically and pathologicaly. A total of 20 patients with BCC of any clinical variant underwent intralesional MTX injection at a maximum 1 mL of 25 mg/mL MTX per session. Histopathological assessments were performed before and 1 month after treatment. 40% of patients showed >50% clinical improvement after 1-4 sessions. Intralesional MTX is a suitable and safe treatment modality for BCC and may be used as an adjuvant to surgery.

Needle-free jet injection-induced small-droplet aerosol formation during intralesional bleomycin therapy

OBJECTIVES

Needle-free jet injectors are frequently used in dermatological practice. Injection-generated small-droplet aerosols could be harmful upon inhalation when chemotherapeutics, like bleomycin, are used. Here, we aim to explore jet injector-induced small-droplet aerosol formation of bleomycin in relation to air ventilation and to provide safety measures for clinical practice.

MATERIALS AND METHODS

With a professional particle sensor, we measured airborne aerosol particles (0.2-10.0 µm) after electronic pneumatic injection (EPI), spring-loaded jet injection (SLI), and needle injection (NI) of bleomycin and saline (100 μl) on ex vivo human skin. Three levels of air ventilation were explored: no ventilation, room ventilation, and room ventilation with an additional smoke evacuator.

RESULTS

EPI and SLI induced significant small-droplet aerosol formation compared with none after NI (0.2-1.0 µm; no ventilation). The largest bleomycin aerosol generation was observed for the smallest particles (0.2-1.0 µm) with 673.170 (528.802-789.453) aerosol particles/liter air (EPI; no ventilation). Room ventilation and smoke evacuation led to a reduction of ≥99% and 100% of measured aerosols, respectively.

CONCLUSION

Jet injectors generate a high number of small-droplet aerosols, potentially introducing harmful effects to patients and healthcare personnel. Room ventilation and smoke evacuation are effective safety measures when chemotherapeutics are used in clinical practice.

Intralesional Agents in Dermatology: Pros and Cons

Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.

Non-Surgical Treatments for Keratinocyte Carcinomas

Skin cancer is the most common malignancy worldwide, comprising approximately 30% of all human tumors. In recent decades, the incidence of keratinocyte carcinomas, which include basal cell carcinoma and cutaneous squamous cell carcinoma, has been steadily increasing globally (Rogers et al. in JAMA Dermatol 151(10):1081-1086. https://doi.org/10.1001/jamadermatol.2015.1187 , 2015; Nehal and Bichakjian in N Engl J Med 379(4):363-374. https://doi.org/10.1056/nejmra1708701 , 2018). Most tumors are cured with surgical excision; however, some tumors are best treated with non-surgical approaches. Superficial tumors can often be cured with non-surgical methods whereas more advanced stage tumors may not be amenable to surgery. Additionally, surgical treatment may not be available for all populations depending on geographic location and accessibility to care. This article reviews commonly utilized nonsurgical options such as cryotherapy, photodynamic therapy, topical treatments, and radiation as well as systemic treatments including immunotherapies and chemotherapies.

Effectiveness of neoadjuvant intralesional methotrexate in cutaneous squamous cell carcinoma: A prospective cohorts study

Intralesional methotrexate (il-MTX) has been used in cutaneous squamous cell carcinoma (cSCC) achieving important reductions in tumor size. However, there is a lack of controlled studies on this regard. The primary objective was to analyze the effect of il-MTX on tumor size in cSCC. As a secondary objective, we evaluated its impact on the surgical approach. We conducted a prospective cohorts study that included 200 patients with histologically confirmed cSCC. Patients in Group 1 (Cases) received neoadjuvant treatment with il-MTX prior to surgery. Patients in Group 2 (Controls) underwent scheduled surgery without prior neoadjuvant therapy. Clinical measurements of lesions were made at the time of inclusion in the study and before surgery. No intergroup statistical differences were found between the assessed variables. In Group 1, tumor size reduction occurred in 93% of the patients after il-MTX therapy. Tumor surface was reduced by 54%. Complex reconstructions were needed in 15% of these patients. In Group 2, tumor surface increased by 33.1% and complex reconstructions were needed in 40% of patients. Intergroup differences were statistically significant (p < 0.001). Neoadjuvant Il-MTX therapy achieves very important tumor size reduction and significantly simplifies surgical treatment.

Gold Nanoparticles- Boon in Cancer Theranostics

BACKGROUND

Cancer is the world's second-largest cause of death, with an estimated 9.6 million fatalities in 2018. Malignant tumour (cancer) is caused by a mixture of genetic modifications due to the environmental variables that tend to activate or inactivate different genes, ultimately resulting in neoplastic transformations. Cancer is a multi-stage process that results from the conversion of the ordinary cells to tumour cells and progresses from a pre-cancer lesion to abnormal growth.

METHODS

Chemotherapy inhibits the ability of the cells to divide rapidly in an abnormal manner, but this treatment simultaneously affects the entire cellular network in the human body leading to cytotoxic effects. In this review article, the same issue has been addressed by discussing various aspects of the newer class of drugs in cancer therapeutics, i.e., Gold Nanoparticles (AuNPs) from metal nanoparticle (NP) class.

RESULTS

Metal NPs are advantageous over conventional chemotherapy as the adverse drug reactions are lesser. Additionally, ease of drug delivery, targeting and gene silencing are salient features of this treatment. Functionalized ligand-targeting metal NPs provide better energy deposition control in tumour. AuNPs are promising agents in the field of cancer treatment and are comprehensively studied as contrast agents, carriers of medicinal products, radiosensitizers and photothermal agents. For the targeted delivery of chemotherapeutic agents, AuNPs are used and also tend to enhance tumour imaging in vivo for a variety of cancer types and diseased organs.

CONCLUSION

The first part of the review focuses on various nano-carriers that are used for cancer therapy and deals with the progression of metal NPs in cancer therapy. The second part emphasizes the use of nanotechnology by considering the latest studies for diagnostic and therapeutic properties of AuNPs. AuNPs present the latest studies in the field of nanotechnology, which leads to the development of early-stage clinical trials. The next part of the review discusses the major features of five principal types of AuNPs: gold nanorods, gold nanoshells, gold nanospheres, gold nanocages, and gold nanostars that have their application in photothermal therapy (PTT).

Neoadjuvant Therapy for Non-melanoma Skin Cancer: Updated Therapeutic Approaches for Basal, Squamous, and Merkel Cell Carcinoma

OPINION STATEMENT

Recently introduced systemic therapies for locally advanced and metastatic non-melanoma skin cancers (NMSCs) are paving the way for neoadjuvant approach. Although none of the therapeutic options has currently gained indication in this setting, neoadjuvant approach for NMSCs is an open field and we are likely to see huge developments in the near future. Targeted therapy with sonic hedgehog pathway inhibitors is very effective in locally advanced or multiple basal cell carcinomas while immunotherapy with immune checkpoint inhibitors appears to be promising for advanced cutaneous squamous cell carcinoma and Merkel cell carcinoma. To date, targeted therapy and immunotherapy represent the frontiers in NMSC therapeutic management and, according to recent studies, good results can be achieved.

Intralesional methotrexate in dermatology: Diverse indications and practical considerations

Intralesional methotrexate (IL-MTX) is a long-established treatment, which is arguably underutilized by dermatologists. We describe the underlying evidence base and practical considerations for its broad range of cutaneous indications, including in cutaneous oncology (keratoacanthomas, squamous cell carcinomas, lymphomas), inflammatory dermatology (nail psoriasis, plaque psoriasis, pyoderma gangrenosum, cutaneous Crohn's disease, amyloidosis), cutaneous infections (viral warts) and for treatment of filler complications. In certain circumstances, IL-MTX can be more efficacious and less invasive than other treatments, with fewer adverse effects. Dermatologists should consider using IL-MTX for a range of recalcitrant cutaneous conditions, particularly for those patients not amenable to surgery or systemic therapy.

Histological findings after intralesional methotrexate treatment in cutaneous squamous cell carcinoma

Intralesional methotrexate (il-MTX) has been reported as a useful therapy in keratoacanthoma (KA) and cutaneous squamous cell carcinoma (cSCC). However, the data available on the histological changes induced by this therapy are very scarce. We conducted a single center, prospective study that included 65 cases of cSCC treated with il-MTX before surgical treatment. Two histological studies were conducted in all patients: before intralesional treatment and after surgical removal. Lesions were assessed longitudinally both clinically and histologically. 60 patients (92.3%) responded to il-MTX treatment. There were no differences regarding aggressive histological features of the cSCC between responder and non-responder patients. All cases showed a chronic inflammatory infiltrate after il-MTX. Intratumoral necrosis areas were frequently observed. All cases showed local fibrosis with fine thickening of collagen bundles. Il-MTX induces a chronic lymphohistiocytic inflammatory reaction in both clinical responder and nonresponder patients. Tumor involution after il-MTX is followed by a fine fibrosis that explains the great cosmetic results and improves the accuracy of the follow-up.

In Search of a Phosphorus Dendrimer-Based Carrier of Rose Bengal: Tyramine Linker Limits Fluorescent and Phototoxic Properties of a Photosensitizer

Photodynamic therapy (PDT) is a skin cancer treatment alternative to chemotherapy and radiotherapy. This method exploits three elements: a phototoxic compound (photosensitizer), light source and oxygen. Upon irradiation by light of a specific wavelength, the photosensitizer generates reactive oxygen species triggering the cascade of reactions leading to cell death. The positive therapeutic effect of PDT may be limited due to low solubility, low tumor specificity and inefficient cellular uptake of photosensitizers. A promising approach to overcome these obstacles involves the use of nanocarrier systems. The aim of this initial study was to determine the potential of the application of phosphorus dendrimers as carriers of a photosensitizer—rose bengal (RB). The primary goal involved the synthesis and in vitro studies of covalent drug–dendrimer conjugates. Our approach allowed us to obtain RB–dendrimer conjugates with the use of tyramine as an aromatic linker between the carrier and the drug. The compounds were characterized by FT-IR, ¹H NMR, ¹³C NMR, ³¹P NMR, size and zeta potential measurements and spectrofluorimetric analysis. The dialysis to check the drug release from the conjugate, flow cytometry to specify intracellular uptake, and singlet oxygen generation assay were also applied. Finally, we used MTT assay to determine the biological activity of the tested compounds. The results of our experiments indicate that the conjugation of RB to phosphorus dendrimers via the tyramine linker decreases photodynamic activity of RB.

Field cancerization: Treatment

The goal of field cancerization treatment is to reduce the risk of developing keratinocyte carcinoma. Selecting the appropriate therapy depends on the degree of field cancerization and the number of invasive cutaneous squamous cell carcinomas. Other considerations include treatment efficacy, cost, side effects, and patient preference. Field therapies are preferred because they address clinically visible disease and subclinical atypia. However, lesion-directed therapies are useful for lesions that are more difficult to treat or those where a histologic diagnosis is required. Patients with extensive field cancerization benefit from a combination of field-directed and lesion-directed treatments. The second article in this continuing medical education series provides a framework to guide evidence-based decision making for field cancerization treatment.

STAR particles for enhanced topical drug and vaccine delivery

Drug delivery to the skin is highly constrained by the stratum corneum barrier layer¹. Here, we developed star-shaped particles, termed STAR particles, to dramatically increase skin permeability. STAR particles are millimeter-scale particles made of aluminum oxide or stainless steel with micron-scale projections designed to create microscopic pores across the stratum corneum. After gentle topical application for 10 s to porcine skin ex vivo, delivery of dermatological drugs and macromolecules, including those that cannot be given topically, was increased by 1 to 2 orders of magnitude. In mice treated with topical 5-fluorouracil, use of STAR particles increased the efficacy of the drug in suppressing the growth of subcutaneous melanoma tumors and prolonging survival. Moreover, topical delivery of tetanus toxoid vaccine to mice using STAR particles generated immune responses that were at least as strong as delivery of the vaccine by intramuscular injection, albeit at a higher dose for topical than intramuscular vaccine administration. STAR particles were well tolerated and effective at creating micropores when applied to the skin of human participants. Use of STAR particles provides a simple, low-cost and well-tolerated method for increasing drug and vaccine delivery to the skin and could widen the range of compounds that can be topically administered.

Evolving Role of Systemic Therapies in Non-melanoma Skin Cancer

Keratinocyte cancers - basal and cutaneous squamous cell carcinoma (BCC, cSCC) - are the most common forms of non-melanoma skin cancer (NMSC) and there has been a significant increase in their incidence globally in recent decades. Although the majority of BCC and cSCC are cured with conventional surgery or radiotherapy, certain tumour or patient-determined factors may result in these modalities being inadequate or inappropriate, for example, locally advanced or metastatic disease, high tumour multiplicity, patient comorbidities and patient preferences. In these clinical circumstances, systemic treatment may be indicated, and over the past 10 years a number of new systemic agents have been approved. Nonetheless, effective systemic therapy for keratinocyte cancers remains an area of significant unmet clinical need. Improved understanding of the molecular and immune pathogenesis underlying tumour growth and development is critical for driving future advances and is a research priority. The aim of this review is to provide clinicians with an overview of systemic treatments for BCC and cSCC and will focus on current evidence for conventional chemotherapy, targeted therapies, immunotherapy, adjuvant and neoadjuvant therapy, chemoprevention and future prospects for novel systemic treatment approaches.

Wnt Signaling Pathways in Keratinocyte Carcinomas

The skin functions as a barrier between the organism and the surrounding environment. Direct exposure to external stimuli and the accumulation of genetic mutations may lead to abnormal cell growth, irreversible tissue damage and potentially favor skin malignancy. Skin homeostasis is coordinated by an intricate signaling network, and its dysregulation has been implicated in the development of skin cancers. Wnt signaling is one such regulatory pathway orchestrating skin development, homeostasis, and stem cell activation. Aberrant regulation of Wnt signaling cascades not only gives rise to tumor initiation, progression and invasion, but also maintains cancer stem cells which contribute to tumor recurrence. In this review, we summarize recent studies highlighting functional evidence of Wnt-related oncology in keratinocyte carcinomas, as well as discussing preclinical and clinical approaches that target oncogenic Wnt signaling to treat cancers. Our review provides valuable insight into the significance of Wnt signaling for future interventions against keratinocyte carcinomas.

Aging and the treatment of basal cell carcinoma

Basal cell carcinoma (BCC) is the most commonly diagnosed type of skin cancer. BCCs are especially prevalent in the elderly population, given their association with cumulative sun exposure and other risk factors. In this contribution, we outline geriatric concepts related to the care of older adults with BCCs. We describe how a patient's life expectancy can be estimated and combined with tumor characteristics to determine lag time to benefit, a concept to better understand whether patients will experience the efficacy of a treatment within their life span. We also review the possibility of current BCC overdiagnosis and summarize the effectiveness, benefits, and risks of common treatments for BCCs, noting that all treatment modalities have special considerations when administered to older adults. In particular, nonsurgical treatments might be preferable for older adults with a limited life expectancy. Ultimately, we argue that the decision of whether and how to treat a BCC should be the result of shared decision-making between the provider and the patient and take into account not only tumor characteristics, but also patient values and preferences.

Keratinocyte Carcinomas: Current Concepts and Future Research Priorities

Cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC) are keratinocyte carcinomas, the most frequently diagnosed cancers in fair-skinned populations. Ultraviolet radiation (UVR) is the main driving carcinogen for these tumors, but immunosuppression, pigmentary factors, and aging are also risk factors. Scientific discoveries have improved the understanding of the role of human papillomaviruses (HPV) in cSCC as well as the skin microbiome and a compromised immune system in the development of both cSCC and BCC. Genomic analyses have uncovered genetic risk variants, high-risk susceptibility genes, and somatic events that underlie common pathways important in keratinocyte carcinoma tumorigenesis and tumor characteristics that have enabled development of prediction models for early identification of high-risk individuals. Advances in chemoprevention in high-risk individuals and progress in targeted and immune-based treatment approaches have the potential to decrease the morbidity and mortality associated with these tumors. As the incidence and prevalence of keratinocyte carcinoma continue to increase, strategies for prevention, including effective sun-protective behavior, educational interventions, and reduction of tanning bed access and usage, are essential. Gaps in our knowledge requiring additional research to reduce the high morbidity and costs associated with keratinocyte carcinoma include better understanding of factors leading to more aggressive tumors, the roles of microbiome and HPV infection, prediction of response to therapies including immune checkpoint blockade, and how to tailor both prevention and treatment to individual risk factors and needs.

Intralesional Methotrexate for the Treatment of Keratoacanthoma: The Neapolitan Experience

Introduction

Keratoacanthomas are cutaneous neoplasms known for their rapid growth and spontaneous regression over a long time period. Their treatment can be difficult because of the potentially large field size and number of lesions. Intralesional methotrexate constitutes an effective, nonsurgical treatment of keratoacanthomas, as proven by our experience.

Methods

We treated 11 elderly patients affected by keratoacanthoma with intralesional methotrexate. The injections were performed weekly, followed by 10 mg of folic acid to be taken 24 h later.

Results

All our patients underwent complete resolution of the lesions after 4–8 injections, without side effects.

Conclusion

Intralesional methotrexate seems to be an effective and safe nonoperative treatment modality for keratoacanthoma, especially when it arises in anatomic areas difficult to treat with surgery, in elderly debilitated patients, and in those refusing surgery.

Diagnosis and Management of Basal Cell Carcinoma

OPINION STATEMENT

Basal cell carcinomas (BCCs) are common skin cancers that tend to appear on sun-exposed skin. Pathobiologically, activation of the Hedgehog signaling pathway characterizes the majority of cases. In general, BCCs are slow-growing and rarely metastasize. Nevertheless, they are locally invasive and can be destructive. While typical cases are diagnosed based on clinical findings, the clinicopathological manifestations are varied. Consequently, skin biopsy is essential to confirm the diagnosis and evaluate the risk of recurrence. In the treatment of primary lesions, the initial goal is to complete tumor removal, whether by conventional surgical excision, Mohs micrographic surgery, cryosurgery, electrodesiccation and curettage, topical application of imiquimod or fluorouracil, photodynamic therapy, or radiation therapy. Of these treatments, surgical excision and Mohs surgery are the most commonly used because of their association with a low recurrence rate and the ability to confirm residual tumor pathologically. However, other treatment options may be preferred according to patient condition, tumor location, and risk of recurrence. In the treatment of metastatic or locally advanced lesions, smoothened inhibitors, which inhibit Hedgehog signaling pathway activation, were recently approved and impressive tumor shrinkage effects have been described. Although the exact prognosis of metastatic BCC has not been analyzed, it is probably poor due to the rarity of such condition. However, emerging molecular targeting agents hold therapeutic promise.

Curcumin in combination with anti-cancer drugs: A nanomedicine review

A huge surge of research is being conducted on combination therapy with anticancer compounds formulated in the form of nanoparticles (NPs). Numerous advantages like dose minimalization and synergism, reversal of multi drug resistance (MDRs), enhanced efficacy have emerged with nanoencapsulation of chemotherapeutic agents with chemo-sensitizing agent like curcumin. Within last couple of years various nano-sized formulations have been designed and tested both in vitro with cell lines for different types of cancers and in vivo with cancer types and drug resistance models. Despite the combinatorial models being advanced, translation to human trials has not been as smooth as one would have hoped, with as few as twenty ongoing clinical trials with curcumin combination, with less than 1/10th being nano-particulate formulations. Mass production of nano-formulation based on their physico-chemical and pharmacokinetics deficits poses as major hurdle up the ladder. Combination of these nano-sized dosage with poorly bioavailable drugs, unspecific target binding ability and naturally unstable curcumin further complicates the formulation aspects. Emphasis is now therefore being laid on altering natural forms of curcumin and usage of formulations like prodrug or coating of curcumin to overcome stability issues and focus more on enhancing the pharmaceutical and therapeutic ability of the nano-composites. Current studies and futuristic outlook in this direction are discussed in the review, which can serve as the basis for upcoming research which could boost commercial translational of improved nano-sized curcumin combination chemotherapy.

Recent advances in field cancerization and management of multiple cutaneous squamous cell carcinomas

Cutaneous squamous cell carcinoma (SCC) is among the most common cancers in humans, and many patients with SCC will develop multiple tumors within their lifetime. The field cancerization concept, originally proposed over 60 years ago, hypothesized that multiple primary cancers may arise simultaneously and coexist with subclinical precursor lesions within a defined field. Genetic sequencing of SCC and precursor lesions has identified what may be the earliest clonal proliferations in SCC development and confirmed that field cancerization in the skin is mediated by ultraviolet radiation. For patients with multiple SCCs and severe actinic damage, treatment of precursor lesions within a cancerized field can decrease the risk of subsequent cancer development. Sunblock is an effective intervention for field cancerization, even in patients with established disease. There is now direct evidence that field therapy with topical 5-fluorouracil is effective in reducing the incidence of subsequent SCC, and there is indirect evidence suggesting that topical imiquimod, topical ingenol mebutate, and photodynamic therapy are similarly effective. There is limited direct evidence to show that systemic acitretin or nicotinamide can decrease incident SCC in patients with field cancerization. In this review, an approach to the management of patients with multiple SCCs and field cancerization is presented along with the rationale to support field-directed therapy.

Keratoacanthoma-Like Growths of Incontinentia Pigmenti Successfully Treated with Intralesional Methotrexate

We report the case of a 17-year-old girl with incontinentia pigmenti who developed multiple large hyperkeratotic tumors within Blaschkoid hyperpigmented patches on her left leg. Biopsy demonstrated an endoexophytic nodule with irregular invaginations of keratinizing squamous epithelium and a central keratin-filled crater, consistent with keratoacanthoma-like lesions of incontinentia pigmenti. The tumors were successfully treated with intralesional methotrexate.

Co-delivery of curcumin and STAT3 siRNA using deformable cationic liposomes to treat skin cancer

Skin cancer is one of the most widely prevalent cancer types with over expression of multiple oncogenic signaling molecules including STAT3. Curcumin is a natural compound with effective anti-cancer properties. The objective of this work was to investigate the liposomal co-delivery of curcumin and STAT3 siRNA by non-invasive topical iontophoretic application to treat skin cancer. Curcumin was encapsulated in cationic liposomes and then complexed with STAT3 siRNA. The liposomal nanocomplex was characterized for particle size, zeta-potential, drug release and stability. Human epidermoid (A431) cancer cells were used to study the cell uptake, growth inhibition and apoptosis induction of curcumin-loaded liposome-siRNA complex. Topical iontophoresis was applied to study the skin penetration of nanocomplex in excised porcine skin model. Results showed that curcumin-loaded liposome-siRNA complex was rapidly taken up by cells preferentially through clathrin-mediated endocytosis pathway. The co-delivery of curcumin and STAT3 siRNA using liposomes resulted in significantly (p < .05) greater cancer cell growth inhibition and apoptosis events compared with neat curcumin and free STAT3 siRNA treatment. Furthermore, topical iontophoresis application enhanced skin penetration of nanocomplex to penetrate viable epidermis. In conclusion, cationic liposomal system can be developed for non-invasive iontophoretic co-delivery of curcumin and siRNA to treat skin cancer.

Non-melanoma Skin Cancer in Canada Chapter 5: Management of Squamous Cell Carcinoma

Background

Squamous cell carcinoma (SCC) is the second-most common form of non-melanoma skin cancer (NMSC).

Objective

To provide guidance to Canadian health care practitioners regarding management of SCCs.

Methods

Literature searches and development of graded recommendations were carried out as discussed in the accompanying introduction (chapter 1 of the NMSC guidelines).

Results

SCCs are sometimes confined to the epidermis, but they can also invade nearby tissues and, in some cases, metastasize to neighbouring lymph nodes or other organs. This chapter discusses the natural history, staging, prognosis, and management of SCC—a tumour type that is less common but typically more aggressive than BCC. For this reason, margin control is strongly preferred in treating SCCs.

Conclusions

Although approaches such as cryosurgery and radiation therapy may be considered for some patients, surgical excision—sometimes coupled with radiation—remains the cornerstone of SCC management. Patients with high-risk SCC may also be considered for referral to an appropriate multidisciplinary clinic.

Intralesional Bleomycin as an Adjunct Therapeutic Modality in Eyelid and Extraocular Malignancies and Tumors

To present our recent experience with intralesional bleomycin (IBI) in nonmelanoma extraocular tumors, and present previous experience on periocular capillary hemangiomas and orbital lymphangiomas in a tertiary referral hospital. This was a retrospective descriptive study of patients with eyelid and extraocular malignancies where conventional therapies failed, or surgery was contraindicated or refused and were offered IBI as an alternate therapy. All patients were recruited from the Oculoplastics Clinic at Tygerberg Academic Hospital, Cape Town, South Africa. A solution containing 1 international unit of bleomycin per milliliter saline was injected intralesionally together with 2% lignocaine in a ratio of 4:1. The injected volume was calculated to be equivalent to the estimated volume of the lesion. A multipuncture technique with a 29-gauge needle was used. Patients requiring retreatment were injected every 4–8 weeks until satisfactory clinical endpoints were achieved. Our previous experience with IBI in extensive capillary hemangiomas and orbital lymphangiomas is reviewed. Cases are presented to illustrate that IBI induced significant regression and reduction in tumor size and marked clinical improvement of the eyelid and orbital basal cell carcinomas, Kaposi sarcoma, and mycosis fungoides. The improvements obviated the need for further surgical intervention in most cases. Based on clinical experience we propose that IBI should be considered a treatment modality in select cases of the malignant eyelid and ophthalmic vascular tumors where the conventional standard of care is not possible. IBI is a reasonable alternative or adjunct to consider in such cases.

Keratoacanthoma (KA): An update and review

Keratoacanthoma (KA) is a common but underreported tumor of the skin. Two striking features of KA are its clinical behavior with spontaneous regression after rapid growth and its nosological position on the border between benignity and malignancy. We review current knowledge on the clinical, histopathological, and dermoscopic features of KA to ensure a proper diagnosis and describe its variants, including different types of multiple KAs. We highlight current concepts of KA ethiopathogenesis with special emphasis on the genetic background of multiple familial KA, the role of Wnt signaling pathway, and induction of KA by BRAF inhibitors and procedures of esthetic dermatology. Finally, treatment strategies are presented with surgical excision as a first option, followed by other modalities, including intralesional chemotherapy, topical and systemic agents, lasers, cryotherapy, and photodynamic therapy.