An evolving paradigm for the workup and management of high-risk cutaneous squamous cell carcinoma

Aggressive Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Review

Non-melanoma skin cancer of the head and neck (NMSCHN) is one of the most common malignancies worldwide, and its incidence is growing at a significant rate. It has been found to be aggressive in its spread and has the capacity to metastasize to regional lymph nodes. Cutaneous squamous cell carcinoma (cSCC) has a considerably high mortality rate. It has remarkable characteristics: diameter >2 cm, depth >5 mm, high recurrence, perineural invasion, and locoregional metastases. Aggressive cSCC lesions most commonly metastasize to the parotid gland. Also, immunocompromised patients have a higher risk of developing this aggressive cancer along with the worst prognostic outcomes. It is very important to discuss and assess the risk factors, prognostic factors, and outcomes of patients with cSCC, which will give clinicians future directives for making modifications to their treatment plans. The successful treatment of aggressive cSCC of the head and neck includes early detection and diagnosis, surgery alone or adjuvant chemotherapy, and radiotherapy as required. Multimodal therapy options should be considered by clinicians for better outcomes of aggressive cSCC of the head and neck.

Evidence-Based Consensus Recommendations for the Evolving Treatment of Patients with High-Risk and Advanced Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma is the second most common skin cancer in the United States. Currently, there is no standardized management approach for patients with cutaneous squamous cell carcinoma who develop metastatic or locally advanced disease and are not candidates for curative surgery or curative radiation. To address this issue, the Expert Cutaneous Squamous Cell Carcinoma Leadership program convened an expert steering committee to develop evidence-based consensus recommendations on the basis of a large, structured literature review. Consensus was achieved through modified Delphi methodology. The steering committee included five dermatologists, three medical oncologists, two head and neck surgeons, one radiation oncologist, and a patient advocacy group representative. The steering committee aligned on the following clinical topics: diagnosis and identification of patients considered not candidates for surgery; staging systems and risk stratification in cutaneous squamous cell carcinoma; the role of radiation therapy, surgery, and systemic therapy in the management of advanced disease, with a focus on immunotherapy; referral patterns; survivorship care; and inclusion of the patient’s perspective. Consensus was achieved on 34 recommendations addressing 12 key clinical questions. The Expert Cutaneous Squamous Cell Carcinoma Leadership steering committee’s evidence-based consensus recommendations may provide healthcare professionals with practically oriented guidance to help optimize outcomes for patients with advanced cutaneous squamous cell carcinoma.

Adjuvant radiotherapy may not significantly change outcomes in high-risk cutaneous squamous cell carcinomas with clear surgical margins: A systematic review and meta-analysis

BACKGROUND

The role of adjuvant radiotherapy for high-risk cutaneous squamous cell carcinomas (cSCC) after surgery with negative margins is unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis examining the risk of poor outcomes for those treated with surgery vs. surgery and adjuvant radiotherapy.

METHODS

A comprehensive search of articles was executed in PubMed, Embase, and Cochrane Database. Random-effected meta-analyses were conducted.

RESULTS

Thirty-three studies comprised of 3,867 high-risk cSCC were included. There were no statistically significant differences in poor outcomes between the surgery vs. surgery and adjuvant radiotherapy groups. Estimates for local recurrence were 15.2% (95% confidence interval [CI]: 6.3%-27%) vs. 8.8% (CI: 1.6%-20.9%), regional metastases were 11.5% (CI: 7.2%-16.7%) vs. 4.4% (CI: 0%-18%), distant metastases were 2.6% (CI: 0.6%-6%) vs. 1.7% (CI: 0.2%-4.5%) and disease-specific deaths were 8.2% (CI: 1.2%-20.6%) vs. 19.7% (CI: 3.8%-43.7%) for the surgery group vs. surgery and adjuvant radiotherapy group respectively.

LIMITATIONS

Retrospective nature of most studies with a lack of sufficient patient-specific data.

CONCLUSIONS

For patients with high risk cSCC treated with margin-negative resection, there were no differences in poor outcomes between the surgery vs. surgery and adjuvant radiotherapy groups. Randomized-controlled trials are necessary to define the benefit of adjuvant radiotherapy in this setting.

Review of Perineural Invasion in Keratinocyte Carcinomas

Perineural invasion is an infiltrative process of peripheral nerves by the primary neoplasm within the immediate vicinity. Aggressive forms of keratinocyte carcinomas, such as basal cell and squamous cell carcinomas, may feature perineural invasion, which is often associated with tumor recurrence and poorer prognosis. Diagnosis requires a high clinical suspicion. Imaging and histopathology are used to assess for extent of disease while surgical excision with complete circumferential peripheral and margin assessment is the treatment goal. However, there is still significant uncertainty about adjuvant chemotherapy and definitive management guidelines. Here, we summarize the current understanding of this complex pathogenic process, the clinical presentation, and the significance of perineural inflammation. We also discuss the recommendations about staging, prognosis, adjuvant radiotherapy, and general guidelines for managing keratinocyte carcinomas with perineural invasion. A better understanding of perineural invasion is essential to improve diagnosis, tailor interventions, and mitigate patient morbidity and mortality.

Efficacy and prognostic factors of adjuvant radiotherapy for cutaneous squamous cell carcinoma: A systematic review and meta-analysis

Although adjuvant radiotherapy has been used for cutaneous squamous cell carcinoma, its outcome benefits, especially for patients with clear surgical margins, have not been statistically estimated, and the characteristics that can indicate patients who require adjuvant therapy need to be validated with more evidence. We conducted a systematic review and meta-analysis of literature on the survival outcomes and prognostic factors in patients with cSCC treated by surgery with or without adjuvant radiotherapy. Twenty related studies involving 2605 patients met our inclusion criteria. The significant survival outcomes of adjuvant radiotherapy included lower recurrence (OR, 0.56; 95% CI, 0.36-0.85), longer disease-free survival (OR, 2.17; 95% CI, 1.23-3.83) and longer overall survival (OR, 2.94; 95% CI, 1.75-4.91). Significant prognostic factors for poor outcomes were perineural invasion (HR, 1.61; 95% CI, 1.24-2.09), involved surgical margins (HR, 2.34; 95% CI, 1.42-3.83) and immunosuppression (HR, 3.02; 95% CI, 2.14-4.25) while adjuvant radiotherapy significantly contributed to better overall survival (HR, 0.47; 95% CI, 0.34-0.65). In conclusion, this systematic review suggests that in cutaneous squamous cell carcinoma patients with risk factors, including metastasis to the parotid gland, perineural invasion and immunosuppression, the use of adjuvant radiotherapy may be beneficial irrespective of surgical margin status.

Cemiplimab for locally advanced cutaneous squamous cell carcinoma: safety, efficacy, and position in therapy panel

INTRODUCTION

Locally advanced cutaneous squamous cell carcinoma (lacSCC) is rare. Approximately one-fourth of the cases are observed among immunocompromised patients, in particular in solid organ transplant recipients (OTRs). LacSCC has a very poor prognosis. Surgery with or without radiotherapy remains the golden standard of treatment for cSCC. However, in advanced cases, there is a medical need for alternative treatment options. Classic systemic treatments include chemotherapy and/or EGFR inhibitors. Recently the effectiveness of programmed cell death protein-1 (PD-1) inhibitors has been demonstrated for lacSCC. Cemiplimab is a recombinant IgG4 human monoclonal antibody against the PD-1 protein for the intravenous treatment of lacSCC.

AREAS COVERED

The principal studies evaluating the efficacy and safety of cemiplimab for lacSCC are presented.

EXPERT OPINION

Cemiplimab is the first anti-PD-1 antibody that was FDA (2018) and EMA (2019) approved as a systemic treatment for lacSCC and/or metastatic cSCC when curative surgery or radiotherapy is no longer amenable. For this situation, experts currently recommend cemiplimab as a first-line systemic alternative. As cemiplimab therapy is potentially associated with a risk of organ graft rejection, pros and cons should be evaluated for every individual OTR patient with lacSCC.

High-dose-rate brachytherapy using Leipzig applicators for non-melanoma localized skin cancer

Purpose

Technological advances with commercial production of surface applicators allowed high-dose-rate (HDR) afterloading brachytherapy to overpass challenges associated with the delivery of superficial radiation when treating non-melanoma skin cancer (NMSC). We reviewed our single institutional experience using HDR to treat basal (BCC) and squamous cell (SCC) carcinomas.

Material and methods

A retrospective review of all patients treated with HDR and Leipzig-style applicators for NMSC at the Radiation Oncology Department, AC Camargo Cancer Center, from March 2013 to December 2018 was performed.

Results

Seventy-one patients with 101 lesions (BCCs, 69.3% or n = 70) and median age 80 (range, 51-102) years old were evaluated. The median follow-up was 42.8 (range, 12-82) months. The 3-year and 5-year actuarial local control (LC) rates were 97.9% and 87.2%, respectively. On univariate analysis, treatments with EQD₂ less than 50 Gy (p < 0.001) and dose per fraction smaller than 3 Gy (p < 0.001) were found to be statistically significant predictive factors of a worse outcome. On multivariate analysis, SCC had a worse prognosis over BCC (p = 0.007, HR = 2.3, CI: 1.2-6.6). All patients developed some degree of acute side effects graded 1 to 2. Grade 3 acute side effects were observed in 9 (8.9%) patients. Moreover, severe late side effects (grade 3), hypopigmentation, and telangiectasia were observed in 4 (3.9%) patients. No grade 4 acute or late side effects were seen in this cohort.

Conclusions

HDR offers a convenient treatment schedule for patients and is associated with excellent LC. The most effective regimen, in terms of dose and fractionation, to treat superficial NMSC with HDR remains uncertain, but a moderate minimum EQD₂ dose of 50 Gy should be used.

Vandetanib inhibits cell growth in EGFR-expressing cutaneous squamous cell carcinoma

Advanced cutaneous squamous cell carcinoma (SCC) responds poorly to chemotherapy, leading to significant morbidity or death. Overexpression of epidermal growth factor receptor (EGFR) is frequently observed in advanced cutaneous SCC. Vandetanib is a multiple tyrosine kinase targeting vascular endothelial growth factor receptor-2 (VEGFR2), EGFR, and the rearranged during transfection (RET) proto-oncogene. Vandetanib has been reported to inhibit tumor growth in head and neck SCC. However, the efficacy of vandetanib against cutaneous SCC has not been thoroughly investigated. The aim of this study is to evaluate the efficacy of vandetanib against cutaneous SCC in vitro and in vivo. Vandetanib is found to inhibit the proliferation of cutaneous SCC cells as assessed by cell viability and clonogenic assay. Cell death analysis indicates that vandetanib induces cell death in SCC cells but not in normal human keratinocytes or fibroblasts. The in vivo anti-tumor effect of vandetanib is shown in xenograft tumor models using A431 SCC cells. Mechanistically, vandetanib suppresses the phosphorylation of EGFR in SCC cells. Clinically, EGFR expression levels are elevated in cutaneous SCC specimens, relative to normal epidermis. In conclusion, we identified vandetanib as a novel therapeutic option for cutaneous SCC, especially in tumors with high EGFR expression.

Recent and Emerging Therapies for Cutaneous Squamous Cell Carcinomas of the Head and Neck

OPINION STATEMENT

Cutaneous squamous cell carcinoma (cSCC) of the head and neck is typically managed with Mohs Micrographic Surgery (MMS) for cosmetic reasons. MMS also improves oncologic outcomes for high-risk tumors. Patients with certain high-risk subsets of the disease also benefit from adjuvant radiation therapy. The PD-1 inhibitor, cemiplimab, was recently approved for treatment of locally advanced and metastatic cSCC unamenable to curative surgery or radiation therapy after the drug demonstrated encouraging, durable response rates. Cemiplimab and other systemic immunotherapies are now being evaluated in clinical trials in the neoadjuvant and adjuvant settings as well. Localized immunotherapies are also being studied, including oncolytic viruses such as talimogene laherparepvec, a modified herpes simplex virus previously approved for the treatment of advanced cutaneous melanoma. Most importantly, multidisciplinary care is crucial in optimizing outcomes for patients with high-risk cSCC of the head and neck.

Molecular genetics of cutaneous squamous cell carcinoma: perspective for treatment strategies

Cutaneous squamous cell carcinoma (cSCC) represents 20% of all skin cancers. Although primary cSCCs can be successfully treated with surgery, a subset of highly aggressive lesions may progress to advanced disease, representing a public healthcare problem with significant cancer-related morbidity and mortality. A complex network of genes (TP53, CDKN2A, NOTCH1 and NOTCH2, EGFR and TERT) and molecular pathways (RAS/RAF/MEK/ERK and PI3K/AKT/mTOR) have been shown to play an important role in the pathogenesis of cSCC. The epigenetic regulation of TP53 and CDKN2A is an attractive therapeutic target for the treatment of cSCC, as well as NOTCH-activating agents capable to restore its tumour-suppressor function. EGFR inhibitors including both monoclonal antibodies (cetuximab and panitumumab) and tyrosine kinase inhibitors (erlotinib, gefitinib and dasatinib) have been used in clinical trials for the treatment of advanced cSCC, achieving only partial clinical benefit. Recently, an immune-modulatory drug (cemiplimab) has been introduced for the treatment of advanced cSCC with good clinical results and a favourable safety profile, while other PD1/PD-L1 inhibitors, either as monotherapy or in combination with targeted therapies, are currently under investigation. This review focuses on molecular findings involved in the pathogenesis of cSCC and their implications for the future development of new treatment strategies. In addition, current and ongoing treatments on targeted therapies and/or immunotherapy are illustrated.

Cutaneous Squamous Cell Carcinoma: Updates in Staging and Management

Cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in the United States. Outcomes are generally favorable, but a subset of cSCC is biologically distinct and requires a different approach because of its higher risk of local recurrence, metastasis, and death. This article focuses on the recent literature regarding identification of this high-risk subset, efforts to validate and improve the prognostic ability of staging systems, and updates in management.

Outcomes of Adjuvant Radiotherapy Following Negative Surgical Margins for Cutaneous Squamous Cell Carcinoma

BACKGROUND

The role of adjuvant radiotherapy (ART) for cutaneous squamous cell carcinoma (cSCC) following negative surgical margins is unclear.

OBJECTIVE

To retrospectively examine the clinical outcomes in a cohort of patients with cSCC who completed ART after Mohs micrographic surgery or wide local excision with negative margins.

METHODS AND MATERIALS

After the institutional review board approval, a retrospective review was conducted of all patients with cSCC treated in the Mayo Clinic Department of Radiation Oncology from March 10, 1998, through April 26, 2013. Inclusion criteria were age >18 years, resection with negative histologic surgical margins, and completion of ART.

RESULTS

Thirty-two patients met the inclusion criteria: 15 patients died, 12 without evidence of disease related to cSCC. Three patients developed recurrent disease, all with poorly differentiated cSCC, > 2 cm in clinical diameter, perineural invasion, and Brigham and Women's (BWH) stage T2b/T3; 2 of 3 patients were immunosuppressed; and 2 of 3 patients died of cSCC-related causes.

CONCLUSION

These data suggest that the combination of surgical resection and ART is a reasonable option for Brigham and Women's T2b/T3 tumors.

Rate of growth-A novel surrogate marker for high-risk cutaneous squamous cell carcinoma? A case report and review of the literature

Cutaneous squamous cell carcinoma (cSCC) is one of the most common nonmelanoma skin cancer worldwilde, with a more invasive growth pattern and higher potential to metastatize than basal cell carcinoma. Although several risk factors have been linked to a high metastatic potential of cSCC, no widely accepted classification system for this common subtype of cancer exists. Herein we report an emblematic case of rapidly growing and metastatic cSCC and discuss the rate of growth of the tumour (ROG) as novel prognostic high risk surrogate marker.

Long noncoding RNA LINC00520 prevents the progression of cutaneous squamous cell carcinoma through the inactivation of the PI3K/Akt signaling pathway by downregulating EGFR

BACKGROUND

Long noncoding RNAs (lncRNAs) play pivotal roles in various malignant tumors. Epidermal growth factor receptor (EGFR) signaling is associated with the pathogenesis of cutaneous squamous cell carcinoma (cSCC). This study aimed to explore the role of LINC00520 in the development of cSCC via EGFR and phosphoinositide 3-kinase-protein kinase B (PI3K/Akt) signaling pathways.

METHODS

A microarray analysis was applied to screen differentially expressed lncRNAs in cSCC samples. The A431 cSCC cell line was transfected and assigned different groups. The expression patterns of LINC00520, EGFR, and intermediates in the PI3K/Akt pathway were characterized using reverse transcription quantitative polymerase chain reaction (RT-qPCR) and Western blotting analysis. Cell proliferation, migration, and invasion were detected using the MTT assay, scratch test, and Transwell assay, respectively. Cell-based experiments and a tumorigenicity assay were conducted to assess the effect of LINC00520 on cSCC progression. This study was ended in September 2017. Comparisons between two groups were analyzed with t-test and comparisons among multiple groups were analyzed using one-way analysis of variance. The nonparametric Wilcoxon rank sum test was used to analyze skewed data. The enumerated data were analyzed using the chi-square test or Fisher exact test.

RESULTS

Data from chip GSE66359 revealed depletion of LINC00520 in cSCC. Cells transfected with LINC00520 vector and LINC00520 vector + si-EGFR showed elevated LINC00520 level but decreased levels of the EGFR, PI3K, AKT, VEGF, MMP-2 and MMP-9 mRNAs and proteins, and inhibition of the growth, migration and adhesion of cSCC cells, while the si-LINC00520 group showed opposite trends (all P < 0.05). Compared with the LINC00520 vector group, the LINC00520 vector + si-EGFR group showed decreased levels of the EGFR, PI3K, AKT, VEGF, MMP-2 and MMP-9 mRNAs and proteins, and inhibition of the growth, migration and adhesion of cSCC cells, while the LINC00520 vector + EGFR vector group showed opposite results (all P < 0.05).

CONCLUSION

Based on our results, LINC00520-targeted EGFR inhibition might result in the inactivation of the PI3K/Akt pathway, thus inhibiting cSCC development.

Chimeric Monoclonal Antibody Cetuximab Targeting Epidermal Growth Factor-Receptor in Advanced Non-Melanoma Skin Cancer

BACKGROUND:

Non-melanoma skin cancer (NMSC) is the most common malignancy in humans. Targeted therapy with monoclonal antibody cetuximab is an option in case of advanced tumor or metastasis.

AIM:

We present and update of the use of cetuximab in NMSC searching PUBMED 2011-2017.

METHODS:

The monoclonal antibody cetuximab against epidermal growth factor receptor (EGFR) has been investigated for its use in NMSC during the years 2011 to 2017 by a PUBMED research using the following items: “Non-melanoma skin cancer AND cetuximab,” “cutaneous squamous cell carcinoma AND cetuximab,” and “basal cell carcinoma AND cetuximab”, and “cetuximab AND skin toxicity”. Available data were analyzed including case reports.

RESULTS:

Current evidence of cetuximab efficacy in NMSC was mainly obtained in cutaneous SCC and to a lesser extend in BCC. Response rates vary for neoadjuvant, adjuvant, mono- and combined therapy with cetuximab. Management of cutaneous toxicities is necessary. Guidelines are available.

CONCLUSIONS:

Cetuximab is an option for recurrent or advanced NMSC of the skin. It seems to be justified particularly in very high-risk tumors. There is a need for phase III trials.

A new evidence-based risk stratification system for cutaneous squamous cell carcinoma into low, intermediate, and high risk groups with implications for management

Most primary cutaneous squamous cell carcinomas are cured with surgery. A subset, however, may develop local and nodal metastasis that may eventuate in disease-specific; death. This subset has been variably termed high risk. Herein, we review; an emerging body of data on the risks of these outcomes and propose an evidence-based; risk stratification for low-, intermediate-, and high-risk tumors that takes into; account both tumor and patient characteristics. Finally, we discuss a framework for; management of these tumors on the basis of data, when available, and our; recommendations when data are sparse.

Management of Skin Cancer in the High-Risk Patient

OPINION STATEMENT

Skin cancer is the most common of human cancers and outnumbers all other types of cancer combined in the USA by over threefold. The majority of non-melanoma skin cancers are easily treated with surgery or locally destructive techniques performed under local anesthesia in the cost-effective outpatient setting. However, there is a subset of "high-risk" cases that prove challenging in terms of morbidity, mortality, adjuvant treatment required, as well as overall cost to the health care system. In our opinion, the term "high risk" when applied to skin cancer can mean one of three things: a high-risk tumor with aggressive histologic and/or clinical features with an elevated risk for local recurrence or regional/distant metastasis, a high-risk patient with the ongoing development of multiple skin cancers, and a high-risk patient based on immunosuppression. We have recently proposed classifying NMSC as a chronic disease in a certain subset of patients. Although no consensus definition exists for a chronic disease in medicine, there are three components that are present in most definitions: duration of at least 1 year, need for ongoing medical care, and functional impairment and/or alteration of activities of daily living (ADLs) and quality of life (QOL). Immunosuppression can refer to exogenous (organ or stem cell transplant patients,) or endogenous (HIV, leukemia, lymphoma, genodermatoses with DNA mismatch repair problems or other immunosuppression) causes. These patients are at risk for high-risk tumors and/or the development of multiple tumors.

An Analysis of Laser Therapy for the Treatment of Nonmelanoma Skin Cancer

BACKGROUND

Skin cancer remains the most prevalent type of cancer in the United States, and its burden on the health care system remains substantial. Standard treatments such as cryosurgery, electrodessication and curettage, topical and photodynamic therapies, and surgical excision including Mohs micrographic surgery are not without inherent morbidity, including risk of bleeding, infection, and scar.

OBJECTIVE

Lasers may be an alternative for treatment of nonmelanoma skin cancer, and this paper reviews this therapeutic option.

METHODS

A comprehensive search in the Cochrane Library, MEDLINE, and PUBMED databases was performed to identify relevant literature investigating the role of laser therapy in the treatment of nonmelanoma skin cancer.

RESULTS

New literature regarding laser treatment of nonmelanoma skin cancer is emerging, demonstrating promising clinical outcomes. The greatest efficacy has been seen with vascular-selective and ablative lasers in the treatment of basal cell carcinomas. Some success has been reported for laser treatment of squamous cell carcinoma, but data are less convincing. In summary, laser therapy offers an alternative treatment option for nonmelanoma skin cancer; however, its clinical efficacy is variable and, at this time, remains less than currently accepted standards of care.

CONCLUSION

Further studies are needed to optimize parameters, determine maximum efficacy, and provide long-term follow-up.

Cisplatin and Cetuximab Treatment for Metastatic Cutaneous Squamous Cell Carcinoma: A Systematic Review

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of skin cancer and metastasizes in 2% to 5% of cases.

OBJECTIVE

Systematic evaluation of published cases of metastatic cSCC (mSCC) treated with cisplatin or cetuximab from 1989 to 2014.

MATERIALS AND METHODS

A literature search was performed to identify cases of mSCC treated with cisplatin or cetuximab. Patient demographics, tumor characteristics, response rates, and disease-free survivals were extracted.

RESULTS

A total of 60 cases of mSCC treated with cisplatin and 9 cases treated with cetuximab reported in the literature from 1989 to 2014 were included in the analysis. Patients treated with cetuximab obtained a complete response of 67%, an overall response of 78%, and a median disease-free survival of 25 (range 3-48) months. Patients treated with cisplatin obtained a complete response of 22%, an overall response of 45%, and a median disease-free survival of 14.6 (range 3-112) months.

CONCLUSION

Head-to-head prospective clinical studies between cetuximab and cisplatin are needed to determine which is more efficacious. In addition, prospective tumor registries and randomized controlled trials should be developed in order to establish the ideal systemic regimen in cSCC.

Concordant Surgical Treatment: Non-melanocytic Skin Cancer of the Head and Neck

Background

Skin cancer is the most common type of cancer. Of the 4 million skin lesions excised annually worldwide, approximately 2 million are considered cancerous. In this study, we aimed to describe a regional experience with skin cancers treated by a single senior surgeon and to provide a treatment algorithm.

Methods

The medical records of 176 patients with head and neck non-melanocytic skin cancer (NMSC) who were treated by a single surgeon at our institution between January 2010 and May 2016 were retrospectively reviewed, and their data (age, sex, pathological type, tumor location/size, treatment modality) were analyzed. Patients with cutaneous squamous cell carcinoma (cSCC) who were classified as a high-risk group for nodal metastasis underwent sentinel node mapping according to the National Comprehensive Cancer Network guidelines.

Results

Among the patients with NMSC who were treated during this period, basal cell carcinoma (BCC; n=102, 57.9%) was the most common pathological type, followed by cSCC (n=66, 37.5%). Most lesions were treated by complete excision, with tumor-free surgical margins determined via frozen section pathology. Thirty-one patients with high-metastasis-risk cSCC underwent sentinel node mapping, and 17 (54.8%) exhibited radiologically positive sentinel nodes. Although these nodes were pathologically negative for metastasis, 2 patients (6.5%) later developed lymph node metastases.

Conclusion

In our experience, BCC treatment should comprise wide excision with tumor-free surgical margins and proper reconstruction. In contrast, patients with cSCC should undergo lymphoscintigraphy, as nodal metastases are a possibility. Proper diagnosis and treatment could reduce the undesirably high morbidity and mortality rates.

Update on the Use and Treatment of Targeted Molecular Inhibitors for Locally Advanced and Metastatic Non-Melanoma Skin Cancers

BACKGROUND

Targeting specific molecular pathway inhibitors has provided a successful approach to the management of selected patients with advanced non-melanoma skin cancer (NMSC). Clinical trials and case studies have provided a rationale for their use in clinical settings.

OBJECTIVE

To review the current approaches to the use of targeted molecular inhibitors for locally advanced and metastatic squamous cell carcinoma, basal cell carcinoma, and dermatofibrosarcoma protuberans.

METHODS

Literature review of the current use of molecular inhibitors in the treatment of NMSCs, including case studies, reports, and clinical trials.

CONCLUSION

The development of molecular pathway inhibitors for the treatment of advanced and metastatic NMSC has increased survival rates and improved clinical outcomes in selected patients with advanced disease.

Dramatic response of vemurafenib-induced cutaneous lesions upon switch to dual BRAF/MEK inhibition in a metastatic melanoma patient

BRAF inhibitory therapy is the mainstream treatment for BRAF mutant advanced melanoma. However vemurafenib, a type I mutant BRAF V600 inhibitor, induces an array of proliferative skin disorders from keratosis pilaris-like and keratoacanthoma-like lesions to locally aggressive cutaneous squamous cell carcinoma (cuSCC). Dual BRAF/MEK inhibition is known to lower the incidence of such manifestations, but it is not known whether it can counteract established lesions. Here we show, for the first time, a dramatic response and a restitution ad integro upon dual inhibition of a widespread proliferative affection induced by BRAF monotherapy. A 75-year-old woman was diagnosed with a BRAF V600E mutated metastatic melanoma. Following dacarbazine (DTIC) and ipilimumab, the patient was started on 960 mg twice daily vemurafenib (Zelboraf), which resulted in complete response, but the patient also developed grade IV skin toxicity. Despite dose-reduction to 720 mg twice daily the side effects persisted. We hypothesized that a switch to double inhibition of the mitogen-activated protein kinase pathway with dabrafenib and trametinib could lead to improvement of the skin lesions, while preserving tumor control. The patient was closely followed for changes in skin lesions. We witnessed a rapid regression followed by complete disappearance of all side effects of vemurafenib except for grade I fatigue. The biopsied skin lesions show regression of established keratoacanthoma-like lesions with signs of apoptosis. Switching from the current standard of care vemurafenib therapy to the double BRAF/MEK inhibition in BRAF mutant melanoma patients results in rapid disappearance of established proliferative skin disorders.

Evaluation of frozen section margins in high-risk cutaneous squamous cell carcinomas of the head and neck

OBJECTIVES/HYPOTHESIS

To identify histopathologic features associated with poor correlation of frozen and permanent pathology margins following wide local excision for advanced cutaneous squamous cell carcinomas of the head and neck.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of patients undergoing excision of advanced head and neck squamous cell carcinomas between the years 2010 AND 2013 was performed. Demographic, operative, and pathology data were collected. Overall correlation between frozen section margins and final margins on permanent section results was calculated. Positive and negative predictive values of several histopathologic features were determined.

RESULTS

Forty-one cases were identified from the database. Perineural invasion, lymphovascular invasion, and a component of poorly differentiated carcinoma were identified in 61.3%, 34.5%, and 17.1% of cases, respectively. Discrepancy between frozen section margins and permanent margins was identified in eight cases (19.5%). The false-negative rate for poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion was 14%, 36%, 26%, respectively. The positive and negative predictive value of poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion in predicting discrepancy between frozen and permanent margins was 14% and 80%, 36% and 84%, and 26% and 92%, respectively.

CONCLUSIONS

This study demonstrated a moderate rate of discrepancy between frozen and permanent section analysis of operative margins from high-risk cutaneous squamous cell carcinomas of the head and neck. The presence or absence of certain histopathologic features appears to be associated with a higher rate of frozen section discrepancy. Evaluation of these features in a preoperative biopsy or staging excision may be useful in planning definitive excision and reconstruction.

Advances in the management of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma is one of the most common non-melanoma skin cancers worldwide. While most cutaneous squamous cell carcinomas are easily managed, there is a high-risk subset of tumors that can cause severe morbidity and mortality. Tumor characteristics as well as patient characteristics contribute to the classification of cutaneous squamous cell carcinomas as low-risk vs. high-risk. Advances in the treatment of cutaneous squamous cell carcinomas largely relate to the management of this high-risk subset. Surgical and non-surgical management options, including newer targeted molecular therapies, will be discussed here. Larger, multicenter studies are needed to determine the exact significance of individual risk factors with respect to aggressive clinical behavior and the risks of metastasis and death, as well as the role of surgical and adjuvant therapies in patients with high-risk cutaneous squamous cell carcinomas.

Locally advanced and unresectable cutaneous squamous cell carcinoma: outcomes of concurrent cetuximab and radiotherapy

Background. Advanced age and immune dysfunction are risk factors for cutaneous squamous cell carcinoma (cSCC) and often render patients with locally-advanced disease medically inoperable or surgically unresectable, but potentially curable with radiotherapy. Concurrent chemotherapy and radiotherapy may not be well tolerated in this population, but another systemic therapy may improve disease control. Objective. Determine the tolerance and efficacy of concurrent cetuximab and radiotherapy (CRT) for patients with locally advanced and unresectable cSCC. Methods. Retrospective analysis of 12 patients treated with CRT for locally advanced and unresectable cSCC. Results. Patients were elderly and 75% had moderate-to-severe comorbidities, while 42% had immune dysfunction. Grades 3-4 adverse events were noted in 83% of patients; 67% required hospital admission for adverse events. Complete and partial response was noted in 36% and 27% (response rate, 64%). Stable and progressive disease was noted in 3 and 1 patients, respectively (disease control rate, 91%). Median progression-free and overall survival were 6.4 and 8.0 months, respectively. Limitations. Retrospective small-cohort, single-institution analysis. Conclusion. Patients selected for CRT were elderly, with comorbidities and immune dysfunction, but treatment responses were observed. Patients selected for this treatment approach have a poor prognosis with limited capacity for therapy; more effective treatment is needed.

Ultrasound skin imaging

The interaction of high-frequency ultrasound waves with the skin provides the basis for noninvasive, fast, and accessible diagnostic imaging. This tool is increasingly used in skin cancer and inflammatory conditions as well as in cosmetic dermatology. This article reviews the basic principles of skin ultrasound and its applications in the different areas of dermatology.

Update of cetuximab for non-melanoma skin cancer

INTRODUCTION

Non-melanoma skin cancer (NMSC) has become the most common malignancy in humans. Targeted therapies are recent developments for these tumors. Monoclonal antibody cetuximab has proven its efficacy and has improved tolerability compared to classical chemotherapy protocols, and this prompted us to analyze new data on the use of cetuximab in cutaneous NMSC.

AREAS COVERED

The monoclonal antibody cetuximab against epidermal growth factor receptor (EGFR) has been investigated for its use in NMSC during the years between 2011 and 2013. A PUBMED research 2011 - 2013 has been conducted using the following terms: 'Non-melanoma skin cancer AND cetuximab', 'cutaneous squamous cell carcinoma AND cetuximab', and 'basal cell carcinoma AND cetuximab' and 'cetuximab AND skin toxicity'. Available data were analyzed - irrespective of their level of evidence, that is, case reports and case series were included.

EXPERT OPINION

Current evidence of cetuximab's efficacy in NMSC was mainly obtained in cutaneous squamous cell carcinoma (SCC) and to a lesser extent in basal cell carcinoma (BCC). Response rates vary for neoadjuvant, adjuvant, monotherapy and combined therapy with cetuximab. Limitations are the low number of patients treated (33 patients with SCC, 4 patients with BCC) and the low quality of studies reported. Management of cutaneous toxicities of EGFR inhibitors is necessary, and guidelines are available. Proactive therapy might also prevent skin toxicity of higher grades, with EGFR inhibitor cetuximab as an option for recurrent or advanced NMSC of the skin. It seems to be justified particularly in very high risk epithelial tumors. There is an urgent need for Phase III trials. In the future, combined drug therapy with other monoclonal antibodies and/or radiotherapy may further improve efficacy and response rates for NMSC.