Successful treatment of giant invasive cutaneous squamous cell carcinoma by plum-blossom needle assisted photodynamic therapy sequential with imiquimod: Case experience

An insight into photodynamic therapy towards treating major dermatological conditions

Photodynamic therapy (PDT), as the name suggests is a light-based, non-invasive therapeutic treatment method that has garnered immense interest in the recent past for its efficacy in treating several pathological conditions. PDT has prominent use in the treatment of several dermatological conditions, which consequently have cosmetic benefits associated with it as PDT improves the overall appearance of the affected area. PDT is commonly used for repairing sun-damaged skin, providing skin rejuvenation, curbing pre-cancerous cells, treating conditions like acne, keratosis, skin-microbial infections, and cutaneous warts, etc. PDT mediates its action by generating oxygen species that are involved in bringing about immunomodulation, suppression of microbial load, wound-healing, lightening of scarring, etc. Although there are several challenges associated with PDT, the prominent ones being pain, erythema, insufficient delivery of the photosensitizing agent, and poor clinical outcomes, still PDT stands to be a promising approach with continuous efforts towards maximizing clinical efficacy while being cautious of the side effects and working towards lessening them. This article discusses the major skin-related conditions which can be treated or managed by employing PDT as a better or comparable alternative to conventional treatment approaches such that it also brings about aesthetic improvements thereof.

Halofuginone enhances the anti-tumor effect of ALA-PDT by suppressing NRF2 signaling in cSCC

BACKGROUND

5-aminolevulinic acid-mediated PDT (ALA-PDT) has been used in a variety of skin diseases including cSCC (cutaneous squamous cell carcinoma). Halofuginone (HL) is a less-toxic febrifugine derivative and has inhibitory effects on a variety of cancer cells. For now, there are no published study focusing on the combination use of ALA-PDT with HL to improve clinical efficacy of cSCC.

OBJECTIVE

In this study, we will examine the effectiveness of combined treatment of ALA-PDT and HL in cSCC as well as its underlying mechanism.

METHODS

The human epidermoid carcinoma cell line SCL-1 was treated with ALA-PDT or/ and HL, and cell viability, cell migration, ROS production, apoptosis were evaluated by CCK-8, colony formation, scratch assay, DCFH-DA probe, flow cytometry, respectively. The protein expression of NRF2 signaling was examined by western blot.

RESULTS

HL strengthened ALA-PDT's inhibition of SCL-1 cell viability, migration, as well as NRF2 related β-catenin, p-Erk1/2, p-Akt and p-S6K1 expression. Overexpression of NRF2 conferred resistance to co-treatment's effects on c-Myc, Cyclin D1, Bcl-2, as well as cell proliferation. HL also strengthened ALA-PDT's inhibition of tumor volume in cSCC mouse model and elevated ROS generation of ALA-PDT.

CONCLUSION

HL enhances the anti-tumor effect of ALA-PDT in vitro and in vivo. HL has the potential to enhance the anti-tumor effect of ALA-PDT in cSCC via inhibiting NRF2 signaling.

Modified 5-aminolevulinic acid photodynamic therapy reduces pain and improves therapeutic effects in cutaneous squamous cell carcinoma mouse model

BACKGROUND AND OBJECTIVES

Conventional ALA-PDT (C-PDT) has limited efficacy in cutaneous squamous cell carcinoma (cSCC), and there is obvious pain during treatment, which limits its clinical application. We sought to modify photodynamic therapy into a more painless and effective treatment.

METHODS

We modified C-PDT by reducing the incubation time of the pro-sensitizer and increasing the light dose; we named this method modified ALA-PDT (M-PDT). We compared the pain response and curative effect between C-PDT and M-PDT in cSCC mouse models. Pain-related proteins were examined by western blot analysis and immunohistochemistry. Tumor progression-associated signaling pathways were analyzed by RNA-seq and western blot analysis. Reactive oxygen species (ROS) generation was measured with a ROS test kit and Microplate reader.

RESULTS

M-PDT greatly reduced pain during treatment. Interestingly, when the cSCC tumor volume increased to 150-200 mm³ , M-PDT almost completely eliminated the tumors, while C-PDT did not. The better curative effect of M-PDT might be due to the stronger suppression of the Stat3, Erk1/2, and mTOR signaling pathways. Moreover, flow cytometry demonstrated that M-PDT could recruit CD8⁺ T cells to inhibit cSCC progression. Further investigation determined that the different mechanisms of C-PDT and M-PDT were related to more ROS generation induced by M-PDT.

CONCLUSIONS

Our results suggest that M-PDT, which is more painless and effective than C-PDT, is expected to provide a solution for the treatment of cSCC.

PD-L1 blockade potentiates the antitumor effects of ALA-PDT and optimizes the tumor microenvironment in cutaneous squamous cell carcinoma

Immune checkpoint blockade (ICB) is a powerful oncologic treatment modality for a wide variety of human malignancies, but the patient response rate to this treatment remains low, especially in patients with cutaneous squamous cell carcinoma (cSCC). 5-Aminoleuvulinic acid-photodynamic therapy (ALA-PDT) is widely used to treat cancerous and precancerous skin diseases, but the value of ALA-PDT in the treatment of invasive cSCC is debatable. Our previous studies have shown that ALA-PDT can induce antitumor immune responses by promoting the immunogenic death of tumor cells. However, it is unclear whether ALA-PDT exerts synergistic effects with ICB in cSCC. Here, we report that PD-L1 blockade potentiates the antitumor effects of ALA-PDT both on primary and distant tumors, and optimizes the tumor microenvironment in cSCC. In this study, we first detected PD-L1 expression in patients with different grades of cSCC. Then we found the combination of anti-PD-L1 monoclonal antibody (mAb) and ALA-PDT killed tumor cells by apoptosis- and/or ferroptosis-mediated immunogenic cell death (ICD) and stimulated systemic immune response, as well as building the immunological memory response to prevent tumor recurrence. Furthermore, we found that combination therapy can be used to recruit tertiary lymphoid structure (TLS)-like intratumoral lymphoid aggregates, which may promote tumor-infiltrating lymphocyte (TIL)-mediated antitumor immunity. In summary, our work demonstrates that ICB treatment with an anti-PD-L1 antibody is a promising strategy that may potentiate the antitumor effects of ALA-PDT in cSCC.

ALA-PDT successfully treated multiple cSCC in situ and AK in a patient with Epidermodysplasia verruciformis

5-aminolaevulinic acid photodynamic therapy (ALA-PDT) has emerged as a non-invasive treatment modality for premalignant and malignant skin lesions. It has the advantage of better tolerance and providing better cosmetic outcomes than conventional treatment methods. Herein, we report a patient who suffered from multiple cutaneous squamous cell carcinoma (cSCC) in situ and actinic keratosis (AK) scattered in the body's sun-exposed areas, which had led him to undergo multiple surgical resections since the age of 16. Next-generation sequencing-based on a targeted gene capture panel revealed compound heterozygous mutations c.G559A and c.G1389A in the TMC8 gene. Combined with the typical clinical manifestations and mutation analysis, the patient was diagnosed with Epidermodysplasia verruciformis (EV). Due to the multiple AK and cSCC in situ lesions, ALA-PDT was applied. After 8 courses of ALA-PDT all lesions were successfully cleared without causing any scarring. Therefore, the use of ALA-PDT treatment may constitute a very promising and effective therapeutic modality for multiple cSCC in situ and AK secondary to EV.

Extra-anogenital giant cutaneous squamous cell carcinomas require multidisciplinary management

Cutaneous squamous cell carcinoma (cSCC) is a highly prevalent cancer and the majority of cSCC have a good prognosis. However, a subset of cSCC can progress to advanced disease. We present the first reported case of a giant cSCC located on the breast. In addition, a systematic literature search on extra-anogenital giant (EAG) cSCC was performed using Pubmed and MEDLINE databases. Thirty-one articles could be retained which were relevant for this review. A total of 42 well-described cases were identified. Median age at presentation was 70 years (range 9-100 years). Twenty-four (57%) patients were male, eighteen were female (43%). The estimated median delay of treatment was 12 months (range 1 to >240 months). In 27 patients (64%) the giant cSCC was localized on the neck, face or scalp, 6 on the thoracic wall or back (14%), 4 on the lower limb (10%), 2 on the hip or buttock (5%), 2 on the upper limb (5%), one (2%) on the breast. Tumor stage at presentation was T2, T3 and T4 in respectively 26 (62%), 11 (26%) and 5 (12%) cases. Lymph node metastases were identified in 1 patient (2%) and distant metastases in another patient (2%). In 34 out of 42 cases (81%) primary radical surgical excision was performed, 3 received radiotherapy, 2 chemotherapy and 3 palliative care. In the cases with reported follow-up, four patients (4/30: 13%) died of disease. The treatment of EAG cSCC poses many problems, making a multidisciplinary approach of paramount importance.

5-Aminolevulinic acid photodynamic therapy for early-stage lip squamous cell carcinoma

BACKGROUND

Squamous cell carcinoma (SCC) of the lip removed by surgery may cause lip dysfunction and scar. ALA-PDT (5-Aminolevulinic acid photodynamic therapy) is a minimally invasive treatment for superficial SCC in situ. However, few studies reported the use of topical ALA-PDT to manage lip SCC.

METHODS

Between 2015 and 2017, 6 patients with Tis to T2 lip squamous cell carcinoma without evidence of lymph node spread, were treated with topical ALA-PDT at Shanghai Skin Disease Hospital. Clinical responses and side effect were evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) at 1 month, 6 months, 12 months and 24 months after ALA-PDT.

RESULTS

All of the 6 patients achieved complete response (CR) by 2-7 sessions of ALA-PDT. There was no relapse during 24 months follow up for 4 patients. Two out of 6 patients relapsed at 10 months and 20 months post PDT but achieved CR again by 1-3 more sessions of PDT. There was no functional or aesthetic problem.

CONCLUSION

Topical 5-Aminolevulinic acid photodynamic could be considered a potential alternative therapeutic option for early-stage lip squamous cell carcinoma without lymph node spread.

ALA-PDT successfully treated Majocchi's granuloma by directly killing Trichophyton tonsurans and recruiting T lymphocytes

BACKGROUND

Majocchi's granuloma (MG) is a deep persistent suppurative granulomatous perifolliculitis which might be caused by Trichophyton tonsurans (T. tonsurans). Conventional treatment for MG is oral administration of systematic antifungal drugs, associated with a low cure rate and a high relapse rate. ALA-PDT is a new approach for fungal infection.

METHODS

A case of refractory MG was treated by 3 times of ALA-PDT. At the same time, T. tonsurans strains isolated from the lesions of the patient were used for an in vitro inhibition experiment and an in vivo experiment in guinea pig model to furtherly verify the effectiveness and investigate the mechanism of ALA-PDT for T. tonsurans.

RESULTS

After 3 times of ALA-PDT, the lesions of MG were eliminated. And the mycological and pathological examination showed a disappearance of fungi in follicles. In vitro and in vivo experiment both demonstrated that ALA-PDT could obviously inhibit the growth of T. tonsurans partly by directly destroying the structure of fungal cells and recruiting CD4 + T cells.

CONCLUSION

ALA-PDT is a potentially effective noninvasive method for the treatment of MG with mechanisms of direct killing and with CD4⁺ T cell-mediated immune response.

Chinese guidelines on the clinical application of 5-aminolevulinic acid-based photodynamic therapy in dermatology (2021 edition)

Photodynamic Therapy with 5-aminolevulinic acid (ALA-PDT) has been widely applied in the treatment of skin diseases in China. To further standardize, guide, and promote the clinical applications of ALA-PDT in dermatology, the Chinese Society of Dermatology, Chinese Association of Rehabilitation Dermatology, Photomedicine Therapeutic Equipment Group of Committee on Skin Disease, and Cosmetic Dermatology of China Association of Medical Equipment invited relevant experts engaged in ALA-PDT to revise and update the first edition of "Clinical application of 5-aminolevulinic acid-based photodynamic therapy: an expert consensus statement" and establish a more current edition, to provide an updated reference for Chinese dermatologists in clinical practice. In the guideline, the expert group reached consensus opinions on ALA-PDT with regard to mechanisms of action, therapeutic protocol, clinical applications, adverse reactions and countermeasures, precautions, care, and evaluation of efficacy.

Sequential Treatment of Superficial Basal Cell Carcinomas With Topical Methyl Aminolevulinate Photodynamic Therapy and Imiquimod 5% Cream: A Retrospective Study of Clinical and Cosmetic Outcomes

BACKGROUND

Topical photodynamic therapy (PDT) and imiquimod 5% (IMQ) cream are established treatments for superficial basal cell carcinoma (sBCC). Both have high initial response rates and recurrence rates of up to 37%. Recent studies demonstrate that PDT and imiquimod may act on sBCCs via synergistic immunomodulatory pathways.

OBJECTIVE

To describe the sequential use of MAL-PDT and imiquimod 5% cream in the treatment of sBCCs and report treatment tolerability, cosmetic outcomes, and efficacy.

MATERIALS AND METHODS

This is a retrospective case series of patients presenting over a 2-year period with primary sBCC who underwent 2 cycles of topical MAL-PDT, followed by 6 weeks of imiquimod 5% cream. Outcome measures were resolution of the index lesion at 3 months, side effects, cosmetic outcome, and long-term recurrence (LTR).

RESULTS

A total of 17 consecutive patients (n = 17) with a combined 21 sBCCs (n = 21) were included. The median length of follow-up was 72 months (range 24-95 months). Long-term recurrence occurred in 2/21 lesions (10%).

CONCLUSION

Sequential use of PDT and imiquimod was well tolerated with good cosmetic outcomes. The 10% LTR rate is at the lower end of the range reported for single modality treatment; however, larger samples are required to evaluate efficacy differences.

Ulceration occurring after ALA-PDT combined with plum-blossom needle percussion for the treatment of pretibial Bowen's disease: A case report

We used 5-aminolevulinic acid-photodynamic therapy (ALA-PDT) combined with plum-blossom needle (PBN) on a 3.5 cm × 3.0 cm pretibial region to treat an elderly woman suffering from Bowen's disease (BD). Before the application of ALA, the PBN was inserted 3-4 times vertically starting at 5 cm above the lesion. Then, 20 % 5-ALA cream was applied with an incubation time of 3.5 h. A semiconductor laser at a wavelength of 635 nm was used to illuminate the lesion at 100 J/cm² using 60 mW/cm². A total of three sessions of ALA-PDT were performed at 2-3-week intervals, thus removing the lesion of BD. However, a 1.5 cm × 1.0 cm ulceration occurred 2 weeks after the third session when the PBN was used. Therefore, PBN percussion or other methods for promoting ALA penetration should be carefully applied to avoid ulceration, especially on the sites with less subcutaneous tissue.

Surgery sequential with 5-Aminolevulinic acid photodynamic therapy for lip squamous cell carcinoma: Two cases reports

Squamous cell carcinoma (SCC) of thelip is conventionally treated by extended surgery or radiotherapy, which may cause deformities and dysfunction due to this special location. Topical 5-Aminolevulinic acid photodynamic therapy (ALA-PDT) for SCC in situ is effective and non-invasive, and may preserve normal morphological structure. However, the effectiveness is limited by tumor size and depth due to the permeability of photosensitizer and penetration depth of the therapeutic light source. We successfully treated two cases of lip invasive SCC (tumor size is 22.4 mm × 16.1 mm × 11.9 mm and 23 mm × 15 mm × 5 mm) with superficial resection surgery to reduce tumor load and sequential ALA-PDT (20 % ALA, 3 h incubation, 200 J/cm²) to remove residual tumor. During the treatment, ultrasonography was used to monitor the tumor invasion depth and assess the therapeutic efficacy. Both cases showed tumor free at 12 months of follow-up. These two cases suggest that ALA-PDT combined with minimal invasive surgery is a viable treatment for special cases of lip SCC.

Photodynamic therapy as an alternative treatment in patients with invasive cutaneous SCC where surgery is not feasible: Single center experience

The aim of this study was to demonstrate the efficacy of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) as an alternative treatment in cutaneous squamous cell carcinoma (cSCC) patients who are not fit for surgery. Thirty-three invasive cSCC patients who, for some reasons, cannot undergo surgery were enrolled in this study. All patients received plum blossom needle (PBN) pretreated ALA-PDT combined with topical application of 5% imiquimod cream. Two patients dropped the study because of severe pain and two patients discontinue treatment due to lack of response. Of 29 patients, who completed the treatment, 5 patients had complete response after 2-9 sessions of PDT and these patients had no recurrence till 18 months after treatment. Twenty-four patients achieved partial response and are satisfied with treatment outcome in terms of decreased symptoms and improved quality of life. PBN pretreated PDT in combination with topical imiquimod may be a viable treatment option for non resectable cSCC lesions.

Efficacy and safety of 5-aminolevulinic acid photodynamic therapy for the treatment of ulcerative squamous cell carcinoma

BACKGROUND

Photodynamic therapy is a nonsurgical alternative to conventional tumor excision for squamous cell carcinoma. In addition, photodynamic therapy has many advantages in improving wound healing, especially for diabetic foot lesions and infected ulcers. However, the effect of photodynamic therapy on ulcerative squamous cell carcinoma is not yet clear. In this study, we aimed to evaluate the effectiveness of photodynamic therapy in treating squamous cell carcinoma.

METHODS

A total of six cases of ulcerative squamous cell carcinoma were included in our study. Each ulcer region was irradiated with 120 J/cm² using a 635-nm red light-emitting diode after application of 5-aminolevulinic acid solution at 1-week intervals. The number of treatment sessions depended on the healing of the lesions.

RESULTS

The ulcerative lesions showed complete clinical remission with an average 3.7 photodynamic therapy sessions. There was no recurrence during a follow-up of 8.5 months (range, 3 months to 1 year). The patients were able to complete the treatment protocol with good cosmetic results and no significant complications. In addition, most patients reported significant improvement in their quality of life.

CONCLUSIONS

Photodynamic therapy is a promising method for treating ulcerative squamous cell carcinoma. However, its effects need to be validated in larger patient samples in clinical trials.

Water-Soluble Chlorin/Arylaminoquinazoline Conjugate for Photodynamic and Targeted Therapy

A new water-soluble conjugate, consisting of a chlorin-e₆ photosensitizer part, a 4-arylaminoquinazoline moiety with affinity to epidermal growth factor receptors, and a hydrophilic β-d-maltose fragment, was synthesized starting from methylpheophorbide-a in seven steps. The prepared conjugate exhibited low levels of dark cytotoxicity and pronounced photoinduced cytotoxicity at submicromolar concentrations in vitro, with an IC₅₀(dark)/IC₅₀(light) ratio of ∼368 and a singlet oxygen quantum yield of about 20%. In tumor-bearing Balb/c nude mice, conjugate 1 preferentially accumulates in the tumor tissue. Irradiation of the nude mice bearing A431 xenograft tumors after intravenous administration of the prepared conjugate with a relatively low light dose (50 J/cm²) produced an excellent therapeutic effect with profound tumor regression and low systemic toxicity.

Present and future perspectives of photodynamic therapy for cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer. Surgery remains the main stay of treatment, but some patients are not eligible for surgery and, more importantly, lesions at critical sites need nonsurgical approaches for tissue preservation. In this context, photodynamic therapy (PDT) has been extensively studied as noninvasive or minimally invasive treatment, and studies have shown promising results in terms of safety, efficacy, and cosmetic outcome. Also, studies have proposed different mechanism for its efficacy. However, human studies demonstrating its efficacy are limited in terms of sample size and tumor depth of invasion. Good results are mainly seen in case reports of microinvasive SCC, which is defined as SCC limited to papillary dermis. This inadequacy is due to inadequate penetration of topically applied photosensitizers through keratinized tumor surfaces. To overcome these hurdles, pretreatment with lasers or microneedles and encapsulation of photosensitizers into nanoparticles have been tried. Hence, the present article will discuss studies that have demonstrated the efficacy and safety of PDT for cutaneous SCC, studies that have postulated the mechanism of action of PDT, agents that have been used as PDT enhancers, and finally, the recent use of adjuvant therapy in combination with PDT.