Management of nonmelanoma skin cancer in 2007

Reproducibility and air gap pockets of 3D-printed brachytherapy applicator placement in high-dose-rate skin cancer

BACKGROUND AND PURPOSE

This study aimed to investigate the reproducibility of a novel approach using 3D printed brachytherapy applicators for the treatment of skin cancer. Specifically, we aimed to assess the accuracy of applicator placement and to minimize the existence of air gap pockets between the applicator and the patient's skin.

MATERIALS AND METHODS

A total of 20 patients plans diagnosed with skin cancer were enrolled in this study. All patients underwent high dose rate (HDR) brachytherapy. To ensure precise applicator placement, patient-specific 3D printed applicators were designed based on individual body and tumor topography, utilizing data obtained from computer tomography (CT) scans. All applicators were fabricated using fused deposition modeling technology.

RESULTS

The error in applicator placement was measured and found to be less than 1.0 mm on average, with a standard deviation of 0.9 mm. Additionally, the average error in air gap pockets between the applicator and the patient's skin was 0.4 mm (standard deviation was 0.5 mm). The study demonstrated that the personalized approach of 3D printed brachytherapy applicator placement in skin cancer treatment yielded highly accurate results. The average error of less than 1.0 mm in applicator positioning and the minimal air gap pockets demonstrated the reproducibility and precision of this technique.

CONCLUSION

Our study establishes the reproducibility and accuracy of 3D-printed brachytherapy applicator placement in the treatment of skin cancer. This personalized treatment approach offers a highly precise method for delivering radiation therapy, minimizing the risk to adjacent healthy tissues, and enhancing overall patient outcomes.

Facilitating clinically relevant skin tumor diagnostics with spectroscopy-driven machine learning

In the dawning era of artificial intelligence (AI), health care stands to undergo a significant transformation with the increasing digitalization of patient data. Digital imaging, in particular, will serve as an important platform for AI to aid decision making and diagnostics. A growing number of studies demonstrate the potential of automatic pre-surgical skin tumor delineation, which could have tremendous impact on clinical practice. However, current methods rely on having ground truth images in which tumor borders are already identified, which is not clinically possible. We report a novel approach where hyperspectral images provide spectra from small regions representing healthy tissue and tumor, which are used to generate prediction maps using artificial neural networks (ANNs), after which a segmentation algorithm automatically identifies the tumor borders. This circumvents the need for ground truth images, since an ANN model is trained with data from each individual patient, representing a more clinically relevant approach.

Cryosurgery for Basal Cell Skin Cancer of the Head: 15 Years of Experience

The clinical relevance of head and neck (H&N) tumors is related to the potential disfiguration of anatomical structures (by the tumor or surgical intervention), defining patients' individual features and emotional expression, loss or restraint of vital structures functions, and untoward socio-economic sequelae. This study is aimed to improve clinical outcomes of cryosurgery in patients with H&N basal cell skin cancer by refining the indications for cryosurgical treatment. In this study, cryosurgery was used in 234 patients with different stages of cutaneous basal cell carcinoma (BCC) of the head, including 101 patients with T1 tumors, 86-with T2, 5-T3, and 42 patients with tumors relapsing after failure of preceding various treatment modalities. Post-cryosurgery recurrence rate in patients with stage I BCC was 2.7%, with stage II tumors-5.6% and 34.9%-in patients with recurred tumors. Re-recurrence after cryoablation of recurrent tumors correlated with the tumor baseline size. The best aesthetic and long-term clinical results were documented in patients with lesions <1 cm in size with clear boundaries. Thus, cryosurgery is the method of choice for the majority of stage I basal cell carcinomas of the head. For patients with advanced and recurrent skin cancer, cryosurgery is relevant in rare cases selected according to refined indications.

Evaluating Rates of Positive Margins After Standard Excision of Cutaneous Adnexal Malignancies

BACKGROUND

It is recommended to excise adnexal neoplasms with standard local excision or Mohs micrographic surgery (MMS), although many occur on high-risk sites such as the head and neck (H&N) and exhibit subclinical extension. Minimal evidence exists on the efficacy of standard excisions for these tumors.

OBJECTIVE

To evaluate the rate of positive surgical margins after standard excision of adnexal tumors.

METHODS

Retrospective cohort study of cutaneous adnexal malignancies from the National Cancer Database diagnosed from 2004 to 2019.

RESULTS

The authors identified a total of 4,402 cases treated with standard excision. Tumors on the H&N were approximately twice as likely as those on the trunk and extremities (T&E) to be excised with positive margins (odds ratio 2.146, p < .001), with the highest estimated rate for eccrine adenocarcinoma (12.1%, SE: 2.3%). The subtype with the highest positive margin rate on the T&E was microcystic adnexal carcinoma (8.0%, SE: 2.9). Positive margins were associated with poorer overall survival on multivariable survival analysis (hazard ratio 1.299, p = .015).

CONCLUSION

The authors present subtype- and site-specific positive margin rates for adnexal tumors treated with standard excision, which suggest that tumors on the H&N and some T&E subtypes, should be considered for MMS.

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma

BACKGROUND

Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning.

OBJECTIVE

We present an approach to the management of BCC when cost reduction is a priority.

METHODS

A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment.

RESULTS

The cost of treating a primary superficial BCC < 0.5 cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2 cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10 cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc.

CONCLUSIONS

For a primary superficial BCC < 0.5 cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2 cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

Development and Optimization of Novel Emulgel Loaded with Andrographolide-Rich Extract and Sesame Oil Using Quality by Design Approach: In Silico and In Vitro Cytotoxic Evaluation against A431 Cells

An epidermoid carcinoma is a form of non-melanoma skin cancer that originates from the outer layer of the skin's squamous cells. Previous studies have shown that andrographis extract and andrographolide inhibit the growth and proliferation of epidermoid carcinoma cells while also inducing cell cycle arrest and apoptosis. The objective of this study was to improve the anticancer efficacy of the andrographolide-rich extract by delivering it in the form of nanoemulgel. During the formulation of emulgels, sonication, and homogenization were employed, and a 2²-factorial design was used to optimize the formulations through the quality by design (QbD) approach. The optimized formulation (AEE8) was subjected to preliminary evaluations along with particle size, drug release, and scanning electron microscopy (SEM) studies. The potential of the optimized emulgel against A431 cell lines was also investigated using MTT assay followed by flow cytometric analysis. The SEM results reveal that the optimized emulgel had a well-defined spherical shape, with a droplet size of 226 ± 1.8 nm, a negative surface charge of -30.1 ± 1.6 mV, and a PDI of 0.157. The cellular data indicate that AEE8 reduced the viability of the A431 cells with an IC₅₀ of 16.56 μg/mL, as determined by MTT assay when compared to cells treated with the extract alone. Furthermore, the flow cytometric analysis of the optimized emulgel formulation demonstrated a marked G2/M phase arrest. This finding further supports the effectiveness of the gel in disrupting the cell cycle at the critical G2 and M phases, which are pivotal for cell division and proliferation. This disruption in cell cycle progression can impede the growth and spread of cancer cells, making the gel a promising candidate for anti-skin-cancer therapy. The safety of emulgels (AEE8) was validated through rigorous biocompatibility testing conducted on HDF (human dermal fibroblast) cell lines, ensuring their suitability for use. Considering the potential of the nanoemulgel, particularly AEE8, as demonstrated by its favorable properties and its ability to disrupt the cell cycle, it holds great promise as an innovative approach to treating skin cancer.

Same Day Biopsy and Treatment of Non-Melanoma Skin Cancer in Patients with Field Cancerization: A Retrospective Chart Study

Background

Patients with field cancerization will develop numerous superficial non-melanoma skin cancers (NMSCs). Treating patients with field cancerization can be challenging and burdensome due to the numerous non-melanoma skin cancers (NMSCs) they develop and the frequent dermatology visits required for biopsy and treatment.

Objective

The success rate of diagnosing and treating lesions suspicious for NMSCs on the same day is measured, immediately after biopsy.

Methods

We retrospectively reviewed records of patients with same day lesion diagnosis and curettage treatment to determine diagnostic accuracy, treatment failure, and number needed to treat to reduce a follow-up treatment.

Results

A total of 237 lesions underwent same day biopsy and treatment, of which the majority were NMSC (66%) or actinic keratosis (23%). Patients had at least 3 months and a median of 17 months follow-up. A total of 20 lesions either recurred or were deemed to require additional treatment. The number needed to treat (NNT) to prevent one follow-up treatment was 1.3. Limitations: sample size limited ability to determine risk factors for treatment failure.

Conclusion

Simultaneous diagnosis and treatment of superficial NMSCs is a successful way of improving efficiency and patient satisfaction.

Skin Cancer Management: Current Scenario And Future Perspectives

Skin cancer is a life-threatening disease and has caused significant loss to human health across the globe. Its prevalence has been increasing every year and is one of the common malignancies in the case of organ transplant recipients, of which 95% constitute basal cell and squamous cell carcinomas. The prime factor causing skin cancer is UV radiation. Around the 20th century, sunlight was the primary cause of skin cancer. A novel hypothesis by US scientists stated that cutaneous melanoma was mainly due to recurrent exposure to the sun, whereas keratinocyte cancer occurred due to progressive accumulation of sun exposure. Management of skin cancer is done via various approaches, including cryotherapy, radiotherapy, and photodynamic therapy. Post-discovery of X-rays, radiotherapy has proven to treat skin cancers to some extent, but the indications are uncertain since it depends upon the type of tumour and surgical treatment required for the patient. Due to various limitations of skin cancer treatment and increased severity, there is a requirement for cost-effective, novel, and efficient treatment. Various nanocarriers such as SLNs, magnetic nanoparticles, gold nanoparticles, carbon nanotubes, etc., are the potential carriers in the management and prognosis of both non-melanoma and melanoma skin cancer. Various research and review databases and patent reports have been studied, and information compiled to extract the results. The review also discusses the role of various nanocarriers in treating and diagnosing skin cancer.

Local control comparison of early-stage non-melanoma skin Cancer (NMSC) treated by superficial radiotherapy (SRT) and external beam radiotherapy (XRT) with and without dermal image guidance: a meta-analysis

BACKGROUND

Various treatments exist for non-melanoma skin cancer (NMSC), but the mainstay is surgical removal. Superficial radiotherapy (SRT) is one non-surgical technique that has been used for over a century but fell out of favor due to the advent of Mohs micrographic surgery (MMS). A new technology that combines a 22 megahertz (MHz) dermal ultrasound with SRT (US-SRT) enables tumor visualization before, during, and after treatment, and demonstrates increased cure rates and reduced recurrences.

METHODS

We conducted a meta-analysis comparing the local control (LC) of four studies using traditional non-image-guided forms of radiotherapy for NMSC treatment to two seminal studies utilizing high-resolution dermal ultrasound-guided SRT (HRUS-SRT). The four traditional radiotherapy studies were obtained from a comprehensive literature search used in an article published by the American Society of Radiation Oncology (ASTRO) on curative radiation treatment of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and squamous cell carcinoma in-situ (SCCIS) lesions. The meta-analysis employed a logit as the effect size indicator with Q-statistic to test the null hypothesis.

RESULTS

LC rates for the 2 US-SRT studies were statistically superior to the 4 traditional therapies individually and collectively. When stratified by histology, statistically superior outcomes for US-SRT were observed in all subtypes with p-values ranging from p < 0.0001 to p = 0.0438. These results validated an earlier analysis using a logistic regression statistical method showing the same results.

CONCLUSION

US-SRT is statistically superior to non-image-guided radiotherapies for NMSC treatment. This modality may represent the future standard of non-surgical treatment for early-stage NMSC.

Goldnanorods-loaded hydrogel-forming needlesfor local hyperthermia applications: Proof of concept

Basal cell carcinoma (BCC) is the most common form of skin cancer and responsible for most of the cancer related morbidities and pose a significant public health concern worldwide. Surgery treatment modality is able to clear the BCC, yet it mostly leads to scar formation. Plasmonic photothermal therapy (PPTT) which involves using gold nanostructures and near-infrared light to kill the BCC cells by local heating is associated with excellent tissue preservation and healing without scarring. Parenteral administration of such gold nanostructures suffers from off-target delivery and side effects. Delivering such phototherapeutics directly to the BCC proved to be an attractive alternative route of administration yet encountered with penetration limitations due to the stratum corneum (SC) fierce barrier. In the current study, we developed and optimised a novel near-infrared light-responsive hydrogel-forming long needle (HFLN) loaded with Gold nanorods (GNRs) as a potential plasmonic photothermal device for localised treatment of nodular BCC. The HFLN was prepared from Gantrez® S-97 and PEG 200 Da and characterized in terms of swelling, insertion and mechanical properties. GNRs were synthesised and tunned using seed-mediated growth method. The integrated devices developed could revolutionise BCC treatment benefiting both patients and healthcare providers.

Advances in Management and Therapeutics of Cutaneous Basal Cell Carcinoma

Simple Summary

Basal cell carcinoma (BCC) is the most common malignancy in humans with a range of treatment options available. Tumor and patient characteristics aid in risk-stratification, which influences treatment considerations. Here, we review the advancements in surgical, topical, field, immunotherapeutic, molecular-targeted, and experimental treatment modalities that can be employed in the correct clinical setting for the treatment of BCC.

Abstract

Basal cell carcinoma (BCC), the most common cancer in humans, is a malignant neoplasm of cells derived from the basal layer of the epidermis. Tumor characteristics such as histologic subtype, primary versus recurrent tumor, anatomic location, size, and patient attributes determine the risk level and acceptable treatment options. Surgical options offer histologic confirmation of tumor clearance. Standard excision provides post-treatment histologic assessment, while Mohs micrographic surgery (MMS) provides complete margin assessment intraoperatively. Additional treatment options may be employed in the correct clinical context. Small and low-risk BCCs, broad field cancerization, locally-advanced disease, metastatic disease, cosmetic concerns, or morbidity with surgical approaches raise consideration of other treatment modalities. We review herein a range of treatment approaches and advances in treatments for BCC, including standard excision, MMS, electrodesiccation and curettage, ablative laser treatment, radiation therapy, targeted molecular therapies, topical therapies, field therapies, immunotherapy, and experimental therapies.

Predicting Mohs surgery complexity by applying machine learning to patient demographics and tumor characteristics

Mohs micrographic surgery (MMS) is considered the gold standard for difficult-to-treat malignant skin tumors, whose incidence is on the rise. Currently, there are no agreed upon classifiers to predict complex MMS procedures. Such classifiers could enable better patient scheduling, reduce staff burnout and improve patient education. Our goal was to create an accessible and interpretable classifier(s) that would predict complex MMS procedures. A retrospective study applying machine learning models to a dataset of 8644 MMS procedures to predict complex wound reconstruction and number of MMS procedure stages. Each procedure record contained preoperative data on patient demographics, estimated clinical tumor size prior to surgery (mean diameter), tumor characteristics and tumor location, and postoperative procedure outcomes included the wound reconstruction technique and the number of MMS stages performed in order to achieve tumor-free margins. For the number of stages complexity classification model, the area under the receiver operating characteristic curve (AUROC) was 0.79 (good performance), with model accuracy of 77%, sensitivity of 71%, specificity of 77%, positive prediction value (PPV) of 14% and negative prediction value (NPV) of 98%. The results for the wound reconstruction complexity classification model were 0.84 for the AUROC (excellent performance), with model accuracy of 75%, sensitivity of 72%, specificity of 76%, PPV of 39% and NPV of 93%. The ML models we created predict the complexity of the components that comprise the MMS procedure. Using the accessible and interpretable tool we provide online, clinicians can improve the management and well-being of their patients. Study limitation is that models are based on data generated from a single surgeon.

Loss of epidermal MCPIP1 is associated with aggressive squamous cell carcinoma

BACKGROUND

Squamous cell carcinoma (SCC) of the skin is a common form of nonmelanoma skin cancer. Monocyte chemotactic protein 1-induced protein 1 (MCPIP1), also called Regnase-1, is an RNase with anti-inflammatory properties. In normal human skin, its expression is predominantly restricted to the suprabasal epidermis. The main aim of this study was to investigate whether MCPIP1 is involved in the pathogenesis of SCC.

METHODS

We analyzed the distribution of MCPIP1 in skin biopsies of patients with actinic keratoses (AKs) and SCCs. To explore the mechanisms by which MCPIP1 may modulate tumorigenesis in vivo, we established a mouse model of chemically induced carcinogenesis.

RESULTS

Skin expression of MCPIP1 changed during the transformation of precancerous lesions into cutaneous SCC. MCPIP1 immunoreactivity was high in the thickened area of the AK epidermis but was predominantly restricted to keratin pearls in fully developed SCC lesions. Accelerated development of chemically induced skin tumors was observed in mice with loss of epidermal MCPIP1 (Mcpip1^eKO). Papillomas that developed in Mcpip1^eKO mouse skin were larger and characterized by elevated expression of markers typical of keratinocyte proliferation and tumor angiogenesis. This phenotype was correlated with enhanced expression of IL-6, IL-33 and transforming growth factor-beta (TGF-β). Moreover, our results demonstrated that in keratinocytes, the RNase MCPIP1 is essential for the negative regulation of genes encoding SCC antigens and matrix metallopeptidase 9.

CONCLUSIONS

Overall, our results provide a mechanistic understanding of how MCPIP1 contributes to the development of epidermoid carcinoma.

Efficacy and safety of laser-assisted combination chemotherapy: A follow-up study of treatment with 5-fluorouracil and cisplatin for basal cell carcinoma

BACKGROUND AND OBJECTIVES

There is a growing need for effective topical treatments for basal cell carcinoma (BCC). By altering the skin barrier, ablative fractional lasers (AFLs) enhance cutaneous uptake of the synergistic chemotherapeutic agents, cisplatin, and 5-fluorouracil (5-FU). In our recently reported clinical trial, AFL-assisted delivery of cisplatin and 5-FU showed favorable short-term clearance rates of 95% with good cosmetic results at 3 months. This follow-up study assessed sustained tumor clearance, safety, and cosmesis in the same patient cohort, observed 6- and 12-months posttreatment.

MATERIALS AND METHODS

This follow-up study assessed AFL-assisted cisplatin and 5-FU in low-risk BCC. Among the 18/19 patients who achieved clinical tumor clearance in our 3-months primary trial, all were included for a 6-months follow-up. At 12 months, 17/19 were included due to one 6-month residual. During follow-up visits, treated areas were evaluated for signs of recurrent tumour by clinical inspection and optical coherence tomography (OCT). Residual tumors were confirmed histologically. Cosmetic outcome was evaluated at both follow-up visits by patients and physicians.

RESULTS

Overall, complete tumor clearance was 89% (17/19) and 79% (15/19) at 6 and 12 months, respectively. Clearance rate for superficial BCCs (sBCCs) 1 year after treatment was 100% (6/6) and lower for nodular BCC (nBCC) at 69% (9/13). Among recurrent tumors, 67% (2/3) had received only a single treatment and all were of the nodular subtype, situated in the head and neck area. All histologically confirmed BCC recurrences were identified by OCT. Cosmetic outcomes were similarly rated "good" or "excellent" by patients and evaluators (p = 0.289 and p = 0.250). Treatment-related local skin reactions were mild and tolerable, consisting of persisting erythema in two patients at the end of the study. Dyspigmentation was commonly observed at both follow-up visits, while the appearance of scarring resolved in the majority of patients between 6 months (56%; 10/18) and 12 months (76%; 13/17).

CONCLUSION

AFL-assisted cisplatin + 5-FU in double sessions represents an acceptable and safe treatment strategy for low-risk sBCC, while clearance rates following single treatment or for nBCC seem inferior. This intensified topical strategy may be best suited to cases of multiple lesions or in instances where surgical excision or extended courses of at-home therapy is challenging.

Characterization of the Biomechanical Properties of Skin Using Vibrational Optical Coherence Tomography: Do Changes in the Biomechanical Properties of Skin Stroma Reflect Structural Changes in the Extracellular Matrix of Cancerous Lesions?

Early detection of skin cancer is of critical importance since the five-year survival rate for early detected skin malignancies is 99% but drops to 27% for cancer that has spread to distant lymph nodes and other organs. Over 2.5 million benign skin biopsies (55% of the total) are performed each year in the US at an alarming cost of USD ~2.5 B. Therefore there is an unmet need for novel non-invasive diagnostic approaches to better differentiate between cancerous and non-cancerous lesions, especially in cases when there is a legitimate doubt that a biopsy may be required. The purpose of this study is to determine whether the differences in the extracellular matrices among normal skin, actinic keratosis (AK), basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) can be assessed non-invasively using vibrational optical coherence tomography (VOCT). VOCT is a new diagnostic technology that uses infrared light and audible sound applied transversely to tissue to measure the resonant frequencies and elastic moduli of cells, dermal collagen, blood vessels and fibrous tissue in skin and lesion stroma without physically touching the skin. Our results indicate that the cellular, vascular and fibrotic resonant frequency peaks are altered in AK, BCC and SCC compared to those peaks observed in normal skin and can serve as physical biomarkers defining the differences between benign and cancerous skin lesions. The resonant frequency is increased from a value of 50 Hz in normal skin to a value of about 80 Hz in pre- and cancerous lesions. A new vascular peak is seen at 130 Hz in cancerous lesions that may reflect the formation of new tumor blood vessels. The peak at 260 Hz is similar to that seen in the skin of a subject with Scleroderma and skin wounds that have healed. The peak at 260 Hz appears to be associated with the deposition of large amounts of stiff fibrous collagen in the stroma surrounding cancerous lesions. Based on the results of this pilot study, VOCT can be used to non-invasively identify physical biomarkers that can help differentiate between benign and cancerous skin lesions. The appearance of new stiff cellular, fragile new vessels, and stiff fibrous material based on resonant frequency peaks and changes in the extracellular matrix can be used as a fingerprint of pre- and cancerous skin lesions.

Site-Specific Vesicular Drug Delivery System for Skin Cancer: A Novel Approach for Targeting

Skin cancer, one of the most prevalent cancers worldwide, has demonstrated an alarming increase in prevalence and mortality. Hence, it is a public health issue and a high burden of disease, contributing to the economic burden in its treatment. There are multiple treatment options available for skin cancer, ranging from chemotherapy to surgery. However, these conventional treatment modalities possess several limitations, urging the need for the development of an effective and safe treatment for skin cancer that could provide targeted drug delivery and site-specific tumor penetration and minimize unwanted systemic toxicity. Therefore, it is vital to understand the critical biological barriers involved in skin cancer therapeutics for the optimal development of the formulations. Various nanocarriers for targeted delivery of chemotherapeutic drugs have been developed and extensively studied to overcome the limitations faced by topical conventional dosage forms. A site-specific vesicular drug delivery system appears to be an attractive strategy in topical drug delivery for the treatment of skin malignancies. In this review, vesicular drug delivery systems, including liposomes, niosomes, ethosomes, and transfersomes in developing novel drug delivery for skin cancer therapeutics, are discussed. Firstly, the prevalence statistics, current treatments, and limitations of convention dosage form for skin cancer treatment are discussed. Then, the common type of nanocarriers involved in the research for skin cancer treatment are summarized. Lastly, the utilization of vesicular drug delivery systems in delivering chemotherapeutics is reviewed and discussed, along with their beneficial aspects over other nanocarriers, safety concerns, and clinical aspects against skin cancer treatment.

Development of a novel polymer-based carrier for deformable liposomes for the controlled dermal delivery of naringenin

In recent years, the incidence of skin cancer has increased worldwide, presenting a significant burden on healthcare services. Chemotherapy intervention is often not appropriate for all patients due to localized adverse effects on skin physiology. The aim of this study was, therefore, to consider the development of a novel phytochemical-based deformable liposomal formulation suspended in an aqueous gel for the controlled-release of naringenin. Naringenin is an antioxidant, free radical scavenger, anti-inflammatory agent, and immune system modulator thus may be potentially useful as a pharmacological anti-cancer agent. Formulated liposomes incorporating an increasing loading of Tween 20 (from 0% w/w to 10% w/w) demonstrated a significant decrease in deformability index (DI) (80.71 ± 2.02-59.17 ± 4.42 %), indicating an increase in elasticity. The release of naringenin over 24 h was directly affected by Tween-20 concentration, decreasing from 100.72%±4.98% to 79.53%±3.68% for 0% and 2% w/w Tween 20, respectively. Further, the incorporation of deformable liposomes into hydroxyethylcellulose (HEC) and hydroxypropyl methylcellulose (HPMC) gels resulting in a further retardation of naringenin release, 23.21%±1.17% and 19.83%±1.50%, respectively, over 24 h. Incubation of 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate-loaded liposomes with human dermal fibroblast (HDF) and keratinocyte cells demonstrated intracellular accumulation within 2 h, confirming deformable liposomes may be beneficial in improving drug penetration across dermal cells and would be valuable in emerging controlled-release formulations.

Integrated care pathways and the hub-and-spoke model for the management of non-melanoma skin cancer: A proposal of the Italian Association of Hospital Dermatologists (ADOI)

The term non-melanoma skin cancer (NMSC) refers to skin cancer different from melanoma, and it is usually restricted to basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and their pre-cancerous lesions, e.g., actinic keratosis. These conditions represent the most frequent tumors in Caucasians and are characterized by an increasing incidence worldwide and a high socio-economic impact. The term Integrated Care Pathway (ICP) refers to "a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period". The purpose of this paper is to present a proposal from the Italian Association of Hospital Dermatologists (ADOI) for an ICP organization of care of NMSC, considering the hub-and-spoke model in the different geographical areas. This proposal is based on the most recent literature and on documents from the Italian Association of Medical Oncology (AIOM), the European consensus-based interdisciplinary guidelines from the European Association of Dermato- Oncology (EADO), and the National Comprehensive Cancer Network (NCCN). We initially discuss the NMSC outpatient clinic, the role of the multidisciplinary working groups, and the hub-and-spoke model regarding this topic. Then, we define the ICP processes specific for BCC and SCC. The ICP for NMSC is an innovative strategy to guarantee the highest possible quality of health care while the hub-andspoke model is crucial for the organization of different health care structures. Considering the importance on this topic, it is essential to create a valid ICP together with an efficient organization within the different geographical areas.

Phenethyl Isothiocyanate-Containing Carbomer Gel for Use against Squamous Cell Carcinoma

It is currently estimated that one in every five Americans will develop skin cancer during their lifetime. Squamous cell carcinoma (SCC) is a common type of skin cancer that can develop due to the skin’s exposure to the sun. Herein, we prepared a topical gel containing 0.5% v/w phenethyl isothiocyanate (PEITC) for the treatment of SCC. PEITC is a naturally occurring isothiocyanate that has been shown to have efficacy against various types of cancer in preclinical studies. We first incorporated PEITC into a carbomer gel. A uniform formulation was prepared, and its viscosity was appropriate for topical application. We then demonstrated the release of PEITC from the gel into and through a Strat-M skin-like membrane. Finally, the effects of the PEITC-containing gel were tested against SCC and normal keratinocytes skin cells in culture, and these results were compared to those obtained for free 5-fluoruracil (5-FU), a commonly used skin-cancer drug. Our results show that a homogeneous PEITC-containing topical gel can be prepared and used to kill SCC cells. Thus, our formulation may be useful for treating SCC in the clinic.

Lifestyle behaviors and sun exposure among individuals diagnosed with skin cancer: a cross-sectional analysis of 2018 BRFSS data

PURPOSE

With the continued increase in skin cancer incidence rates, the population of skin cancer survivors continues to grow. Understanding skin cancer survivors' lifestyle behaviors, including ultraviolet radiation exposure, is important in reducing skin cancer recurrences and improving health outcomes. The objective of this study is to compare the differences in lifestyle behaviors among skin cancer survivors or individuals who currently have skin cancer versus individuals who have never had a skin cancer diagnosis.

METHODS

To investigate these lifestyle behaviors, we performed a cross-sectional analysis comparing lifestyle behaviors in persons diagnosed with skin cancer and those without a history of skin cancer among US citizens using publicly available data from the 2018 Behavior Risk Factor Surveillance System (BRFSS).

RESULTS

In total, there were 437,436 respondents. No significant difference existed between the two cohorts in sunburn frequency, use of sun protection, or indoor tanning; in fact, males were more likely to be afflicted with sunburns following diagnosis. Skin cancer survivors were less likely to be current smokers and sedentary. Female survivors were more likely to binge and heavily drink alcohol.

CONCLUSION

Our findings highlight important areas for reducing risk factors, which could reduce the recurrence of skin malignancies in skin cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Our study provides insight to lifestyle behaviors among skin cancer survivors. Being aware of these behaviors has the potential to reduce skin cancer recurrence.

Recurrence of Basal Cell Carcinoma After Mohs Micrographic Surgery: A 4-Year Retrospective Analysis

Background: Among non-melanoma skin cancers (NMSC), Basal cell carcinoma (BCC) is one of the most common. Objectives: We endeavored to assess the recurrence rate of BCC after surgery and compare tumors recurrence based on different aspects. Methods: This was a retrospective and observational study which was analyzed medical records of 154 patients who had Mohs micrographic surgery (MMS) from March 2013 to February 2017 in two clinical centers. For finding if the clinical characteristics of the patients have related to tumoral recurrence, we gathered them, including gender and age of the patient, tumor size, site, and its histological type plus the existence of ulcer in malignancy. Data were analyzed using SPSS 22 statistical software. Statistical difference between proportions was determined by χ2 analysis. Results: The majority of patients (74%) were female (57%) older than 60 years old. Most tumors, based on the histopathological diagnosis, were Infiltrating (43.5%) and nodular and infiltrating (40.3%), respectively. The mean tumor size was 1.81 cm and most of them (74%) were larger than 1 cm. The tumor site was mostly in the nasal (56.5%) followed by the cheek (11%). Most patients (96.8%) had one lesion. The recurrence rate was 1.9%. The mean interval between surgeries to recurrence was 13 months. There was no significant difference between recurrence rate and age, sex, tumor type in terms of clinical diagnosis, tumor location, tumor size, number of lesions, and type of tumor (P < 0.05). Conclusions: the rate of recurrence of BCC in patients treated with MMS is low (1.9%). We recommend the utilization of the MMS technique for the treatment of BCC.

Basal Cell Carcinoma: From Pathophysiology to Novel Therapeutic Approaches

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

Solar ultraviolet-induced DNA damage response: Melanocytes story in transformation to environmental melanomagenesis

Exposure to sunlight is both beneficial, as it heats the planet to a comfortable temperature, and potentially harmful, since sunlight contains ultraviolet radiation (UVR), which is deemed detrimental for living organisms. Earth's ozone layer plays a vital role in blocking most of the extremely dangerous UVC; however, low frequency/energy UVR (i.e., UVB and UVA) seeps through in minute amount and reaches the Earth's surface. Both UVB and UVA are physiologically responsible for a plethora of skin ailments, including skin cancers. The UVR is readily absorbed by the genomic DNA of skin cells, causing DNA bond distortion and UV-induced DNA damage. As a defense mechanism, the DNA damage response (DDR) signaling in skin cells activates nucleotide excision repair (NER), which is responsible for the removal of UVR-induced DNA photolesions and helps maintain the genomic integrity of the cells. Failure of proper NER function leads to mutagenesis and development of skin cancers. One of the deadliest form of skin cancers is melanoma which originates upon the genetic transformation of melanocytes, melanin producing skin cells. NER is a well-studied DNA repair system in the whole skin, as a tissue, but not much is known about it in melanocytes. Therefore, this review encapsulates NER in melanocytes, with a specific focus on its functional regulators and their cross talks due to skin heterogeneity and divulging the potential knowledge gap in the field.

Assessment of Functionality in Elderly Patients When Determining Appropriate Treatment for Nonmelanoma Skin Cancers

BACKGROUND

The treatment of nonmelanoma skin cancer (NMSC) in the elderly population is a source of significant debate. Mohs micrographic surgery (MMS) is a highly effective treatment option yet not every patient with a cutaneous malignancy that meets appropriate use criteria (AUC) should be treated with surgery.

OBJECTIVE

The purpose of this study was to use the Karnofsky Performance Status (KPS) scale to categorize the functional status of patients aged 75 years and older who required treatment of NMSC. The authors wanted to see whether functionality played a role on the treatment selection.

METHODS

Patients aged 75 years and older presenting for biopsy of a suspected NMSC that met AUC for MMS were included in the study. Trained medical assistants used the KPS scale to assess patient functionality. Treatment modality was recorded once the biopsy confirmed the NMSC.

RESULTS

A cohort of 203 subjects met inclusion criteria for the study. There was a statistically significant difference in utilization of surgical treatments between high and low functionality patients (p = .03).

CONCLUSION

Dermatologists consider patient functionality when selecting a treatment for NMSC and use less invasive modalities for patients with poor functional status, even when the tumor meets AUC.

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.

Basal Cell Carcinoma Review

Basal cell carcinoma (BCC) is the most common malignancy and the incidence is rising. BCCs have low mortality but can cause significant morbidity primarily through local destruction. The pathogenesis is linked to the interplay between environmental and patient-derived characteristics. There are multiple therapeutic modalities, and appropriate selection requires knowledge of complications, cosmetic outcomes, and recurrence rates. This article reviews the epidemiology, staging, treatment, and prevention of BCC.

Revisiting the value of the 'bandoneon' flap for lower lip reconstruction: a report of two cases and outcome

Mild- to moderate-sized lip defects that affect one- to two-thirds of the total lip length often require that utilization of local soft tissue rearrangement in order to re-establish lip anatomy, function and esthetics. The use of local flaps in lip reconstruction often follows oncologic resection of common skin malignancies including basal cell carcinoma and squamous cell carcinoma. When considering the types of flaps to use for lip defects of one- to two-third total length, a variety of flaps designs have been described, each with its benefits in drawbacks. In this article, we reintroduce the use and value of the bilateral mucomyocutaneous 'bandoneon' flaps for lower lip reconstruction in two of our patients. When compared with other flap designs, it can be used as a single-stage procedure with a very good esthetic outcome, minimal to no microstomia and preservation of lip competence and sensory function.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Surgical management of non melanoma skin cancer of the head and neck

Non-melanoma skin cancer (NMSC) is the most common malignancy in the world and is reaching epidemic proportions. The most common types of NMSC include basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). The head and neck is the most common site for NMSC, and surgery remains the mainstay of treatment. We review the etiology, risk factors, pathogenesis as well as the preoperative, operative, and postoperative considerations in the management of NMSC. Multidisciplinary evaluation and attention to each of these phases is imperative for favorable oncologic and functional patient outcomes.

Management of keratinocyte carcinoma - Special considerations in the elderly

Keratinocyte carcinomas (KCs) are now an epidemic in The United States of America, especially in elderly patients. KCs, including basal cell carcinoma and squamous cell carcinoma, can lead to disfigurement and occasionally death. However, the lower mortality rate associated with KC compared with melanoma allows for increased flexibility in the selection of treatment. Flexibility in treatment is particularly important in the elderly given that this patient population often has medical comorbidities that should be considered. These patients may have multiple KCs, higher risk tolerance to recurrence, and different concerns about cosmetic outcomes compared with their younger counterparts. We review treatment options for KCs and how the selection of each option may affect the elderly patient.

Intracellular uptake of EGCG-loaded deformable controlled release liposomes for skin cancer

Caucasian population groups have a higher propensity to develop skin cancer, and associated clinical interventions often present substantial financial burden on healthcare services. Conventional treatments are often not suitable for all patient groups as a result of poor efficacy and toxicity profiles. The primary objective of this study was to develop a deformable liposomal formulation, the properties of which being dictated by the surfactant Tween 20, for the dermal cellular delivery of epigallocatechin gallatein (EGCG), a compound possessing antineoplastic properties. The results demonstrated a significant (p ≤ 0.05) decrease in liposome deformability index (74 ± 8 to 37 ± 7) as Tween 20 loading increased from 0 to 10% w/w, indicating an increase in elasticity. EGCG release over 24-h demonstrated Tween 20 incorporation directly increased release from 13.7% ± 1.1% to 94.4% ± 4.9% (for 0 and 10% w/w Tween 20 respectively). Finally, we demonstrated DilC-loaded deformable liposomes were localized intracellularly within human dermal fibroblast and keratinocyte cells within 2 h. Thus, it was evident that deformable liposomes may aid drug penetration into dermal cells and would be useful in developing a controlled-release formulation.

Gene-Specific Intron Retention Serves as Molecular Signature that Distinguishes Melanoma from Non-Melanoma Cancer Cells in Greek Patients

Background: Skin cancer represents the most common human malignancy, and it includes BCC, SCC, and melanoma. Since melanoma is one of the most aggressive types of cancer, we have herein attempted to develop a gene-specific intron retention signature that can distinguish BCC and SCC from melanoma biopsy tumors. Methods: Intron retention events were examined through RT-sqPCR protocols, using total RNA preparations derived from BCC, SCC, and melanoma Greek biopsy specimens. Intron-hosted miRNA species and their target transcripts were predicted via the miRbase and miRDB bioinformatics platforms, respectively. Ιntronic ORFs were recognized through the ORF Finder application. Generation and visualization of protein interactomes were achieved by the IntAct and Cytoscape softwares, while tertiary protein structures were produced by using the I-TASSER online server. Results: c-MYC and Sestrin-1 genes proved to undergo intron retention specifically in melanoma. Interaction maps of proteins encoded by genes being potentially targeted by retained intron-accommodated miRNAs were generated and SRPX2 was additionally delivered to our melanoma-specific signature. Novel ORFs were identified in MCT4 and Sestrin-1 introns, with potentially critical roles in melanoma development. Conclusions: The property of c-MYC, Sestrin-1, and SRPX2 genes to retain specific introns could be clinically used to molecularly differentiate non-melanoma from melanoma tumors.

The Role of CXCR3 and Its Chemokine Ligands in Skin Disease and Cancer

Chemokines and their receptors play an important role in the recruitment, activation and differentiation of immune cells. The chemokine receptor, CXCR3, and its ligands, CXCL9, CXCL10, and CXCL11 are key immune chemoattractants during interferon-induced inflammatory responses. Inflammation of the skin resulting from infections or autoimmune disease drives expression of CXCL9/10/11 and the subsequent recruitment of effector, CXCR3⁺ T cells from the circulation. The relative contributions of the different CXCR3 chemokines and the three variant isoforms of CXCR3 (CXCR3A, CXCR3B, CXCR3alt) to the inflammatory process in human skin requires further investigation. In skin cancers, the CXCR3 receptor can play a dual role whereby expression on tumor cells can lead to cancer metastasis to systemic sites while receptor expression on immune cells can frequently promote anti-tumor immune responses. This review will discuss the biology of CXCR3 and its associated ligands with particular emphasis on the skin during inflammation and carcinogenesis.

Effectiveness of Mohs micrographic surgery for nonmelanoma skin cancer: a systematic review protocol

REVIEW OBJECTIVES/QUESTIONS

The objective of the review is to evaluate the effectiveness of Mohs micrographic surgery on the mortality, recurrence and quality of life of patients with nonmelanoma skin cancers when compared with other treatment modalities.Specifically, it aims to examine the effectiveness of Mohs micrographic surgery compared with other treatment modalities such as excisional surgery, curettage and electrodessication and radiation therapy, as well as nonsurgical/chemotherapeutic interventions such as topical 5-fluorouracil and imiquimod immunotherapy in the management of nonmelanoma skin cancers.

A Review of the Literature of Surgical and Nonsurgical Treatments of Invasive Squamous Cells Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is an increasing public health problem. It is a primary malignant skin tumor with Malpighian differentiation and together with basal cell carcinoma is classified among nonmelanoma skin cancers (NMSCs). cSCC usually occurs on photoexposed areas, such as the head, the neck, and the extremities, and its incidence increases with age. Invasive forms of this skin tumor tend to be more aggressive showing a higher metastatic potential, usually regarding regional lymph nodes. Treatment options for invasive cSCCs include both surgical and nonsurgical options. The therapeutic choice depends on several factors, such as anatomic location, risk factors for tumor recurrence, age, and health status of the patient. This review aims to provide an overview of the current evidence on therapeutic surgical and nonsurgical management of invasive cSCC.

5-Fluorouracil ethosomes - skin deposition and melanoma permeation synergism with microwave

This study focuses on the use of ethosome and microwave technologies to facilitate skin penetration and/or deposition of 5-fluorouracil in vitro and in vivo. Low ethanol ethosomes were designed and processed by mechanical dispersion technique and had their size, zeta potential, morphology, drug content and encapsulation efficiency characterized. The skin was pre-treated with microwave at 2450 MHz for 2.5 min with ethosomes applied topically and subjected to in vitro and in vivo skin drug permeation as well as retention evaluation. The drug and/or ethosomes cytotoxicity, uptake and intracellular trafficking by SKMEL-28 melanoma cell culture were evaluated. Pre-treatment of skin by microwave promoted significant drug deposition in skin from ethosomes in vitro while keeping the level of drug permeation unaffected. Similar observations were obtained in vivo with reduced drug permeation into blood. Combination ethosome and microwave technologies enhanced intracellular localization of ethosomes through fluidization of cell membrane lipidic components as well as facilitating endocytosis by means of clathrin, macropinocytosis and in particularly lipid rafts pathways. The synergistic use of microwave and ethosomes opens a new horizon for skin malignant melanoma treatment.

Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

AIM

To review the efficacy of perioperative antibiotics in reducing the risk of surgical-site infections (SSIs) following excision of ulcerated skin cancers.

SETTING AND DESIGN

Study selection, data extraction and analysis were carried out independently by four authors. Only randomized controlled trials (RCTs) reported in the English language were included.

INCLUDED STUDIES

RCTs in the English language in which patients received perioperative topical, intralesional or oral antibiotics for dermatological surgery, including Mohs micrographic surgery in general practice, dermatology or plastic surgery departments, were included.

OUTCOME

The proportion of participants developing SSI following excision of skin lesions.

RESULTS

Thirteen RCTs were identified from our literature search of PubMed and Embase, which evaluated SSI following use of topical (n = 5), oral (n = 3), intramuscular (n = 2), intravenous (n = 1) and intralesional antibiotics (n = 2) in dermatological surgery. Two RCTs specifically investigated SSIs in ulcerated skin cancer excisions; one RCT investigated the SSI rate following surgical treatment specifically for ulcerated skin cancers in individuals randomized to topical antibiotics vs. oral cephalexin; and one RCT compared intravenous cefazolin with no antibiotic, demonstrating significant reduction in SSI rates for ulcerated tumours (P = 0·04).

CONCLUSIONS

The heterogeneity of the RCTs included in this study makes it difficult to make a direct comparison of the outcomes measured. High-quality evidence demonstrating a beneficial effect of the use of perioperative antibiotics to prevent SSI following excision of ulcerated skin cancers is lacking. In the absence of an evidence base, we propose that a well-designed multicentre RCT could evaluate the effect of perioperative antibiotics following excision of ulcerated tumours, and potentially reduce inappropriate antibiotic prescription.

Bakuchiol suppresses proliferation of skin cancer cells by directly targeting Hck, Blk, and p38 MAP kinase

Bakuchiol is a meroterpene present in the medicinal plant Psoralea corylifolia, which has been traditionally used in China, India, Japan and Korea for the treatment of premature ejaculation, knee pain, alopecia spermatorrhea, enuresis, backache, pollakiuria, vitiligo, callus, and psoriasis. Here, we report the chemopreventive properties of bakuchiol, which acts by inhibiting epidermal growth factor (EGF)-induced neoplastic cell transformation. Bakuchiol also decreased viability and inhibited anchorage-independent growth of A431 human epithelial carcinoma cells. Bakuchiol reduced A431 xenograft tumor growth in an in vivo mouse model. Using kinase profiling, we identified Hck, Blk and p38 mitogen activated protein kinase (MAPK) as targets of bakuchiol, which directly bound to each kinase in an ATP-competitive manner. Bakuchiol also inhibited EGF-induced signaling pathways downstream of Hck, Blk and p38 MAPK, including the MEK/ERKs, p38 MAPK/MSK1 and AKT/p70S6K pathways. This report is the first mechanistic study identifying molecular targets for the anticancer activity of bakuchiol and our findings indicate that bakuchiol exhibits potent anticancer activity by targeting Hck, Blk and p38 MAPK.

Neoplastic Multifocal Skin Lesions: Biology, Etiology, and Targeted Therapies for Nonmelanoma Skin Cancers

Neoplastic skin lesions are multifocal, diffuse skin infiltrations of particular relevance in the differential diagnosis of ulcerative, nodular, or crusting skin lesions. Nonmelanoma skin cancers (NMSCs), namely, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and also actinic keratosis (AK), are the most common malignant tumors in humans. BCCs do not proliferate rapidly and most of the times do not metastasize, while SCCs are more infiltrative, metastatic, and destructive. AKs are precursor lesions of cutaneous SCCs. The classical therapy of NMSCs makes use of photodynamic therapy associated with chemotherapeutics. With improved understanding of the pathological mechanisms of tumor initiation, progression, and differentiation, a case is made towards the use of targeted chemotherapy with the intent to reduce the cytotoxicity of classical treatments. The present review aims to describe the current state of the art on the knowledge of NMSC, including its risks factors, oncogenes, and skin carcinogenesis, discussing the classical therapy against new therapeutic options.

Stage-dependent therapeutic efficacy in PI3K/mTOR-driven squamous cell carcinoma of the skin

Cutaneous squamous cell carcinoma (SCC) is a recurrent cancer that is prevalent in predisposed subjects such as immunosuppressed patients and patients being treated for other malignancies. Model systems to trial therapies at different stages of SCC development are lacking, therefore precluding efficient therapeutic interventions. Here, we have disrupted the expression of the tumor suppressor GRHL3 to induce loss of PTEN and activation of the PI3K/mTOR signaling pathway in mice and human skin, promoting aggressive SCC development. We then examined the potential for targeting PI3K/mTOR and an oncogenic driver miR-21, alone and in combination, for the prevention and treatment of SCC during the initiation, promotion/progression and establishment stages. Treatment with PI3K/mTOR inhibitors completely prevented tumor initiation, and these inhibitors significantly delayed the course of papilloma progression to malignancy. However, established SCC did not undergo any growth regression, indicating that this therapy is ineffective in established cancers. Mechanistically, the resistant SCCs displayed increased miR-21 expression in mice and humans where antagonists of miR-21 rescued expression levels of GRHL3/PTEN, but the combination of miR-21 antagonism with PI3K/mTOR inhibition resulted in acquired SCC resistance in part via c-MYC and OCT-4 upregulation. In conclusion, our data provide molecular evidence for the efficacy of targeting oncogenic drivers of SCC during the initiation and promotion stages and indicate that combination therapy may induce an aggressive phenotype when applied in the establishment stage.

Basal cell carcinoma pathogenesis and therapy involving hedgehog signaling and beyond

Basal cell carcinoma (BCC) of the skin is driven by aberrant hedgehog signaling. Thus blocking this signaling pathway by small molecules such as vismodegib inhibits tumor growth. Primary cilium in the epidermal cells plays an integral role in the processing of hedgehog signaling-related proteins. Recent genomic studies point to the involvement of additional genetic mutations that might be associated with the development of BCCs, suggesting significance of other signaling pathways, such as WNT, NOTCH, mTOR, and Hippo, aside from hedgehog in the pathogenesis of this human neoplasm. Some of these pathways could be regulated by noncoding microRNA. Altered microRNA expression profile is recognized with the progression of these lesions. Stopping treatment with Smoothened (SMO) inhibitors often leads to tumor reoccurrence in the patients with basal cell nevus syndrome, who develop 10-100 of BCCs. In addition, the initial effectiveness of these SMO inhibitors is impaired due to the onset of mutations in the drug-binding domain of SMO. These data point to a need to develop strategies to overcome tumor recurrence and resistance and to enhance efficacy by developing novel single agent-based or multiple agents-based combinatorial approaches. Immunotherapy and photodynamic therapy could be additional successful approaches particularly if developed in combination with chemotherapy for inoperable and metastatic BCCs.

Individualized 3D scanning and printing for non-melanoma skin cancer brachytherapy: a financial study for its integration into clinical workflow

Purpose

Skin cancer is the most common tumor in the population. There are different therapeutic modalities. Brachytherapy is one of the techniques used, in which it is necessary to build customized moulds for some patients. Currently, these moulds are made by hand using rudimentary techniques. We present a new procedure based on 3D printing and the analysis of the clinical workflow.

Material and methods

Moulds can be made either by hand or by automated 3D printing. For making moulds by hand, a patient’s alginate negative is created and, from that, the gypsum cast and customized moulds are made by hand from the patient’s negative template. The new process is based on 3D printing. The first step is to take a 3D scan of the surface of the patient and then, 3D modelling software is used to obtain an accurate anatomical reconstruction of the treatment area. We present the clinical workflow using 3D scanning and printing technology, comparing its costs with the usual custom handmade mould protocol.

Results

The time spent for the new process is 6.25 hours, in contrast to the time spent for the conventional process, which is 9.5 hours. We found a 34% reduction in time required to create a mould for brachytherapy treatment. The labor cost of the conventional process is 211.5 vs. 152.5 hours, so the reduction is 59 hours. There is also a 49.5% reduction in the financial costs, mostly due to lack of need of a computed tomography (CT) scan of the gypsum and the mould. 3D scanning and printing offers financial benefits and reduces the clinical workload.

Conclusions

As the present project demonstrates, through the application of 3D printing technologies, the costs and time spent during the process in the clinical workload in brachytherapy treatment are reduced. Overall, 3D printing is a promising technique for brachytherapy that might be well received in the community.