Expert opinion on sonidegib efficacy, safety and tolerability

Therapeutic Approaches for Non-Melanoma Skin Cancer: Standard of Care and Emerging Modalities

Skin cancer encompasses a range of cutaneous malignancies, with non-melanoma skin cancers (NMSCs) being the most common neoplasm worldwide. Skin exposure is the leading risk factor for initiating NMSC. Ultraviolet (UV) light induces various genomic aberrations in both tumor-promoting and tumor-suppressing genes in epidermal cells. In conjunction with interactions with a changed stromal microenvironment and local immune suppression, these aberrations contribute to the occurrence and expansion of cancerous lesions. Surgical excision is still the most common treatment for these lesions; however, locally advanced or metastatic disease significantly increases the chances of morbidity or death. In recent years, numerous pharmacological targets were found through extensive research on the pathogenic mechanisms of NMSCs, leading to the development of novel treatments including Hedgehog pathway inhibitors for advanced and metastatic basal cell carcinoma (BCC) and PD-1/PD-L1 inhibitors for locally advanced cutaneous squamous cell carcinoma (cSCC) and Merkel cell carcinoma (MCC). Despite the efficacy of these new drugs, drug resistance and tolerability issues often arise with long-term treatment. Ongoing studies aim to identify alternative strategies with reduced adverse effects and increased tolerability. This review summarizes the current and emerging therapies used to treat NMSC.

Dynamic optical coherence tomography evaluation in locally advanced basal cell carcinoma during sonidegib treatment

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer in the Caucasian population. It has a multifactorial pathogenesis, in which constitutive activation of the Sonic Hedgehog signalling (SHH) pathway (via mutations in PTCH1 or SMO genes) represents by far the most common genetic aberration. The introduction of vismodegib and sonidegib, two SHH pathway inhibitors, changed the therapeutic approach of locally advanced and metastatic BCCs. EADO's (European Association of Dermato-Oncology) new staging system refers to these as 'difficult-to-treat' BCCs.

OBJECTIVE

The aim was to evaluate sonidegib's effectiveness in patients affected by difficult-to-treat BCCs by using non-invasive diagnostic techniques.

METHODS

We retrospectively evaluated 14 patients (4 females, 10 males; mean age 77 ± 11 years) affected by difficult-to-treat BCCs treated with oral sonidegib 200 mg/day that were followed with total body videodermoscopy (V-Track, Vidix 4.0) and dynamic optical coherence tomography (D-OCT, VivoSight Dx) since May 2022. Considering the risk of rhabdomyolysis routine blood tests, especially for creatine kinase concentrations, were performed. All treated patients were inserted in the BasoCare database, which aims to offer support to patients taking sonidegib. Complete and partial responses were evaluated by the overall reduction of the number of lesions and their individual sizes. Safety was evaluated by assessing the occurrence and severity of adverse reactions.

RESULTS

Eighty per cent achieved complete clearance and 75% reduction of diameter. D-OCT scans performed at every follow-up showed concordance with clinical appearance and demonstrated reduction of hyporeflective structures, that is, islets of tumour cells and overall improvement of morphology.

CONCLUSION

Sonidegib can be considered an effective treatment option in cases where surgery or radiotherapy would be unfeasible or has previously failed, although pigmented lesions did not show complete clearance, suggesting that there are factors other than the SHH pathway involved in tumour growth. Videodermoscopy and D-OCT were useful in the quick and seamless follow-up of lesions and added valuable information in assessing efficacy.

The Efficacy of Sonidegib in Treating Locally Advanced Basal Cell Carcinoma Involving the Periocular Area

INTRODUCTION

Basal cell carcinoma (BCC) is the most common skin malignancy in Caucasians. Globally, about 20% of BCCs involve the periocular region. The treatment of periocular BCC may be very challenging because of its proximity to the intracranial structures. Thus, early diagnosis and early treatment is mandatory. Recently, the introduction of Hedgehog pathway inhibitor therapy revolutionized the management of unresectable BCCs. The aim of our study was to evaluate the outcome of sonidegib treatment in patients affected by periocular locally advanced (la) BCC at our skin cancer center.

METHODS

A 3-year retrospective study was carried out enrolling patients with periocular laBCC treated with sonidegib. Therapeutic response was defined as complete remission (CR) in case of complete regression of the tumor, partial remission (PR) in case of tumor regression not achieving complete remission, and stable disease (SD).

RESULTS

A total 16 patients (11 men and 5 women; medium age 71.6 ± 11.5 years) with periocular laBCCs undergoing treatment with 200 mg/day of sonidegib were included in our study. Patients included in the study were treated for at least 6 months for a median duration of 9 months. Overall, CR was reported in 9/16 (56.2%) patients, PR was reported in 4/16 patients (25%), and tumor remained stable in 3 patients (18.8%). No cases of disease progression were collected. Fourteen out of 16 patients experienced multiple adverse events (AEs): dysgeusia was reported in 12 (75%) patients, muscle spasms in 13 (81%) patients, and 7 (43.7%) patients presented with alopecia. However, all of the AEs were mild and none required treatment discontinuation.

CONCLUSION

To the best of our knowledge, this is the first study investigating the effectiveness and safety of sonidegib in the management of BCC localized at the periocular region. Even if limited, our study suggests this drug as a valuable and safe option in periocular BCC management.

An update on the current and emerging pharmacotherapies for basal cell carcinomas

INTRODUCTION

Despite surgical approach is still the mainstay for basal cell carcinoma (BCC) management, several issues may limit the use of this technique, leading to the need for new treatments to offer patients a personalized approach.

AREAS COVERED

A comprehensive review of the available and emerging pharmacologic strategies for BCC management, including mechanisms of action, and potential adverse effects, has been performed to provide with an up-to-date manuscript on the current treatment scenario of BCC. Globally, targeting the Sonic-Hedgehog pathway is one of the main mechanisms of action of currently investigated drugs. Other alternatives are based on the concept of an enhancement of the immune response such as immune checkpoint inhibitors, or intra-tumor treatments.

EXPERT OPINION

Although low-risk BCCs are often treated with destructive methods or topical treatments, surgery is the mainstay of treatment for the majority of BCCs. However, several factors may limit the use of surgery in BCC management. Recently, major knowledge on BCCs pathogenesis has led to the development of effective and selective drugs. In our opinion, soon many drugs will be licensed, allowing clinicians to offer patients with BCC the right treatment at the right moment. Certainly, further studies are needed.

Treatment of basal cell carcinoma with intralesional interferon alfa-2b: an open-label clinical trial

INTRODUCTION

Basal cell carcinoma (BCC) is the most common cutaneous cancer. We report the efficacy and aesthetic outcome of intralesional IFN-α 2b injection for the treatment of BCC and compare with the surgical method.

MATERIALS AND METHODS

Intralesional IFN-α 2b was injected in 58 BCC lesions from 20 patients three times a week for three weeks. Control group was retrospectively selected among patients who underwent surgical method (standard surgical excision) for BCC including 58 lesions from 24 patients. All patients were followed up for one year in terms of recurrence and cosmetic outcome.

RESULTS

Two patients (four lesions) failed to complete the treatment period. After three weeks, 40 (68.96%) lesions were completely cured. Nine (15.51%) lesions achieved complete healing in less than 9 sessions. Five (8.62%) lesions were completely cured by an extra week of injection. In aggregate, complete healing was observed in 54 (93.10%) lesions. In the surgery group, complete lesion elimination was detected in 52 (89.65%) lesions (p = 0.40). After one year, cosmetic outcome was significantly more favorable in the study group compared to the surgery group (p = 0.003). Recurrence was not detected in any of the groups after one year follow-up.

CONCLUSION

Intralesional IFN-α 2b injection is an appropriate treatment choice for BCC.

CLINICAL TRIAL REGISTRY

We used Iranian registery of Clinical trials; The IRCT code is: 2017093017756N30.

Efficacy and safety of sonidegib for the management of basal cell carcinoma: a drug safety evaluation

INTRODUCTION

Surgery is the standard management for most of basal cell carcinomas (BBCs). In some cases, also radiotherapy may be a valuable weapon as well as ablative and topical treatments. However, all these approaches may be limited by some tumor features. In this scenario, locally advanced BCCs (laBCC) and metastatic BCC, also defined as 'difficult-to-treat' BCC, remain the real treatment challenge. New knowledge on BCC pathogenesis, particularly the Hedgehog (HH) pathway, led to the development of new selective therapies such as vismodegib and sonidegib. In particular, sonidegib is an orally administered small molecules, which inhibits the HH signaling pathway through the binding to SMO receptor, recently approved for the management of adult patients with laBCC who are not amenable to curative surgery or radiation therapy.

AREAS COVERED

The purpose of this review is to analyze and discuss the efficacy and safety of sonidegib for the management of BCC, to provide a broad perspective on the currently available data.

EXPERT OPINION

Sonidegib is a valuable weapon for the management of difficult-to-treat BCC. Current data showed promising results in terms of effectiveness and safety. However, more studies are needed to underline its role in BCC management, also considering the presence of vismodegib, and to investigate its use in a long-term period.

Basal Cell Carcinoma and Hedgehog Pathway Inhibitors: Focus on Immune Response

Basal cell carcinoma (BCC) is the most common form of skin cancer, affecting more often elderly patients, but sometimes even younger ones, particularly if immunocompromised or genetically predisposed. Specifically, the Gorlin-Goltz syndrome, an autosomal dominant genodermatosis, also known as nevoid basal cell carcinoma syndrome, characterizes for multiple early onset BCCs. It is caused by a germline mutation in PTCH1, a tumor suppressor gene whose product is the key component of Hedgehog (Hh) signaling pathway, which also appears somatically mutated in more than 85% of sporadic BCCs. Hh pathway inhibitors vismodegib and sonidegib are currently indicated for BCC, in adults with advanced or recurred tumor following surgery or radiation therapy. The principal mechanism of action of these drugs is the inhibition of Smoothened (SMO), a transmembrane protein involved in Hh signal transduction, that plays a role in both cellular differentiation and cancer development. Some studies have reported effects of Hh pathway inhibitors at different levels of the immune response, from cytotoxic T cells to a modified local cytokines pattern. Given the specific relation between immune system and BCC development in some conditions, we will review BCC with focus on immune system changes mediated by Hh signaling pathway and induced by the inhibitors vismodegib and sonidegib in the treatment of BCC. Thus, we will give an overview of their effects on the local immune response, as well as a brief note on the supposed function of Hh pathway inhibition on the systemic one.

An update on local and systemic therapies for non-melanoma skin cancer

INTRODUCTION

Nonmelanoma skin cancers (NMSC) as a group exceed the incidence of all other malignancies combined. NMSC includes basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. As the incidence continues to rise, it is important to appreciate the available treatment options.

AREAS COVERED

This article discusses the treatment of NMSC though surgical, topical, regional, and systemic modalities.

EXPERT OPINION

As there are many treatment options available for these diseases, selection of the appropriate method can be difficult. With time, we expect treatment decisions to become even more complex and personalized. The role of systemic immunotherapies and neoadjuvant therapies in the treatment of NMSC is still not well defined. Local treatment with intralesional injections and isolated limb infusion may prove to be promising alternative therapies.

New Emerging Treatment Options for Advanced Basal Cell Carcinoma and Squamous Cell Carcinoma

Non-melanoma skin cancers, also known as keratinocyte tumors, have an increasing incidence worldwide, with basal cell carcinoma and squamous cell carcinoma being the most represented ones. Although surgery represents the gold-standard treatment for both tumors, some cases can progress to an advanced or a metastatic state and targeted therapy is required. Hedgehog signaling pathway has an important role in the development of basal cell carcinoma, and its inhibition is the key to new treatment options available for the treatment of locally advanced and metastatic basal cell carcinoma. Cutaneous squamous cell carcinoma is the second most frequent malignant skin cancer; when presenting in advanced or metastatic stage, alternative treatments are required; cemiplimab is a human monoclonal antibody directed against programmed cell death-1 receptor that acts by blocking T-cell inactivation and is the first drug approved for the treatment of adult patients with metastatic or locally advanced cutaneous squamous cell carcinoma. Studies evaluating pembrolizumab, ipilimumab and nivolumab as alternative treatments for advanced squamous cell carcinoma are still underway. Objective of this review is to analyze and discuss the novel therapies for advanced basal cell carcinoma and squamous cell carcinoma to obtain a sharper perspective of the available treatment options.