Epidemiology and aetiology of basal cell carcinoma

Basal cell carcinoma at an eccentric location: A rare case report

Basal cell carcinoma (BCC) is the most common form of skin cancer, which presents with local invasion, has low metastasizing potential and a cure rate of 100% after surgical excision. BCC commonly involves sun-exposed areas with approximately 80%-85% of BCC located on the head or neck, 15% on the trunk, and <2% in unusual areas such as the abdomen, genitals, perianal skin, lateral edge of the foot, axilla, superior or inferior lip.

The Association of Vitamin D with Non-Melanoma Skin Cancer Risk: An Umbrella Review of Systematic Reviews and Meta-Analyses

Background and Objectives: Previous studies revealed the anti-angiogenic, antiproliferative, and anti-inflammatory effects of Vitamin D (VitD) on cancer cells. Although this body of evidence supported the correlation of high VitD levels with reduced incidence rates for various malignancies, contradictory results were reported regarding non-melanoma skin cancer (NMSC). The aim of this overview was to summarize the available evidence from the existing pool of systematic reviews and meta-analyses, focusing on VitD serum status, dietary intake, and VitD receptor (VDR) polymorphisms in correlation to NMSC incidence. Materials and Methods: A literature search in electronic databases was conducted from inception to January 2023. The inclusion criteria were systematic reviews and meta-analyses published in peer-reviewed journals, evaluating VitD serum levels, dietary and/or supplementary intake, or VDR gene polymorphisms, and reporting data on NMSC. Results: A total of 10 studies were included in the data analysis models. A positive association between VitD serum levels and NMSC is highlighted. However, dietary/supplementation of VitD does not exhibit a likewise strong linkage to NMSC. Despite the contradictory findings, VDR polymorphisms may play a crucial role in the intricate NMSC pathogenesis. Conclusions: This umbrella review shows that high VitD levels are associated with increased NMSC incidence, potentially due to its direct correlation with increased sun exposure. Further research on VDR polymorphisms is suggested to explore their true effect size on NMSC risk.

Utility of GLI1 RNA Chromogenic in Situ Hybridization in Distinguishing Basal Cell Carcinoma From Histopathologic Mimics

Basal cell carcinoma (BCC) is the most common human malignancy and is a leading cause of nonmelanoma skin cancer-related morbidity. BCC has several histologic mimics which may have treatment and prognostic implications. Furthermore, BCC may show alternative differentiation toward a variety of cutaneous structures. The vast majority of BCCs harbor mutations in the hedgehog signaling pathway, resulting in increased expression of the GLI family of transcription factors. GLI1 immunohistochemistry has been shown to discriminate between several tumor types but demonstrates high background signal and lack of specificity. In this study, we evaluated the utility of GLI1 RNA chromogenic in situ hybridization (CISH) as a novel method of distinguishing between BCC and other epithelial neoplasms. Expression of GLI1 by RNA CISH was retrospectively evaluated in a total of 220 cases, including 60 BCCs, 37 squamous cell carcinomas (SCCs) including conventional, basaloid, and human papillomavirus infection (HPV)-associated tumors, 16 sebaceous neoplasms, 10 Merkel cell carcinomas, 58 benign follicular tumors, and 39 ductal tumors. The threshold for positivity was determined to be greater than or equal to 3 GLI1 signals in at least 50% of tumor cells. Positive GLI1 expression was identified in 57/60 BCCs, including metastatic BCC, collision lesions with SCC, and BCCs with squamous, ductal, or clear cell differentiation or with other unusual features compared to 1/37 SCCs, 0/11 sebaceous carcinomas, 0/5 sebaceomas, 1/10 Merkel cell carcinomas, 0/39 ductal tumors, and 28/58 follicular tumors. With careful evaluation, GLI1 RNA CISH is highly sensitive (95%) and specific (98%) in distinguishing between BCC and nonfollicular epithelial neoplasms. However, GLI1 CISH is not specific for distinguishing BCC from most benign follicular tumors. Overall, detection of GLI1 RNA by CISH may be a useful tool for precise classification of histologically challenging basaloid tumors, particularly in the setting of small biopsy specimens, metaplastic differentiation, or metastatic disease.

Polymeric micelles for cutaneous delivery of the hedgehog pathway inhibitor TAK-441: Formulation development and cutaneous biodistribution in porcine and human skin

TAK-441 is a potent inhibitor of the hedgehog pathway (IC50 4.4 nM) developed for the treatment of basal cell carcinoma that is active against the vismodegib-resistant Smoothened receptor D473H mutant. The objective of this study was to develop a micelle-based formulation of TAK-441 using D-α-Tocopherol polyethylene glycol 1000 succinate (TPGS) and to investigate its cutaneous delivery and biodistribution. The micelles were prepared using solvent evaporation and incorporation of TAK-441 in the TPGS micelles increased aqueous solubility ∼40-fold. The optimal formulation, a 3% HPMC hydrogel of TAK-441 loaded TPGS micelles, retained ∼92% of the initial TAK-441 content (2.5 mgTAK-441/g) after storage at 4 °C for 6 months. Finite dose experiments using human skin demonstrated that this formulation resulted in significantly greater cutaneous deposition of TAK-441 after 12 h than a non-micelle control formulation, (0.40 ± 0.11 µg/cm2 and 0.05 ± 0.02 µg/cm2, respectively) - no transdermal permeation was observed. The cutaneous biodistribution profile demonstrated that TAK-441 was predominantly delivered to the viable epidermis and upper dermis. Delivery from the HPMC hydrogel formulation resulted in TAK-441 epidermal concentrations that were several thousand-fold higher than the IC50, with almost negligible transdermal permeation, thereby decreasing the risk of systemic side effects in vivo.

Sun-Exposed versus Sun-Protected Cutaneous Basal Cell Carcinoma: Clinico-Pathological Profile and p16 Immunostaining

Introduction: Although widespread, BCC is still relatively poorly understood in regards to pathogenesis and prognosis, particularly the lesions formed on anatomical sites away from sun exposure. With the aim of deepening our understanding of the pathogenesis and clinico-pathological correlations of BCCs, we conducted this study. Methods: Tissue blocks and data of 52 Egyptian patients diagnosed with BCC were retrieved for clinical information and inclusion criteria, then re-examined histologically; p16 immunostaining was carried out and evaluated for analysis and comparison between the two groups, i.e., sun-exposed and sun-protected. Results: Sex, age, clinical suspicion, tumor size, recurrence status, and histologic variants did not show a significant difference between the sun-protected and sun-exposed groups; however, the mean ages recorded were 67.2 vs. 62.7 for the sun-protected and sun-exposed groups, respectively. A total of 52% of BCCs were positive for p16. The sun-protected lesions showed p16 positivity in 61% of cases, whereas 49% of the sun-exposed lesions were positive with no significant difference. There was a significant difference in p16 expression between the recurrent and non-recurrent lesions. Conclusions: A significant difference was seen in the case of cancer recurrence, where all the recurrent BCCs in this study demonstrated negative p16 immunostaining of the primary lesions; however, the positively stained cases in total were 52% of BCCs. The mean patient age of the sun-protected group was much higher than in previous peer studies. We assume that the biological, prognostic, and clinical aspects of p16 protein expression in BCCs are still far from being clearly understood. Further studies are highly recommended, with more focus on its role in the pathogenesis and the prognostic factors.

Patients with a history of atopy have fewer cutaneous melanomas than those without atopy: a cross-sectional study in 496 patients at risk of skin cancers

The connection between atopy and skin cancers may be related to the stimulation of protective immune response, for example, through autoreactive immunoglobulin-E (IgE), or to the predisposition to carcinogenesis through chronic inflammation. The aim of this study was to investigate whether a past or present atopic disorder is associated with cutaneous photodamage, pigment cell nevi and skin cancers. For this, adult subjects at risk of any type of skin cancer (aged 21-79 years, 250 males, 246 females, 94 with immunosuppression) were examined for past or present malignancies in skin and extracutaneous site (ECS), photodamage, nevi, past or present atopic disorder in skin or mucus membranes, and possible other cancer-related factors. No association between atopy and photodamage, keratinocyte carcinomas or nevus count was found. Instead, there were fewer subjects with melanoma in 171 atopic (14.6%) than in 325 nonatopic subjects (22.2%) (P = 0.044), and the investigator-estimated risk class of skin cancers was lower in atopic than nonatopic subjects. In all subjects, the multivariate odds ratio (OR) for melanoma was 0.583 (P = 0.046; 95% confidence interval, 0.343-0.990) in atopic subjects, but in immunocompetent subjects, the reduced risk was confined to mucus membrane atopy (OR, 0.417; P = 0.020). Also, there were fewer subjects with malignancy in ECS in atopic (8.8%) than nonatopic subjects (15.7%) (P = 0.031). No association between serum total IgE and skin cancers, photodamage, nevi or malignancies in ECS was found. In conclusion, the atopy, especially mucus membrane atopy, is associated with lower percentages of subjects with a history of melanoma.

Advancements in nanoparticle-based treatment approaches for skin cancer therapy

Skin cancer has emerged as the fifth most commonly reported cancer in the world, causing a burden on global health and the economy. The enormously rising environmental changes, industrialization, and genetic modification have further exacerbated skin cancer statistics. Current treatment modalities such as surgery, radiotherapy, conventional chemotherapy, targeted therapy, and immunotherapy are facing several issues related to cost, toxicity, and bioavailability thereby leading to declined anti-skin cancer therapeutic efficacy and poor patient compliance. In the context of overcoming this limitation, several nanotechnological advancements have been witnessed so far. Among various nanomaterials, nanoparticles have endowed exorbitant advantages by acting as both therapeutic agents and drug carriers for the remarkable treatment of skin cancer. The small size and large surface area to volume ratio of nanoparticles escalate the skin tumor uptake through their leaky vasculature resulting in enhanced therapeutic efficacy. In this context, the present review provides up to date information about different types and pathology of skin cancer, followed by their current treatment modalities and associated drawbacks. Furthermore, it meticulously discusses the role of numerous inorganic, polymer, and lipid-based nanoparticles in skin cancer therapy with subsequent descriptions of their patents and clinical trials.

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.

Epidemiological and clinicopathological analysis of basal cell carcinoma in Egyptian population: a 5-year retrospective multicenter study

Purpose

Basal cell carcinoma (BCC) is the most diagnosed type of cancer accounting for 80% of all keratinocyte malignancies. However, the exact demographic properties and clinicopathological criteria for BCC in Egyptians are not clearly reported. Our aim is to report and analyze the epidemiological and clinicopathological features of BCC in Egyptians.

Methods

We retrospectively reviewed the medical records for patients diagnosed pathologically with BCC during the period from January 2017 to December 2021. Data were recruited from four dermatology centers with different geographical distributions.

Results

We registered 544 patients. Their age ranged between 22–91 years with a mean of 61.6 ± 13.2 years. Females showed younger age of onset. The mean duration of the tumor was 3.9 ± 3.8 years. The most common involved region was the head (79.4%), and about one third of patients (32.2%) had a giant lesion (> 5 cm). The most common clinical presentation was ulcerative lesions (44.9%). Pathologically, the nodular type represented the most common variant (50.4%).

Conclusion

Our results proposed that the annual incidence of BCC is increasing among Egyptians. Ultraviolet radiation is considered a high-risk factor of BCC leading to a higher affection of the head region and more prevalence in men. This study also highlights some criteria of BCC in Egyptians such as the long duration of the tumor, the early onset in females, the higher percentage of giant types, and the predominance of nodular type. To our knowledge, this is the first report describing the characteristic features of BCC among Egyptians.

A systematic review of observational management of cutaneous basal cell carcinoma

BACKGROUND

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom and United States. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of cutaneous BCC.

METHODS

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

RESULTS

We identified 2529 titles, from which 4 full-text articles were eligible, reporting on 2298 individuals. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6-12 weeks. Clearance rates ranged from 52-100% for imiquimod and 2-19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

CONCLUSION

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility-adjusted survival following interventional or observational management of BCC.

Wounding Therapies for Prevention of Photocarcinogenesis

The occurrence of non-melanoma skin cancer (NMSC) is closely linked with advanced age and ultraviolet-B (UVB) exposure. More specifically, the development of NMSC is linked to diminished insulin-like growth factor-1 (IGF-1) signaling from senescent dermal fibroblasts in geriatric skin. Consequently, keratinocyte IGF-1 receptor (IGF-1R) remains inactive, resulting in failure to induce appropriate protective responses including DNA repair and cell cycle checkpoint signaling. This allows UVB-induced DNA damage to proliferate unchecked, which increases the likelihood of malignant transformation. NMSC is estimated to occur in 3.3 million individuals annually. The rising incidence results in increased morbidity and significant healthcare costs, which necessitate identification of effective treatment modalities. In this review, we highlight the pathogenesis of NMSC and discuss the potential of novel preventative therapies. In particular, wounding therapies such as dermabrasion, microneedling, chemical peeling, and fractionated laser resurfacing have been shown to restore IGF-1/IGF-1R signaling in geriatric skin and suppress the propagation of UVB-damaged keratinocytes. This wounding response effectively rejuvenates geriatric skin and decreases the incidence of age-associated NMSC.

Preparation of High-Performance Metal-Free UV/Near Infrared-Shielding Films for Human Skin Protection

A series of metal-free UV/near infrared (NIR)-shielding coatings are successfully fabricated by shielded cathodic arc plasma evaporation (CAPE) and substrate-biased RF magnetron sputtering processes. The UV/NIR-shielding coatings comprising quarter-wave stacks of TiO2/SiO2 multilayers and high-conductivity sputter-deposited ITO films with a thickness in the range of 200-600 nm could block IRA and IRB radiations, respectively. The total thicknesses of UV/near infrared-shielding films are in the range from 375 nm to 1513.8 nm. The anatase-phase TiO2 films with absorption edge located at ∼375 nm were deposited by shielded CAPE at ∼100 °C. Further, the well-crystallized ITO films were found to have high free-electron concentrations (1.12 × 1021 cm-3), resulting in strong absorption of IRB due to the plasmon resonance absorption. The optimal optical design and ITO film thickness were investigated, and the TiO2(SiO2/TiO2)3 multilayer combined with an ITO film thickness of 400 nm was found to provide a high NIR-shielding rate of 94.8%, UVB to UVA-shielding rate of 92.7%, and average visible light transmittance of 68.1%. Further, human skin cells protected by a UV/NIR-shielding coating showed significantly decreased reactive oxygen species generation and inflammatory cytokine expression as compared to those of unprotected cells. The results demonstrate that the development of multifunction coatings have potential for transparent heat insulation windows and human skin protection against UV/IR radiations.

Anatomical distribution of basal cell carcinoma in Israel using relative tumor density scores

BACKGROUND

Ultraviolet radiation (UVR) is considered a major risk factor for the development of basal cell carcinoma (BCC). Calculating the relative tumor density (RTD) by adjusting the proportion of BCC lesions relative to the skin surface area at a specific site enables comparison of the proportion of tumors at different anatomical sites and better understanding of the association with sun exposure.

OBJECTIVES

To characterize anatomical distribution of BCC in the Israeli population using RTD score.

METHODS

A retrospective, cross-sectional study that includes all histologically confirmed BCC samples obtained from a major national pathological institute, which receives specimens from numerous surgeons throughout Israel, during the first trimester of 2012.

RESULTS

A total of 1,712 skin lesions were diagnosed as BCC during the study period. RTD in the head and neck area was the highest over the body (RTD = 6.6). We found that RTD over the upper arms in males was higher than the proportion of skin surface area (RTD = 1.1). A comparison of RTD values in subsites of the head and neck region indicates that men have higher RTD values for the ears, neck, and scalp than women. However, the nose and eyes areas have female predominance.

CONCLUSIONS

Using RTD scores, our study demonstrates the unique UVR exposure pattern in the Mediterranean climate of Israel and supports the notion that UVR is an important risk factor for the development of BCC lesions.

Interventions for basal cell carcinoma: abridged Cochrane systematic review and GRADE assessments

BACKGROUND

Basal cell carcinoma (BCC) is the most common cancer affecting white-skinned individuals, and the worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs.

OBJECTIVES

To assess the effects of interventions for primary BCC in immunocompetent adults.

METHODS

We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and LILACS. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. We used standard methodological procedures expected by Cochrane.

RESULTS

We included 52 randomized controlled trials with 6990 participants (median age 65 years; range 20-95). Mean study duration was 13 months (range 6 weeks-10 years). Ninety-two per cent (n = 48/52) of studies exclusively included histologically low-risk BCC (nodular and superficial subtypes). The certainty of evidence was predominantly low or moderate for the outcomes of interest. Overall, surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with Mohs micrographic surgery over surgical excision for primary, facial BCC (high-risk histological subtype or located in the 'H-zone' or both) (low-certainty evidence). Nonsurgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior.

CONCLUSIONS

Surgical interventions have lower recurrence rates and remain the gold standard for high-risk BCC. Of the nonsurgical treatments, topical imiquimod has the best evidence to support its efficacy for low-risk BCC. Priorities for future research include agreement on core outcome measures and studies with longer follow-up.

HLA-G, cytokines, and cytokine receptors in the non-aggressive basal cell carcinoma microenvironment

Non-aggressive basal cell carcinoma (BCC) growth is slow and might be mediated by the immune system. This study analysed the human leukocyte antigen (HLA)-G expression and cytokine profile in non-aggressive BCC subtypes from distinct locations. HLA-G was evaluated via immunohistochemistry and cytokine expression was analysed by a quantitative real-time polymerase chain reaction in 26 primary BCC samples, including nodular BCC (nBCC, n = 16) and superficial BCC (n = 10) from cephalic (ceBCC, n = 12) and non-cephalic (n = 14) locations, and by bioinformatics analysis of public GEO databases. Inflammatory infiltrate was concentrated around the tumour nests. HLA-G-positive inflammatory cells (53.85%) were more abundant than HLA-G-positive tumour cells (21.54%, p < 0.001). HLA-G immunoreactivity was predominantly cytoplasmic in BCC cells and was primarily associated with lymphocytes and macrophages surrounding the tumour. nBCC showed a higher percentage of HLA-G-positive tumour cells (p = 0.04), and ceBCC showed stronger intensity (p = 0.04). IFN-gamma and IL-10 expression were 1.95 and 1.22-fold higher, respectively, relative to that in normal skin, with a positive correlation between them (r = 0.61; p = 0.002). IL-23 expression was higher in nBCC (p = 0.04) and positively correlated (r = 0.47; p = 0.05) with slight intensity of HLA-G-positive tumour cells. The up-regulation of IL23A and IL10RB and down-regulation of IFNGR1 and IL4R gene expression in BCC compared to levels in adjacent tissues were demonstrated in the GSE125285 dataset. The exhibited cytokine profile was consistent with the induction of HLA-G expression in non-aggressive BCC subtypes. HLA-G expression in tumour cells and inflammatory cells surrounding BCCs supports the generation of inhibitory signals on various immune cells that exert anti-tumour responses.

Basal cell carcinomas of the scalp after radiotherapy for tinea capitis in childhood: A genetic and epigenetic study with comparison with basal cell carcinomas evolving in chronically sun-exposed areas

BACKGROUND

Basal cell carcinoma (BCC) has been mostly associated with sun exposure, but ionizing radiation is also a known risk factor. It is not clear if the pathogenesis of BCC, namely at a genomic and epigenetic level, differs according to the underlying triggering factors.

OBJECTIVE

The present study aims to compare genetic and epigenetic changes in BCCs related to ionizing radiation and chronic sun exposure.

METHODS

Tumor samples from BCCs of the scalp in patients submitted to radiotherapy to treat tinea capitis in childhood and BCCs from sun-exposed areas were analysed through array comparative genomic hybridization (array-CGH) and methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) to detect copy number alterations and methylation status of specific genes.

RESULTS

Genomic characterization of tumor samples revealed several copy number gains and losses in all chromosomes, with the most frequent gains observed at 2p, 6p, 12p, 14q, 15q, 18q, Xp and Yp, and the most frequent losses observed at 3q, 14q, 16p, 17q, 22q, Xp, Yp and Yq. We developed a statistical model, encompassing gains in 3p and 16p and losses in 14q and 20p, with potential to discriminate BCC samples with sporadic aetiology from BCC samples that evolve after radiotherapy in childhood for the treatment of tinea capitis, which presented statistical significance (P = 0.003). Few methylated genes were detected through MS-MLPA, most frequently RARB and CD44.

CONCLUSIONS

Our study represents a step forward in the understanding of the genetic mechanisms underlying the pathogenesis of BCC and suggests potential differences according to the underlying ris k factors.

Differentiation of Basal Cell Carcinoma and Trichoepithelioma: An Immunohistochemical Study

ABSTRACT

Basal cell carcinoma (BCC) is the most common malignancy of the skin. It is an epithelial neoplasm with origin in the precursor cells of the interfollicular epidermis. Even though it has low metastatic potential, delay in management may lead to local destruction and morbidity. In contrast, trichoepithelioma (TE) is a benign tumor originating from the outer root sheath of the hair follicle. Similar to BCC, TE tends to affect the head and neck region. Both neoplasms may exhibit clinical and histopathological similarities, making them prone to misdiagnosis. Multiple immunomarkers have been used to distinguish among these entities, but so far, no single agent or combination of agents appear to be neither sensitive nor specific enough to differentiate between them. This study was divided into 2 parts. First, 17 cases of BCC and 14 cases of TE were stained with androgen receptor and bcl-2. Then, 27 cases of borderline/equivocal of BCC and 13 cases of borderline/equivocal TE were stained with the same protocol. Sensitivity and specificity were calculated for each individual immunomarker and for the combination of them. Androgen receptor positivity was 100% specific for BCC and borderline/equivocal BCC, whereas bcl-2 diffuse staining pattern demonstrated a sensitivity of 82.4% for BCC and 88.9% borderline/equivocal BCC. When both immunomarkers were combined, the sensitivity for BCC decreased (70.6%) but the specificity remained high (100%). Similarly, the sensitivity for borderline/equivocal BCC was 55.6%, whereas the specificity was 100%. Although moderately sensitive, combining both immunomarkers showed an excellent specificity to discriminate between BCC and TE.

Palmar psoriasis or missed BCC?-A case report

Case report

A 76-year-old Caucasian woman with a history of previous BCCs excised from the head and legs was referred from the dermatology team with a biopsy proven superficial BCC to the left palm. The patient had presented to the dermatology team with the same lesion 7 years prior to the definitive diagnosis. The lesion was described as 27 × 15 mm scaly, poorly-defined, plaque-like lesion to the central palm. There was no ulceration or visible telangiectasia. At the time, an initial diagnosis of psoriasis was given and she received several courses of topical treatments to no avail. Eventually, a biopsy was taken which revealed a multifocal superficial BCC. After unsuccessful attempts at treating with topical Imiquimod, the lesion was surgically excised and resurfaced with a full thickness skin graft.

Discussion

The current understanding that BCCs derive from cells of the hair follicle cannot explain their appearance on the palm. Alternative hypotheses have been proposed as to their actual origin which would account for this rare occurrence. Ultimately, histology can determine the nature of the lesion. We urge clinicians encountering atypical, non-healing lesions to glabrous skin to keep in mind a diagnosis of skin cancer as a delayed diagnosis can lead to increased morbidity.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the commonest cancer affecting white-skinned individuals, and worldwide incidence is increasing. Although rarely fatal, BCC is associated with significant morbidity and costs. First-line treatment is usually surgical excision, but alternatives are available. New published studies and the development of non-surgical treatments meant an update of our Cochrane Review (first published in 2003, and previously updated in 2007) was timely.

OBJECTIVES

To assess the effects of interventions for BCC in immunocompetent adults.

SEARCH METHODS

We updated our searches of the following databases to November 2019: Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions for BCC in immunocompetent adults with histologically-proven, primary BCC. Eligible comparators were placebo, active treatment, other treatments, or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcome measures were recurrence at three years and five years (measured clinically) (we included recurrence data outside of these time points if there was no measurement at three or five years) and participant- and observer-rated good/excellent cosmetic outcome. Secondary outcomes included pain during and after treatment, early treatment failure within six months, and adverse effects (AEs). We used GRADE to assess evidence certainty for each outcome.

MAIN RESULTS

We included 52 RCTs (26 new) involving 6690 participants (median 89) in this update. All studies recruited from secondary care outpatient clinics. More males than females were included. Study duration ranged from six weeks to 10 years (average 13 months). Most studies (48/52) included only low-risk BCC (superficial (sBCC) and nodular (nBCC) histological subtypes). The majority of studies were at low or unclear risk of bias for most domains. Twenty-two studies were industry-funded: commercial sponsors conducted most of the studies assessing imiquimod, and just under half of the photodynamic therapy (PDT) studies. Overall, surgical interventions have the lowest recurrence rates. For high-risk facial BCC (high-risk histological subtype or located in the facial 'H-zone' or both), there may be slightly fewer recurrences with Mohs micrographic surgery (MMS) compared to surgical excision (SE) at three years (1.9% versus 2.9%, respectively) (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.16 to 2.64; 1 study, 331 participants; low-certainty evidence) and at five years (3.2% versus 5.2%, respectively) (RR 0.61, 95% CI 0.18 to 2.04; 1 study, 259 participants; low-certainty evidence). However, the 95% CI also includes the possibility of increased risk of recurrence and no difference between treatments. There may be little to no difference regarding improvement of cosmetic outcomes between MMS and SE, judged by participants and observers 18 months post-operatively (one study; low-certainty evidence); however, no raw data were available for this outcome. When comparing imiquimod and SE for nBCC or sBCC at low-risk sites, imiquimod probably results in more recurrences than SE at three years (16.4% versus 1.6%, respectively) (RR 10.30, 95% CI 3.22 to 32.94; 1 study, 401 participants; moderate-certainty evidence) and five years (17.5% versus 2.3%, respectively) (RR 7.73, 95% CI 2.81 to 21.3; 1 study, 383 participants; moderate-certainty evidence). There may be little to no difference in the number of participant-rated good/excellent cosmetic outcomes (RR 1.00, 95% CI 0.94 to 1.06; 1 study, 326 participants; low-certainty evidence). However, imiquimod may result in greater numbers of good/excellent cosmetic outcomes compared to SE when observer-rated (60.6% versus 35.6%, respectively) (RR 1.70, 95% CI 1.35 to 2.15; 1 study, 344 participants; low-certainty evidence). Both cosmetic outcomes were measured at three years. Based on one study of 347 participants with high- and low-risk primary BCC of the face, radiotherapy may result in more recurrences compared to SE under frozen section margin control at three years (5.2% versus 0%, respectively) (RR 19.11, 95% CI 1.12 to 325.78; low-certainty evidence) and at four years (6.4% versus 0.6%, respectively) (RR 11.06, 95% CI 1.44 to 84.77; low-certainty evidence). Radiotherapy probably results in a smaller number of good participant- (RR 0.76, 95% CI 0.63 to 0.91; 50.3% versus 66.1%, respectively) or observer-rated (RR 0.48, 95% CI 0.37 to 0.62; 28.9% versus 60.3%, respectively) good/excellent cosmetic outcomes compared to SE, when measured at four years, where dyspigmentation and telangiectasia can occur (both moderate-certainty evidence). Methyl-aminolevulinate (MAL)-PDT may result in more recurrences compared to SE at three years (36.4% versus 0%, respectively) (RR 26.47, 95% CI 1.63 to 429.92; 1 study; 68 participants with low-risk nBCC in the head and neck area; low-certainty evidence). There were no useable data for measurement at five years. MAL-PDT probably results in greater numbers of participant- (RR 1.18, 95% CI 1.09 to 1.27; 97.3% versus 82.5%) or observer-rated (RR 1.87, 95% CI 1.54 to 2.26; 87.1% versus 46.6%) good/excellent cosmetic outcomes at one year compared to SE (2 studies, 309 participants with low-risk nBCC and sBCC; moderate-certainty evidence). Based on moderate-certainty evidence (single low-risk sBCC), imiquimod probably results in fewer recurrences at three years compared to MAL-PDT (22.8% versus 51.6%, respectively) (RR 0.44, 95% CI 0.32 to 0.62; 277 participants) and five years (28.6% versus 68.6%, respectively) (RR 0.42, 95% CI 0.31 to 0.57; 228 participants). There is probably little to no difference in numbers of observer-rated good/excellent cosmetic outcomes at one year (RR 0.98, 95% CI 0.84 to 1.16; 370 participants). Participant-rated cosmetic outcomes were not measured for this comparison. AEs with surgical interventions include wound infections, graft necrosis and post-operative bleeding. Local AEs such as itching, weeping, pain and redness occur frequently with non-surgical interventions. Treatment-related AEs resulting in study modification or withdrawal occurred with imiquimod and MAL-PDT.

AUTHORS' CONCLUSIONS

Surgical interventions have the lowest recurrence rates, and there may be slightly fewer recurrences with MMS over SE for high-risk facial primary BCC (low-certainty evidence). Non-surgical treatments, when used for low-risk BCC, are less effective than surgical treatments, but recurrence rates are acceptable and cosmetic outcomes are probably superior. Of the non-surgical treatments, imiquimod has the best evidence to support its efficacy. Overall, evidence certainty was low to moderate. Priorities for future research include core outcome measures and studies with longer-term follow-up.

Immunotherapies in cutaneous pathologies: an overview

Skin is a vital protective organ, the main role of which is to provide a physical barrier and to prevent the entry of pathogens. Various pathologies, such as atopic dermatitis (AD), psoriasis (PSO), or skin cancers, can affect the skin, and all show a high and increasing prevalence. Many antibodies are currently used in the treatment of these diseases. However, various studies are underway for the development of new biologics directed against specific targets. In this review, we describe current biologics used in skin pathologies as well as antibodies in development. We also discuss various immunotherapy examples that use new delivery technologies, such as microneedle patch, nanoparticles (NPs), liposomes, or gel formulation.

SHARPIN regulates cell proliferation of cutaneous basal cell carcinoma via inactivation of the transcriptional factors GLI2 and c‑JUN

SHANK‑associated RH domain‑interacting protein (SHARPIN) is a component of the linear ubiquitin chain assembly complex that can enhance the NF‑κB and JNK signaling pathways, acting as a tumor‑associated protein in a variety of cancer types. The present study investigated the role of SHARPIN in cutaneous basal cell carcinoma (BCC). Human BCC (n=26) and normal skin (n=5) tissues, and BCC (TE354.T) and normal skin (HaCaT) cell lines were used to evaluate SHARPIN expression level using immunohistochemistry and western blotting, respectively. A lentivirus carrying SHARPIN‑targeting or negative control short hairpin RNA was infected into TE354.T cells, and the infected stable cells were assayed to analyze tumor cell proliferation, cell cycle, apoptosis, migration and invasion by Cell Counting Kit‑8 and 5‑ethynyl‑2'‑deoxyuridine incorporation assays, flow cytometry and Transwell assays. Western blotting was performed to assess the protein expression levels of gene signaling in SHARPIN‑silenced BCC cells. SHARPIN protein expression levels were downregulated or absent in BCC cancer nests and precancerous lesions compared with normal skin samples. In addition, SHARPIN expression levels were lower in TE354.T cells compared with HaCaT cells. SHARPIN shRNA enhanced tumor cell proliferation and the S phase of the cell cycle, whereas BCC cell apoptotic rates, and migratory and invasive abilities were not significantly altered. The expression levels of cyclin D1, cyclin‑dependent kinase 4, phosphorylated‑c‑JUN and GLI family zinc finger 2 proteins were increased, whereas Patched 1 (PTCH1) and PTCH2 were decreased in the SHARPIN‑shRNA‑infected BCC cells. Therefore, the present results suggested that SHARPIN may act as a tumor suppressor during BCC development.

Head and neck cutaneous basal cell carcinoma: what should the otorhinolaryngology head and neck surgeon care about?

Cutaneous basal cell carcinoma (cBCC) is the most common malignancy diagnosed in the human population. cBCC presents an increasing incidence which, in the near future, will be higher than all other cancers combined. The majority of cBCC are located in the head and the neck. A diversity of management modalities is currently available; nonetheless, surgical excision remains the main modality of treatment. cBCC rarely metastasises and presents a low mortality rate. cBCC morbidity is influenced by local invasion and destruction, especially in the face, where function and aesthetics are major issues. Easy accessibility to the face and skin on the neck makes cBCC an important issue for otorhinolaryngology head and neck surgeons who must be aware and committed in its management, as the main modality of treatment continues to be surgical. The aim of this review is to present a brief and practical overview of head and neck cBCC management for ear, nose and throat (ENT) surgeons, discussing key issues about its epidemiology, risk factors, diagnosis and pathogenesis.

Synthesis of hierarchically mesoporous silica with encapsulated avobenzone as a UV protection filter

In this study, hierarchically mesoporous silica (HMS) with properties such as high specific surface area, high photostability, and no cellular toxicity was synthesized. The synthesized silica can be considered as an excellent carrier candidate material. Through the use of nitrogen adsorption and desorption analysis, the shape of the hysteresis loop implied the presence of mesoporous structures in the HMS powder. In addition, the encapsulation efficiency was more than 90%. These results showed that avobenzone could be encapsulated into the HMS powder because of its high specific surface area and pore volume. Additionally, X-ray diffractometry (XRD), Fourier transform infrared spectroscopy (FTIR), thermal gravimetric analysis (TGA), and UV-visible (Vis) spectrophotometry were used to prove that the hierarchically mesoporous silica was able to effectively encapsulate avobenzone. In addition, the new synthetic sunscreen kept its excellent UVA absorption properties after being encapsulated.

This study provides a preparing method for mesoporous silica to effectively encapsulate with avobenzone.

[Descriptive dermoscopic study of a series of 100 patients with basal cell carcinoma diagnosed in Morocco]

Introduction

La dermatoscopie est une technique d'examen non invasive, permettant de donner un nouveau regard de la morphologie clinique des lésions pigmentées et des tumeurs cutanées. Nous montrons à travers notre série les caractéristiques morphologiques dermotoscopiques du carcinome basocellulaire (CBC) chez notre population.

Méthodes

Notre étude est une étude prospective unicentrique étalée sur une période de 2 ans. Nous avons utilisé le dermoscope chez tous les patients ayant un CBC. L'analyse statistique était réalisée à 'aide du logiciel SPSS version 17.

Résultats

On avait recensé 100 CBC, L'âge moyen des patients était de 51,87 ans, avec un sex ratio F/H = 0,6. Le visage était la localisation la plus fréquente et la plupart des patients étaient de phototype III et IV. On a distingué des critères dermatoscopiques classiques et non classiques. On a montré qu'il existe une relation significative entre le phototype et le degré de la pigmentation des CBC.

Conclusion

Dans ce présent travail, le dermoscope était bénéfique d'une part pour détecter les CBC de petite taille, d'autre part pour faciliter le diagnostic des CBC pigmentés.

Evaluation of Immunohistochemical Findings and Clinical Features Associated with Local Aggressiveness in Basal Cell Carcinoma

BACKGROUND & OBJECTIVE

Basal cell carcinoma (BCC) is classified into BCC1 or low risk (nodular, superficial type) and BCC2 or high risk (micronodular, morpheaform, infiltrative, and basosquamous types) based on clinical behavior. This study attempts to evaluate immunohistochemical (IHC) findings and clinical features associated with local aggressiveness and recurrence in BCC lesions.

METHODS

This is a cross-sectional descriptive study conducted on 42 paraffin blocks (22 BCC1, 20 in BCC2) at Pathology Department of Afzalipour Teaching Hospital. First, demographic features of the patients were recorded and pathology blocks were classified by two dermatopathologists based on histopathological types of BCC1 and BCC2. Then, primary monoclonal antibodies including CD10, CD1a, SMA, Ki67, CD34, and P53 were utilized for IHC study. We compared BCC1 and BCC2 according to IHC markers, demographic features of patients, and tumoral features.

RESULTS

The mean number of Langerhans cells (LCs) within epidermis above tumor mass was 14+1.92 and 4.7±1.23 in BCC1 and BCC2, respectively; these results show a significant difference between the two groups (P=0.001). P53 was positive in 41.13±6.39% and 74.5 ±6.26% of the tumor cells in BCC1 and BCC2 groups, which was statistically significant (P=0.001). Also, the mean number of blood vessels was 14.40±1.30 and 21.40±1.97 in BCC1 and BCC2, that was statistically significant (P=0.005).

CONCLUSION

Higher numbers of angiogenesis (SMA positive) and positive P53 were observed in BCC2 than BCC1. Also, more active positive CD1a cells were observed in BCC1 compared to BCC2.

STAT3 polymorphisms and IL-6 polymorphism are associated with the risk of basal cell carcinoma in patients from northern Poland

Basal cell carcinoma (BCC) environment consists of stromal and inflammatory cells which produce variety of cytokines, chemokines and growth factors that may affect tumor behavior. One of the cytokines suggested to be involved in the pathogenesis of BCC is IL-6, which is the upstream element of IL-6/JAK/STAT3 pathway. The correlation between polymorphisms of the genes related to this pathway and cancer risk/prognosis have been previously investigated in several neoplasia, but available data concerning BCC are scarce. In the present study, rs1800795 (-174 G/C) IL-6 gene polymorphism and two polymorphisms in the STAT3 gene, namely rs2293152 (intron 11, C/G) and rs4796793 (-1697, C/G) were assessed in relation to the BCC risk and clinical course. Additionally, IL-6 serum level was assessed in relation to IL-6 genotype and clinical variables. The study included 254 unrelated patients with BCC and of mean age 70.39 ± 11.43 (69.83 ± 12.32 women, 71.03 ± 10.31 men) and 198 healthy, unrelated age- and sex-matched volunteers. IL-6 and STAT3 polymorphisms were analyzed using polymerase chain reaction with sequence-specific primers (SSP-PCR). Serum concentration of IL-6 was measured using the ELISA test. We have found that the presence of C allele in rs1800795 IL-6 gene polymorphism was associated with increased risk of BCC (aOR 1.86; 95% CI 1.22–2.84; p = 0.004). The presence of CC genotype in STAT3 rs2293152 polymorphism was associated with increased BCC risk in recessive model analysis (aOR 3.94; 95% CI 1.59–9.77; p = 0.003). In contrast, the presence of GC genotype in overdominant model was associated with decreased risk of BCC (aOR = 0.24; 95% CI 0.12–0.49; p < 0.0001). The presence of C allele in STAT3 rs2293152 polymorphism was associated with increased risk of BCC (aOR 1.31; 95% CI 1.01–1.69; p = 0.04). The presence of GG genotype in STAT3 rs4796793 polymorphism was associated with increased BCC risk in recessive model analysis (aOR 3.66; 95% CI 1.33–10.10; p = 0.012). The presence of G allele in STAT3 rs4796793 polymorphism was associated with increased risk of BCC (aOR 1.59; 95% CI 1.01–2.49; p = 0.04). IL-6 serum level positively correlated with the tumor size.

STAT3, STAT5A, STAT5B and STAT6 proteins are overexpressed in human basal cell carcinoma

BACKGROUND

The molecular pathogenesis of basal cell carcinoma (BCC) is still not precisely described and is the subject of ongoing studies. The role of signal transducers and activators of transcription (STATs) in human epithelial carcinogenesis has been poorly investigated, but in the era of studies on inhibitors targeting STAT proteins this topic seems worth exploring. Increased expression of STAT3 in human nonmelanoma skin cancer (NMSC) has been confirmed in a few studies, but to our knowledge, expression of STAT5A, STAT5B and STAT6 in BCC has not been previously evaluated.

AIM

To measure expression of STAT3, STAT5A, STAT5B and STAT6 expression in different histopathological subtypes of human BCC and its correlation with selected clinical variables.

METHODS

Immunohistochemistry was used to assess 60 BCC tumour specimens [20 superficial (s)BCCs, 20 nodular (n)BCCs and 20 infiltrative (i)BCCs] and to compare with specimens of healthy skin. There was no significant difference in age or sex between the three groups of patients with BCC. As many tumours showed heterogeneity of staining, the H-score system was applied to calculate the intensity of immunoexpression.

RESULTS

Expression of STAT3, STAT5A, STAT5B and STAT6 was observed in all histopathological subtypes of BCC, and was stronger than the expression within the adjacent epidermis and also stronger than the expression within the epidermis in the healthy control group. Statistical analysis revealed no significant differences in mean H-scores calculated for sBCCs, nBCCs and iBCCs. There were no statistically significant associations between STAT3, STAT5A, STAT5B and STAT6 expression and patient sex/age, and tumour size/site.

CONCLUSION

Our results confirm a possible role of STATs in the pathogenesis of BCC and should encourage future investigations on the possible therapeutic implications of this finding.

Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.

Study of skin neoplasms in a university hospital: integration of anatomopathological records and its interface with the literature

BACKGROUND

Skin cancer is a highly prevalent condition with a multifactorial etiology resulting from genetic alterations, environmental and lifestyle factors. In Brazil, among all malignant tumors, skin cancers have the highest incidences.

OBJECTIVE

To retrospectively evaluate the incidence, prevalence and profile of basal cell carcinoma, squamous cell carcinoma and cutaneous melanoma in Campos dos Goytacazes and region.

METHODS

In total, 2,207 histopathological reports of a local reference hospital were analyzed between January 2013 and December 2015, of which 306 corresponded to the neoplasms studied.

RESULTS

Of the 306 reports evaluated, 232 basal cell carcinomas (75.9%), 55 squamous cell carcinomas (18%) and 19 cutaneous melanomas (6.5%) were identified. The face was the most involved anatomical site (58.8%) and women (51%) were the most affected gender. The temporal analysis revealed a decrease in the overall incidence of 3.4% from 2013 to 2014 and 5.4% from 2014 to 2015. There was a 10.1% increase in basal cell carcinomas and 38% in melanomas in this period; however, there was a decrease in the number of squamous cell carcinomas of 14.8% during the studied years.

STUDY LIMITATIONS

Some samples of cutaneous fragments had no identification of the anatomical site of origin.

CONCLUSION

Research that generates statistical data on cutaneous tumors produces epidemiological tools useful in the identification of risk groups and allows the adoption of more targeted and efficient future prevention measures.

A case of contralateral breast cancer and skin cancer associated with NBN heterozygous pathogenic variant c.698_701delAACA

Approximately 39.6% of people will be diagnosed with cancer during their lifetime. Several factors including, lifestyle, environment and genetics may play a role in its development. Understanding these causes will greatly improve treatment methods, prevention, and survival rates of these patients. Our patient, who has a positive family history of cancer, presented with contralateral breast cancer and multiple skin malignancies. Genetic testing revealed a frameshift variant in NBN. This gene encodes the protein, nibrin, which is involved in maintaining genomic stability. Several reports have identified heterozygous NBN frameshift (c.2028delT, c.2097dupT, c.657-661delACAAA) and splice site variants (c.1397+delG) in patients with breast cancer. However, our report is the first to describe a heterozygous c.698_701delAACA NBN variant in a patient with breast cancer. Since NBN is involved in DNA integrity, loss of functional protein due to pathogenic variants significantly increases the risk of various cancers. Given the family and personal history of our patient, in connection with previous reports of NBN pathogenic variants predisposition to cancer, this variant is predicted to be pathogenic and clinically significant.

A Prediction Tool to Facilitate Risk-Stratified Screening for Squamous Cell Skin Cancer

Cutaneous squamous cell cancers (cSCCs) present an under-recognized health issue among non-Hispanic whites, one that is likely to increase as populations age. cSCC risks vary considerably among non-Hispanic whites, and this heterogeneity indicates the need for risk-stratified screening strategies that are guided by patients' personal characteristics and clinical histories. Here we describe cSCCscore, a prediction tool that uses patients' covariates and clinical histories to assign them personal probabilities of developing cSCCs within 3 years after risk assessment. cSCCscore uses a statistical model for the occurrence and timing of a patient's cSCCs, whose parameters we estimated using cohort data from 66,995 patients in the Kaiser Permanente Northern California healthcare system. We found that patients' covariates and histories explained approximately 75% of their interpersonal cSCC risk variation. Using cross-validated performance measures, we also found cSCCscore's predictions to be moderately well calibrated to the patients' observed cSCC incidence. Moreover, cSCCscore discriminated well between patients who subsequently did and did not develop a new primary cSCC within 3 years after risk assignment, with area under the receiver operating characteristic curve of approximately 85%. Thus, cSCCscore can facilitate more informed management of non-Hispanic white patients at cSCC risk. cSCCscore's predictions are available at https://researchapps.github.io/cSCCscore/.

Cutaneous Head and Neck Malignancies in the Elderly

Cutaneous malignancy of the head and neck affects a large proportion of elderly patients. The severity ranges from small, easily treatable lesions to large, invasive, potentially metastatic tumors. Surgical treatment is the primary treatment of most skin cancers; however, geriatric patients are more likely to have multiple comorbidities that increase the risk of surgery. Multiple treatment modalities exist, including surgical, radiation, and medical therapy. Recommendations and treatment options for basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and melanoma are outlined and reviewed.

Photodynamic Therapy Activated by Intense Pulsed Light in the Treatment of Nonmelanoma Skin Cancer

Photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) has proven to be a highly effective conservative method for the treatment of actinic keratosis (AK), Bowen’s disease (BD), and superficial basal cell carcinoma (sBCC). PDT is traditionally performed in association with broad-spectrum continuous-wave light sources, such as red or blue light. Recently, intense pulsed light (IPL) devices have been investigated as an alternative light source for PDT in the treatment of nonmelanoma skin cancers (NMSC). We herein report our observational findings in a cohort of patients with a diagnosis of AK, sBCC, and BD that is treated with MAL-PDT using IPL, as well as we review published data on the use of IPL-PDT in NMSC.

Trends of basal cell carcinoma at the Centre of Dermatovenereology of Vilnius University

Introduction and objectives

Basal cell carcinoma is the most common locally invasive malignant epidermal neoplasm in humans and its incidence has increased over the last decades worldwide, especially among the Caucasian population. Basal cell carcinoma accounts for about 75% of all skin cancers. Incidence data on basal cell carcinoma is sparse because traditional cancer registries often do not register these tumours. In Lithuania, patients with skin cancer and melanoma were traditionally treated in centralized oncological institutes. From 2006, the Centre of Dermatovenereology at Vilnius University Hospital Santaros Klinikos (Vilnius, Lithuania) provides modern diagnostic and treatment facilities to oncodermatological patients. The objective of the study was to evaluate epidemiological and clinical data of basal cell carcinoma at the Centre of Dermatovenereology during the last 15 years.

Materials and methods

Medical documentation of the cases of histologically-proven basal cell carcinoma diagnosed between 2000 and 2015 was analyzed. Epidemiological and clinical evaluation according to the patients' age, sex, and place of residence, as well as tumour localization, its histological type, and treatment options was performed.

Results

After the skin lesion biopsy and histopathological examination, a total of 847 basal cell carcinomas were confirmed to 782 patients. During the study period, the total annual number of newly diagnosed basal cell carcinomas rose steadily in our centre: 2.7% between 2000 and 2003, 6.5% between 2004 and 2006, 13.6% between 2007 and 2009, 27.6% between 2010 and 2012, and 49.6% between 2013 and 2015. The biggest part of patients (28.4%) were 70-79 years old, 4.6% - younger than 40, 7.3% - 40-49, 17.1% - 50-59, 27.2% - 60-69, 14.1% - 80-89, and 1.3% ≥90 years old. The average patient age was 66.0 (±13.6). Of these patients, 62.0% were female and 38.0% male; 63.6% were from the capital city, 18.3% from other cities, and 18.2% from rural areas. Basal cell carcinomas occurred most often in the face region 49.0%, followed by the trunk - 29.4%, the scalp and neck - 10.9%, arms and legs - 7.7%, in 2.9% location was not specified and the whole body - 0.1%. The predominant histological type of basal cell carcinomas was nodular (60.6%), other diagnosed types were superficial (22.9%), infiltrative/morpheaform (8.0%), mixed nodular and infiltrative (1.7%), pigmented (0.2%), rare types (micronodular, infundibulocystic, ductal and mixed) - 0.6%; the type was not specified in 6.0% of cases. Nodular, superficial, and infiltrative types were the most common morphological types in all body sites: respectively, in the face - 67.5%, 12.5%, 9.4%; in the scalp and neck region - 77.2%, 14.1%, 5.4%; in the trunk - 49.8%, 37.3%, 7.2%; in extremities - 41.5%, 43.1%, 7.7%. The nodular type was more common among the elderly and its incidence increased with age (p = 0.009), meanwhile, superficial basal cell carcinomas prevailed among younger patients (<40 years), and its incidence decreased with age (p < 0.001). Also, the nodular type was usually found in the areas of the face (p < 0.001) and the scalp and neck (p = 0.045), and the superficial type - in the areas of the trunk (p < 0.001) and extremities, specifically in the hand (p = 0.022). Basal cell carcinomas were mostly treated with surgical excision (79.6%), photodynamic therapy (5.5%; in our centre, this treatment option is available from 2007), and other/combined methods (14.9%).

Conclusions

The results showed that the number of newly diagnosed basal cell carcinomas increased continuously between 2000 and 2015. Basal cell carcinomas in our centre occurred most often among the patients aged 70-79 years. This tumour was more often diagnosed in female than male patients. Most of basal cell carcinomas were located on the chronically sun-exposed skin, such as the face region, and were of the nodular histological type, which is more common among the elderly, while the superficial type is more prevalent among younger patients. The most commonly used treatment option for basal cell carcinoma was surgical excision. Acknowledgment of the tendency of the rising number of basal cell carcinomas, healthcare resources, highlights the need for an effective skin cancer prevention strategy in Lithuania.

Epidemiology of skin cancer in the mature patient

Epidermal cancers include keratinocyte cancer, melanocyte cancer, and Merkel cell carcinoma. These cancers account for the vast majority of new cancers diagnosed in Australia, North America, and Europe. Keratinocyte cancer is the most common epidermal cancer and accounts for 7 out of 8 new cancers diagnosed in Australia. Melanoma and Merkel cell carcinoma are less common than keratinocyte carcinoma but are more important causes of mortality in Australia. Keratinocyte cancer has also been demonstrated to be a marker of cancer-prone phenotype. Risk factors for epidermal cancer include intrinsic and environmental factors, in particular exposure to ultraviolet radiation and advanced age. Actinic keratosis has an approximate prevalence of 79% of men and 68% of women between 60 and 69 years of age, and has a low risk of malignant transformation into squamous cell carcinoma. Basal cell carcinoma is the most common malignancy in Caucasians worldwide, with the incidence increasing by 2% per year in Australia. Squamous cell carcinoma is the second most common epidermal cancer, with an incidence of approximately 1035 or 472 per 100,000 person-years in men and women, respectively. Primary risk factors for both basal cell carcinoma and squamous cell carcinoma include light skin color, UV radiation exposure, and chronic immunosuppression. Although the rate of melanoma is increasing, the mortality in Australia is reducing and is currently 9%. The overall incidence of melanoma in Australia is approximately 50 cases per 100,000 persons (62 for men and 40 for women). Keratinocyte carcinoma and melanoma are risk factors for developing further skin cancer and primary malignancy. This contribution reviews the incidence, prevalence, and risk factors associated with the development of epidermal cancer and premalignant epidermal neoplasia.

Molecular basis of basal cell carcinoma

Basal cell carcinoma is the most common cancer, presenting low mortality but high morbidity, and it has as risk factor exposure to sunlight, especially UVB spectrum. The most important constitutional risk factors for basal cell carcinoma development are clear phototypes (I and II, Fitzpatrick classification), family history of basal cell carcinoma (30-60%), freckles in childhood, eyes and light hair. The environmental risk factor better established is exposure to ultraviolet radiation. However, different solar exposure scenarios probably are independent risk factors for certain clinical and histological types, topographies and prognosis of this tumor, and focus of controversy among researchers. Studies confirm that changes in cellular genes Hedgehog signaling pathway are associated with the development of basal cell carcinoma. The cellular Hedgehog signaling pathway is activated in organogenesis, but is altered in various types of tumors.

Skin Cancer Epidemics in the Elderly as An Emerging Issue in Geriatric Oncology

Skin cancer is a worldwide, emerging clinical need in the elderly white population, with a steady increase in incidence rates, morbidity and related medical costs. Skin cancer is a heterogeneous group of cancers comprising cutaneous melanoma and non-melanoma skin cancers (NMSC), which predominantly affect elderly patients, aged older than 65 years. Melanoma has distinct clinical presentations in the elderly patient and represents a challenging question in terms of clinical management. NMSC includes the basal cell carcinoma and cutaneous squamous cell carcinoma and presents a wide disease spectrum in the elderly population, ranging from low-risk to high-risk tumours, advanced and inoperable disease. Treatment decisions for NMSC are preferentially based on tumour characteristics, patient’s chronological age and physician’s preferences and operational settings. Several treatment options are available for NMSC, from surgery to non-invasive/medical therapies, but patient-based factors, such as geriatric comorbidities and patient’s life expectancy, do not frequently modulate treatment goals. In melanoma, age-related variations in clinical management are significant and may frequently lead to under-treatment, limiting access to advanced surgical and medical treatments. Clinical decision-making in the care of elderly skin cancer patient should ideally implement a geriatric assessment, prioritizing patient-based factors and efficiently differentiating fit from frail cancer patients. Current clinical practice guidelines for NMSC and melanoma only partially address geriatric aspects of cancer care, such as frailty, limited life-expectancy, geriatric comorbidities and treatment compliance. We review the recent evidence on the scope and problem of skin cancer in the elderly population as well as age-related variations in its clinical management, highlighting the potential role of a geriatric approach in optimizing dermato-oncological care.

A Network Meta-Analysis of Non-Melanoma Skin Cancer (NMSC) Treatments: Efficacy and Safety Assessment

The mainstream treatments for non-melanoma skin cancer (NMSC) include photodynamic therapy (PDT), surgery excision (SE), cryotherapy (CT), imiquimod (IM), radiotherapy (RT), 5-fluorouracil (FU), and vehicle (VE). Our network meta-analysis (NMA) was aimed at evaluating the efficacy and safety of these seven treatments and providing superior ones. After searching the trials from Embase and PubMed and screening with our criteria, we conducted the NMA with software R 3.2.3 and STATA 13.0. Complete lesion response (CLR), complete lesion clearance (CLC), cumulative recurrence probabilities (CRP), and adverse effects (AEs) were considered as outcomes and displayed as odds ratios (ORs) and 95% credible intervals (CrI). The surface under the cumulative ranking curve (SUCRA) was calculated to rank each treatment on each index. The consistency of direct and indirect evidence was also assessed by node-splitting and heat plot methods. Data from 18 trials with 3706 patients were included. Both IM and SE were demonstrated significantly higher CLR rate than VE (OR = 9.12, 95% CrI = 1.92-47.5; OR = 26.1, 95% CrI = 1.92-347; respectively), while only IM was proved to be statistically better than VE in CLC rate (OR = 7.03, 95% CrI = 1.51-32.8). No significant difference was observed concerning CRP, and IM was more likely to induce AEs than VE (OR = 4.44, 95% CrI = 1.58-13.9). The SUCRA results indicated that SE was the treatment with best ranking in the entire three efficacy indexes and a relatively high safety. Taking efficacy and safety into account, our study recommended SE as the optimal regimen for NMSC with high efficacy considering CLR, CLC, and CRP and moderate AEs when compared with other interventions. J. Cell. Biochem. 118: 3686-3695, 2017. © 2017 Wiley Periodicals, Inc.

Nonsurgical Therapies for Basal Cell Carcinoma: A Review

Basal cell carcinoma (BCC) is the most prevalent malignant tumor in humans and the local destruction of tissue that can result from excision has a significant impact on well-being. Treating BCC is costly for health care systems given the high incidence of this tumor, especially in older patients. Standard treatment involves either resection with histologic assessment of margins or Mohs micrographic surgery. Surgery is sometimes contraindicated, however, due to the presence of significant comorbidity or high cosmetic expectations. For such patients, nonsurgical treatments have become available. These alternatives can offer good local control of disease, preserve function, and achieve excellent cosmetic results.

Meta-analysis of the Correlation Between Interleukin-6 Promoter Polymorphism -174G/C and Interferon Regulatory Factor 4 rs12203592 Polymorphism With Skin Cancer Susceptibility

Inflammation is a process whereby the immune system responds to a disease or injury. Chronic inflammation, however, has been linked to several types of cancers such as skin cancer. Molecular epidemiological studies were carried out in recent years evaluating interferon regulatory factor 4 (IRF4) rs12203592 and interleukin-6 (IL-6) gene -174G/C polymorphism associated with skin cancer risk for different groups of people. However, the results are still conflicting, not conclusive. We performed a meta-analysis to investigate the association between cancer susceptibility and IL-6 -174G/C (1130 cases and 1260 controls from 7 studies) and IRF4 rs12203592 polymorphisms (3879 cases and 6759 controls from 9 studies) in different inheritance models. We assess the strength of association of odds ratio (ORs), 95% confidence interval (CI). Overall, significantly elevated skin cancer risk was found when all studies were pooled into the meta-analysis of IL-6 -174G/C (For GC vs. GG: OR = 1.28, 95% CI, 1.06-1.54, I = 0, Pheterogeneity = 0.816; for CC/GC vs. GG: OR = 1.26, 95% CI, 1.05-1.50, I = 0, Pheterogeneity = 0.618). However, for IRF4 rs12203592 polymorphism, significantly increased risk of skin cancer was observed in TT versus CC (OR = 1.99, 95% CI, 1.30-3.07, I = 76.7%, Pheterogeneity < 0.001) and in recessive model (OR = 1.91, 95% CI, 1.31-2.77, I = 69.9%, Pheterogeneity < 0.001). This meta-analysis indicates that the IL-6 gene -174G/C and IRF4 rs12203592 polymorphisms may be associated with an increased skin cancer risk.

[Characteristics and risk factors for recurrence of cutaneous squamous cell carcinoma with conventional surgery and surgery with delayed intraoperative margin assessment]

BACKGROUND

Non-melanoma skin cancer includes basal cell carcinoma and squamous cell carcinoma (SCC). Basal cell carcinoma is the most common and least aggressive but in a low percentage of cases, despite appropriate wide surgical margins, it can be aggressive, producing local invasion, recurrences and distance metastasis. SCC has a more aggressive behaviour invading first the skin, the lymph nodes and less frequently produces distance metastasis OBJECTIVE: To identify the characteristics of recurrent SCC and frequency of new SCC after conventional surgical and primary closure or closure delayed until a histological reporting of tumour-free surgical margins, in order to achieve a better surgical option, in our Mexican population.

MATERIALS AND METHOD

We reviewed clinical records from the last 10 years, and included those with a diagnosis of SCC.

RESULTS

One hundred and fourteen tumours in 103 patients were included. The mean new tumour diagnosis was 32.2 per year; there were 46.6% men and 53.4% women. Age range 19-91, with mean 71.94 years (SD=13.34). The evolution time was from 1-112 months (mean=12 months, SD=2.65). The most affected site was the cheek. In addition, an invasive tumour was reported in 54% in the histopathological study. At 10-year follow-up we found a second SCC in 14 patients and only 4 recurrences, between the 1st and 4th year and 3were treated with delayed closure until margins were tumour-free.

CONCLUSION

In this study we demonstrated that delayed closure technique is easy and adaptable in our population in the treatment of SCC, achieving good results with very low recurrences at 10- year follow -up.