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Council ML, Sheinbein DM. Common Skin Cancers in Older Adults Approach to Diagnosis and Management. Clin Geriatr Med 2024; 40:25-36. [PMID: 38000861 DOI: 10.1016/j.cger.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Skin cancers are the most common malignancies to affect older adults. The most common skin cancers, basal and squamous cell carcinoma, can usually be cured with surgery. Although less common, melanoma can be deadly when not caught in its earliest stages.
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Affiliation(s)
- Martha Laurin Council
- Department of Medicine (Dermatology), Washington University School of Medicine in St. Louis, 969 North Mason Road, Suite 200, St Louis, MO 63141, USA.
| | - David M Sheinbein
- Department of Medicine (Dermatology), Washington University School of Medicine in St. Louis, 969 North Mason Road, Suite 200, St Louis, MO 63141, USA
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2
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Long-Term Follow-Up of Lentigo Maligna Patients Treated with Imiquimod 5% Cream. Cancers (Basel) 2023; 15:cancers15051546. [PMID: 36900337 PMCID: PMC10001243 DOI: 10.3390/cancers15051546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND The study investigated the long-term efficacy of imiquimod 5% cream for LM, with a focus on disease recurrence and the possible prognostic factors of disease-free survival (DFS) in a cohort, with long-term follow-up. METHODS Consecutive patients with histologically confirmed LM were included. Imiquimod 5% cream was applied until weeping erosion appeared on the LM-affected skin. The evaluation was performed through clinical examination and dermoscopy. RESULTS We analyzed 111 patients with LM (median age: 72 years, 61.3% women) with tumor clearance after imiquimod therapy, with a median follow-up of 8 years. The overall patient survival rates were 85.5% (95% confidence interval (CI): 78.5-92.6) and 70.4% (95% CI: 60.3-80.5) at 5 and 10 years, respectively. Among the 23 patients (20.1%) with relapse at follow-up, 17 (73.9%) were treated with surgery, five (21.7%) continued imiquimod therapy, and one (4.3%) underwent both surgery and radiotherapy. After adjustment for age and LM area in multivariable models, localization of LM in the nasal region was identified as a prognostic factor for DFS (HR = 2.66; 95% CI: 1.06-6.64). CONCLUSION If surgical excision is not possible due to the patients' age/comorbidities or critical cosmetic localization, imiquimod could provide optimal outcomes with an optimal risk of relapse for the management of LM.
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Fuchs E, Khanijow A, Garcia RL, Goff BA. Imiquimod treatment of vulvar melanoma in situ invading the urethra. Gynecol Oncol Rep 2021; 38:100875. [PMID: 34926757 PMCID: PMC8651895 DOI: 10.1016/j.gore.2021.100875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/11/2022] Open
Abstract
Surgical approach is standard of care, topical imiquimod still experimental for mucosal melanoma. Imiquimod beneficial for local control of disease if surgery not an option for MIS of vulva/ vagina. In situ and invasive vulvovaginal melanoma have a high risk for recurrence even years later. Long-term follow-up after topical imiquimod treatment needed as metastasis can arise years later.
The primary treatment of both in situ and invasive vulvar melanoma is wide local excision of the primary neoplasm. However, this can be a surgical challenge for size, multifocal presentation with proximity to urethra or anus and tendency for local recurrence. The data on adjuvant therapy for vulvar MIS is very limited. A 69-year-old patient with melanoma of the vulva underwent a simple vulvectomy with positive margins in peri-clitoral area, followed by modified radical vulvectomy and bilateral inguinofemoral sentinel lymph node dissection with negative margins. She was later diagnosed with MIS of the vulva on different locations and had multiple wide local excisions over several years. One lesion was close to the urethra and a complete excision was difficult. Topical imiquimod × 16 weeks (5% cream) was given. The regimen was augmented from 3 to 5 times weekly. Complete resolution was found at 16 weeks and patient was disease free for 4 years. Recently however, a vaginal melanoma was detected. Imiquimod appeared to be beneficial in the treatment of melanoma in situ of the vulva/ vagina when surgical options were not feasible producing local control of disease with the remaining risk for local and distant metastasis. Metastasis can appear years later, therefore long-term follow-up of patients treated with topical imiquimod is needed.
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Gaitanis G, Bassukas ID. A Review of Immunocryosurgery and a Practical Guide to Its Applications. Diseases 2021; 9:71. [PMID: 34698134 PMCID: PMC8544578 DOI: 10.3390/diseases9040071] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Immunocryosurgery is a minimally invasive combinational therapeutic procedure that has been designed, developed, and evaluated in the Dermatology Department of the University of Ioannina from 2004. In a fixed time protocol, this approach combines immune stimulatory therapy with imiquimod and cryosurgery, i.e., cryosurgery is applied during continuous imiquimod treatment. Laboratory findings in tissue and blood level credit the efficacy to the synergy of imiquimod and cryosurgery. The synergy has been established through clinical trials and the excellent feasibility and efficacy demonstrated in clinical practice. Immunocryosurgery has extensive proof of excellent efficacy, comparable to surgery, in the treatment of basal cell carcinoma. It has also been evaluated in cases of Bowen's disease, keratoacanthoma, Merkel cell carcinoma, lentigo maligna, and cutaneous squamous cell carcinoma with or without the addition of adjuvants. The aims of this review are to detail the immunocryosurgery protocol with the addition of daily practice clinical tips, compile data on the mechanism of action of immunocryosurgery, and delineate indications and possible future applications. Most of the available data originate from the treatment of BCC, of all histological types and localizations, and the principles reported mainly reflect on evidence related to the treatment of this common skin cancer.
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Affiliation(s)
- Georgios Gaitanis
- Department of Skin and Venereal Diseases, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece;
- Delc Clinique, 2502 Biel/Bienne, Switzerland
| | - Ioannis D. Bassukas
- Department of Skin and Venereal Diseases, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece;
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Naik PP. Diagnosis and Management of Lentigo Maligna: Clinical Presentation and Comprehensive Review. J Skin Cancer 2021; 2021:7178305. [PMID: 34350036 PMCID: PMC8328731 DOI: 10.1155/2021/7178305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/10/2021] [Accepted: 07/21/2021] [Indexed: 11/17/2022] Open
Abstract
Lentigo maligna (LM), also known as Hutchinson's melanotic freckle, is a form of in situ melanoma characterized by the proliferation of atypical melanocytes along the basal epidermis in sun-damaged skin. If left untreated, LM will progress to lentigo maligna melanoma (LMM), a form of invasive melanoma with the same prognosis as other forms of invasive melanoma. LM is more common in the elderly, with a peak occurrence between the ages of 65 and 80 years. LM, however, is rarely present on the trunk and extremities. The diagnosis of LM, confirmed by histopathological and biopsy examination, is based on clinical and dermoscopic features. It typically begins as a tan-brown macule or patch, but it can progress to a variegated pigmentation with dark black color or even amelanotic characteristics. The risk factors involved in the LM development include a history of sunburns, lighter skin types, advanced age, history of nonmelanoma skin cancers, and tendency to form solar lentigines. This article explains the clinical presentation of LM, also reviews the available information on the diagnosis and management of LM, and discusses the potential of such information in facilitating the future prospective.
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Affiliation(s)
- Piyu Parth Naik
- Department of Dermatology, Saudi German Hospitals and Clinics, Hessa Street 331 West, Al Barsha 3, Exit 36 Sheikh Zayed Road, Opposite of American School, Dubai, UAE
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Change in lentigo maligna score assessed by in vivo reflectance confocal microscopy after 1 month of imiquimod treatment for lentigo maligna management. J Am Acad Dermatol 2021; 86:1042-1048. [PMID: 33785385 DOI: 10.1016/j.jaad.2021.03.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/18/2021] [Accepted: 03/18/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Treatment of lentigo maligna (LM) is challenging because of the potential functional and esthetic surgical sequelae. Imiquimod has been proposed as a treatment for LM. Reflectance confocal microscopy (RCM) is a noninvasive method for the diagnosis of LM and margin assessment. OBJECTIVES To compare the overall LM score (LMS) assessed by RCM before and 1 month after the start of imiquimod treatment compared to placebo and to define the immunohistochemical (IHC) profile of responders to imiquimod. METHODS A controlled randomized study was conducted. Forty patients underwent RCM examination with calculation of the LMS at baseline and after 1 month of treatment. An IHC analysis of excised tissues was performed. RESULTS The 1-month LMS was significantly lower in patients treated with imiquimod compared to those treated with placebo (P < .001). The criteria in the imiquimod-treated patients that demonstrated significant decrease were nonedged papillae; large, round pagetoid cells; atypical cells at the dermoepidermal junction; and follicular location of atypical cells. IHC analysis showed a higher level of interferon gamma in the resected specimens of patients responding to imiquimod (P = .04). LIMITATIONS Sample size was small. CONCLUSION Assessing the LMS by RCM was useful to monitor LM response to imiquimod accurately.
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Funck F, Pahl J, Kyjacova L, Freund L, Oehrl S, Gräbe G, Pezer S, Hassel JC, Sleeman J, Cerwenka A, Schäkel K. Human innate immune cell crosstalk induces melanoma cell senescence. Oncoimmunology 2020; 9:1808424. [PMID: 32939325 PMCID: PMC7470184 DOI: 10.1080/2162402x.2020.1808424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Mononuclear phagocytes and NK cells constitute the first line of innate immune defense. How these cells interact and join forces against cancer is incompletely understood. Here, we observed an early accumulation of slan+ (6-sulfo LacNAc) non-classical monocytes (slanMo) in stage I melanoma, which was followed by an increase in NK cell numbers in stage III. Accordingly, culture supernatants of slanMo induced migration of primary human NK cells in vitro via the chemotactic cytokine IL-8 (CXCL8), suggesting a role for slanMo in NK cell recruitment into cancer tissues. High levels of TNF-α and IFN-γ were produced in co-cultures of TLR-ligand stimulated slanMo and NK cells, whereas much lower levels were contained in cultures of slanMo and NK cells alone. Moreover, TNF-α and IFN-γ concentrations in slanMo/NK cell co-cultures exceeded those in CD14+ monocyte/NK cell and slanMo/T cell co-cultures. Importantly, TNF-α and IFN-γ that was produced in TLR-ligand stimulated slanMo/NK cell co-cultures induced senescence in different melanoma cell lines, as indicated by reduced melanoma cell proliferation, increased senescence-associated β-galactosidase expression, p21 upregulation, and induction of a senescence-associated secretory phenotype (SASP). Taken together, we identified a role for slanMo and NK cells in a collaborative innate immune defense against melanoma by generating a tumor senescence-inducing microenvironment. We conclude that enhancing the synergistic innate immune crosstalk of slanMo and NK cells could improve current immunotherapeutic approaches in melanoma.
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Affiliation(s)
- Felix Funck
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.,Department for Immunobiochemistry, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jens Pahl
- Department for Immunobiochemistry, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lenka Kyjacova
- European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lukas Freund
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stephanie Oehrl
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Galina Gräbe
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Silvia Pezer
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany.,, National Center for Tumor Diseases, Heidelberg, Germany
| | - Jonathan Sleeman
- European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Mannheim Institute for Innate Immunoscience MI3, Mannheim, Germany
| | - Adelheid Cerwenka
- Department for Immunobiochemistry, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Mannheim Institute for Innate Immunoscience MI3, Mannheim, Germany
| | - Knut Schäkel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
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Curcumin and Quercetin-Loaded Nanoemulsions: Physicochemical Compatibility Study and Validation of a Simultaneous Quantification Method. NANOMATERIALS 2020; 10:nano10091650. [PMID: 32842590 PMCID: PMC7558409 DOI: 10.3390/nano10091650] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 02/07/2023]
Abstract
Biphasic oil/water nanoemulsions have been proposed as delivery systems for the intranasal administration of curcumin (CUR) and quercetin (QU), due to their high drug entrapment efficiency, the possibility of simultaneous drug administration and protection of the encapsulated compounds from degradation. To better understand the physicochemical and biological performance of the selected formulation simultaneously co-encapsulating CUR and QU, a stability test of the compound mixture was firstly carried out using X-ray powder diffraction and thermal analyses, such as differential scanning calorimetry (DSC) and thermogravimetric analyses (TGA). The determination and quantification of the encapsulated active compounds were then carried out being an essential parameter for the development of innovative nanomedicines. Thus, a new HPLC-UV/Vis method for the simultaneous determination of CUR and QU in the nanoemulsions was developed and validated. The X-ray diffraction analyses demonstrated that no interaction between the mixture of active ingredients, if any, is strong enough to take place in the solid state. Moreover, the thermal analysis demonstrated that the CUR and QU are stable in the nanoemulsion production temperature range. The proposed analytical method for the simultaneous quantification of the two actives was selective and linear for both compounds in the range of 0.5-12.5 µg/mL (R2 > 0.9997), precise (RSD below 3%), robust and accurate (recovery 100 ± 5 %). The method was validated in accordance with ICH Q2 R1 "Validation of Analytical Procedures" and CDER-FDA "Validation of chromatographic methods" guideline. Furthermore, the low limit of detection (LOD 0.005 µg/mL for CUR and 0.14 µg/mL for QU) and the low limit of quantification (LOQ 0.017 µg/mL for CUR and 0.48 µg/mL for QU) of the method were suitable for the application to drug release and permeation studies planned for the development of the nanoemulsions. The method was then applied for the determination of nanoemulsions CUR and QU encapsulation efficiencies (> 99%), as well as for the stability studies of the two compounds in simulated biological fluids over time. The proposed method represents, to our knowledge, the only method for the simultaneous quantification of CUR and QU in nanoemulsions.
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9
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An Algorithm for the Management of Residual Head and Neck Melanoma In Situ Using Topical Imiquimod. Ann Plast Surg 2019; 82:S199-S201. [DOI: 10.1097/sap.0000000000001840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Brand F, Seyed Jafari S, Hunger R. Confocal Microscopy and Lentigo Maligna: An in vivo Pilot Study for the Assessment of Response to Imiquimod Therapy. Dermatology 2018; 235:150-155. [DOI: 10.1159/000495034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/01/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Reflectance confocal microscopy (RCM) is a noninvasive technique that provides real-time in vivo images of the epidermal layer. Imiquimod has been recommended as an alternative treatment in lentigo maligna (LM) when surgical excision is not the treatment of choice. In the present study we compare the results of in vivo RCM to the histopathological examination before and after treatment of LM with topical imiquimod. Methods: Thirty-four patients with confirmed LM were included. Imiquimod 5% was applied until a weeping erosion appeared in the LM-affected skin. Evaluation was performed by clinical examination, dermatoscopy, histopathology and RCM. Results: During the follow-up, 27 of 34 patients (79.42%) demonstrated a total tumor clearance by imiquimod treatment. In the treated area, a significant decrease of atypical cells was detected using RCM (p < 0.0001). Furthermore, a significant positive correlation in the detected atypical cells was shown using confocal microscopy and histology (p = 0.0001, r = 0.7335, respectively). Conclusion: In patients not suitable for surgical intervention imiquimod treatment is an appropriate treatment alternative. Thereby, in vivo RCM was demonstrated to be an excellent examining device, which not only allows diagnosis of LM, but also therapy and follow-up examinations. An important benefit of RCM, in contrast to conventional histopathology, is the simple handling with in vivo examination of epidermal skin without any pain for the patient.
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11
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Stefanis AJ, Apalla Z, Papageorgiou C, Ioannides D, Nikolaidou C, Lallas A. A tiny facial pigmented macule: overcoming the diagnostic challenge. Dermatol Pract Concept 2018; 8:322-323. [PMID: 30479865 PMCID: PMC6246060 DOI: 10.5826/dpc.0804a15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/07/2018] [Indexed: 12/03/2022] Open
Affiliation(s)
- Athanasios J Stefanis
- Department of Dermatology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zoe Apalla
- First Department of Dermatology, Aristotle University, Thessaloniki, Greece
| | | | | | - Christina Nikolaidou
- Department of Histopathology, Hippokration General Hospital, Thessaloniki, Greece
| | - Aimilios Lallas
- First Department of Dermatology, Aristotle University, Thessaloniki, Greece
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12
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Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 2018; 80:208-250. [PMID: 30392755 DOI: 10.1016/j.jaad.2018.08.055] [Citation(s) in RCA: 328] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022]
Abstract
The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.
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Affiliation(s)
- Susan M Swetter
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, Stanford, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
| | - Hensin Tsao
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Wellman Center for Photomedicine, Boston, Massachusetts
| | - Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Clara Curiel-Lewandrowski
- Division of Dermatology, University of Arizona, Tucson, Arizona; University of Arizona Cancer Center, Tucson, Arizona
| | - David E Elder
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; Department of Cancer Biology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pathology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut
| | - Allan C Halpern
- Department of Dermatology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy M Johnson
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Arthur J Sober
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John A Thompson
- Division of Oncology, University of Washington, Seattle, Washington; Seattle Cancer Care Alliance, Seattle, Washington
| | - Oliver J Wisco
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | | | - Shasa Hu
- Department of Dermatology, University of Miami Health System, Miami, Florida
| | - Toyin Lamina
- American Academy of Dermatology, Rosemont, Illinois
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13
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Krishnasamy SR, Almazan TH, Suero-Abreu GA, Jung JY. Successful treatment of cutaneous metastatic breast cancer with topical treatments that potentially synergize with systemic therapy: A case series. JAAD Case Rep 2018; 4:711-715. [PMID: 30128345 PMCID: PMC6098206 DOI: 10.1016/j.jdcr.2018.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Shalini R Krishnasamy
- Department of Internal Medicine, Rutgers New Jersey Medical School, New Brunswick, New Jersey.,Department of Dermatology, City of Hope National Comprehensive Cancer Center, Los Angeles, California
| | - Timothy H Almazan
- Department of Dermatology, Stanford University School of Medicine Stanford, Los Angeles.,Department of Dermatology, City of Hope National Comprehensive Cancer Center, Los Angeles, California
| | - Giselle A Suero-Abreu
- Department of Internal Medicine, Rutgers New Jersey Medical School, New Brunswick, New Jersey
| | - Jae Y Jung
- Department of Dermatology, City of Hope National Comprehensive Cancer Center, Los Angeles, California.,Department of Dermatology, University of Louisville, Louisville, Kentucky
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14
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Oh G, Farley CR, Lopez-Aguiar AG, Russell MC, Delman KA, Lowe MC. Recurrence Patterns after Primary Excision of Invasive Melanoma with Melanoma in situ at the Margin. Am Surg 2018. [DOI: 10.1177/000313481808400845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The significance and management of melanoma in situ (MIS) at the margin of excision of invasive melanoma is debated. Patients undergoing excision of invasive melanoma from 2000 to 2016 with MIS at the margin were identified. A cohort without MIS was matched for age, gender, location, and Breslow depth. Thirty-two patients with 33 cases of MIS at the margin were identified. Melanoma was located on the head/neck (66.7%), extremities (24.2%), and trunk (9.1%). Median Breslow depth was 1.0 mm (range 0.25–10.80). Margin treatment included re-excision (45.5%), re-excision plus imiquimod (3.0%), imiquimod alone (9.1%), and observation alone (42.4%). At a median follow-up of 91 months (range 28–126), five patients (15.2%) with a median Breslow depth of 4.75 mm (range 1.10–6.70) developed local recurrence (LR). Three underwent re-excision of the positive margin and two were observed. Intervention for positive margins did not decrease LR compared with observation (P = 0.905, OR = 1.125, 95% confidence interval [CI] 0.162–7.824). All five patients with LR were alive at the last follow-up. There were two recurrences in the matched cohort (6.1%); both were alive at the last follow-up. Risk of LR is higher with MIS at the margin, but this does not seem to impact survival. Larger studies may elucidate predictive factors and interventions that decrease risk for LR.
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Affiliation(s)
- Grace Oh
- Emory University School of Medicine
| | - Clara R. Farley
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Maria C. Russell
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Keith A. Delman
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Michael C. Lowe
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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15
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Kim NH, Lee JB, Yun SJ. Development of Vitiligo-Like Depigmentation after Treatment of Lentigo Maligna Melanoma with 5% Imiquimod Cream. Ann Dermatol 2018; 30:454-457. [PMID: 30065586 PMCID: PMC6029957 DOI: 10.5021/ad.2018.30.4.454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 11/08/2022] Open
Abstract
A 69-year-old man presented with a black irregular patch on his left cheek. Skin biopsy revealed lentigo maligna melanoma in situ. He was treated via partial excision of the melanoma, followed by the application of 5% imiquimod cream every other night for 6 to 8 hours. The patient experienced severe local inflammation accompanied by burning, edema, and erythema, as well as oozing and crusting. The patient discontinued using the imiquimod cream after 15 applications because of the inflammation. Depigmentation was noted in the treated area 3 months after the initiation of treatment with imiquimod cream. Histological examination using Melan-A staining of the depigmented area revealed an absence of melanocytes, which is consistent with vitiligo. The depigmented lesions improved considerably after a 5-year follow-up, and there was no recurrence of melanoma.
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Affiliation(s)
- Na Hee Kim
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Jee Bum Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Sook Jung Yun
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
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Matas-Nadal C, Sòria X, García-de-la-Fuente MR, Huerva V, Ortega E, Vilardell F, Gatius S, Casanova JM, Martí RM. Immunocryosurgery as monotherapy for lentigo maligna or combined with surgical excision for lentigo maligna melanoma. J Dermatol 2018; 45:564-570. [DOI: 10.1111/1346-8138.14248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/10/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Clara Matas-Nadal
- Department of Dermatology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
| | - Xavier Sòria
- Department of Dermatology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
| | | | - Valentín Huerva
- Department of Ophthalmology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
| | - Eugenia Ortega
- Department of Oncology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
| | - Felip Vilardell
- Department of Pathology and Molecular Genetics; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Lleida Spain
| | - Sònia Gatius
- Department of Pathology and Molecular Genetics; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Lleida Spain
| | - Josep M. Casanova
- Department of Dermatology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
| | - Rosa M. Martí
- Department of Dermatology; Hospital Universitari Arnau de Vilanova; University of Lleida; IRBLleida Spain
- Centre of Biomedical Research on Cancer (CIBERONC); Instituto de Salud Carlos III (ISCIII); Madrid Spain
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17
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Telò I, Favero ED, Cantù L, Frattini N, Pescina S, Padula C, Santi P, Sonvico F, Nicoli S. Gel-like TPGS-Based Microemulsions for Imiquimod Dermal Delivery: Role of Mesostructure on the Uptake and Distribution into the Skin. Mol Pharm 2017; 14:3281-3289. [DOI: 10.1021/acs.molpharmaceut.7b00348] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Isabella Telò
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Elena Del Favero
- Department
of Medical Biotechnologies and Translational Medicine, LITA, University of Milan, Via F.lli Cervi, 93, 20090 Segrate, Italy
| | - Laura Cantù
- Department
of Medical Biotechnologies and Translational Medicine, LITA, University of Milan, Via F.lli Cervi, 93, 20090 Segrate, Italy
| | - Noemi Frattini
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Silvia Pescina
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Cristina Padula
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Patrizia Santi
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Fabio Sonvico
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Sara Nicoli
- Food
and Drug Department, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
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18
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Tio D, van der Woude J, Prinsen CAC, Jansma EP, Hoekzema R, van Montfrans C. A systematic review on the role of imiquimod in lentigo maligna and lentigo maligna melanoma: need for standardization of treatment schedule and outcome measures. J Eur Acad Dermatol Venereol 2017; 31:616-624. [PMID: 27987308 DOI: 10.1111/jdv.14085] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022]
Abstract
Lentigo maligna (LM) is an in situ variant of melanoma. Our objective was to systematically review clinical and histological clearance and recurrence rates of imiquimod treatment of LM with emphasis on progression to lentigo maligna melanoma (LMM). PubMed, EMBASE and the Cochrane library were searched from inception to May 2015. Articles were included if they described histologically proven LM treated with imiquimod 5% monotherapy or combined with another topical therapy. Analysed outcomes were clinical and histological clearance, recurrence rates and number of LMM. The quality was assessed using the GRADE-like checklist, and results were reported according to the PRISMA Statement. Twenty-six case reports, 11 retrospective studies, three prospective studies and one randomized controlled trial were included. One case report of poor quality was excluded. Complete clinical clearance was seen in 369 of 471 patients (78.3%). Histological clearance was present in 285 of 370 (77%) patients. LMM was diagnosed in nine (1.8%) patients 3.9 months (range 0-11 months) post-treatment. Univariate multinominal logistic regression showed that 6-7 applications/week had a 6.47 greater odds (P = 0.017) of resulting in complete clinical clearance compared to 1-4 applications/week. An intensity of 6-7 applications/week showed a 8.85 greater odds (P = 0.003) of resulting in histological clearance compared to 1-4 applications. Applying imiquimod >60 times during a treatment period of 12 weeks (range 4-36) showed a 7.75 greater odds (P = 0.001) of resulting in histological clearance compared to <60 total applications. In conclusion, a treatment schedule using imiquimod 6-7 applications per week, with at least 60 applications, shows the greatest odds of complete clinical and histological clearance of LM. Imiquimod is an option for patients unfit for or not willing to undergo surgery or radiotherapy. Nine cases of LM progressed to LMM shortly after treatment. Our hypothesis is that these LMM may have been present before starting imiquimod.
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Affiliation(s)
- D Tio
- Department of Dermatology, VUmc Amsterdam, Amsterdam, The Netherlands
| | | | - C A C Prinsen
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VUmc Amsterdam, Amsterdam, The Netherlands
| | - E P Jansma
- VU University Amsterdam, Amsterdam, The Netherlands
| | - R Hoekzema
- Department of Dermatology, VUmc Amsterdam, Amsterdam, The Netherlands
| | - C van Montfrans
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
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19
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20
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Elia MD, Lally SE, Hanlon AM, Choi JN, Servat JJ, Shields JA, Shields CL, Levin F. Periocular Melanoma In Situ Treated With Imiquimod. Ophthalmic Plast Reconstr Surg 2016; 32:371-3. [PMID: 26325381 DOI: 10.1097/iop.0000000000000554] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of topical 5% imiquimod cream in the treatment of periocular melanoma in situ (lentigo maligna). DESIGN Retrospective case series. SUBJECTS There were 12 patients in this series, and the mean patient age was 77 years. The anatomical locations were the lower eyelid (n=5), upper and lower eyelid (n=4), lower eyelid including the eyelid margin (n=1), brow (n=1), and the medial canthus (n=1). Topical 5% imiquimod cream was used as a primary treatment (n=6) or as an adjunctive therapy following local excision (n=2), cryotherapy (n=2), or excisional biopsy with cryotherapy (n=2). METHODS Twelve patients with periocular melanoma in situ were treated with topical 5% imiquimod cream daily for a mean treatment period of 3.9 months. The clinical features of the patients and the responses to treatment were evaluated in a retrospective case series. MAIN OUTCOME MEASURES Histologic clearance of atypical melanocytes. RESULTS Eleven patients achieved complete histologic clearance of atypical melanocytes on post-treatment biopsy. One patient could not tolerate local irritation from imiquimod and stopped in the first month of therapy with residual disease. The median follow-up time was 1.5 years. Side effects included redness (n=12), discomfort (n=6), swelling (n=4), ectropion (n=1), and conjunctival chemosis (n=1). The patients experienced no systemic side effects from the treatment. CONCLUSIONS Topical 5% imiquimod cream is an effective option as primary or adjunct therapy in the treatment of periocular melanoma in situ.
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Affiliation(s)
- Maxwell D Elia
- *Department of Ophthalmology and Visual Sciences, Yale School of Medicine, New Haven, Connecticut; †Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania; ‡Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; and §Oculofacial Plastic Surgeons of Georgia, Atlanta, Georgia, U.S.A
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21
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Telò I, Pescina S, Padula C, Santi P, Nicoli S. Mechanisms of imiquimod skin penetration. Int J Pharm 2016; 511:516-523. [PMID: 27452419 DOI: 10.1016/j.ijpharm.2016.07.043] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 12/31/2022]
Abstract
Imiquimod (IMQ) ia an immunostimulating drug used for the treatment of neoplastic skin diseases, such as actinic keratosis (AK) and superficial basal cell carcinoma (sBCC), and as adjuvant for vaccination. Imiquimod formulation and skin delivery is highly challenging because of its very low solubility in most pharmaceutical excipients and poor penetration properties. Objectives of the work were: (1) to evaluate IMQ solubility in different solvents and pharmaceutical excipients; (2) to evaluate IMQ skin retention after the application of simple saturated solutions; (3) to evaluate the role of stratum corneum and solvent uptake on IMQ skin retention and (4) to formulate IMQ in microemulsions - prepared using previously investigated components - and compare them with the commercial formulation. The results show that IMQ solubility is not related to the solubility parameter of the solvents considered. The highest solubility was found with oleic acid (74mg/ml); in the case of PEGs, the solubility increased linearly with MW (PEG 200: 1.9mg/ml; PEG 400 7.3mg/ml, PEG 600 12.8mg/ml). Imiquimod skin retention from saturated solutions (Tween 80, oleic acid, propylene glycol, PEG 200, PEG 400, PEG 600, Transcutol, 2-pyrrolidone, DMSO) resulted relatively similar, being 1.6μg/cm(2) in case of oleic acid (solubility 74mg/ml) and 0.18μg/cm(2) in case of propylene glycol (solubility 0.60mg/ml). Permeation experiments on stripped skin (no stratum corneum) and isolated dermis as well as uptake experiments on isolated stratum corneum sheets demonstrated that IMQ accumulation is related to skin solvent uptake. Finally, microemulsions (MEs) prepared with the above-studied components demonstrated a very good performance. In particular, a ME composed of 10% oleic acid, 35% Transcutol, 35% Tween 80 and 20% water is able to accumulate the same amount of drug as the commercial formulation but with far more efficiency, since its concentration was 12 times lower.
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Affiliation(s)
- Isabella Telò
- Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Silvia Pescina
- Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Cristina Padula
- Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Patrizia Santi
- Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Sara Nicoli
- Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy.
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22
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de Vries K, Greveling K, Prens L, Munte K, Koljenović S, van Doorn M, Prens E. Recurrence rate of lentigo maligna after micrographically controlled staged surgical excision. Br J Dermatol 2016; 174:588-93. [DOI: 10.1111/bjd.14325] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/29/2022]
Affiliation(s)
- K. de Vries
- Department of Dermatology; University Medical Center Groningen; Groningen the Netherlands
- Department of Dermatology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
| | - K. Greveling
- Department of Dermatology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
| | - L.M. Prens
- Department of Dermatology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
| | - K. Munte
- Department of Dermatology; Maasstad Ziekenhuis; Rotterdam the Netherlands
| | - S. Koljenović
- Department of Pathology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
| | - M.B.A. van Doorn
- Department of Dermatology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
| | - E.P. Prens
- Department of Dermatology; Erasmus University Medical Center; 3000 CA Rotterdam the Netherlands
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23
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Prognostic markers in lentigo maligna patients treated with imiquimod cream: A long-term follow-up study. J Am Acad Dermatol 2016; 74:81-87.e1. [DOI: 10.1016/j.jaad.2015.08.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 08/10/2015] [Accepted: 08/13/2015] [Indexed: 11/22/2022]
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24
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Ethun CG, Delman KA. The importance of surgical margins in melanoma. J Surg Oncol 2015; 113:339-45. [DOI: 10.1002/jso.24111] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/14/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute; Emory University; Atlanta Georgia
| | - Keith A. Delman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute; Emory University; Atlanta Georgia
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25
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Higgins HW, Lee KC, Galan A, Leffell DJ. Melanoma in situ: Part II. Histopathology, treatment, and clinical management. J Am Acad Dermatol 2015; 73:193-203; quiz 203-4. [PMID: 26183968 DOI: 10.1016/j.jaad.2015.03.057] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 03/18/2015] [Accepted: 03/31/2015] [Indexed: 11/20/2022]
Abstract
Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.
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Affiliation(s)
- H William Higgins
- Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island.
| | - Kachiu C Lee
- Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island
| | - Anjela Galan
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - David J Leffell
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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26
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Mora AN, Karia PS, Nguyen BM. A quantitative systematic review of the efficacy of imiquimod monotherapy for lentigo maligna and an analysis of factors that affect tumor clearance. J Am Acad Dermatol 2015; 73:205-12. [PMID: 26088690 DOI: 10.1016/j.jaad.2015.05.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/11/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The reported efficacy of imiquimod for lentigo maligna varies widely, without consensus on tumor or treatment factors that can impact tumor clearance. OBJECTIVE We sought to provide a more precise estimate of clearance rates in patients with lentigo maligna who are treated with imiquimod and to analyze factors that can impact tumor clearance. METHODS We performed a literature search for biopsy-proven lentigo maligna treated with imiquimod monotherapy, linked treatment and outcome data to individual tumors, calculated histologic and clinical clearance rates with 95% confidence intervals (CIs), and analyzed the impact of tumor and treatment factors on tumor clearance using logistic regression. RESULTS Based on 347 tumors from 45 studies, histologic and clinical clearance rates were 76.2% (95% CI, 71.4-81.0%) and 78.3% (95% CI, 73.6-82.9%), respectively. The incidence of clinical recurrence was 2.3% (95% CI, 0.5-4.2%), with a mean follow-up of 34.2 ± 11.8 months. Treatment with >60 total applications, or with >5 applications per week was associated with a higher likelihood of histologic clearance (odds ratio, 8.4 [95% CI, 2.9-24.1] and odds ratio, 6.0 [95% CI, 2.4-14.7], respectively). LIMITATIONS Our limitations included the accuracy and scope of published data, variable follow-up times, potential patient selection, and publication bias related to case series/cohort designs of previous studies. CONCLUSION Imiquimod offers a 76% histologic and 78% clinical clearance rate for lentigo maligna. Both cumulative dose and treatment intensity affect tumor clearance.
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Affiliation(s)
- Ariana N Mora
- Department of Dermatology at Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pritesh S Karia
- Department of Dermatology at Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bichchau Michelle Nguyen
- Department of Dermatology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
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27
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Connolly KL, Nehal KS, Busam KJ. Lentigo maligna and lentigo maligna melanoma: contemporary issues in diagnosis and management. Melanoma Manag 2015; 2:171-178. [PMID: 30190846 DOI: 10.2217/mmt.15.3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Lentigo maligna and lentigo maligna melanomas present diagnostic and treatment dilemmas due to their frequent presence within a background of sun-damaged skin, and their location on cosmetically and functionally sensitive areas. As the incidence of this entity is increasing, diagnostic and management controversies have developed. While surgery remains the gold standard of treatment, nonsurgical treatment options are also emerging for both adjunctive and primary therapy.
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Affiliation(s)
- Karen L Connolly
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kishwer S Nehal
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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28
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Swetter SM, Chen FW, Kim DD, Egbert BM. Imiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type. J Am Acad Dermatol 2015; 72:1047-53. [PMID: 25791801 DOI: 10.1016/j.jaad.2015.02.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 01/23/2015] [Accepted: 02/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical resection of lentigo maligna (LM) is complicated by noncontiguous, subclinical extension and actinic melanocytic hyperplasia in sun-damaged skin of older individuals. OBJECTIVE We sought to determine the long-term effectiveness of imiquimod as primary or adjuvant therapy for LM. METHODS Patients were retrospectively identified from January 1, 2003, to December 31, 2013, with LM, early/evolving LM, and LM melanoma who had used topical imiquimod 5% cream for either primary therapy after diagnostic biopsy, or adjuvant therapy after narrow-margin surgical resection or complete clinical but not histologic resection of LM. Follow-up occurred through December 31, 2014. RESULTS In all, 63 cases were identified in 61 patients, mean (SD) age 71.1 (12.4) years; 58 were analyzed for local recurrence. Imiquimod was used as primary therapy in 22 of 63 (34.9%) and adjuvant therapy in 41 of 63 (65.1%) for mean duration of 11.7 (range 2-60) weeks. Fifty cases (86.2%) demonstrated clinical clearance at mean (SD) follow-up of 42.1 (27.4) months: 72.7% primary and 94.4% adjuvant at 39.7 (23.9) and 43.1 (28.9) months, respectively. LIMITATIONS Retrospective cohort study and lack of standardized imiquimod application are limitations. CONCLUSION Imiquimod cream appears to be a viable option for primary or adjuvant treatment of LM in older patients who are poor surgical candidates.
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Affiliation(s)
- Susan M Swetter
- Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, California.
| | - Frank W Chen
- Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, California
| | - David D Kim
- Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, California
| | - Barbara M Egbert
- Pathology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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29
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Combination Topical Therapy for Conjunctival Primary Acquired Melanosis With Atypia and Periocular Lentigo Maligna. Cornea 2015; 34:90-3. [DOI: 10.1097/ico.0000000000000277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Fan Q, Cohen S, John B, Riker AI. Melanoma in Situ Treated with Topical Imiquimod for Management of Persistently Positive Margins: A Review of Treatment Methods. Ochsner J 2015; 15:443-7. [PMID: 26730231 PMCID: PMC4679308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Imiquimod is a topical cream approved by the US Food and Drug Administration for treatment of superficial basal cell carcinoma, actinic keratosis, and genital-perianal warts. Its successful use in patients with persistently positive margins of melanoma in situ (MIS) after surgical excision has been previously reported. CASE REPORT A 75-year-old female presented with a primary melanoma that was removed through an elliptical excision with 1 cm margins. Pathology revealed 3 involved margins with residual MIS without an invasive component. After a second operation removed an additional 1 cm margin, pathology revealed 2 positive margins with residual MIS. Rather than undergoing a third excision, the patient decided to pursue a nonsurgical approach with topical imiquimod, and at the 4-month follow-up examination, the incision was completely healed with no clinical evidence of tumor recurrence. CONCLUSION A nonsurgical approach with 5% topical imiquimod cream applied along the incision was utilized. In specific patient populations, the use of imiquimod is a reasonable alternative approach for the management of persistently positive MIS margins. Long-term follow-up is necessary to assess for evidence of recurrence and the ultimate success of this nonsurgical approach.
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Affiliation(s)
- Qing Fan
- General & Oncology Surgery Departments, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Stephanie Cohen
- Department of Surgery, Advocate Cancer Institute, Advocate Christ Medical Center, Oak Lawn, IL
| | - Becky John
- Department of Pathology, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Adam I. Riker
- Department of Surgery, Advocate Cancer Institute, Advocate Christ Medical Center, Oak Lawn, IL
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Abstract
In-transit disease is defined as any dermal or subcutaneous metastases that arise between the primary melanoma but not beyond the draining regional nodal basin. Patients who develop in-transit disease are at further risk to develop additional locoregional and distant disease. Treatment must be individualized and take into consideration the extent of disease, tumor characteristics, and patient characteristics including age, comorbidities, previous therapies, and site of recurrence. Surgery, regional perfusions and intralesional injections all play a role in management options. These patients should be discussed and managed by a multidisciplinary team whenever possible.
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32
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Successful treatment of lower eyelid melanoma in situ. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e154. [PMID: 25289347 PMCID: PMC4174083 DOI: 10.1097/gox.0000000000000041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 12/04/2013] [Indexed: 12/02/2022]
Abstract
Summary: We present a brief literature review of the topical immune-modulating medication Imiquimod. The treatment of periorbital melanoma in situ typically requires surgical resection. Here we discuss a case of lower eyelid melanoma in situ successfully treated non-operatively with Imiquimod.
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Alarcon I, Carrera C, Alos L, Palou J, Malvehy J, Puig S. In vivo reflectance confocal microscopy to monitor the response of lentigo maligna to imiquimod. J Am Acad Dermatol 2014; 71:49-55. [PMID: 24725478 DOI: 10.1016/j.jaad.2014.02.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/26/2014] [Accepted: 02/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Imiquimod has been used for treating lentigo maligna (LM) in selected cases when surgery is not an appropriate option because of functional or aesthetic impairment. Reflectance confocal microscopy (RCM) is a noninvasive method that has not been validated for monitoring the treatment of LM with imiquimod. OBJECTIVE We sought to evaluate the use of in vivo RCM to accurately monitor the response of LM to nonsurgical treatment with topical imiquimod. METHODS Twenty patients with confirmed facial LM, not amenable to surgical treatment or radiation therapy, were included prospectively. Clinical evaluation was performed by dermoscopy, RCM, and histopathology. Patients applied imiquimod 5% for 8 weeks. The affected area was assessed using the previously described LM score on RCM, and target sample biopsies were performed to confirm or discard RCM findings. RESULTS Fifteen of the 20 patients (75%) presented histologic tumor clearance. Confocal microscopy identified 70% of these responders with no false-negative results, and when compared with histopathology, there was no significant difference in evaluating the response to imiquimod. LIMITATIONS The impossibility of examining the entire lesion by means of histopathology is a limitation. CONCLUSION In vivo RCM evaluation was useful in accurately monitoring the response of LM to nonsurgical treatment with topical imiquimod in patients when surgery is contraindicated.
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Affiliation(s)
- Ivette Alarcon
- Dermatology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut de Recerca Biomédica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Cristina Carrera
- Dermatology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut de Recerca Biomédica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Llucia Alos
- Pathology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Josep Palou
- Pathology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Josep Malvehy
- Dermatology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut de Recerca Biomédica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Susana Puig
- Dermatology Department, Melanoma Unit, Hospital Clinic of Barcelona, Barcelona, Spain; Institut de Recerca Biomédica August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
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Mansuy M, Nikkels-Tassoudji N, Arrese JE, Rorive A, Nikkels AF. Recurrent in situ melanoma successfully treated with ingenol mebutate. Dermatol Ther (Heidelb) 2014; 4:131-5. [PMID: 24691652 PMCID: PMC4065276 DOI: 10.1007/s13555-014-0051-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Indexed: 11/26/2022] Open
Abstract
Background Treatment options for melanoma in situ (MIS) include imiquimod, radiation therapy, cryotherapy, excisional and Mohs surgery. Ingenol mebutate is a new topical treatment option recognized for actinic keratosis. Although in vitro effectiveness has been demonstrated on melanoma cell lines, its therapeutic potential for in vivo melanomas is unknown. Case Report In 2011, a 91-year-old woman presented a thick melanoma of her cheek. The lateral sections revealed persisting in situ melanoma, which were again excised. She presented for follow-up and a recurrent MIS was evidenced centered on the previous scar. She refused further surgery and ingenol mebutate (0.015% gel) was administered on three consecutive days. One month later, a complete clinical resolution was observed. Histology and immunohistology revealed no residual MIS. Conclusion In this patient, ingenol mebutate was successful and well-tolerated as a topical, alternative therapy for MIS after failure of other treatment options. Electronic supplementary material The online version of this article (doi:10.1007/s13555-014-0051-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marion Mansuy
- Department of Dermatology, Skin Cancer Centre, CHU du Sart Tilman, University de Liège, 4000 Liège, Belgium
| | - Nazli Nikkels-Tassoudji
- Department of Dermatology, Skin Cancer Centre, CHU du Sart Tilman, University de Liège, 4000 Liège, Belgium
| | - Jorge E. Arrese
- Department of Pathology, Skin Cancer Centre, CHU du Sart Tilman, University de Liège, 4000 Liège, Belgium
| | - Andree Rorive
- Department of Oncology, Skin Cancer Centre, CHU du Sart Tilman, University de Liège, 4000 Liège, Belgium
| | - Arjen F. Nikkels
- Department of Dermatology, Skin Cancer Centre, CHU du Sart Tilman, University de Liège, 4000 Liège, Belgium
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Shiau CJ, Thompson JF, Scolyer RA. Controversies and evolving concepts in the diagnosis, classification and management of lentigo maligna. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.13.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Uzarska M, Czajkowski R, Schwartz RA, Bajek A, Zegarska B, Drewa T. Chemoprevention of skin melanoma: facts and myths. Melanoma Res 2013; 23:426-33. [PMID: 24077511 DOI: 10.1097/cmr.0000000000000016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Melanoma is the most dangerous type of skin cancer. Despite the rise of public awareness, the incidence rate among the white population has been rising constantly for several decades. Systematic improvement in knowledge about the biology of pigment cells and molecular mechanisms of their neoplastic transformation has enhanced the possibility of melanoma chemoprevention. Hence, chemopreventive agents that prevent, inhibit, or reverse melanoma development are being investigated intensively. Among synthetic compounds, especially well studied are lipid-lowering drugs and cyclooxygenase inhibitors. Substances found in everyday diet, such as genistein, apigenin, quercetin, resveratrol, and curcumin may also have potential chemopreventive qualities. However, studies examining the chemopreventive activity of these compounds have shown widely varying results. Early reports on the possible chemopreventive activity of statins and fibrates were not proved by the results of randomized clinical trials. Similarly, case-control studies examining the influence of NSAIDs on the risk of melanoma do not confirm the antitumor activity of cyclooxygenase inhibitors. Further clinical trials involving carefully selected target populations as well as the identification of specific biomarkers of prognostic and predictive value seem to be essential for the evaluation of the chemopreventive activity of the studied substances.
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Affiliation(s)
- Małgorzata Uzarska
- Departments of aTissue Engineering bDermatology, Sexually Transmitted Diseases and Immunodermatology cCosmetology and Esthetic Dermatology dUrology Department, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Medical College in Bydgoszcz, Bydgoszcz, Poland eDepartment of Dermatology and Pathology, Rutgers University New Jersey Medical School, Newark, New Jersey, USA
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Trowbridge RM, Mitkov MV, Pittelkow MR, Agrawal DK. Immunomodulation of malignant melanoma by contact sensitizing agents. Expert Rev Clin Immunol 2013; 10:63-76. [DOI: 10.1586/1744666x.2014.850415] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dekmezian MS, Cohen PR, Sami M, Tschen JA. Malignancies of the eyelid: a review of primary and metastatic cancers. Int J Dermatol 2013; 52:903-26; quiz 922-3, 926. [DOI: 10.1111/ijd.12089] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Mirwat Sami
- Plastic Eye Surgery Associates; Houston; TX; USA
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de Vries K, Rellum R, Habets J, Prens E. A novel two-stage treatment of lentigo maligna using ablative laser therapy followed by imiquimod. Br J Dermatol 2013; 168:1362-4. [DOI: 10.1111/bjd.12157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Council ML. Common skin cancers in older adults: approach to diagnosis and management. Clin Geriatr Med 2013; 29:361-72. [PMID: 23571033 DOI: 10.1016/j.cger.2013.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Skin cancer is one of the most common malignancies to affect the elderly, and the incidence of cutaneous neoplasia is rising. The purpose of this article is to review the most common and deadly forms of skin cancer: malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. Epidemiology, clinical diagnosis, staging, and treatment are discussed for each of these malignancies.
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Affiliation(s)
- M Laurin Council
- Center for Dermatologic and Cosmetic Surgery, Department of Internal Medicine, Washington University School of Medicine, 969 North Mason Road, Suite 200, St Louis, MO 63141, USA.
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Dewan MZ, Vanpouille-Box C, Kawashima N, DiNapoli S, Babb JS, Formenti SC, Adams S, Demaria S. Synergy of topical toll-like receptor 7 agonist with radiation and low-dose cyclophosphamide in a mouse model of cutaneous breast cancer. Clin Cancer Res 2012; 18:6668-78. [PMID: 23048078 DOI: 10.1158/1078-0432.ccr-12-0984] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE This study tested the hypothesis that topical Toll-like receptor (TLR) 7 agonist imiquimod promotes antitumor immunity and synergizes with other treatments in a model of skin-involving breast cancer. EXPERIMENTAL DESIGN TSA mouse breast carcinoma cells were injected s.c. into syngeneic mice. Imiquimod 5% or placebo cream was applied topically on the shaved skin overlying tumors three times/wk. In some experiments, local ionizing radiation therapy (RT) was delivered to the tumor in three fractions of 8 Gy, given on consecutive days. Cyclophosphamide was given intraperitoneally (i.p.) in one dose of 2 mg/mouse. Mice were followed for tumor growth and survival. RESULTS Treatment with imiquimod significantly inhibited tumor growth, an effect that was associated with increased tumor infiltration by CD11c(+), CD4(+), and CD8(+) cells, and abolished by depletion of CD8(+) cells. Administration of imiquimod in combination with RT enhanced significantly tumor response compared with either treatment alone (P < 0.005), and 11% to 66% of irradiated tumors completely regressed. Importantly, the addition of topical imiquimod also resulted in growth inhibition of a secondary tumor outside of the radiation field. Low-dose cyclophosphamide given before start of treatment with imiquimod and RT further improved tumor inhibition and reduced tumor recurrence. Mice that remained tumor-free rejected a tumorigenic inoculum of TSA cells, showing long-term immunologic memory. CONCLUSIONS Topical imiquimod inhibits tumor growth and synergizes with RT. Addition of cyclophosphamide further increases the therapeutic effect and induces protective immunologic memory, suggesting that this combination is a promising strategy for cutaneous breast cancer metastases.
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Affiliation(s)
- M Zahidunnabi Dewan
- Department of Pathology, Radiology, Radiation Oncology, and Medicine, New York University School of Medicine, and NYU Langone Medical Center, New York, New York 10016, USA
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Topical therapies for periorbital cutaneous malignancies: indications and treatment regimens. Curr Opin Ophthalmol 2012; 23:439-42. [PMID: 22828167 DOI: 10.1097/icu.0b013e328356ad55] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To present a brief review of periorbital cutaneous tumorogenesis, highlighting the steps which might be amenable to topical treatments and then discuss the use of topical agents in the management of periorbital skin malignancy. RECENT FINDINGS A rapid expansion in the understanding of the pathogenesis of melanoma and nonmelanoma skin cancer has allowed the development of a number of topical agents targeting specific tumor-forming processes. Topical agents have been shown to be effective in the management of periorbital skin malignancy. SUMMARY 5-Fluorouracil and imiquimod have established roles in the management of periorbital skin malignancy. Newer agents such as ingenol mebutate, tazarotene, and diclofenac gel probably have evolving roles that require further research but show promise.
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