Cornulin as a Key Diagnostic and Prognostic Biomarker in Cancers of the Squamous Epithelium

The prevalence of squamous cell carcinoma is increasing, and efforts that aid in an early and accurate diagnosis are crucial to improve clinical outcomes for patients. Cornulin, a squamous epithelium-specific protein, has recently garnered attention due to its implications in the progression of squamous cell carcinoma developed in several tissues. As an epidermal differentiation marker, it is involved in skin anchoring, regulating cellular proliferation, and is a putative tumor suppressor. The physiologically healthy squamous epithelium displays a considerable level of Cornulin, whereas squamous cell carcinomas have marked downregulation, suggesting that Cornulin expression levels can be utilized for the early detection and follow-up on the progression of these types of cancer. Cornulin's expression patterns in cervical cancer have been examined, and findings support the stepwise downregulation of Cornulin levels that accompanies the progression to neoplasia in the cervix. Additional studies documented a similar trend in expression in other types of cancer, such as cutaneous, esophageal, and oropharyngeal squamous cell carcinomas. The consistent and predictable pattern of Cornulin expression across several squamous cell carcinomas and its correlation with key clinicopathological parameters make it a reliable biomarker for assessing the transformation and progression events in the squamous epithelium, thus potentially contributing to the early detection, definitive diagnosis, and more favorable prognosis for these cancer patients.

Complications and Recurrences after Excision and Reconstruction of Eyelid Tumours

INTRODUCTION

The eyelids are a common site for skin tumours and account for 5-10% of all skin tumours. Treatment is mainly surgical and aims to preserve the anatomical structure of the eyelid, its function and not least its aesthetic appearance.

AIM

Presentation of recurrence and complication rates of tumour-related eyelid surgery in a cohort of 450 tumours.

RESULTS

Analysis of a cohort of 450 tumours operated on revealed 13 (2.8%) operations with recurrences and 32 (7%) with complications. The statistical significance of recurrences was observed for the involved and uninvolved ciliary margin. At the temporal canthus, 23.1% of recurrences occurred compared to 7.7% at the medial canthus. SGC has the highest recurrence rate. Complications include the following: ectropion, dehiscence, gross cicatrix with normal function, retraction, post-radiation damage, sub-graft haemorrhage and graft rejection.

CONCLUSIONS

The recurrence rate of eyelid tumours is lower than that of complications. The choice of surgical technique determines the frequency of complications and histological control of the excised tissue, as well as the frequency of recurrences.

New, simplified versus standard photodynamic therapy (PDT) regimen for superficial and nodular basal cell carcinoma (BCC): A single-blind, non-inferiority, randomised controlled multicentre study

BACKGROUND

Topical photodynamic therapy (PDT) is an approved and widely used treatment for low-risk basal cell carcinoma (BCC), comprising two sessions with an interval of 1 week. Simplification of the treatment course can be cost-effective, easier to organize, and cause less discomfort for the patients.

METHODS AND FINDINGS

We performed an investigator-initiated, single-blind, non-inferiority, randomized controlled multicentre study with the objective of investigating whether a simpler and more flexible PDT regimen was not >10% less effective than the standard double PDT in the treatment of primary, superficial, and nodular ≤2 mm-thick BCC and evaluate the cosmetic outcome. With a non-inferiority margin of 0.1 and an expected probability complete response of 0.85, 190 tumours were required in each group. Histologically verified BCCs from seven centres in Norway were randomly assigned (1:1) to either receive a new regimen of single PDT with one possible re-treatment of non-complete responding tumours, or the standard regimen. The primary endpoint was the number of tumours with complete response or treatment failure at 36 months of follow-up, assessed by investigators blinded to the treatment regimen. Intention-to-treat and per-protocol analyses were performed. The cosmetic outcome was recorded. The study was registered with ClinicalTrials.gov, NCT-01482104, and EudraCT, 2011-004797-28. A total of 402 BCCs in 246 patients were included; 209 tumours assigned to the new and 193 to the standard regimen. After 36 months, there were 61 treatment failures with the new and 34 failures with the standard regimen. Complete response rate was 69.5% in the new and 81.1% in the standard treatment group. The difference was 11.6% (upper 97.5% CI 20.3), i.e. > than the non-inferiority margin of 10%. Cosmetic outcomes were excellent or good in 92% and 89% following the new and standard regimens, respectively.

CONCLUSIONS

Single PDT with possible re-treatment of primary, superficial, and nodular ≤ 2-mm-thick BCC was significantly less effective than the approved standard double treatment. The cosmetic outcome was favorable and comparable between the two treatment groups.

Optically Guided High-Frequency Ultrasound to Differentiate High-Risk Basal Cell Carcinoma Subtypes: A Single-Centre Prospective Study

BACKGROUND

Basal cell carcinoma (BCC) is the most common type of skin cancer in the Caucasian population. Currently, invasive biopsy is the only way of establishing the histological subtype (HST) that determines the treatment options. Our study aimed to evaluate whether optically guided high-frequency ultrasound (OG-HFUS) imaging could differentiate aggressive HST BCCs from low-risk tumors.

METHODS

We conducted prospective clinical and dermoscopic examinations of BCCs, followed by 33 MHz OG-HFUS imaging, surgical excision, and a histological analysis. We enrolled 75 patients with 78 BCCs. In total, 63 BCCs were utilized to establish a novel OG-HFUS risk classification algorithm, while 15 were employed for the validation of this algorithm. The mean age of the patients was 72.9 ± 11.2 years. Histology identified 16 lesions as aggressive HST (infiltrative or micronodular subtypes) and 47 as low-risk HST (superficial or nodular subtypes). To assess the data, we used a one-sided Fisher's exact test for a categorical analysis and a Receiver Operating Characteristic (ROC) curve analysis to evaluate the diagnostic accuracy.

RESULTS

OG-HFUS distinguished aggressive BCC HSTs by their irregular shape (p < 0.0001), ill-defined margins (p < 0.0001), and non-homogeneous internal echoes (p = 0.004). We developed a risk-categorizing algorithm that differentiated aggressive HSTs from low-risk HSTs with a higher sensitivity (82.4%) and specificity (91.3%) than a combined macroscopic and dermoscopic evaluation (sensitivity: 40.1% and specificity: 73.1%). The positive and negative predictive values (PPV and NPV, respectively) for dermoscopy were 30.2% and 76.8%, respectively. In comparison, the OG-HFUS-based algorithm demonstrated a PPV of 94.7% and an NPV of 78.6%. We verified the algorithm using an independent image set, n = 15, including 12 low-risk and 3 high-risk (high-risk) with two blinded evaluators, where we found a sensitivity of 83.33% and specificity of 91.66%.

CONCLUSIONS

Our study shows that OG-HFUS can identify aggressive BCC HSTs based on easily identifiable morphological parameters, supporting early therapeutic decision making.

Postoperative clinical analyze of 450 eyelid tumors

BACKGROUND

The eyelids are a small anatomical structure, yet they contain several histological layers from which benign and malignant tumors can originate. Compared to other parts of the face, the eyelids are often the first place where neoplasms or disease changes are noticed.

AIM

To analyze localization and its predictive malignancy of eyelid tumors over a 10-year period.

METHOD

A retrospective study of 436 (450 eyes) patients operated on over a 10-year period. Descriptive, dispersion and correlation analyzes were performed.

RESULTS

The results provide a clear assessment of the distribution and incidence of eyelid tumors according to the localization of the defect, involvement of the lash line, inflammatory response, etc. Tumor distribution is significantly skewed in favor of the medial canthus, 80% to 20% by all tumors. The involvement of the lid margin occurs in 83% of malignant tumors and has significant predictive value.

CONCLUSION

The lower eyelid and the medial canthus are preferred locations for malignant tumors, and the upper eyelid for benign ones. Our study does not affect the types of surgical techniques; its purpose is to show the expected malignancy of the different combinations by location. The location of the tumor is a leading factor in the choice of the oculoplastic reconstructive procedure.

Catching Cancer Early: The Importance of Dermato-Oncology Screening

The European Society for Medical Oncology experts have identified the main components of the long-term management of oncological patients. These include early diagnosis through population screening and periodic control of already diagnosed patients to identify relapses, recurrences, and other associated neoplasms. There are no generally accepted international guidelines for the long-term monitoring of patients with skin neoplasms (nonmelanoma skin cancer, malignant melanoma, precancerous-high-risk skin lesions). Still, depending on the experience of the attending physician and based on the data from the literature, one can establish monitoring intervals to supervise these high-risk population groups, educate the patient and monitor the general population.

Management of Non-Melanoma Skin Cancer: Radiologists Challenging and Risk Assessment

Basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma are the three main types of nonmelanoma skin cancers and their rates of occurrence and mortality have been steadily rising over the past few decades. For radiologists, it is still difficult to treat patients with advanced nonmelanoma skin cancer. Nonmelanoma skin cancer patients would benefit greatly from an improved diagnostic imaging-based risk stratification and staging method that takes into account patient characteristics. The risk is especially elevated among those who previously received systemic treatment or phototherapy. Systemic treatments, including biologic therapies and methotrexate (MTX), are effective in managing immune-mediated diseases; however, they may increase susceptibility to NMSC due to immunosuppression or other factors. Risk stratification and staging tools are crucial in treatment planning and prognostic evaluation. PET/CT appears more sensitive and superior to CT and MRI for nodal and distant metastasis as well as in surveillance after surgery. The patient treatment response improved with advent and utilization of immunotherapy and different immune-specific criteria are established to standardized evaluation criteria of clinical trials but none of them have been utilized routinely with immunotherapy. The advent of immunotherapy has also arisen new critical issues for radiologists, such as atypical response pattern, pseudo-progression, as well as immune-related adverse events that require early identification to optimize and improve patient prognosis and management. It is important for radiologists to have knowledge of the radiologic features site of the tumor, clinical stage, histological subtype, and any high-risk features to assess immunotherapy treatment response and immune-related adverse events.

[Translated article] Interventions for Basal Cell Carcinoma: Summary of Main Comparisons From a Cochrane Review and a Practical Interpretation of Findings

Numerous surgical and nonsurgical modalities are available to treat basal cell carcinoma (BCC), but their true effectiveness and safety is unknown. This article summarizes the evidence presented in a recent Cochrane review and aims to facilitate the interpretation of the review's findings for the Spanish and Latin American scientific communities. Much of the evidence the reviewers found came from single studies, preventing meta-analysis. Conventional surgical excision continues to be the most effective treatment for low-risk BCC. Most studies had small sample sizes, and some had problems with blinding, limitations which will have affected the assessment of subjective outcomes, such as pain and cosmetic results. The authors identified a lack of standardization in relation to recurrences and cosmetic outcomes that threatens not only the internal validity of the studies but also their external validity and reproducibility.

Interventions for Basal Cell Carcinoma: Summary of Main Comparisons From a Cochrane Review and a Practical Interpretation of Findings

Numerous surgical and nonsurgical modalities are available to treat basal cell carcinoma (BCC), but their true effectiveness and safety is unknown. This article summarizes the evidence presented in a recent Cochrane review and aims to facilitate the interpretation of the review's findings for the Spanish and Latin American scientific communities. Much of the evidence the reviewers found came from single studies, preventing meta-analysis. Conventional surgical excision continues to be the most effective treatment for low-risk BCC. Most studies had small sample sizes, and some had problems with blinding, limitations which will have affected the assessment of subjective outcomes, such as pain and cosmetic results. The authors identified a lack of standardization in relation to recurrences and cosmetic outcomes that threatens not only the internal validity of the studies but also their external validity and reproducibility.

Metastatic parotid gland malignancy: A preliminary study in an eastern Chinese population

OBJECTIVE

This study aimed to determine the incidence and clinicopathological patterns of metastatic carcinoma of the parotid gland.

METHOD

Ninety patients with parotid gland metastases admitted to our hospital between January 2003 and December 2018 were included in this study. Clinical and pathological data were obtained from the medical records and follow-ups. Kaplan-Meier analysis was used to assess overall survival of patients.

RESULTS

Among the 90 patients, parotid gland metastases originated from the head and neck in 86 (95.6%), from non-head and neck in 4 (4.4%), from the oral cavity in 30(33.3%), and from the eyelid in 21 (23.3%). Among the 85 cases with parotid gland lymph node metastasis, 45 (52.9%) were diagnosed with extra-lymph node metastasis. The capsule of the parotid lymph nodes was thinner than that of the cervical lymph nodes (P < 0.05). Hematogenous metastases to the parotid gland (only five cases) were rare, mainly from the non-head and neck malignancies. Patients with oral squamous cell carcinoma and meibomian adenocarcinoma with parotid metastatic disease had poorer overall survival (P < 0.05).

CONCLUSION

Eastern China population analysis showed that parotid gland metastases usually arise from oral squamous cell carcinoma and eyelid, but rarely from cutaneous squamous cell carcinoma. Most cases metastasize to the parotid lymph nodes via the lymphatic system and are prone to extranodal extension with little or no facial nerve involvement. These findings have important implications for the treatment of metastatic parotid malignancies.

Clinical activity of PD-1 inhibition in the treatment of locally advanced or metastatic basal cell carcinoma

Background

Basal cell carcinoma (BCC) is the most common malignancy worldwide, yet the management of patients with advanced or metastatic disease is challenging, with limited treatment options. Recently, programmed death receptor 1 (PD-1) inhibition has demonstrated activity in BCC after prior Hedgehog inhibitor treatment.

Methods

We conducted a multicenter, retrospective analysis of BCC patients treated with PD-1 inhibitor therapy. We examined the efficacy and safety of PD-1 therapy, as well as clinical and pathological variables in association with outcomes. Progression-free survival (PFS), overall survival (OS) and duration of response (DOR) were calculated using Kaplan-Meier methodology. Toxicity was graded per Common Terminology Criteria for Adverse Events V.5.0.

Results

A total of 29 patients with BCC who were treated with PD-1 inhibition were included for analysis, including 20 (69.0%) with locally advanced and 9 (31.0%) with metastatic disease. The objective response rate was 31.0%, with five partial responses (17.2%), and four complete responses (13.8%). Nine patients had stable disease (31.0%), with a disease control rate of 62.1%. The median DOR was not reached. Median PFS was 12.2 months (95% CI 0.0 to 27.4). Median OS was 32.4 months (95% CI 18.1 to 46.7). Two patients (6.9%) developed grade 3 or higher toxicity, while four patients (13.8%) discontinued PD-1 inhibition because of toxicity. Higher platelets (p=0.022) and any grade toxicity (p=0.024) were significantly associated with disease control rate.

Conclusions

The clinical efficacy of PD-1 inhibition among patients with advanced or metastatic BCC in this real-world cohort were comparable to published trial data. Further investigation of PD-1 inhibition is needed to define its optimal role for patients with this disease.

Dissolving microneedles containing aminolevulinic acid improves protoporphyrin IX distribution

One important limitation of topical photodynamic therapy (PDT) is the limited tissue penetration of precursors. Microneedles (MNs) are minimally invasive devices used to promote intradermal drug delivery. Dissolving MNs contain drug-associated to polymer blends, dissolving after insertion into skin, allowing drug release. This study comprises development and characterization of a pyramidal model of dissolving MNs (500 μm) prepared with 5% wt/wt aminolevulinic acid and 20% wt/wt Gantrez AN-139 in aqueous blend. Protoporphyrin IX formation and distribution were evaluated in tumor mice model by using fluorescence widefield imaging, spectroscopy, and confocal microscopy. MNs demonstrated excellent mechanical resistance penetrating about 250 μm with minor size alteration in vitro, and fluorescence intensity was 5-times higher at 0.5 mm on average compared to cream in vivo (being 10 ± 5 a.u. for MNs and 2.4 ± 0.8 a.u. for cream). Dissolving MNs have overcome topical cream application, being extremely promising especially for thicker skin lesions treatment using PDT.

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.

Arsenic and chromium levels in hair correlate with actinic keratosis/non-melanoma skin cancer: results of an observational controlled study

BACKGROUND

The role of heavy metals in carcinogenetic process has been widely established; however, information on the most common environmental metals that serve as major risk factors for actinic keratosis (AK)/non-melanoma skin cancer (NMSC) are still lacking. The aim of this study was to evaluate levels of the most common environmental heavy metals in hair of patients with AK/NMSC as compared to healthy controls.

METHODS

Thirty-one patients diagnosed with AK/NMSC and 34 healthy controls were enrolled. Patients were interviewed for heavy metals exposure and underwent hair analysis for detection of arsenic (As), cadmium (Cd), chromium (Cr), nickel (Ni) and lead (Pb). Continuous variables were analyzed using Wilcoxon Non-Parametric Rank Test and proportions were compared by Fisher's Exact Test. Statistical significance was determined by P<0.05.

RESULTS

In our cohort we observed 48.4% patients had AKs, 16.1% basal cell carcinoma (BCC), 9.7% squamous cell carcinoma (SCC) and 25.9% of patients presented with a combination of these lesions. There were significantly elevated levels of As and Cr in AK-NMSC group as compared to controls.

CONCLUSIONS

We identified a strong positive correlation between As and Cr concentration and AK/NMSC adding new clues to the scenery of NMSC risk factors that should be taken under consideration in exposed populations.

An unusual cause of a common presentation: a case of metastatic basal cell carcinoma

Metastasis of basal cell carcinoma is exceedingly rare and usually not considered in the differential diagnosis of neck lumps. We present a case highlighting the importance of a thorough history and consideration of metastatic basal cell carcinoma in patients with a basaloid metastasis and an unknown primary.

The prognostic roles of cyclooxygenase-2 for patients with basal cell carcinoma

Background: Cyclooxygenase-2 (Cox-2) is critical for tumor invasion, angiogenesis, and poor prognosis in many human cancers. It was reported to be an abnormal expression in many human malignancies, including basal cell carcinoma (BCC). However, the prognostic significance of cox-2 in BCC was still unclear. The aim of this study was to investigate the prognostic roles of cox-2 for patients with BCC. Methods: We detected the expression of cox-2 both at mRNA and protein level in tumor tissue and adjacent normal tissues from 180 patients with BCC by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot analysis, respectively. Results: Cox-2 expression was significantly increased in BCC tissues compared with the adjacent normal cohorts (p < .001). Its expression was significantly associated with angiogenesis (p < .001) and depth of invasion (p < .001). Kaplan-Meier analysis suggested patients with high expression of cox-2 had a shorter overall survival rate than those with low expression (log rank test, p < .001). Conclusions: The expression of cox-2 was up-regulated in BCC and it could be used as a bio-marker for the prognosis of BCC patients with a high risk of recurrence.

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.

Exposure to Trace Elements and Risk of Skin Cancer: A Systematic Review of Epidemiologic Studies

Exposure to environmental trace elements has been studied in relation to many cancers. However, an association between exposure to trace elements and skin cancer remains less understood. Therefore, we conducted a systematic review of published epidemiologic literature examining the association between exposure to trace elements, and risk of melanoma and keratinocyte carcinoma in humans. We identified epidemiologic studies investigating exposure to arsenic, cadmium, chromium, copper, iron, selenium, and zinc and risk of skin cancer in humans. Among the minerals, arsenic, selenium, and zinc had more than five studies available. Exposure to arsenic was associated with increased risk of keratinocyte carcinoma, while too few studies existed on melanoma to draw conclusions. Exposure to selenium was associated with possible increased risk of keratinocyte carcinoma. Studies of zinc and skin cancer were case-control in design and were found to have inconsistent associations. The data on the association between cadmium, chromium, copper, and iron and risk of skin cancer remain too sparse to draw any conclusions. In summary, epidemiologic studies on exposure to trace elements and cutaneous malignancies are limited. Studies with larger sample sizes and prospective designs are warranted to improve our knowledge of trace elements and skin cancer.

Noninvasive evaluation of hemodynamics and light scattering property during two-stage mouse cutaneous carcinogenesis based on multispectral diffuse reflectance images at isosbestic wavelengths of hemoglobin

We investigate a multispectral imaging method to evaluate spatiotemporal changes in both cutaneous hemoglobin concentration and light scattering parameter in mouse skin through diffuse reflectance spectroscopy using the reflectance images acquired at isosbestic wavelengths of hemoglobin (420, 450, 500, and 585 nm). In the proposed approach, Monte Carlo simulation-based empirical formulas are introduced to extract the scattering power b representing the wavelength dependence of light scattering spectrum of skin tissue, as well as the total hemoglobin concentration Cth in dermal vasculatures. The use of isosbestic wavelengths of hemoglobin enables the values of Cth and b to be estimated independently of the oxygenation of hemoglobin. Experiments using in vivo mice two-stage chemical carcinogenesis model are performed to confirm the feasibility of the proposed method for evaluating the changes in cutaneous vasculatures and tissue morphology during tumor initiation, promotion, and progression processes. The experimental results reveal that the changes in scattering power b of back skin are significantly reduced and followed by the increase in total hemoglobin concentration Cth in the carcinogenesis mice group, which indicates morphological changes in skin tissue such as edema and cell swelling caused by tumor promotion and successive angiogenesis along with tumor progression. The results suggest that the potential of the present method to detect cutaneous carcinogenesis in an early stage and monitor physiological changes during promotion and progression process of nonmelanoma tumors.

Experience With Vismodegib in the Treatment of Advanced Basal Cell Carcinoma at a Cancer Center

INTRODUCTION AND OBJECTIVES

Vismodegib is the first selective Hedgehog inhibitor approved for the treatment of locally advanced and metastatic basal cell carcinoma (BCC). In this article, we describe our experience with the use of this drug to treat advanced and/or multiple BCCs at a cancer center over 5 years.

MATERIAL AND METHODS

We analyzed the following variables: patient age and sex; tumor location, size, type, and characteristics; time since onset; primary or recurrent status; duration of treatment; response to treatment (complete, partial, stabilization, or absence of response); adverse effects; and recurrences.

RESULTS

We treated 22 patients, of whom 20 had locally advanced BCCs and 2 had metastatic BCCs with lymph node involvement. The treatment was administered over a mean of 11.8 months. Nine patients (41%) achieved complete response and 10 (45%) partial response. The disease was stabilized in 3 (14%). Two patients relapsed after a median of 21 months. The main adverse effects were dysgeusia, alopecia, and muscle cramps, all of which were mild. None of the patients developed squamous cell carcinoma in an area treated with vismodegib, although metatypical changes were observed after treatment.

CONCLUSIONS

With a response rate of 96%, vismodegib is a safe and effective treatment for locally advanced BCC. Adverse effects are generally mild but they need to be taken into account owing to their high frequency.

Basosquamous carcinoma: appearance and reality

Basosquamous carcinoma (BsC) is a controversial entity and both a diagnostic and therapeutic challenge. BsC has mixed histopathological characteristics of both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). BCC and SCC display characteristic histopathology and behaviour; on the other hand, BsC is a rare tumour, which has variable morphology and displays less predictable behaviour. An early diagnosis of BsC is important due to the particularly aggressive nature of the tumour, the increased likelihood of recurrence and the potential for metastasis. Here, we present a case of BsC presenting as an extensive ulcer on the back. The case highlights the aggressive nature of the tumour and variation in appearance. It is important for all clinicians to be aware of this diagnosis so that the urgency of adequate biopsy in specialist clinics is not underestimated.

Basal Cell Carcinoma: Review of Epidemiology, Pathogenesis, and Associated Risk Factors

Background:

Basal cell carcinoma (BCC) is extremely common, and its incidence continues to rise.

Objective:

This review presents the literature pertaining to the epidemiology, pathogenesis, and risk factors associated with BCC.

Conclusions:

The risk of developing BCC depends on both genetic predisposition and exposure to risk. Fair-skinned people account for the overwhelming majority of patients, beyond what would be expected by skin phototype alone. Damage to multiple lines of defense appears to be necessary for cancer development and spread. This damage distorts the concerted effort of deoxyribonucleic acid (DNA) repair, immunosurveillance, and cellular growth regulation to protect against malignant progression. Ultraviolet light exposure is the most critical modifiable factor determining early expression and frequency of BCC development.

Giant basal cell carcinoma of the face: surgical management and challenges for reconstruction

BACKGROUND

Giant basal cell carcinoma, in which the tumour measures 5 cm or greater in diameter, is a very rare skin malignancy that accounts for less than 1 per cent of all basal cell tumours. Very few studies have reported on the incidence, resection and reconstruction of this lesion worldwide.

METHODS

In total, 17 patients with giant basal cell carcinoma of the head and neck region underwent surgical excision and reconstruction at our hospital. Medical charts were retrospectively reviewed and analysed.

RESULTS

The lesion was usually in the forehead, eyelid, lips or nasal-cheek region. The greatest diameter ranged from 5 to 11 cm, with 5-6 cm being the most common size at the time of presentation. All patients had their tumour resected and reconstructed in a single-stage procedure, mostly with a local advancement flap, and with no post-operative flap failure.

CONCLUSION

Giant basal cell carcinoma of the head and neck can be successfully treated with a local flap in a single-stage approach.

Protein expression of MMP-2 and MT1-MMP in actinic keratosis, squamous cell carcinoma of the skin, and basal cell carcinoma

Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are 2 skin neoplasms with distinct potentials to invasion and metastasis. Actinic keratosis (AK) is a precursor lesion of SCC. Immunohistochemistry was performed to evaluate the expression of MMP-2 and MT1-MMP in samples of BCC (n = 29), SCC (n = 12), and AK (n = 13). The ratio of positive cells to total cells was used to quantify the staining. Statistical significance was considered under the level P < .05. We found a higher expression of MMP-2 in tumor stroma and parenchyma of SCC as compared to BCC. The expression of this protein was also similar between SCC and its precursor actinic keratosis, and it was higher in the stroma of high-risk BCC when compared to low-risk BCC. MT1-MMP, which is an activator of MMP-2, was similarly expressed in all groups. Our results suggest that MMP-2 expression may contribute to the distinct invasive patterns seen in SCC and BCC.

Case of metastatic basal cell carcinoma to bone marrow, resulting in myelophthisic anemia

BACKGROUND

While basal cell carcinoma (BCC) remains the most common skin cancer, the incidence of metastasis is rare. Most cases of metastatic BCC have been to regional lymph nodes. Metastasis to bone marrow with myelophthisic anemia is especially rare. To our knowledge, there have been only 5 reported cases in literature. We report a sixth case.

OBSERVATIONS

A 46-year-old male patient presented with an 8 × 7-cm ulcerated plaque on his chest, found to be morpheaform basal cell on pathology. Laboratory findings were notable for normocytic anemia, thrombocytopenia, and elevated LDH. Further work up with bone marrow biopsy revealed tumor cells staining positive for CK AE1/AE3, BerEP4, CK7, CD56, and PIN-4. This confirmed the diagnosis of metastatic BCC (MBCC) to bone marrow.

CONCLUSIONS

Although the rate of metastasis for BCC is rare, once it occurs, prognosis is poor. MBCC remains a challenge to treat. Therefore, it is critical to resolve the primary BCC and obtain vigilant follow-up, especially in patients with multiple risk factors for MBCC.

Basal Cell Carcinoma Aggressiveness, Molecular Factors And Therapy: A Clinician Perspective

Basal cell carcinoma represents the most common skin and epithelial cancer. Most of the patients are cured by surgery. However, some cases display fullblown aggressiveness which has a dual connotation. The tumour may reach an impressive size being locally destructive while in rare cases, basal cell carcinomas may metastasize. If this agressivetumour is located on the face or neck, the surgeon is confronted with a clinical dilemma since total removal of the lesion with clear margins is impossible. Therefore, nonsurgical approaches need to be adopted in these cases. A better understand of the molecular pathways could theoretically lead to new improved therapeutic treatments. The current paper presents an update on the molecular factors with clinical importance for the treatment of basal cell carcinoma in parallel with presentation of an aggressive case as well as a review of the current therapeutic methods.

Invasive giant basal cell carcinoma of the head: case report, reconstruction choice and literature review

It is unusual to find a giant invasive basal cell carcinoma in the occipital region of the head. We are presenting a case of basal cell carcinoma invading and eroding occipital bone, managed with an unusual scalp reconstruction method. A 69-year-old female presented with a 16x19 cm diameter tumour in the occipital region. Preoperative biopsy revealed a basal cell carcinoma. A complete surgical excision of the tumour was performed in one-step surgery and tissue defect was reconstructed by a pedicle latissimus dorsi musculocutaneous flap. Our case shows that this distant pedicle flap is safe and reliable, and should be revised as the option for the occipital region reconstruction.