Imiquimod cream efficacy in the treatment of periocular nodular basal cell carcinoma: a non-randomized trial

Drug-Related Keratitis: A Real-World FDA Adverse Event Reporting System Database Study

Purpose

This study aimed to assess the drug risk of drug-related keratitis and track the epidemiological characteristics of drug-related keratitis.

Methods

This study analyzed data from the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from January 2004 to December 2023. A disproportionality analysis was conducted to assess drug-related keratitis with positive signals, and drugs were classified and assessed with regard to their drug-induced timing and risk of drug-related keratitis.

Results

A total of 1606 drugs were reported to pose a risk of drug-related keratitis in the FAERS database, and, after disproportionality analysis and screening, 17 drugs were found to significantly increase the risk of drug-related keratitis. Among them, seven were ophthalmic medications, including dorzolamide (reporting odds ratio [ROR] = 3695.82), travoprost (ROR = 2287.27), and brimonidine (ROR = 2118.52), and 10 were non-ophthalmic medications, including tralokinumab (ROR = 2609.12), trazodone (ROR = 2377.07), and belantamab mafodotin (ROR = 680.28). The top three drugs having the highest risk of drug-related keratitis were dorzolamide (Bayesian confidence propagation neural network [BCPNN] = 11.71), trazodone (BCPNN = 11.11), and tralokinumab (BCPNN = 11.08). The drug-induced times for non-ophthalmic medications were significantly shorter than those for ophthalmic medications (mean days, 141.02 vs. 321.96, respectively; P < 0.001). The incidence of drug-related keratitis reached its peak in 2023.

Conclusions

Prevention of drug-related keratitis is more important than treatment. Identifying the specific risks and timing of drug-induced keratitis can support the development of preventive measures.

Translational Relevance

Identifying the specific drugs related to medication-related keratitis is of significant importance for drug vigilance in the occurrence of drug-related keratitis.

Xeroderma Pigmentosum With Ocular Surface Squamous Neoplasia: A Case Report

Xeroderma pigmentosum (XP) is a rare, autosomal recessive disorder characterized by defective DNA repair. Patients with this disorder are at increased risk of developing various oculocutaneous malignancies. We report a rare case of a child with XP with bilateral ocular surface squamous neoplasia (OSSN) and left eye (OS) medial canthal basal cell carcinoma (BCC). Ultrasound biomicroscopy and contrast-enhanced computed tomography (CECT) of the orbit showed intraocular extension with no orbital involvement. The patient was started on topical interferon therapy in both eyes for OSSN. Topical 5% imiquimod was started for BCC for eight hours a day and then washed off. During follow-up, there was no recurrence of tumors. Since ocular and cutaneous neoplasms tend to occur at an early age in XP with a high rate of recurrence and they tend to be more aggressive, multimodal therapy with long-term follow-up is more advantageous for these patients. Topical 5% imiquimod can be used as a treatment for periocular BCC as an alternative to excision.

Topical and Intralesional Immunotherapy for the Management of Skin Cancer in Special Locations: Lips and Eyelids

The use of topical and intralesional immunotherapy in the treatment of cutaneous malignant neoplasia in sensitive areas such as the lips and eyelids is discussed. Surgery may not be feasible or may result in deformities in these areas, making alternative treatment options necessary. A narrative literature review was conducted using MEDLINE (PubMed) as the main literature database, collecting available evidence of experiences with various topical and intralesional therapies in the aforementioned anatomical locations, ranging from case reports to clinical trials. The clearance rates and potential adverse reactions of therapeutic options such as imiquimod 5%, 5-fluorouracil (5-FU), photodynamic therapy (PDT), ingenol mebutate (IM), diclofenac, intralesional methotrexate, and interferon are reviewed. Although limited by their heterogeneity and the scarcity of clinical trials, these studies point towards promising response rates and minimal adverse effects, making these treatments viable options in selected cases.

A narrative review of tumor-associated macrophages in lung cancer: regulation of macrophage polarization and therapeutic implications

Lung cancer is the deadliest malignancy worldwide. An inflammatory microenvironment is a key factor contributing to lung tumor progression. Tumor-Associated Macrophages (TAMs) are prominent components of the cancer immune microenvironment with diverse supportive and inhibitory effects on growth, progression, and metastasis of lung tumors. Two main macrophage phenotypes with different functions have been identified. They include inflammatory or classically activated (M1) and anti-inflammatory or alternatively activated (M2) macrophages. The contrasting functions of TAMs in relation to lung neoplasm progression stem from the presence of TAMs with varying tumor-promoting or anti-tumor activities. This wide spectrum of functions is governed by a network of cytokines and chemokines, cell-cell interactions, and signaling pathways. TAMs are promising therapeutic targets for non-small cell lung cancer (NSCLC) treatment. There are several strategies for TAM targeting and utilizing them for therapeutic purposes including limiting monocyte recruitment and localization through various pathways such as CCL2-CCR2, CSF1-CSF1R, and CXCL12-CXCR4, targeting the activation of TAMs, genetic and epigenetic reprogramming of TAMs to antitumor phenotype, and utilizing TAMs as the carrier for anti-cancer drugs. In this review, we will outline the role of macrophages in the lung cancer initiation and progression, pathways regulating their function in lung cancer microenvironment as well as the role of these immune cells in the development of future therapeutic strategies.

Ocular surface complications of local anticancer drugs for treatment of ocular tumors

Local chemotherapy is increasingly used, either in combination with surgery or as monotherapy, for management of ocular tumors. Yet many of the local chemotherapeutic agents used for ocular tumors are cytotoxic drugs that are frequently associated with toxicities in normal ocular tissues. Understanding and managing these side effects are important because they affect treatment tolerability, outcome and quality of vision. Herein, we review local anticancer drugs administered for the treatment of ocular tumors, with an emphasis on their toxicities to the ocular surface, adnexa and lacrimal drainage system. We provide the underlying mechanisms and management strategies for the ocular side effects. Recent innovations in anticancer immunotherapy and ocular drug delivery systems also are discussed as new potential therapeutic modalities for alleviation of side effects.

Basal cell carcinoma with compromised margins: retrospective study of management, evolution, and prognosis

Background

Non-melanoma skin cancer is the most common type of malignancy in the Western world, and surgical excision is the preferred approach. The approach adopted in the face of incomplete excisions of basal cell carcinoma is still controversial.

Objectives

To compare the number of tumor recurrences after treatment for incompletely excised basal cell carcinoma.

Methods

Selection and statistical analysis of medical records of patients who had compromised margins after excision of basal cell carcinoma in a tertiary hospital from 2008 to 2013.

Results

A total of 120 medical records were analyzed; the mean age was 69.6 years, and 50% of the patients were female. The most prevalent histological type was nodular; the mean size was 1.1 cm, and the tumor location with the highest incidence was the nose. The lateral margin was the most frequently positive. Clinical follow-up was more widely adopted; only 40 patients underwent a second surgery. The total number of patients who had tumor recurrence was 34 (28.3%). Only the malar location significantly influenced the incidence of recurrence (p = 0.02). The mean follow-up time was 29.54 months, with no significant difference between the follow-ups, although 32.9% of the patients followed-up clinically showed recurrence, against only 20% of those who underwent a second surgery.

Study limitations

Mean follow-up time of less than five years and sample size.

Conclusions

The presence of compromised margins does not necessarily imply recurrence. Location, tumor size, histological subtype, previous epithelial tumors, and clinical conditions of the patient must be considered when choosing the best treatment option.

Topical Imiquimod as a Treatment Option for Nodular Basal Cell Carcinoma: A Systematic Review

BACKGROUND

Surgical excision is considered standard treatment for nodular basal cell carcinoma (nBCC). However, patients who reject or are unsuited for surgery may benefit from imiquimod (IMQ) 5% cream as an alternative treatment.

OBJECTIVES

The objective of this study was to conduct a systematic review on the efficacy and safety of IMQ for the treatment of nBCC.

MATERIALS AND METHODS

The terms basal cell carcinoma AND imiquimod OR Aldara were searched on Ovid-MEDLINE, EMBASE, and Cochrane Library databases. Articles were included if they reported the efficacy or side effects of IMQ for nBCC. Primary outcomes included clearance (clinical and histological), recurrence rates, and adverse events. Number of lesions/subjects, treatment regimens, length of treatment, and time to recurrence were secondary outcomes.

RESULTS

Thirty-nine publications, totaling 738 lesions, revealed a 77.4% (335/433 lesions) clinical and 72.9% (390/535 lesions) histological clearance rate. Regimens ranged from once daily 2 days a week to twice daily 7 days a week. Average treatment duration was 8.81 (±3.49) weeks. There was a 1.80% recurrence rate after an average follow-up period of 13.03 (±15.09) months. Common adverse effects included erythema (77.2%), crusting (50.5%), pruritus (34.1%), tenderness/irritation (27.3%), ulceration (25.4%), burning (22.1%), and erosion (21.7%). Unforeseen side effects included conjunctivitis, keratitis, depigmentation, comedone formation, and ruptured epidermoid cysts.

CONCLUSION

Imiquimod showed clinical and histological clearance rates of over 70% for nBCC, with a recurrence rate of 1.80%. Although clearance rates are lower than surgery, IMQ can be considered as a treatment option for nBCC in those who decline or are unfit for surgical intervention.

Periocular basal cell carcinoma - clinical perspectives

Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.

Bilateral ocular surface squamous neoplasia with bilateral periocular basal cell carcinoma in a case of xeroderma pigmentosum

Xeroderma pigmentosum (XP) is an autosomal recessive disorder associated with multiple oculocutaneous manifestations.We discuss a unique case of XP having bilateral ocular surface squamous neoplasia (OSSN) and periocular basal cell carcinoma. In the right eye, a large OSSN mass involving the ocular surface extensively along with intraocular invasion was noted, whereas in the left eye, the tumour mass was involving the limbus, and extending up to three clock hours. Because of extensive disease in the right eye, orbital exenteration was performed, and for the left eye, a wide excision of the mass with triple freeze thaw cryo application to the margins followed by amniotic membrane grafting was done. Basal cell carcinoma was noted around the medial canthus on both sides. The right-sided basal cell carcinoma was treated by wide excision followed by a forehead rotation flap and the left-sided lesion was managed with topical 5% imiquimod cream.

Long-Term Follow-Up Results of Topical Imiquimod Treatment in Basal Cell Carcinoma

BACKGROUND

Imiquimod 5% topical cream is approved for treatment of superficial basal cell carcinoma (BCC). Data on the long-term efficacy and usage in other BCC subtypes are scarce.

OBJECTIVE

Evaluation of long-term safety and efficacy of topical imiquimod treatment in various BCC subtypes and locations, with individualized treatment duration.

MATERIALS AND METHODS

Histopathologically confirmed BCCs treated solely with topical imiquimod were identified retrospectively and included in this study. Clinical and histopathologic tumor clearances were the primary end point. After treatment was concluded, patients were examined every 3 to 6 months.

RESULTS

In total, 24 BCC samples from 22 patients (F:M = 9:13; mean age: 73.5 years, SD: 10.767) were evaluated. The majority of the lesions were located in the head and neck area (83%). Mean treatment duration until complete clearance was 15.7 ± 6.9 weeks (6-28 weeks). Imiquimod was discontinued in 3 lesions, due to either clinically or histopathologically insufficient response. During follow-up, 2 lesions recurred, at 42 and 50 months after treatment. During a mean follow-up time of 72.7 (SD = 9) months, 79.1% of the lesions were cured without local recurrence.

CONCLUSION

Although imiquimod is only approved for superficial BCC, treatment success was high among the study patients with various histological subtypes, with good long-term cosmetic results.

Imiquimod 5% cream for the treatment of large nodular basal cell carcinoma at the medial canthal area

Context (Background):

Imiquimod (IMQ) 5% cream is an immunomodulatory and antitumorigenic agent, which was used as a topical treatment regimen, who had periocular basal cell carcinoma (BCC).

Aim:

This study aims to present three cases with large BCC at the medial canthal area treated with IMQ 5% cream.

Materials and Methods:

IMQ 5% cream was used in three patients with ages 45, 49, and 73 who preferred medical treatment over surgery. Following incisional biopsy IMQ cream was used once a day, 5 times a week and the patients were followed up weekly during 12 week treatment period and monthly after the clearance of the lesion.

Results:

Erythema and erosion on the surface of the lesion, injection of conjunctiva, burning and itching sensation, epiphora and punctate keratitis were seen in all patients during the treatment period. The ophthalmic side effects could be managed by topical lubricating eye drops and the inflammatory reactions resolved within 1 month after cessation of therapy. The patients were followed up for at least 3 years without tumor recurrence and the biopsies taken from the suspected area were found to be tumor free.

Conclusion:

Surgical excision of carcinoma of the eyelid at medial canthal area can be difficult without causing damage to the lacrimal system and reconstruction of the defect may need grafts or flaps. IMQ may provide an alternative therapy to surgery in certain cases.

Ocular basal cell carcinoma: a brief literature review of clinical diagnosis and treatment

Basal cell carcinoma (BCC) is a common malignant tumor throughout the world. One of the known risk factors of BCC is intense exposure to ultraviolet radiation. More than 50% of BCCs of the eyelid initially occur on the lower lid. The gold standard of diagnosis of BCC is histopathology. Treatment options for BCC consist of surgery, vismodegib, radiotherapy and imiquimod. Surgical excision using Mohs micrographic surgery or wide surgical excision with frozen section margin control is the first consideration for treatment of periocular BCC. Eyelid reconstruction should be carefully considered as both function and esthetic outcome in patients are important after clear excision of tumors. Exenteration is considered in the case of extensive orbital invasion or high-risk aggressive tumors in order to reduce the rate of recurrence.

What's New in Eyelid Tumors

Eyelid malignancies represent between 5% and 10% of all skin cancers. Basal cell carcinoma is the most common, followed by squamous cell carcinoma, sebaceous cell carcinoma, Merkel cell carcinoma, and melanoma. The gold standard treatment for periocular epithelial malignancies is surgical excision. Given the constraints of the anatomy and function of the eyelids, excision with negative margins and reconstruction can be challenging. In cases of significant tissue invasion or metastasis, complete tumor removal may not be possible. This review examines the management of periocular skin cancer from diagnosis and staging, including the role of sentinel lymph node biopsy, to both surgical and nonsurgical treatment. The development of targeted drug therapy against specific genetic mutations in cutaneous malignancies has allowed for the treatment of specific cancer cells with less systemic toxicity than more traditional treatments.

Resistance of Nonmelanoma Skin Cancer to Nonsurgical Treatments. Part I: Topical Treatments

A wide range of treatments is now available for nonmelanoma skin cancer (NMSC), including 5-fluorouracil, ingenol mebutate, imiquimod, diclofenac, photodynamic therapy, methotrexate, cetuximab, vismodegib, and radiotherapy. All are associated with high clinical and histologic response rates. However, some tumors do not respond due to resistance, which may be primary or acquired. Study of the resistance processes is a broad area of research that aims to increase our understanding of the nature of each tumor and the biologic features that make it resistant, as well as to facilitate the design of new therapies directed against these tumors. In this article we review resistance to the authorized topical treatments for NMSC.

Cryosurgery during Imiquimod (Immunocryosurgery) for Periocular Basal Cell Carcinomas: An Efficacious Minimally Invasive Treatment Alternative

BACKGROUND/AIM

Periocular basal cell carcinomas (pBCC) remain a treatment challenge. Our aim was to retrospectively evaluate the feasibility and efficacy of immunocryosurgery for the treatment of pBCC.

METHODS

Immunocryosurgery is given in 5-week cycles of daily imiquimod, with cryosurgery on day 14. Patients treated between 1/1/2008 and 31/12/2014 were included in this study.

RESULTS

Immunocryosurgery was offered to 19 patients. Of these, 16 (i.e., 6 males and 10 females, average age 74.9 years, median tumor diameter 15 mm, range 5-60 mm), with 1 tumor each, were treated. Six tumors (37.5%) were relapses after surgery and 2 were of metatypical histology. All BCC were high risk for recurrence after treatment; 10 tumors had 2 risk factors for relapse, 5 had 3, and 1 had 4. The follow-up period ranged between 3 and 60 months (average 25.6 months). Of the 16 tumors treated, 14 (all with a diameter <40 mm) cleared with immunocryosurgery (total efficacy 87.5%); 7 out of 16 tumors (44%; all with a diameter ≤20 mm) cleared with 1 conventional 5-week immunocryosurgery treatment cycle. Seven additional tumors (including 2 with a diameter >20 mm) required intensified treatment schemes (of up to 10 weeks) for clearance. The 2 tumors that did not clear responded partially and were also the 2 largest ones (diameter 40 and 60 mm). Of the 14 cleared tumors, 2 relapsed during follow-up; 1 cleared with immunocryosurgery. At the last examination during follow-up, 13 out of 16 (81%) patients were in sustained clinical remission.

CONCLUSIONS

For most pBCC, immunocryosurgery is a feasible and efficacious alternative to surgical excision.

Imiquimod 5% as Adjuvant Therapy for Incompletely Excised Infiltrative Nodular Basal Cell Carcinoma and Dermoscopy to Monitor Treatment Response

Introduction

A relatively novel application for dermoscopy is its use in the monitoring of topical treatment response for non-melanoma skin cancer. Basal cell carcinoma (BCC) is the most frequent type of skin cancer in humans. Surgical excision is still considered the “gold-standard” of treatment. However, a number of topical therapies are now available for the treatment of different types of basal cell carcinoma.

Case Report

This case report exemplifies the usefulness of dermoscopy in the monitoring of residual disease after incomplete surgical excision and also in the monitoring of topical treatment response. Imiquimod 5% cream acts as a topical immune response modifier promoting a Th-1 immune response enhancing the removal of neoplastic cells and has proven to reduce deregulated Hedgehog (HH)/GLI signal strength independent of Toll-like receptor signaling, which makes it a valuable adjuvant topical therapy for the treatment of basal cell carcinoma.

Conclusion

Imiquimod 5% cream is a valuable adjuvant therapy for the treatment of incompletely excised BCC. This case report adds further evidence to the usefulness of dermoscopy in the assessment and monitoring of treatment outcome.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0088-z) contains supplementary material, which is available to authorized users.