Vismodegib for the treatment of basal cell skin cancer

Case report: Sequential treatment strategy for advanced basal cell carcinoma in Gorlin-Goltz syndrome: integration of vismodegib, radiotherapy, surgery, and high-intensity focused ultrasound

Managing advanced basal cell carcinoma (BCC) in patients with Gorlin-Goltz syndrome presents unique clinical challenges due to the tumor's aggressive nature and potential for widespread metastasis. This case study details a sequential treatment regimen for a 68-year-old female patient with an extensive, inoperable BCC. Employing a multimodal approach that integrates radiotherapy, the Hedgehog pathway inhibitor vismodegib, and High-Intensity Focused Ultrasound (HIFU), we demonstrate the potential for nearly complete remission in a patient with advanced BCC. Initial treatment with radiotherapy and vismodegib reduced tumor size significantly, but the largest mass displayed resistance over time, signifying the need for innovative therapies. Subsequent HIFU treatment targeted individual lesions, showcasing a non-invasive method that provided precise treatment while mitigating systemic side effects. The case emphasizes the necessity of continual adaptation in treatment plans to address the development of resistance and underscores the importance of incorporating new technologies and targeted therapies for complex BCC cases. The successful outcome of this integrated strategy suggests a promising direction for future research and highlights the importance of multidisciplinary approaches that tailor treatment to individual patient needs, tumor characteristics, and evolving therapeutic landscapes.

Review of sociodemographic risk factors for presentation with advanced non-melanoma skin cancer

PURPOSE

Non-melanoma skin cancers (NMSC) are often localized and associated with an excellent prognosis but a minority present with locally advanced or metastatic disease requiring extensive resection or systemic treatment. Medical factors that increase the risk of advanced skin cancers such as tobacco use, systemic immunosuppression or genetic syndromes have been described but the sociodemographic risk factors are relatively uninvestigated and under reported. In this review a cohort of patients presenting with periorbital NMSC is reviewed for social determinants of health correlated with presentation with advanced disease.

METHODS

Patients presenting with periorbital NMSC during a 10-year period are categorized as advanced (those tumors requiring extensive local resection, sacrifice of the globe or systemic therapy) or non-advanced and demographic features are compared between the two groups.

RESULTS

274 cases of periorbital NMSC were classified as either non-advanced (177) or advanced (97). Patients with public safety net health insurance were twice as likely to present with advanced disease (25% vs 13%). Patients with advanced disease were significantly less likely to be under the care of a primary care physician, lived in economically depressed areas with lower mean household incomes, and lived further from tertiary medical care.

CONCLUSION

Financial and sociodemographic features are strongly associated with presentation with advanced NMSC. Further work is needed to determine which sociodemographic features are independent risk factors. A better understanding of the relevant barriers to care may reduce the burden of advanced disease at presentation in the future.

The Role of Surgery After Remission of Nonsystemic Extensive Periorbital Basal Cell Carcinoma Treated by Vismodegib: A Systematic Review

BACKGROUND

Eyelid basal cell carcinoma (BCC) is usually cured by surgery. However, for a minority of patients, extensive disease progression and recurrence contraindicate surgery or radiotherapy because of severe ocular morbidity. The hedgehog signaling pathway inhibitor vismodegib is becoming the key treatment for this specific form.

OBJECTIVE

The aim of this review was to define the role of surgery after vismodegib treatment.

MATERIALS AND METHODS

A literature search of the PubMed, Cochrane Library, ScienceDirect, and Embase databases was conducted for all articles published up to March 2021 to identify studies that examined treatment of BCC of the eyelid by vismodegib.

RESULTS

Level 1 evidence was found for the use of vismodegib as neoadjuvant therapy in locally advanced eyelid BCC contraindicated to surgery and/or radiotherapy with a rather good tolerance of treatment. Level 3 evidence was found for the role of surgical excision of residual clinically suspicious lesions as for the indication of eyelid reconstruction after mapping or during residual tumoral resection if frozen sections or Mohs surgery were performed.

CONCLUSION

Vismodegib is a well-tolerated treatment for advanced periorbital BCC. The hedgehog signaling pathway inhibitor vismodegib is a potential treatment option in patients with these challenging tumors.

Targeted drug delivery strategies for precision medicines

Progress in the field of precision medicine has changed the landscape of cancer therapy. Precision medicine is propelled by technologies that enable molecular profiling, genomic analysis, and optimized drug design to tailor treatments for individual patients. Although precision medicines have resulted in some clinical successes, the use of many potential therapeutics has been hindered by pharmacological issues, including toxicities and drug resistance. Drug delivery materials and approaches have now advanced to a point where they can enable the modulation of a drug's pharmacological parameters without compromising the desired effect on molecular targets. Specifically, they can modulate a drug's pharmacokinetics, stability, absorption, and exposure to tumours and healthy tissues, and facilitate the administration of synergistic drug combinations. This Review highlights recent progress in precision therapeutics and drug delivery, and identifies opportunities for strategies to improve the therapeutic index of cancer drugs, and consequently, clinical outcomes.

Concentration-dependent Early Antivascular and Antitumor Effects of Itraconazole in Non-Small Cell Lung Cancer

PURPOSE

Itraconazole has been repurposed as an anticancer therapeutic agent for multiple malignancies. In preclinical models, itraconazole has antiangiogenic properties and inhibits Hedgehog pathway activity. We performed a window-of-opportunity trial to determine the biologic effects of itraconazole in human patients.

EXPERIMENTAL DESIGN

Patients with non-small cell lung cancer (NSCLC) who had planned for surgical resection were administered with itraconazole 300 mg orally twice daily for 10-14 days. Patients underwent dynamic contrast-enhanced MRI and plasma collection for pharmacokinetic and pharmacodynamic analyses. Tissues from pretreatment biopsy, surgical resection, and skin biopsies were analyzed for itraconazole and hydroxyitraconazole concentration, and vascular and Hedgehog pathway biomarkers.

RESULTS

Thirteen patients were enrolled in this study. Itraconazole was well-tolerated. Steady-state plasma concentrations of itraconazole and hydroxyitraconazole demonstrated a 6-fold difference across patients. Tumor itraconazole concentrations trended with and exceeded those of plasma. Greater itraconazole levels were significantly and meaningfully associated with reduction in tumor volume (Spearman correlation, -0.71; P = 0.05) and tumor perfusion (K^trans; Spearman correlation, -0.71; P = 0.01), decrease in the proangiogenic cytokines IL1b (Spearman correlation, -0.73; P = 0.01) and GM-CSF (Spearman correlation, -1.00; P < 0.001), and reduction in tumor microvessel density (Spearman correlation, -0.69; P = 0.03). Itraconazole-treated tumors also demonstrated distinct metabolic profiles. Itraconazole treatment did not alter transcription of GLI1 and PTCH1 mRNA. Patient size, renal function, and hepatic function did not predict itraconazole concentrations.

CONCLUSIONS

Itraconazole demonstrates concentration-dependent early antivascular, metabolic, and antitumor effects in patients with NSCLC. As the number of fixed dose cancer therapies increases, attention to interpatient pharmacokinetics and pharmacodynamics differences may be warranted.

Capecitabine Plus Oxaliplatin Combination Therapy for Basal Cell Carcinoma

No effective systemic chemotherapy is well-established in basal cell carcinoma. We report a case with three simultaneous malignancies: colon cancer, basal cell carcinoma, and smoldering multiple myeloma. The patient was treated with capecitabine and oxaliplatin after surgery for colon cancer. Surprisingly, he achieved a complete response for basal cell carcinoma. This is the first report of this chemotherapy regimen in basal cell carcinoma. This finding suggests that combination capecitabine and oxaliplatin can be a treatment option for patients unable to receive local therapy.

Is early detection of basal cell carcinoma worthwhile? Systematic review based on the WHO criteria for screening

The incidence of basal cell carcinoma (BCC) has risen three- to fourfold over the last 30 years and is expected to continue to increase with ageing of the population. Although BCC has a good prognosis, it causes significant morbidity and has an important impact on the public health budget due to direct treatment costs. Based on the existing evidence, a systematic evaluation of the World Health Organization criteria was performed to determine whether earlier detection of BCC could reduce morbidity and cost. BCC slowly increases in size, with a median increase in diameter of 0·5 mm over 10 weeks. There is an important delay in diagnosis ranging from 19 to 25 months. In several studies BCC size was the main determinant of treatment cost, surgical complexity, reconstruction technique and the specific surgical procedure performed, such as Mohs micrographic surgery or surgical excision. One study showed that size also seems to affect the cost per treatment for other nonsurgical options. The use of vismodegib, an inhibitor of the hedgehog pathway, is confined to locally advanced or metastatic BCC. Delays in diagnosis and appropriate treatment are the most important underlying causes in the occurrence of giant BCC and/or BCC with metastasis. Although the latter represent only a very small fraction of all BCCs, the majority of them are located in the facial region. The available data point to a slow increase in the size of BCCs over time. Size is one of the major determinants in choice of treatment and the associated cost, especially for facial BCC. Therefore we conclude that current data support early detection and adequate management of BCCs on the face.

Safe handling of oral antineoplastic medications: Focus on targeted therapeutics in the home setting

Introduction With the growing number of oral targeted therapies being approved for use in cancer therapy, the potential for long-term administration of these drugs to cancer patients is expanding. The use of these drugs in the home setting has the potential to expose family members and caregivers to them either through direct contact with the drugs or indirectly by exposure to the parent compounds and/or their active metabolites in contaminated patients' waste. Methods A systematic literature review was performed and the known adverse health effect of 32 oral targeted therapeutics is summarized. In particular, the carcinogenicity, genotoxicity, and embryo-fetal toxicity, along with the route of excretion were evaluated. Results Carcinogenicity testing has not been performed on most of the oral targeted therapeutics and the genotoxicity data are mixed. However, the majority of these drugs exhibit adverse reproductive effects, some of which are severe. Currently, available data does not permit the possibility of a health hazard from inappropriate handling of drugs and contaminated patients waste to be ignored, especially in a long-term home setting. Further research is needed to understand these issues. Conclusions With the expanding use of targeted therapies in the home setting, family members and caregivers, especially those of reproductive risk age, are, potentially at risk. Overall basic education and related precautions should be taken to protect family members and caregivers from indirect or direct exposure from these drugs. Further investigations and discussion on this subject are warranted.

Hedgehog- and mTOR-targeted therapies for advanced basal cell carcinomas

Basal cell carcinomas (BCCs) are the most frequent human cancer. Over 90% of all BCCs have a mutation in PTCH1 or smoothened, two conducting proteins of the Hedgehog pathway. They rarely progress deeply and metastasize; however, if they do, these advanced basal cell carcinoma become amenable to treatment by inhibiting the Hedgehog and the P13K-mTOR pathways. Such innovative drugs include vismodegib, cyclopamine, itraconazole, everolimus and a few other agents that are in early clinical development.

Non-melanoma Skin Cancer in Canada Chapter 4: Management of Basal Cell Carcinoma

Background

Basal cell carcinoma (BCC) is the most common malignancy. Growth of BCCs leads to local destruction of neighbouring healthy skin and underlying tissue and can result in significant functional and cosmetic morbidity.

Objective

To provide guidance to Canadian health care practitioners regarding management of BCCs.

Methods

Literature searches and development of graded recommendations were carried out as discussed in the accompanying Introduction.

Results

Although BCCs rarely metastasize“ they can be aggressive and disfiguring. This chapter describes the natural history and prognosis of BCCs. Risk stratification is based on clinical features” including the site and size of the tumour“ its histologic subtype (nodular vs sclerosing)” and its history of recurrence.

Conclusions

Various options should be considered for BCC treatment” including cryosurgery” curettage” and topical or photodynamic approaches, as well as fixed-margin surgery and Mohs micrographic surgery. Stratification of recurrence risk for individual BCCs determines the most appropriate therapeutic course.

Basal cell nevus syndrome or Gorlin syndrome

Basal cell nevus syndrome (BCNS) or Gorlin syndrome is a rare neurocutaneous syndrome sometimes known as the fifth phacomatosis, inherited in autosomal dominant fashion with complete penetrance and variable expressivity. Gorlin syndrome is characterized by development of multiple basal cell carcinomas (BCCs), jaw cysts, palmar or plantar pits, calcification of falx cerebri, various developmental skeletal abnormalities such as bifid rib, hemi- or bifid vertebra and predisposition to the development of various tumors. BCNS is caused by a mutation in the PTCH1 gene localized to 9q22.3. Its estimated prevalence varies between 1/55600 and 1/256000 with an equal male to female ratio. The medulloblastoma variant seen in Gorlin syndrome patients is of the desmoplastic type, characteristically presenting during the first 3 years of life. Therefore, children with desmoplastic medulloblastoma should be carefully screened for other features of BCNS. Radiation therapy for desmoplastic medulloblastoma should be avoided in BCNS patients as it may induce development of invasive BCCs and other tumors in the skin area exposed to radiation. This syndrome is a multisystem disorder so involvement of multiple specialists with a multimodal approach to detect and treat various manifestations at early stages will reduce the long-term sequelae and severity of the condition. Life expectancy is not significantly altered but morbidity from complications and cosmetic scarring can be substantial.

Hedgehog signaling pathway is a potential therapeutic target for gallbladder cancer

Gallbladder cancer (GBC) is a particularly deadly type of cancer with a 5-year survival rate of only 10%. New effective therapeutic strategies are greatly needed. Recently, we have shown that Hedgehog (Hh) signaling is reactivated in various types of cancer and is a potential therapeutic target. However, little is known about the biological significance of Hh signaling in human GBC. In this study, we determined whether Hh signaling could be a therapeutic target in GBC. The Hh transcription factor Gli1 was detected in the nucleus of GBC cells but not in the nucleus of normal gallbladder cells. The expression levels of Sonic Hh (Shh) and Smoothened (Smo) in human GBC specimens (n = 37) were higher than those in normal gallbladder tissue. The addition of exogenous Shh ligand augmented the anchor-dependent and anchor-independent proliferation and invasiveness of GBC cells in vitro. In contrast, inhibiting the effector Smo decreased the anchor-dependent and anchor-independent proliferation. Furthermore, the suppression of Smo decreased GBC cell invasiveness through the inhibition of MMP-2 and MMP-9 expression and inhibited the epithelial–mesenchymal transition. In a xenograft model, tumor volume in Smo siRNA-transfected GBC cells was significantly lower than in control tumors. These results suggest that Hh signaling is elevated in GBC and may be involved in the acquisition of malignant phenotypes, and that Hh signaling may be a potential therapeutic target for GBC.

Liver renewal: detecting misrepair and optimizing regeneration

Cirrhosis and liver cancer, the main causes of liver-related morbidity and mortality, result from defective repair of liver injury. This article summarizes rapidly evolving knowledge about liver myofibroblasts and progenitors, the 2 key cell types that interact to orchestrate effective repair, because deregulation of these cells is likely to be central to the pathogenesis of both cirrhosis and liver cancer. We focus on cirrhosis pathogenesis because cirrhosis is the main risk factor for primary liver cancer. Emerging evidence suggests that the defective repair process has certain characteristics that might be exploited for biomarker development. Recent findings in preclinical models also indicate that the newly identified cellular and molecular targets are amenable to therapeutic manipulation. Thus, recent advances in our understanding about key cell types and fundamental mechanisms that regulate liver regeneration have opened new avenues to improve the outcomes of liver injury.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01899859.