The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician

Management of Cutaneous Squamous Cell Carcinoma of the Scalp in Kidney Transplant Recipients

BACKGROUND

Organ transplant recipients are at a significantly higher risk of developing skin cancer compared to the general population, particularly cutaneous squamous cell carcinoma. Approximately 3-8% of these carcinomas are located on the scalp. Scalp reconstruction is particularly challenging, especially for large excisions, due to the thickness of the scalp, the inelastic aponeurosis of the galea, and the integrity of the hair-bearing scalp. Additionally, in organ transplant recipients, the presence of numerous comorbidities and the increased risk of infection due to immunosuppressive therapy make management more complex. Based on our experience and the existing literature, we aim to describe possible reconstruction methods and discuss the combined management of medical and immunosuppressive therapy.

METHOD

We present our experience with seven kidney transplant patients who underwent excision of cutaneous squamous cell carcinoma with a diameter larger than 3 cm. The crane technique involves three key steps. First, the tumor is excised with wide margins of disease-free tissue. Next, a pericranial flap is rotated and positioned to cover the exposed cranial bone. Finally, a bilayer dermal substitute is applied to create a microenvironment that supports skin graft implantation.

RESULTS

The crane technique was used for six patients. In one case, an O-Z rotation flap was used. All patients modified their immunosuppressive therapy, with those receiving antiproliferative therapy switching everolimus after surgery.

CONCLUSIONS

When combined with a post-operative modification of the immunosuppressive regimen, the crane technique could be considered a feasible, safe, and effective approach to managing large cSCC of the scalp in fragile patients.

Risk factors analysis and nomogram for predicting recurrence in periocular basal cell carcinoma

OBJECTIVES

Aim to develop a nomogram to effectively predict the potential for recurrence after surgical resection in patients with periocular basal cell carcinoma (BCC).

METHODS

We conducted a retrospective study involving 329 patients with eyelid BCC. Univariate and multivariate Cox proportional risk regression was used to screen for independent factors affecting BCC recurrence. Kaplan-Meier survival curve analysis was performed to evaluate their impact on prognosis. On the basis of the results obtained from Cox regression analysis, a nomogram was established for the 1-, 2-, and 3-year recurrence-free survival (RFS) rates of BCC.

RESULTS

In this study, a total of 15 patients out of 329 patients (4.6%) developed local recurrence. Multivariate analysis revealed that age, pathological type, previous history of BCC, and the number of surgeries were independent risk factors for BCC recurrence (p < 0.05, respectively). These risk factors were utilized to construct a nomogram to predict postoperative recurrence for these patients. The C-index of the nomogram was 0.867 (95% CI: 0.817-0.916), and the receiver operating characteristic curves were used to assess the discriminatory degree of the nomogram, with area under the curve values of 0.978, 0.870, and 0.916 at 1, 2, and 3 years, respectively. The calibration curves were basically fitted to the ideal curves.

CONCLUSIONS

Age, pathological type, previous history of BCC, and the number of surgeries are significant risk factors for periocular BCC recurrence. Establishing a nomogram related to recurrence risk factors can more accurately predict the recurrence-free survival of individual patients.

Cutaneous Squamous Cell Carcinoma: From Diagnosis to Follow-Up

Cutaneous squamous cell carcinoma (SCC) is the second most frequent skin cancer, accounting for approximately 20% of all cutaneous malignancies, and with an increasing incidence due to the progressive increment of the average age of life. The diagnosis is usually firstly suspected based on clinical manifestations; however, dermoscopic features may improve diagnostic sensitivity in cases of an uncertain diagnosis and may guide the biopsy, which should be performed to histopathologically prove the tumor. New diagnostic strategies may improve the sensitivity of the cutaneous SCC, such as reflectance confocal microscopy and line-field confocal optical coherence, for which increasing data have been recently published. Imaging has a central role in the staging of the diseases, while its exact role, as well as the choice of the best techniques, during the follow-up are not fully clarified. The aim of this literature review is to describe diagnostic clinical and instrumental tools of cutaneous SCC, with an insight into the role of imaging in the diagnosis and follow-up of cutaneous SCC.

Unveiling the potential of photodynamic therapy with nanocarriers as a compelling therapeutic approach for skin cancer treatment: current explorations and insights

Skin carcinoma is one of the most prevalent types of carcinomas. Due to high incidence of side effects in conventional therapies (radiotherapy and chemotherapy), photodynamic therapy (PDT) has gained huge attention as an alternate treatment strategy. PDT involves the administration of photosensitizers (PS) to carcinoma cells which produce reactive oxygen species (ROS) on irradiation by specific wavelengths of light that result in cancer cells' death via apoptosis, autophagy, or necrosis. Topical delivery of PS to the skin cancer cells at the required concentration is a challenge due to the compounds' innate physicochemical characteristics. Nanocarriers have been observed to improve skin permeability and enhance the therapeutic efficiency of PDT. Polymeric nanoparticles (NPs), metallic NPs, and lipid nanocarriers have been reported to carry PS successfully with minimal side effects and high effectiveness in both melanoma and non-melanoma skin cancers. Advanced carriers such as quantum dots, microneedles, and cubosomes have also been addressed with reported studies to show their scope of use in PDT-assisted skin cancer treatment. In this review, nanocarrier-aided PDT in skin cancer therapies has been discussed with clinical trials and patents. Additionally, novel nanocarriers that are being investigated in PDT are also covered with their future prospects in skin carcinoma treatment.

In vitro effects of undifferentiated callus extracts from Plantago major L, Rhodiola rosea L and Silybum marianum L in normal and malignant human skin cells

Background and objectives

The occurrence of non-melanoma and melanoma skin cancers is currently increasing rapidly with one in every three cancers diagnosed as a skin cancer. A useful strategy to control the progression of skin cancer could be the use of plant flavonoids that suppress pro-inflammatory cytokines involved in tumor initiation and progression. In this study, the anti-inflammatory and antioxidant activity of undifferentiated callus extracts from Plantago major L, Silybum marianum L and Rhodiola rosea L was investigated both in normal and malignant skin cells.

Methods

Antioxidant activity of the extracts was analyzed by using the Trolox Equivalent Antioxidant Capacity (TEAC) assay. High-Performance Thin-Layer Chromatography (HPTLC) was performed to demonstrate the phytochemical profile, and the total flavonoid content was analyzed with an aluminum chloride colorimetric method. The anti-inflammatory effect was investigated by cell treatments using the plant extracts. Thereafter, the possible suppression of induced IL-6 response was measured from the cultured skin cancer cell lines A2058 and A431, and normal primary keratinocytes with Enzyme-Linked Immunosorbent Assay (ELISA).

Results

The HPTLC analysis assessed that the extracts contained a complex phytochemical profile that was rich in phenolic and flavonoid compounds. Dose response assays showed that concentrations between 15 and 125 μg/mL of all three plant extracts could be used to investigate an effect on the IL-6 production. The S. marianum extract had the most pronounced anti-inflammatory effect, which significantly inhibited induced IL-6 production in both normal keratinocytes and skin cells derived from epidermal carcinoma. The extract from S. marianum also had the highest flavonoid content and showed the highest antioxidant activity of the three extracts tested.

Conclusion

All in all, we have confirmed that undifferentiated callus extracts of S. marianum possess properties such as antioxidant and anti-inflammatory activities in both normal and malignant keratinocytes, and thus could be a promising agent controlling the pro-inflammatory IL-6 production.

Diabetes and skin cancers: Risk factors, molecular mechanisms and impact on prognosis

Diabetes and skin cancers have emerged as threats to public health worldwide. However, their association has been less intensively studied. In this narrative review, we explore the common risk factors, molecular mechanisms, and prognosis of the association between cutaneous malignancies and diabetes. Hyperglycemia, oxidative stress, low-grade chronic inflammation, genetic, lifestyle, and environmental factors partially explain the crosstalk between skin cancers and this metabolic disorder. In addition, diabetes and its related complications may interfere with the appropriate management of cutaneous malignancies. Antidiabetic medication seems to exert an antineoplastic effect, however, future large, observation studies with a prospective design are needed to clarify its impact on the risk of malignancy in diabetes. Screening for diabetes in skin cancers, as well as close follow-up for the development of cutaneous malignancies in subjects suffering from diabetes, is warranted.

Skin cancer, including related pathways and therapy and the role of luteolin derivatives as potential therapeutics

Cutaneous malignant melanoma is the fastest growing and the most aggressive form of skin cancer that is diagnosed. However, its incidence is relatively scarce compared to the highest mortality rate of all skin cancers. The much more common skin cancers include nonmelanoma malignant skin cancers. Moreover, over the past several decades, the frequency of all skin cancers has increased much more dynamically than that of almost any other type of cancer. Among the available therapeutic options for skin cancers, chemotherapy used immediately after the surgical intervention has been an essential element. Unfortunately, the main problem with conventional chemopreventive regimens involves the lack of response to treatment and the associated side effects. Hence, there is a need for much more effective anticancer drugs. Correspondingly, the targeted alternatives have involved phytochemicals, which are safer chemotherapeutic agents and exhibit competitive anticancer activity with high therapeutic efficacy. Among polyphenolic compounds, some flavonoids and their derivatives, which are mostly found in medicinal plants, have been demonstrated to influence the modulation of signaling pathways at each stage of the carcinogenesis process, which is also important in the context of skin cancers. Hence, this review focuses on an exhaustive overview of the therapeutic effects of luteolin and its derivatives in the treatment and prevention of skin cancers. The bioavailability and structure–activity relationships of luteolin derivatives are also discussed. This review is the first such complete account of all of the scientific reports concerning this particular group of natural compounds that target a specific area of neoplastic diseases.

Argon-Helium Cryoablation for Cutaneous Squamous Cell Carcinoma in the Elderly

Cutaneous squamous cell carcinoma (cSCC) is a common type of malignant neoplasm in non-melanoma skin cancer (NMSC). Most cases of simple cSCC are considered curable by surgical removal of the lesion. However, clinical treatments for cSCC with medium- or large-sized lesions are difficult. Meanwhile, the effectiveness of the treatments is not guaranteed, especially for elderly patients, because of an intolerance to surgical resection or other adjuvant modalities. In such cases, safe and effective treatments with excellent aesthetic outcomes are urgently needed. In this study, we reported 6 elderly cSCC patients with medium- or large-sized lesions treated with argon-helium cryoablation. The average age of all 6 patients was 78 years (range 72-85 years). They were all diagnosed with cSCC with a median tumor size of 5.8 cm (range 2.5-15.5 cm) and dermal invasion. Complete ablation was achieved in all cases after a single ablation session (2 freeze-thaw cycles). Patients experienced mild pain and hemorrhage after ablation, but the symptoms were manageable. One patient developed infection and fever because of extensive necrosis of the tumor, which was eventually cured after treatment. All patients obtained good cosmetic outcomes, and their quality of life improved significantly. In the 5-year follow-up study, 4 patients were alive while 2 patients died of unrelated diseases 3 years after cryotherapy. None of the 6 patients had a recurrence. These results suggested the feasibility of argon-helium cryoablation as a novel therapeutic strategy for elderly cSCC with medium- or large-sized lesions.

Ultrasound-targeted nucleic acid delivery for solid tumor therapy

Depending upon multiple factors, malignant solid tumors are conventionally treated by some combination of surgical resection, radiation, chemotherapy, and immunotherapy. Despite decades of research, therapeutic responses remain poor for many cancer indications. Further, many current therapies in our armamentarium are either invasive or accompanied by toxic side effects. In lieu of traditional pharmaceutics and invasive therapeutic interventions, gene therapies offer more flexible and potentially more durable approaches for new anti-cancer therapies. Nonetheless, many current gene delivery approaches suffer from low transfection efficiency due to physiological barriers limiting extravasation and uptake of genetic material. Additionally, systemically administered gene therapies may lack target-specificity, which can lead to off-target effects. To overcome these challenges, many preclinical studies have shown the utility of focused ultrasound (FUS) to increase macromolecule uptake in cells and tissue under image guidance, demonstrating promise for improved delivery of therapeutics to solid tumors. As FUS-based drug delivery is now being tested in several clinical trials around the world, FUS-targeted gene therapy for solid tumor therapy may not be far behind. In this review, we comprehensively cover the literature pertaining to preclinical attempts to more efficiently deliver therapeutic genetic material with FUS and offer perspectives for future studies and clinical translation.

Attitudes among dermatologists regarding non-melanoma skin cancer treatment options

Non-melanoma skin cancers include basal and squamous cell carcinoma. These tumors have become an important health issue for their high incidence and for the morbidity, especially if untreated for a long period. Over the last 20 years, therapeutic approaches for these tumours have been improved and tailored. In this survey we provided data from one hundred and ten Italian dermatologists regarding knowledge and attitude towards different therapeutic approaches on non-melanoma skin cancers. In our study, we observed that surgery and imiquimod 5% cream were the most used treatment by dermatologists for basal cell carcinoma, while, surgery was the most common treatment for cutaneous squamous cell carcinoma. Furthermore, we observed some differences regarding the prescribed therapies in the different Italian geographical areas (i.e., Mohs' surgery and electrochemotherapy were more frequently used in Northern compared to Central and Southern Italy whereas immunotherapy was more used in Southern compared to Northern and Central Italy) and even considering the year of specialization of the dermatologists (i.e., immunotherapy with cemiplimab was prescribed mainly by dermatologists with 10-19 years of specialization). However, for locally advanced and metastatic forms of basal and squamous cell carcinoma, Hedgehog Pathway Inhibitors and anti- Programmed cell death protein antibody treatment, respectively, were used in line with the newest evolution of therapies regarding this topic. Considering the importance of skin cancers and its progressive increase in incidence, it is crucial to improve the knowledge of different therapeutic approaches among dermatologists.

Therapeutic strategies and potential implications of silver nanoparticles in the management of skin cancer

Skin cancer (SC) is the most common carcinoma affecting 3 million people annually in the United States and millions of people worldwide. It is classified as melanoma SC (MSC) and non-melanoma SC (NMSC). NMSC represents approximately 80% of SC and includes squamous cell carcinoma and basal cell carcinoma. MSC, however, has a higher mortality rate than SC because of its ability to metastasize. SC is a major health problem in the United States with significant morbidity and mortality in the Caucasian population. Treatment options for SC include cryotherapy, excisional surgery, Mohs surgery, curettage and electrodessication, radiation therapy, photodynamic therapy, immunotherapy, and chemotherapy. Treatment is chosen based on the type of SC and the potential for side effects. Novel targeted therapies are being used with increased frequency for large tumors and for metastatic disease. A scoping literature search on PubMed, Google Scholar, and Cancer Registry websites revealed that traditional chemotherapeutic drugs have little effect against SC after the cancer has metastasized. Following an overview of SC biology, epidemiology, and treatment options, this review focuses on the mechanisms of advanced technologies that use silver nanoparticles in SC treatment regimens.

Basal Cell Carcinoma Surgery in general practice: Is there a role for the local General Practitioner?

Basal cell carcinoma (BCC) is a common disease of the skin caused principally by prolonged solar radiation exposure. It is normally a malignancy with favorable prognostic features and is potentially curable by standard excision. In White populations with high disease incidence, general practitioners (GPs) play a vital role in diagnosing and managing BCC, including surgical excision. Dedicated care at the primary care level by adequately trained GPs is conceivably cost effective for the health system and more convenient for the patient. In Asia and other parts of the world with low incidence, this valuable role of GPs may appear to be inconsequential. In this regard, any justification for the involvement of local GPs in BCC surgery is debatable. This article aims to provide a clinical update on essential information relevant to BCC surgery and advance understanding of the intricate issues of making a treatment decision at the primary care level.

CASE REPORT

Madam Tan, a 71-year-old Malaysian Chinese lady, otherwise healthy, presented to her local GP with a complaint of a nodule over the left cheek that had been there for more than a decade. Her concern was that the lesion was growing and had become conspicuous. She had spent most of her life as a farmer working in her orchard.Upon examination, she had an obvious dome-shaped nodule over the left cheek measuring approximately 1.8 cm in diameter. The lesion was firm, pigmented, well-demarcated, and slightly ulcerated at the top. Clinically, she was diagnosed with a pigmented nodular basal cell carcinoma of the left cheek. Examination of the systems was unremarkable.She requested that the consulting GP remove the growth. The cost for specialist treatment and waiting time at the local hospital were her concerns.

CLINICAL QUESTIONS

Can the basal cell skin cancer be excised safely and effectively in the local primary care setting? What are the crucial preoperative concerns?

Cancer-Associated Fibroblasts Differentiated by Exosomes Isolated from Cancer Cells Promote Cancer Cell Invasion

Cancer-associated fibroblasts (CAFs) in the cancer microenvironment play an essential role in metastasis. Differentiation of endothelial cells into CAFs is induced by cancer cell-derived exosomes secreted from cancer cells that transfer molecular signals to surrounding cells. Differentiated CAFs facilitate migration of cancer cells to different regions through promoting extracellular matrix (ECM) modifications. However, in vitro models in which endothelial cells exposed to cancer cell-derived exosomes secreted from various cancer cell types differentiate into CAFs or a microenvironmentally controlled model for investigating cancer cell invasion by CAFs have not yet been studied. In this study, we propose a three-dimensional in vitro cancer cell invasion model for real-time monitoring of the process of forming a cancer invasion site through CAFs induced by exosomes isolated from three types of cancer cell lines. The invasiveness of cancer cells with CAFs induced by cancer cell-derived exosomes (eCAFs) was significantly higher than that of CAFs induced by cancer cells (cCAFs) through physiological and genetic manner. In addition, different genetic tendencies of the invasion process were observed in the process of invading cancer cells according to CAFs. Our 3D microfluidic platform helps to identify specific interactions among multiple factors within the cancer microenvironment and provides a model for cancer drug development.

Assessment of Functionality in Elderly Patients When Determining Appropriate Treatment for Nonmelanoma Skin Cancers

BACKGROUND

The treatment of nonmelanoma skin cancer (NMSC) in the elderly population is a source of significant debate. Mohs micrographic surgery (MMS) is a highly effective treatment option yet not every patient with a cutaneous malignancy that meets appropriate use criteria (AUC) should be treated with surgery.

OBJECTIVE

The purpose of this study was to use the Karnofsky Performance Status (KPS) scale to categorize the functional status of patients aged 75 years and older who required treatment of NMSC. The authors wanted to see whether functionality played a role on the treatment selection.

METHODS

Patients aged 75 years and older presenting for biopsy of a suspected NMSC that met AUC for MMS were included in the study. Trained medical assistants used the KPS scale to assess patient functionality. Treatment modality was recorded once the biopsy confirmed the NMSC.

RESULTS

A cohort of 203 subjects met inclusion criteria for the study. There was a statistically significant difference in utilization of surgical treatments between high and low functionality patients (p = .03).

CONCLUSION

Dermatologists consider patient functionality when selecting a treatment for NMSC and use less invasive modalities for patients with poor functional status, even when the tumor meets AUC.

Development of Topical Nanocarriers for Skin Cancer Treatment Using Quality by Design Approach

BACKGROUND

One of the most compelling medical challenges of this century is the treatment of cancer and among them, skin cancer is the most common type. Thus, current treatments need to be renewed continuously to handle this challenge.

OBJECTIVE

This review presents considerations which can be employed during the development of nanosized formulations dedicated to the topical treatment of skin cancer. We aimed to collect and organize literature data on the treatment options for skin cancer in order to determine the required quality attributes of an effective dermal anticancer formulation.

METHOD

With the consideration of the Quality by Design (QbD) approach related to the development of new pharmaceutical formulations, a cost-saving process ensuring a high-quality product taking into account patient expectations, industrial and regulatory aspects can be achieved. Furthermore, this concept is highly recommended by regulatory agencies.

RESULTS

Our work discusses the current therapies, active agents, drug carrier systems, and evaluation methods in connection with the treatment of skin cancer and outlines Critical Quality Attributes which need to be considered during the development of a nanosized dermal anticancer formulation.

CONCLUSION

The first part of this review summarizes the most important topical treatment therapies for skin cancer and highlights the future therapeutic perspectives, focusing on the benefits of nanotechnology and dermal administration. The second part outlines the critical points of nanosized dermal anticancer formulation development in the view of QbD approach. Our research emphasizes the application of QbD method for a rationalized and more effective anticancer formulation development process.

A Review of the Literature of Surgical and Nonsurgical Treatments of Invasive Squamous Cells Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is an increasing public health problem. It is a primary malignant skin tumor with Malpighian differentiation and together with basal cell carcinoma is classified among nonmelanoma skin cancers (NMSCs). cSCC usually occurs on photoexposed areas, such as the head, the neck, and the extremities, and its incidence increases with age. Invasive forms of this skin tumor tend to be more aggressive showing a higher metastatic potential, usually regarding regional lymph nodes. Treatment options for invasive cSCCs include both surgical and nonsurgical options. The therapeutic choice depends on several factors, such as anatomic location, risk factors for tumor recurrence, age, and health status of the patient. This review aims to provide an overview of the current evidence on therapeutic surgical and nonsurgical management of invasive cSCC.

PLGA-loaded nanomedicines in melanoma treatment: Future prospect for efficient drug delivery

Current treatment methods for melanoma have some limitations such as less target-specific action, severe side effects and resistance to drugs. Significant progress has been made in exploring novel drug delivery systems based on suitable biochemical mechanisms using nanoparticles ranging from 10 to 400 nm for drug delivery and imaging, utilizing their enhanced penetration and retention properties. Poly-lactide-co-glycolide (PLGA), a copolymer of poly-lactic acid and poly-glycolic acid, provides an ideally suited performance-based design for better penetration into skin cells, thereby having a greater potential for the treatment of melanoma. Moreover, encapsulation protects the drug from deactivation by biological reactions and interactions with biomolecules, ensuring successful delivery and bioavailability for effective treatment. Controlled and sustained delivery of drugs across the skin barrier that otherwise prohibits entry of larger molecules can be successfully made with adequately stable biocompatible nanocarriers such as PLGA for taking drugs through the small cutaneous pores permitting targeted deposition and prolonged drug action. PLGA is now being extensively used in photodynamic therapy and targeted therapy through modulation of signal proteins and drug-DNA interactions. Recent advances made on these nanomedicines and their advantages in the treatment of skin melanoma are highlighted and discussed in this review.

A Review of Black Salve: Cancer Specificity, Cure, and Cosmesis

Black salve is a topical escharotic used for the treatment of skin cancer. Although promoted as a safe and effective alternative to conventional management by its proponents, limited clinical research has been undertaken to assess its efficacy and potential toxicities. Patients are increasingly utilizing the Internet as a source of health information. As a minimally regulated space, the quality and accuracy of this information vary considerably. This review explores four health claims made by black salve vendors, investigating its natural therapy credentials, tumour specificity, and equivalence to orthodox medicine in relation to skin cancer cure rates and cosmesis. Based upon an analysis of in vitro constituent cytotoxicity, in vivo post black salve histology, and experience with Mohs paste, black salve is likely to possess normal tissue toxicity with some cancer cell lines being relatively resistant to its effects. This may explain the incongruous case study reports of excessive scarring, deformity, and treatment failure.

Chronic Inflammation in Skin Malignancies

Chronic inflammation is linked to the development and progression of multiple cancers, including those of the lung, stomach, liver, colon, breast and skin. Inflammation not only drives the oncogenic transformation of epithelial cells under the stress of chronic infection and autoimmune diseases, but also promotes the growth, progression and metastatic spread of cancers. Tumor-infiltrating inflammatory cells are comprised of a diverse population of myeloid and immune cell types, including monocytes, macrophages, dendritic cells, T and B cells, and others. Different myeloid and lymphoid cells within tumor microenvironment exert diverse, often contradicting, effects during skin cancer development and progression. The nature of tumor-immune interaction determines the rate of cancer progression and the outcome of cancer treatment. Inflammatory environment within skin tumor also inhibits naturally occurring anti-tumor immunity and limits the efficacy of cancer immunotherapy. In this article we aim to give an overview on the mechanism by which inflammation interferes with the development and therapeutic intervention of cancers, especially those of the skin.

Safety and Efficacy of a Bilayered Skin Construct in Full-Thickness Surgical Wounds

This was a prospective, randomized, controlled clinical trial assessing the safety and efficacy of a living bilayered skin construct (BSC; Organogenesis, Canton, MA) in treating full-thickness surgical excision wounds. We enrolled 31 patients needing excision of a non-melanoma skin cancer. The patients consisted of 18 females and 13 males, with an average age of 67 years (range: 44 to 84 years). Patients were randomized to either receive a single application of BSC or to heal by secondary intention. Endpoints to assess efficacy included time to complete wound closure, intensity and duration of post-operative pain, cosmetic appearance, patient satisfaction, and quality of the healed wound. Endpoints to assess safety included infection at the wound site and rejection of the BSC. Findings indicate that BSC is safe in the post-operative treatment of acute surgical wounds for removal of non-melanoma skin cancer. The data also suggest that BSC may facilitate management by decreasing post-operative pain. It is unclear whether or not BSC decreases healing time of acute wounds or results in a better cosmetic outcome.

Tazarotene induces apoptosis in human basal cell carcinoma via activation of caspase-8/t-Bid and the reactive oxygen species-dependent mitochondrial pathway

Previous studies suggest that tazarotene, a new member of the acetylenic class of RARβ/γ selective retinoids which is approved to treat a variety of skin diseases, exhibits an anti-proliferative effect in human basal cell carcinoma (BCC) by triggering caspase-dependent apoptosis. However, the detailed molecular mechanisms underlying the anti-tumor activity of tazarotene are poorly understood. This study aims at investigating the molecular mechanisms of tazarotene-induced apoptosis in human BCC cells. Our results are the first to demonstrate that tazarotene induces mitochondria-dependent cleavage of caspase-9 and -3 and PARP in BCC cells by producing reactive oxygen species (ROS) and activating caspase-8 through both ROS and death receptor signaling. These events are accompanied by a decrease in BCL-2 and BCL-xl anti-apoptotic proteins as well as by survivin and XIAP, two IAP family members. Furthermore, our results presented for the first time that tazarotene triggers a convergence of the intrinsic and extrinsic apoptotic pathways via the caspase-8-truncated Bid signaling pathway. Collectively, these data provide insights into the molecular mechanisms underlying tazarotene-induced apoptosis in human BCC cells, suggesting that this compound is a potential anti-skin cancer drug.

Strategic formulation of apigenin-loaded PLGA nanoparticles for intracellular trafficking, DNA targeting and improved therapeutic effects in skin melanoma in vitro

The aim of the present study was the evaluation of anti-proliferative potentials of apigenin (Ap), (a dietary flavonoid) loaded in poly (lactic-co-glycolide) nanoparticles (NAp) in A375 cells in vitro. NAp was characterized for particle size, morphology, zeta potential, drug release and encapsulation. Cellular entry and intracellular localization of NAp were assessed by transmission electron and confocal microscopies. Circular dichroic spectral analysis and stability curve for Gibb's free energy of dsDNA of A375 cells were also analyzed. DNA fragmentation, intracellular ROS accumulation, superoxide-dismutase activity, intracellular glutathione-reductase content and mitochondrial functioning through relevant markers like mitochondrial transmembrane potential, ATPase activity, ATP/ADP ratio, volume changes/swelling, cytochrome-c release, expressions of Apaf-1, bax, bcl-2, caspase-9, 3, and PARP cleavage were analyzed. NAp produced better effects due to their smaller size, faster mobility and site-specific action. Photostability studies revealed that PLGA encapsulations were efficient at preserving apigenin ultraviolet-light mediated photodegradation. NAp readily entered cancer cells, could intercalate with dsDNA, inducing conformational change. Corresponding increase in ROS accumulation and depletion of the antioxidant enzyme activities exacerbated DNA damage, mediating apoptosis through mitochondrial dysfunction. Overall results indicate that therapeutic efficacy of NAp may be enhanced by PLGA nanoparticle formulations to have better ameliorative potentials in combating skin melanoma.

Longitudinal, mixed method study to look at the experiences and knowledge of non melanoma skin cancer from diagnosis to one year

Background

Skin cancer is the most common type of cancer in humans and the incidence is increasing worldwide. Our objective was to understanding the needs, experiences and knowledge of individuals with Non Melanoma Skin Cancer (NMSC) from diagnosis up until one year.

Methods

Patients with NMSC completed questionnaires at diagnosis, treatment, 8 weeks post treatment and 12 months post diagnosis. Body image, psychological morbidity and Quality of Life (QOL) were assessed at each time point, with the exception of QOL that was not assessed at diagnosis. Knowledge of NMSC was assessed at baseline and 8 weeks. A sub-sample of participants was also interviewed to allow a more in-depth exploration of patients’ experiences.

Results

76 participants completed the initial questionnaire, of which 15 were interviewed. Patients were anxious about a diagnosis of skin cancer, however they were no more depressed or anxious than the general population. QOL significantly improved from diagnosis to 8 weeks and from diagnosis to one year. Knowledge of NMSC was poor and did not improve after treatment. Hairdressers were highlighted as playing an important role in raising awareness and encouraging individuals to seek medical help. Most participants were aware of the need to check their skin for suspicious lesions but were not sure what to look for. At one year participants had forgotten their experience and were not overly concerned about skin cancer.

Conclusion

There is a need to raise awareness of the signs and symptoms of NMSC. Information on skin cancer needs to be tailored to the individual both at the start of treatment and during the follow up months, ensuring that participants’ needs and expectations are met. Targeting education at individuals in the community who regularly come into contact with skin should help in early identification of NMSC. This is important since skin cancer caught early is easily treatable and delay in presentation leads to larger and more complex lesions which impacts in terms of increased morbidity and increased health care costs.

Triptolide induced DNA damage in A375.S2 human malignant melanoma cells is mediated via reduction of DNA repair genes

Numerous studies have demonstrated that triptolide induces cell cycle arrest and apoptosis in human cancer cell lines. However, triptolide-induced DNA damage and inhibition of DNA repair gene expression in human skin cancer cells has not previously been reported. We sought the effects of triptolide on DNA damage and associated gene expression in A375.S2 human malignant melanoma cells in vitro. Comet assay, DAPI staining and DNA gel electrophoresis were used for examining DNA damage and results indicated that triptolide induced a longer DNA migration smear based on single cell electrophoresis and DNA condensation and damage occurred based on the examination of DAPI straining and DNA gel electrophoresis. The real-time PCR technique was used to examine DNA damage and repair gene expression (mRNA) and results indicated that triptolide led to a decrease in the ataxia telangiectasia mutated (ATM), ataxia-telangiectasia and Rad3-related (ATR), breast cancer 1, early onset (BRCA-1), p53, DNA-dependent serine/threonine protein kinase (DNA-PK) and O6-methylguanine-DNA methyltransferase (MGMT) mRNA expression. Thus, these observations indicated that triptolide induced DNA damage and inhibited DNA damage and repair-associated gene expression (mRNA) that may be factors for triptolide-mediated inhibition of cell growth in vitro in A375.S2 cells.

Skin cancers of the hand: a series of 541 malignancies

BACKGROUND

Skin cancers of the hand are uncommon and poorly documented. The objective of this study was to review a large cohort of patients with hand skin malignancies to determine tumor characteristics, management techniques, and outcomes.

METHODS

A retrospective review of consecutive patients with surgically excised primary cutaneous hand malignancies at the John Radcliffe Hospital between 1993 and 2010 was performed. Records were reviewed to determine tumor characteristics, demographics, and management details. Outcome parameters included margins and completeness of excision, recurrence, metastatic spread, and survival.

RESULTS

A total of 407 patients (65.8 percent male; mean age, 72.2 ± 0.7 yr) presented with 541 primary cutaneous hand malignancies and were followed up for a mean period of 24 months. Half the cohort had previous skin cancers and almost one in five developed further hand skin cancers. Squamous cell carcinoma comprised 78.0 percent, basal cell carcinoma 11.3 percent, and melanoma 3.9 percent of cases. Incidence was highest on the dorsum of the hand. Surgical margins were proportionate to tumor size, and most defects required soft-tissue reconstruction. Recurrence was uncommon in melanoma and rare in squamous and basal cell carcinomas. Lymph node metastasis and death were rare in patients with squamous cell carcinoma but relatively common in those with melanoma.

CONCLUSIONS

Squamous cell carcinomas are the most common skin malignancy of the hand, frequently require soft-tissue reconstruction, and those occurring in the web spaces or on the dorsum of the proximal phalanges are more sinister malignancies with a greater propensity for metastatic spread.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

An estimate of the cost of treating non-melanoma skin cancer in the state of São Paulo, Brazil

BACKGROUND

The most common form of cancer in Brazil is non-melanoma skin cancer, which affects approximately 0.06% of the population. There are no public policies for its prevention and the economic impact of its diagnosis has yet to be established.

OBJECTIVES

To estimate the costs of the diagnosis and treatment of non-melanoma skin cancer in the state of São Paulo between 2000 and 2007 and to compare them with the costs associated with skin melanoma in the same period.

METHODS

The Clinical Practice Guidelines in Oncology (National Comprehensive Cancer Network) was used as a procedure model, adapted to the procedures at the SOBECCan Foundation at the Ribeirão Preto Cancer Hospital in São Paulo. The estimated costs were based on the costs of medical treatment in the public and private sectors in 2007.

RESULTS

The mean annual costs of each individual treatment of non-melanoma skin cancer were much lower than those estimated for the treatment of skin melanoma. Nevertheless, when the total costs of the treatment of non-melanoma skin cancer were taken into consideration, it was found that the total cost of the 42,184 cases of this type of cancer in São Paulo within the study period was 14% higher than the costs of the 2,740 cases of skin melanoma registered in the same period within the Brazilian National Health Service (SUS). However, in the private sector, the total cost was approximately 34% less for the treatment of non-melanoma skin cancer compared to melanoma.

CONCLUSION

The high number of cases of non-melanoma skin cancer in Brazil, with 114,000 new cases predicted for 2010, 95% of which are diagnosed at early stages, represents a financial burden to the public and private healthcare systems of around R$37 million and R$26 million annually, respectively.

5-Year Review of a Unique Multidisciplinary Nonmelanoma Skin Cancer Clinic

Background:

A multidisciplinary nonmelanoma skin cancer (NMSC) clinic is held weekly at our center, where all new patients are jointly assessed by dermatology/dermatopathology, radiation oncology, and plastic surgery. A new patient database was established in 2004. The purpose of this study was to provide a preliminary report on the patients seen in the NMSC clinic and the treatment recommendations rendered.

Methods:

The new patient database was reviewed from January 2004 to December 2008, and patient demographics, tumor characteristics, and treatment recommendations were extracted. Cochran-Mantel-Harnszel (CMH) testing and chi-square analysis were used to detect any associations or relationships between variables within the database. A p value of less than .05 was considered significant.

Results:

During the 5-year study period, 2,146 new patients were seen in the NMSC clinic. The majority of patients presented with basal cell carcinoma (64%) or squamous cell carcinoma (22%), with a median tumor size of 1 to 2 cm (range 0 to #x003E; 9 cm). Tumors were located in the head and neck region (80%), extremities (14%), and torso (6%). Previous treatment included biopsy only (62%), surgery (20%), electrodesiccation and curettage (11%), topical imiquimod (3%), and radiotherapy (1%). Treatment recommendations included surgery (55%) (with either simple excision [31%] or excision with margin control under frozen-section guidance [24%]), radiotherapy (19%), topical imiquimod (10%), observation (7%), and electrodesiccation and curettage (4%).

Conclusions:

The NMSC clinic at our center sees a high volume of patients who benefit from the multidisciplinary assessment provided. Treatment recommendations were based on patient and disease characteristics as well as patient preference.

The needs and experiences of people with a diagnosis of skin cancer: a systematic review

EXECUTIVE SUMMARY

Background Skin cancer is the most common cancer in Caucasians and the incidence is increasing worldwide. There has been no qualitative systematic review looking at the needs and experiences of patients through the skin cancer journey.Objectives The main objective of this systematic review was to identify, appraise and synthesise the literature relating to the needs and experiences of people with a diagnosis of skin cancer.

INCLUSION CRITERIA

Adults with a diagnosis of skin cancer.The needs and experiences of people with skin cancer.All qualitative studies that described or analysed the needs and experiences with people who had been diagnosed with skin cancer.Search strategy The search strategy sought to identify both published and unpublished research studies. A three step search strategy was used, limited to English language papers.Methodological quality Each paper was independently assessed by two independent reviewers for methodological quality, using the critical appraisal instrument from Joanna Briggs Institute Qualitative Assessment of Review Instrument (QARI), prior to inclusion in the review.Data collection The standardised data extraction tool from JBI-QARI was used to extract data from the papers.Data synthesis The qualitative research findings were pooled using JBI-QARI approach. This involved the aggregation of findings.Results Only two studies were included. The 12 findings were grouped according to their similarities of meaning to form 4 categories. These four categories resulted in two synthesised findings. The diagnosis of skin cancer produces a range of emotional responses in individuals. Individuals also delay seeking medical help however once treated are satisfied with care.Conclusions There is very little good research on patient's experiences and needs of skin cancer. People require support in coming to terms with the diagnosis and there is a need for an educational intervention of some form to prevent delay in seeking medical help.Implications for practice There is a real need to increase knowledge of skin cancer so that people do not delay in seeking medical help as early diagnosis can dramatically improve both prognosis and the patient experience since early lesions are treated more simply compared with larger or neglected lesions. Health professionals caring for these patients need to understand the psychosocial concerns of this patient group in order to design services appropriately and to provide patients with the support they need and information that they can easily understand.Implications for research Results from this review have identified that the needs and experiences of individuals with skin cancer remains under-researched and this has implications for those caring for and delivering services to this group of patients. There are very few studies considering this aspect of patients' experiences and therefore a real need to conduct further research into the needs and experience of skin cancer patients.

Neck dissection and post-operative chemotherapy with dimethyl triazeno imidazole carboxamide and cisplatin protocol are useful for oral mucosal melanoma

Background

Oral mucosal melanoma (OMM) is a clinically rare disease with poor prognosis. Various treatment methods have been investigated with the aim of improving the prognosis. This study aimed to analyze the data of a single institution in the management of OMM.

Methods

A total of 78 consecutive OMM patients were included in this retrospective study. The intraoral lesion was treated either by cryotherapy, surgery or both; the neck was treated by neck dissection or observation; post-operative chemotherapy with dimethyl triazeno imidazole carboxamide and cisplatin was performed in some patients. The Kaplan-Meier method was used for statistical analysis.

Results

Among the 78 patients, there were 50 males and 28 females with an average age of 53.8 years (ranging from 27 to 85 years). The most common sites of OMM were the hard palate and gingiva. The main cause of death in OMM was distant metastasis. No significant difference was found between the intraoral/cervical lesion recurrence/post-operative distant metastasis and the intraoral lesion site/biopsy method/treatment method. The metastasis rate of cervical lymph node was high in the OMM patients, even in the patients with clinically negative necks. Cervical lesion recurrence was correlated with N stage and intraoral lesion recurrence. The survival period was longer in the patients with T3 staging, clinical stage III disease, with post-operative chemotherapy and without post-operative distant metastasis when compared to those patients with T4a staging, clinical stage IV disease, without post-operative chemotherapy and with post-operative distant metastasis.

Conclusions

Radical surgery including wide intraoral resection and neck dissection is recommended for OMM patients. Post-operative chemotherapy may also be beneficial for both primary and recurrent OMM patients.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Bone invasion by squamous cell carcinoma in situ (Bowen's disease) of the finger during treatment with imiquimod 5% cream: case report

Imiquimod 5% cream is known as an alternative treatment option for squamous cell carcinoma in situ (SCCIS), frequently termed Bowen's disease. Although imiquimod cream has been reported by many authors to treat SCCIS successfully, its efficacy and safety have not been fully established. The authors experienced a case in which ray amputation was necessary because of bone invasion by SCCIS in a finger being treated with imiquimod cream.

Intralesional chemotherapy for nonmelanoma skin cancer: a practical review

Intralesional chemotherapy for nonmelanoma skin cancer has existed for more than 5 decades. However, it is used so infrequently that recent consensus guidelines for the treatment of basal cell and squamous cell carcinoma do not include intralesional chemotherapy. Barriers to the use of intralesional chemotherapy include the off-label use of these agents, absence of therapeutic guidelines, a relatively small number of patients treated, and a lack of large, well-designed trials with long-term follow-up. Surgical intervention remains the gold standard for the treatment of nonmelanoma skin cancer; however, intralesional chemotherapy remains an option for well-selected patients who cannot or will not undergo surgery. The objectives of this article are to determine response rates and suggest reasonable treatment guidelines for the treatment of squamous cell carcinoma, keratoacanthoma, and basal cell carcinoma with the most widely available intralesional agents (methotrexate, 5-fluorouracil, bleomycin, and interferon).

Mohs micrographic surgery for the management of nonmelanoma skin cancers

Many treatment modalities have been described to address the growing epidemic of nonmelanoma skin cancer (NMSC). Mohs micrographic surgery (MMS) is a surgical technique that allows complete and precise microscopic margin analysis by using horizontal frozen sections. The purpose of MMS is twofold: to ensure definitive excision and to minimize loss of normal surrounding tissue. MMS offers the advantages of superior cure rates and, because tissue removal is minimized, excellent cosmetic outcomes. Therefore, MMS has become the treatment of choice for many high-risk tumors. Because this technique is labor intensive, MMS is not indicated in certain situations. Understanding the indications, advantages, and disadvantages of MMS remains paramount for facial plastic surgeons managing NMSC.

Systematic comparison of nonmelanoma skin cancer microarray datasets reveals lack of consensus genes

BACKGROUND

DNA microarray technology has revealed vast numbers of gene expression alterations associated with human malignancies. Assigning validity and biological significance to these changes, however, remains a considerable hurdle. Recently, microarray analysis has been applied to the study of nonmelanoma skin cancer.

OBJECTIVES

To compare experimental data rigorously in order to strengthen conclusions regarding the pathogenesis of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), and to evaluate systematically the experimental and statistical parameters that may impact the degree of consensus among differentially expressed genes (DEGs) between studies.

METHODS

We performed a systematic comparison of 10 studies that applied DNA microarray technology to study BCC/SCC.

RESULTS

A total of 1133 DEGs collectively reported across the studies were compared, and 64 DEG overlaps were found: 18 DEG overlaps in SCC vs. SCC study comparisons, 18 DEG overlaps in BCC vs. BCC study comparisons and 28 DEG overlaps in BCC vs. SCC study comparisons. We documented differences in several experimental methods that may account for the relative lack of consensus between studies, including sample type, tissue procurement/handling, microarray chip and statistical analysis. The two most dysregulated biological pathways across all studies involved genes with enzymatic and structural/adhesion functions.

CONCLUSIONS

DEGs that were found to overlap across two or more studies and biological pathways with the largest representation of DEGs across studies may be particularly relevant to disease pathogenesis and serve as targets for future therapy. In future work, more consistent experimental methods across laboratories may improve the validity of reported DEGs and strengthen conclusions drawn from microarray data.

[Recurrent acral lentigous melanoma successfully treated with Mohs' micrographic surgery. Case report and review of the literature]

Mohs' micrographic surgery is an approach to selected skin cancer removal that aims to achieve the best prospect of total tumor excision simultaneously with maximal functional and cosmetic preservation. The advantage of the technique is that 100% of the surgical margin of the specimen, including the periphery and deep surface, can be examined intraoperatively by horizontally oriented frozen sections. This method offers cure rates significantly higher than conventional excision or other modalities. Mohs' micrographic surgery is the method of choice for removal of large, recurrent or incompletely excised skin cancers or for tumors located in functional and aesthetic relevant anatomic regions. The authors present a case of a 75-year-old man with a second time recurrent plantar invasive malignant melanoma successfully treated with Mohs' micrographic surgery technique and an immediate reconstruction using split-thickness skin graft.

T4 endonuclease V: review and application to dermatology

BACKGROUND

T4 endonuclease V was originally isolated from Escherichia coli infected with T4 bacteriophage. It has been shown to repair ultraviolet (UV)-induced cyclobutane pyrimidine dimers in DNA, which, when unrepaired, contribute to mutations that result in actinic keratoses and non-melanoma skin cancers (NMSC). This is a particular concern in patients with genetic defects in their DNA repair systems, especially those with xeroderma pigmentosum (XP). When packaged in liposomes and applied topically, T4 endonuclease V can traverse the stratum corneum and become incorporated within the cytoplasm and nucleus of epidermal keratinocytes and Langerhans cells.

OBJECTIVE

To review all major studies evaluating the efficacy of T4 endonuclease V in animals and humans, the toxicity and safety profile of the topical medication and its potential clinical uses.

METHODS

A literature search was performed through PubMed/Medline, using the keywords 'T4N5', 'T4 endonuclease V' and 'dimericine'. Papers found in the bibliographies of those identified in the initial search and deemed relevant were also included.

CONCLUSION

This enzyme increases the repair of UV-damaged DNA and produces other beneficial effects on UV-damaged cells. In clinical trials in XP patients, topical application of liposome-encapsulated T4 endonuclease V reduced the incidence of basal cell carcinomas by 30% and of actinic keratoses by > 68%. Adverse effects were minimal, and there was no evidence of allergic or irritant contact dermatitis. Although the photoprotective effect of T4N5 has been investigated only in XP patients, the possibility exists that it may benefit others likely to develop premalignant keratoses and NMSC, such as organ transplant recipients receiving immunosuppressive therapy and individuals who have had numerous psoralen plus UVA photochemotherapy treatments. It may be also be effective for normal individuals.