Multiple aggregated yellow-white globules are a major dermoscopic sign of basal cell carcinoma regardless of their histological subtype

Multiple aggregated yellow-white globules (MAY globules) have been recently described as dermoscopic structures of high specificity associated with high-risk non-pigmented basal cell carcinoma (BCC). To evaluate the diagnostic accuracy of MAY globules in a cohort of pigmented and non-pigmented BCC of all histological types. This was a retrospective case-control study. Dermoscopic and clinical images were all histopathologically confirmed as BCCs of patients seen consecutively at dermatology consultation. Control cases were benign or malignant tumours randomly selected from the database of 8,250 patients. A total of 389 BCCs were included. MAY globules were present in 192 (49%) cases in the BCC group and in only 25 cases in the control group (6,4%). The odds ratio for the diagnosis of BCC was 14.2 (95% CI: 9.62-20.95]). The presence of MAY globules was significant in three histological subtypes, including superficial BCCs. This study shows that MAY globules are a major dermoscopic sign for the diagnosis of BCC, regardless of their histological subtype and their pigmentation.

The incidence of non-melanoma skin cancer in the UK and the Republic of Ireland: a systematic review

BACKGROUND

Basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) remain the most prevalent malignancies, contributing a higher workload to cancer registries than all cancers combined. The nature of skin cancers in addition to current coding methods employed by registries give a skewed representation of the workload.

OBJECTIVES

A comprehensive search examining the incidence of BCC and/or cSCC at a regional or national level in the UK and Ireland was devised. Standardisation methods were grouped to permit comparison, and a bias assessment tool was employed.

MATERIALS & METHODS

Sixteen UK and Republic of Ireland epidemiological studies on BCC/cSCC over a 48-year period were compiled, examining incidence, trends and emerging risk factors.

RESULTS

Incidence of BCC within the UK is increasing annually by up to 4%, with rates in Wales increasing by up to 6.6% and 1.6% annually for BCC and cSCC, respectively. Inverse relationships are noted between BCC/cSCC and social deprivation. Although the elderly remain the most at risk, the 30-49 age group have illustrated growth rates of approximately 4%.

CONCLUSION

This review outlines increasing incidence in the UK with higher rates noted in Wales, the Southeast, West and Central regions. Incidence rates are higher amongst the least socially deprived and an increasing incidence amongst younger age groups was found, however further trend analysis is required. A more comprehensive data collection method within registries is necessary to ensure accurate representation and fluid comparison. Service planning and public awareness campaigns must be implemented to prevent overwhelming future services.

Perianal basosquamous carcinoma treated with radiation therapy, a case report

Background

Perianal basal cell carcinoma (BCC) is very rare and estimated to account for 0.08% of all BCC and 0.02% of all anorectal neoplasms. Perianal lesions are more likely to be squamous cell carcinoma (SCC) as BCC usually develops on areas of skin exposed to ultraviolet (UV) light such as the face and arms. Proper diagnosis with the assistance of immunohistochemistry (IHC) stains to distinguish the two entities can help inform the suitable course of treatment.

Case Description

Our case is an 82-year-old male with a history of cutaneous BCC on the arms and trunk presenting with a symptomatic perianal lesion. Initial biopsy demonstrated BCC with subsequent IHC studies differentiating from basaloid SCC. Standard treatment includes wide local excision (WLE) but given his poor performance status, radiation only was recommended. He was successfully treated and tolerated 30 Gy in 5 daily fractions.

Conclusions

Radiation only is a unique and feasible non-surgical treatment for basosquamous carcinoma of the anus.

Feasibility of Intratumoral Anti-PD1 as Treatment of Human Basal Cell Carcinoma: An Explorative Study with Adjuvant Ablative Fractional Laser

The use of immune checkpoint inhibitors (ICI) is expanding with the approval for advanced/metastatic keratinocyte carcinoma; however, most tumors are non-aggressive. Local administration could broaden ICI, but adequate immune response might require an immune-attractive adjuvant such as ablative fractional laser (AFL). Accordingly, this study aimed to explore intratumoral injection of anti-PD1 with and without AFL in basal cell carcinoma (BCC), exploring anti-PD1 concentration, immune cell infiltration, tumor response, and safety. This open-label, proof-of-concept trial investigated intratumoral anti-PD1 + AFL combination therapy versus anti-PD1 or AFL monotherapy in 28 BCC patients. The primary endpoints were immune cell infiltration evaluated immunohistochemically and clinical tumor response after 3 months. The secondary outcomes were tumoral drug concentration and safety. The most robust response was obtained following intervention with combined anti-PD1+AFL, leading to a ~2.5-fold increase in CD3+ cells (p = 0.027), and tumor reduction ≥25% in 73%, including two tumors with complete remission. Upon anti-PD1 monotherapy, a slight decrease in CD3+ cells was observed while a non-significant increase following AFL was seen. Tumor reduction ≥25% was seen in 45% and 50%, respectively, after anti-PD1 and AFL monotherapy. The CD8/CD3 ratio remained unchanged after anti-PD1+AFL and anti-PD1 monotherapy, while AFL led to a decreased ratio. A non-significant decline in the Foxp3/CD3 ratio was observed for all groups. Side-effects were mild with no systemic drug concentration detected. Intratumoral anti-PD1 injection is feasible, and a single exposure to locally injected anti-PD1 with adjuvant AFL increased immune cell infiltration and reduction in BCC with limited side-effects.

Tertiary lymphoid structures accompanied by fibrillary matrix morphology impact anti-tumor immunity in basal cell carcinomas

Tertiary lymphoid structures (TLS) are specialized lymphoid formations that serve as local repertoire of T- and B-cells at sites of chronic inflammation, autoimmunity, and cancer. While presence of TLS has been associated with improved response to immune checkpoint blockade therapies and overall outcomes in several cancers, its prognostic value in basal cell carcinoma (BCC) has not been investigated. Herein, we determined the prognostic impact of TLS by relating its prevalence and maturation with outcome measures of anti-tumor immunity, namely tumor infiltrating lymphocytes (TILs) and tumor killing. In 30 distinct BCCs, we show the presence of TLS was significantly enriched in tumors harboring a nodular component and more mature primary TLS was associated with TIL counts. Moreover, assessment of the fibrillary matrix surrounding tumors showed discrete morphologies significantly associated with higher TIL counts, critically accounting for heterogeneity in TIL count distribution within TLS maturation stages. Specifically, increased length of fibers and lacunarity of the matrix with concomitant reduction in density and alignment of fibers were present surrounding tumors displaying high TIL counts. Given the interest in inducing TLS formation as a therapeutic intervention as well as its documented prognostic value, elucidating potential impediments to the ability of TLS in driving anti-tumor immunity within the tumor microenvironment warrants further investigation. These results begin to address and highlight the need to integrate stromal features which may present a hindrance to TLS formation and/or effective function as a mediator of immunotherapy response.

Development and validation of an automated basal cell carcinoma histopathology information extraction system using natural language processing

Introduction

Routinely collected healthcare data are a powerful research resource, but often lack detailed disease-specific information that is collected in clinical free text such as histopathology reports. We aim to use natural Language Processing (NLP) techniques to extract detailed clinical and pathological information from histopathology reports to enrich routinely collected data.

Methods

We used the general architecture for text engineering (GATE) framework to build an NLP information extraction system using rule-based techniques. During validation, we deployed our rule-based NLP pipeline on 200 previously unseen, de-identified and pseudonymised basal cell carcinoma (BCC) histopathological reports from Swansea Bay University Health Board, Wales, UK. The results of our algorithm were compared with gold standard human annotation by two independent and blinded expert clinicians involved in skin cancer care.

Results

We identified 11,224 items of information with a mean precision, recall, and F1 score of 86.0% (95% CI: 75.1-96.9), 84.2% (95% CI: 72.8-96.1), and 84.5% (95% CI: 73.0-95.1), respectively. The difference between clinician annotator F1 scores was 7.9% in comparison with 15.5% between the NLP pipeline and the gold standard corpus. Cohen's Kappa score on annotated tokens was 0.85.

Conclusion

Using an NLP rule-based approach for named entity recognition in BCC, we have been able to develop and validate a pipeline with a potential application in improving the quality of cancer registry data, supporting service planning, and enhancing the quality of routinely collected data for research.

Profile of Basal Cell Carcinoma Mutations and Copy Number Alterations - Focus on Gene-Associated Noncoding Variants

Basal cell carcinoma (BCC) of the skin is the most common cancer in humans, characterized by the highest mutation rate among cancers, and is mostly driven by mutations in genes involved in the hedgehog pathway. To date, almost all BCC genetic studies have focused exclusively on protein-coding sequences; therefore, the impact of noncoding variants on the BCC genome is unrecognized. In this study, with the use of whole-exome sequencing of 27 tumor/normal pairs of BCC samples, we performed an analysis of somatic mutations in both protein-coding sequences and gene-associated noncoding regions, including 5'UTRs, 3'UTRs, and exon-adjacent intron sequences. Separately, in each region, we performed hotspot identification, mutation enrichment analysis, and cancer driver identification with OncodriveFML. Additionally, we performed a whole-genome copy number alteration analysis with GISTIC2. Of the >80,000 identified mutations, ~50% were localized in noncoding regions. The results of the analysis generally corroborated the previous findings regarding genes mutated in coding sequences, including PTCH1, TP53, and MYCN, but more importantly showed that mutations were also clustered in specific noncoding regions, including hotspots. Some of the genes specifically mutated in noncoding regions were identified as highly potent cancer drivers, of which BAD had a mutation hotspot in the 3'UTR, DHODH had a mutation hotspot in the Kozak sequence in the 5'UTR, and CHCHD2 frequently showed mutations in the 5'UTR. All of these genes are functionally implicated in cancer-related processes (e.g., apoptosis, mitochondrial metabolism, and de novo pyrimidine synthesis) or the pathogenesis of UV radiation-induced cancers. We also found that the identified BAD and CHCHD2 mutations frequently occur in melanoma but not in other cancers via The Cancer Genome Atlas analysis. Finally, we identified a frequent deletion of chr9q, encompassing PTCH1, and unreported frequent copy number gain of chr9p, encompassing the genes encoding the immune checkpoint ligands PD-L1 and PD-L2. In conclusion, this study is the first systematic analysis of coding and noncoding mutations in BCC and provides a strong basis for further analyses of the variants in BCC and cancer in general.

Laser Immunotherapy: A Potential Treatment Modality for Keratinocyte Carcinoma

Simple Summary

In light of expanding incidences of keratinocyte carcinoma (KC) with many patients developing multiple tumors, the demand for new treatment modalities is high. With the approval of cemplimab for locally advanced and metastasizing basal cell carcinoma and squamous cell carcinoma, KC is now included as an indication for systemic immunotherapy. At present, however, systemic KC therapy remains limited by the severe side effects associated with treatment. Immunotherapy might be more broadly applied if locally administered. Localized to the skin, KCs are easily accessible to topical drugs and physical interventions such as laser. There is an increasing appreciation of lasers’ potential to activate an immune response. Further enhancement of the laser-based immune activation might be obtained by combining laser and immunotherapeutic agents, known as laser immunotherapy. In search of new treatment modalities for KC and aiming to broaden the field of KC immunotherapy, this review discusses the current literature on immune activation following both laser monotherapy and laser immunotherapy.

Abstract

The role of the immune system in cancer growth is well recognized and the development of immunotherapy represents a breakthrough in cancer treatment. Recently, the use of systemic immunotherapy was extended to keratinocyte carcinoma (KC), specifically locally advanced and metastasizing basal and squamous cell carcinoma. However, since most KC lesions are non-aggressive, systemic treatment with associated side effects is rarely justified. Conversely, topical immunotherapy with imiquimod remains restricted to premalignant and superficial lesions. Use of laser in the treatment of KC has evolved from physical tumor destruction and laser-assisted drug delivery to laser-mediated immune modulation. Evidence indicates that laser monotherapy can lead to immune cell infiltration, tumor reduction and resistance to tumor re-inoculation. Combining laser with immunotherapeutic agents, termed laser immunotherapy (LIT), may further potentiate immune activation and tumor response. Studies on LIT show not only direct anti-tumor effects but systemic adaptive immunity, illustrated by the prevention of tumor recurrence and regression in distant untreated tumors. These findings imply a therapeutic potential for both local and metastatic disease. This work provides rationales for immune-based treatment of KC and presents the current status of KC immunotherapy. Aiming to expand the field of KC immunotherapy, the review discusses the literature on immune activation following laser monotherapy and LIT.

Topical L-Ascorbic Acid Formulation for a Better Management of Non-Melanoma Skin Cancer: Perspective for Treatment Strategies

L-ascorbic acid, is a well-known molecule, sometimes used as antioxidant for skin care. Nonetheless, few studies have taken in account its utility as topical treatment for non-melanoma skin vancer. Non-melanoma skin cancer includes basal cell carcinoma and squamous cell carcinoma and is widespread worldwide with an increasing incidence. The purpose of this paper is to analyze the characteristics of L-ascorbic acid topical formulation, its percutaneous absorption and biochemical mechanism, focusing on its anti-cancer properties. In particular, it will be described how the pH and the concentration of the formulation are able to influence its distribution in the skin and tissues. We will report, the current knowledge on the pharmacokinetic aspects of L-ascorbic acid that allows us to reconsider it in the light of its ability to act as a prodrug and as an anticancer agent. Lastly, a short review with the aim to find any evidence of a possible clinical use of L-ascorbic acid for the treatment of non-melanoma skin cancer was made.

High serum 25-hydroxyvitamin D concentration in patients with a recent diagnosis of non-melanoma skin cancer: a case-control study

BACKGROUND

Sun exposure is critical for vitamin D synthesis and is a major risk factor for the development of non-melanoma skin cancer (NMSC). NMSC is the most common type of cancer in Brazil and coexists with a very high prevalence of vitamin D deficiency.

OBJECTIVES

The present study aimed to assess serum 25-hydroxyvitamin D (25[OH]D) concentration in patients with a recent diagnosis of NMSC.

MATERIALS & METHODS

The serum 25(OH)D concentration of patients with a histological diagnosis of NMSC, made between September 2016 and September 2017, was measured by chemiluminescence up to 60 days after diagnosis and compared to healthy individuals without NMSC matched by age, sex, BMI, and skin phototype.

RESULTS

Forty-one patients with NMSC and 200 healthy controls were evaluated. Most of the patients were men (56.1%) and most had basal cell carcinoma (90.2%). Patients were 67 years old on average (21-87 years) with skin Phototype 2 or 3 (80.6%). Mean serum 25(OH)D concentration in NMSC patients was significantly higher than in healthy controls (p < 0.001). Most of the patients with NMSC (65.9%) had vitamin D deficiency (25[OH]D <30 ng/mL). No association was identified between histological type, time from diagnosis, or a previous history of skin neoplasm and 25(OH)D measurements.

CONCLUSION

Patients with recently diagnosed NMSC had significantly higher serum levels of 25(OH)D when compared to healthy controls. On the other hand, most of the NMSC patients were still considered to have vitamin D insufficiency.

FT-IR Spectroscopy Study in Early Diagnosis of Skin Cancer

BACKGROUND/AIM

Mid-infrared spectroscopy (4000-500 cm^-1) was used to analyze the spectral changes and differences of the characteristic absorption bands of the skin components due to cancer development for early clinical diagnosis.

MATERIALS AND METHODS

Human biopsies from basal cell carcinoma, malignant melanoma, and nevus were used, while normal skin tissue served as a control.

RESULTS

The high quality of Fourier-transform infrared (FT-IR) spectra showed that upon cancer development the intensity of the absorption band at approximately 3062 cm^-1 was increased, indicating that most of the proteins had the configuration of amide B and the β-sheet protein structure predominated. The stretching vibration bands of vCH₂ in the region 2950-2850 cm^-1 were increased in melanoma and nevus, while were less pronounced in basal cell carcinoma due to the increased lipophilic environment. In addition, the intensity of a new band at 1744 cm^-1, which is assigned to aldehyde, was increased in melanoma and nevus and appeared as a shoulder in the spectra of normal skin. The absorption band of amide I at 1650 cm^-1 was split into two bands, at 1650 cm^-1 and 1633 cm^-1, due to the presence of both α-helix and random coil protein conformations for melanoma and nevus. This was confirmed from the amide II band at 1550 cm^-1, which shifted to lower frequencies at 1536 cm^-1 and 1540 cm^-1 for basal cell carcinoma and melanoma, respectively, indicating a damage of the native structure of proteins. The bands at 841 and 815 cm^-1, which are assigned to B-DNA and Z-DNA, respectively, indicated that only the bands of the cancerous Z-DNA form are pronounced in melanoma, while in BCC both the characteristic bands of B-DNA and Z-DNA forms are found.

CONCLUSION

It is proposed that the bands described above could be used as "diagnostic marker" bands for DNA forms, in the diagnosis of skin cancer.

Pathway analysis of expression-related SNPs on genome-wide association study of basal cell carcinoma

Genome-wide association studies (GWASs) have primarily focused on the association between individual genetic markers and risk of disease. We applied a novel approach that integrates skin expression-related single-nucleotide polymorphisms (eSNPs) and pathway analysis for GWAS of basal cell carcinoma (BCC) to identify potential novel biological pathways. We evaluated the associations between 70,932 skin eSNPs and risk of BCC among 2,323 cases and 7,275 controls of European ancestry, and then assigned them to the pathways defined by KEGG, GO, and BioCarta databases. Three KEGG pathways (colorectal cancer, actin cytoskeleton, and BCC), two GO pathways (cellular component disassembly in apoptosis, and nucleus organization), and four BioCarta pathways (Ras signaling, T cell receptor signaling, natural killer cell-mediated cytotoxicity, and links between Pyk2 and Map Kinases) showed significant association with BCC risk with p-value<0.05 and FDR<0.2. These pathways also ranked at top in sensitivity analyses. Two positive controls in KEGG, the hedgehog pathway and the BCC pathway, showed significant association with BCC risk in both main and sensitivity analyses. Our results indicate that SNPs that are undetectable by conventional GWASs are significantly associated with BCC when tested as pathways. Biological studies of these gene groups suggest their potential roles in the etiology of BCC.

Vitamin D: An overview

The role of Vitamin D is examined in skin with regards to synthesis and neoplasia. Despite its evolving role in bone health undefined benefits with regards to other disease such as neoplasia and skin cancer are under scrutiny. A brief overview is presented with formalised advice to patients regarding skin cancer, and Vitamin D requirements in the clinical setting. Given that weather conditions in Australia and the Mediterranean climates share similarities, some parallels can be drawn from the Australian experience for Europe.

Emergence of chemoresistance in a metastatic basal cell carcinoma patient after complete response to hedgehog pathway inhibitor vismodegib (GDC-0449)

Vismodegib (GDC-0449, Genentech, USA), a small molecule inhibitor of the Hedgehog signalling pathway, has potent anti-tumour activity in advanced basal cell carcinoma (BCC). We report a case of a 67-year-old Australian man with metastatic BCC including pulmonary disease with malignant effusion who showed a dramatic complete response to vismodegib but subsequently experienced a recurrence of pulmonary disease, indicative of chemoresistance to vismodegib. This case is the first to illustrate chemoresistance in a patient with metastatic BCC, and demonstrates the need for closely monitoring metastatic BCC patients even after an apparently complete response.