TREATMENT PECULIARITIES OF BASAL CELL CARCINOMA OF THE FACE

It has become routine practice in many centers to use two successive freeze-thaw cycles in the treatment of the common types of basal cell carcinoma. Because of the potential morbidity caused by this, we have investigated the cure rate achieved with one freeze-thaw cycle compared with that achieved with two freeze-thaw cycles in the treatment of facial basal cell carcinomas of a uniform type and clinically in the best prognostic group. Superficial truncal basal cell carcinomas are reported to respond to less aggressive cryosurgery, and we have investigated the cure rate achieved with one freeze-thaw cycle.To compare the efficacy of one freeze-thaw cycle versus two freeze-thaw cycles in the treatment of facial basal cell carcinomas. Second, to investigate the efficacy of one freeze-thaw cycle in the treatment of superficial truncal basal cell carcinomas. This was investigated in a prospective randomized post-treatment follow-up study.Over the past 7 years, we have treated 84 facial basal cell carcinomas with either a single 30-second freeze-thaw cycle or a double 30-second freeze-thaw cycle. Patients were allocated randomly into one of the two treatment schedules, and the cure rates achieved were compared. Second, 29 superficial truncal basal cell carcinomas were treated with a single 30-second freeze-thaw cycle. Patients were followed up to assess response to therapy.A 95.3% cure rate was achieved in the treatment of facial basal cell carcinomas with a double freeze-thaw cycle. This compared with a cure rate of only 79.4% when facial lesions were treated with a single freeze-thaw cycle. Treatment of superficial truncal basal cell carcinomas with a single freeze-thaw cycle achieved a cure rate of 95.5%.We recommend that, in order to achieve high cure rates that are equivalent to many reports of formal excision or radiotherapy, facial basal cell carcinomas require a double freeze-thaw cycle with liquid nitrogen. One freeze-thaw cycle to truncal basal cell carcinomas achieves high cure rates, equal to that achieved with a double freeze-thaw cycle to facial basal cell carcinomas.

Patients with nevoid basal cell carcinoma syndrome suffer from multiple basal cell carcinomas, requiring numerous surgical procedures that over time leave them with multiple disfiguring scars. Photodynamic therapy with delta-aminolevulinic acid using red light (approximately 630 nm) sources has been reported as effective in treatment of superficial and small nodular basal cell carcinomas. To our knowledge, the blue light source (417 nm peak irradiance) approved by the FDA for treatment of actinic keratoses has not been used for photodynamic therapy with delta-aminolevulinic acid of basal cell carcinoma. We report treatment of two nevoid basal cell carcinoma syndrome patients, women aged 21 and 47, with 20%delta-aminolevulinic acid solution and 417-nm blue light source (irradiance 10 mW/cm(2)). delta-Aminolevulinic acid was applied topically on lesions 1 to 5 hr before light treatment. Lesions were illuminated with 417+/-5-nm blue light for 1000 sec (10 J/cm(2)). Two consecutive treatments 1 week apart were administered as a therapeutic course. Each patient underwent two courses of photodynamic therapy with delta-aminolevulinic acid 2 to 4 months apart. The reported assessment was made 8 months after initial treatment. In most sessions the entire face, rather than visible basal cell carcinomas only, was treated. The treated basal cell carcinomas were clinically subdivided to superficial or nodular type guided by their morphologic features. A total of 9 superficial and 16 nodular basal cell carcinomas on the face and 27 superficial basal cell carcinomas on the lower extremities were treated. Complete clinical response was observed in 8 of 9 (89%) superficial basal cell carcinomas and 5 of 16 (31%) nodular basal cell carcinomas on the face and in 18 of 27 (67%) of superficial basal cell carcinomas on the lower extremities. The remaining 21 lesions showed partial clinical resolution. No new basal cell carcinomas were observed during the 8-month follow-up period in areas treated with a broad application technique. Resolution of the lesions was accompanied by an excellent cosmetic outcome and decreased prominence of old surgical scars in the more severely affected patient. Treatments were well tolerated, but associated with moderate to severe stinging during illumination. To our knowledge this is the first use of photodynamic therapy with delta-aminolevulinic acid with 417-nm blue light for treatment of multiple basal cell carcinomas in patients with nevoid basal cell carcinoma syndrome. Our clinical results demonstrate that the blue light reduces cutaneous tumor burden in such patients. Further studies are needed to confirm that broad-area photodynamic therapy with delta-aminolevulinic acid may eradicate subclinical tumors in nevoid basal cell carcinoma syndrome sufferers, as suggested by a strikingly decreased incidence of new basal cell carcinomas in our patients.

The mammalian Hippo signaling pathway, through its effectors YAP and TAZ, coerces epithelial progenitor cell expansion for appropriate tissue development or regeneration upon damage. Its ability to drive rapid tissue growth explains why many oncogenic events frequently exploit this pathway to promote cancer phenotypes. Indeed, several tumor types including basal cell carcinoma (BCC) show genetic aberrations in the Hippo (or YAP/TAZ) regulators. Here, we uncover that while YAP is dispensable for homeostatic epidermal regeneration, it is required for BCC development. Our clonal analyses further demonstrate that the few emerging Yap-null dysplasia have lower fitness and thus are diminished as they progress to invasive BCC Mechanistically, YAP depletion in BCC tumors leads to effective impairment of the JNK-JUN signaling, a well-established tumor-driving cascade. Importantly, inthis context, YAP does not influence canonical Wnt or Hedgehog signaling. Overall, we reveal Hippo signaling as an independent promoter of BCCpathogenesis and thereby a viable target for drug-resistant BCC.

Primary superficial basal cell carcinoma of the nipple

In selected cases, conventional photodynamic therapy (C-PDT) is a valid alternative to surgery for the treatment of basal cell carcinoma (BCC). However, it is limited to superficial BCCs. Pretreatment of BCCs with ablative lasers may enhance its efficacy. We evaluated the C-PDT and CO2 laser combination therapy for the treatment of superficial and nodular BCCs. In this prospective, interventional, monocentric study, patients affected by BCC were treated with CO2 laser therapy, using a continuous superpulsed CO2 laser for nodular BCCs and a fractional CO2 laser for superficial BCCs. All patients were subsequently treated with photodynamic therapy using methyl aminolevulinate cream and an Aktilite CL128® (Galderma) lamp. 32 patients (20 males, 12 females) aged from 45 to 96 years (with a total of 181 BCCs) were treated using a CO2 laser combined with C-PDT. A 100% cure rate was achieved at three months, with no signs of relapse in 97.2% of the cases during the mean follow-up period (10.7 months, range 4 to 18 months). We observed mild adverse reactions and good aesthetic results. We recommend this combination therapy in selected cases, based on its high efficacy, good aesthetic results and few side effects.

Topical photodynamic therapy has been used for the treatment of superficial and nodular basal cell carcinomas, with varying cure rates. This study aims to evaluate the effectiveness of topical photodynamic therapy in the treatment of superficial and nodular basal cell carcinomas in Asian patients treated at the National Skin Centre, Singapore. A retrospective analysis of Asian patients with histologically confirmed basal cell carcinomas and treated with photodynamic therapy was performed. Eight Chinese patients, with an equal gender distribution and mean age of 83.4 years were included. Five of eight basal cell carcinomas were superficial while the remaining three were nodular. The basal cell carcinomas were located in the head and neck in seven patients. The overall clearance rate at 3 months was 87.5% while the clearance rate for superficial and nodular basal cell carcinomas was 100% and 66.6% respectively at 3 months. At 12 months, the overall clearance rate was 85. 7%. This is a retrospective analysis with small patient numbers. In this small series of eight Asian patients, topical photodynamic therapy has been shown to be effective and generally well-tolerated in the treatment of basal cell carcinomas, particularly of the superficial subtype. However, larger studies are needed to evaluate its overall efficacy in Asian patients.

BACKGROUND Patients with nevoid basal cell carcinoma syndrome suffer from multiple basal cell carcinomas, requiring numerous surgical procedures that over time leave them with multiple disfiguring scars. Photodynamic therapy with δ-aminolevulinic acid using red light (∼630 nm) sources has been reported as effective in treatment of superficial and small nodular basal cell carcinomas. To our knowledge, the blue light source (417 nm peak irradiance) approved by the FDA for treatment of actinic keratoses has not been used for photodynamic therapy with δ-aminolevulinic acid of basal cell carcinoma. OBJECTIVE We report treatment of two nevoid basal cell carcinoma syndrome patients, women aged 21 and 47, with 20%δ-aminolevulinic acid solution and 417-nm blue light source (irradiance 10 mW/cm2). METHODS δ-Aminolevulinic acid was applied topically on lesions 1 to 5 hr before light treatment. Lesions were illuminated with 417±5-nm blue light for 1000 sec (10 J/cm2). Two consecutive treatments 1 week apart were administered as a therapeutic course. Each patient underwent two courses of photodynamic therapy with δ-aminolevulinic acid 2 to 4 months apart. The reported assessment was made 8 months after initial treatment. In most sessions the entire face, rather than visible basal cell carcinomas only, was treated. The treated basal cell carcinomas were clinically subdivided to superficial or nodular type guided by their morphologic features. A total of 9 superficial and 16 nodular basal cell carcinomas on the face and 27 superficial basal cell carcinomas on the lower extremities were treated. RESULTS Complete clinical response was observed in 8 of 9 (89%) superficial basal cell carcinomas and 5 of 16 (31%) nodular basal cell carcinomas on the face and in 18 of 27 (67%) of superficial basal cell carcinomas on the lower extremities. The remaining 21 lesions showed partial clinical resolution. No new basal cell carcinomas were observed during the 8-month follow-up period in areas treated with a broad application technique. Resolution of the lesions was accompanied by an excellent cosmetic outcome and decreased prominence of old surgical scars in the more severely affected patient. Treatments were well tolerated, but associated with moderate to severe stinging during illumination. CONCLUSION To our knowledge this is the first use of photodynamic therapy with δ-aminolevulinic acid with 417-nm blue light for treatment of multiple basal cell carcinomas in patients with nevoid basal cell carcinoma syndrome. Our clinical results demonstrate that the blue light reduces cutaneous tumor burden in such patients. Further studies are needed to confirm that broad-area photodynamic therapy with δ-aminolevulinic acid may eradicate subclinical tumors in nevoid basal cell carcinoma syndrome sufferers, as suggested by a strikingly decreased incidence of new basal cell carcinomas in our patients.

A pilot study using immunohistochemical staining to characterize dihydropyrimidine dehydrogenase expression in keratinocyte neoplasms

Cells to Surgery Quiz: December 2018

For 1378 patients treated in the 11 years 1988-1998 by conventional excision of 1635 basal cell carcinomas, 1516 first index lesions were histologically completely excised. All patients having more than one BCC excised were identified from the data base from 1988 to 2003 to give minimum 5 years follow for last treated primary lesions in 1998. Measured clearance margins around the initial lesions at or near sites of presumptive recurrent lesions were noted and the lesions recorded photographically. All incompletely excised lesions whether or not re-excised were excluded. The median age for all patients was 70 years. Over minimum 5 years follow up, six patients developed nine subsequent lesions contiguous with the scar or graft repair of primary index lesion excision site (probable recurrences). The median interval to recurrence was 41 months (4 months-8 years 10 months), with median lateral clearance margin around the primary tumour of 2 mm (0.3-6.8 mm). A further nine patients developed 11 new lesions near (within 1cm of) the scar or graft of primary index lesion excision site (possible recurrences). The median interval to recurrence was 59 months (1 year-8 years 6 months). The median lateral clearance margin around the primary tumour was 4.1 mm (0.8-5.8 mm). For the two groups combined the maximum recurrence rate expressed as a percentage of index lesions was 1.3% (20/1516). Two thirds of possible and probable recurrences occurred in the temple and forehead, although these sites represented only 22% of all lesions, which may rather suggest new lesions in an area of field change as opposed to residual disease. The measured clearance margins reported here perhaps suggest that some original lesions may well have been completely excised primarily and many 'recurrences' were new primaries. These figures indicate there is a low order of probability for the incidence of recurrent basal cell carcinoma during minimum 5 years follow period after conventional surgical excision and conventional histological assessment of tumour resection margins.

Background: There is emerging literature regarding laser therapy as a treatment for non-melanoma skin cancer, with reports of vascular selective lasers and ablative lasers showing promise in basal cell carcinoma (BCC). Objectives: To assess the efficacy of the 755-nm laser in the treatment of non-facial BCC of the superficial and nodular subtypes. To provide patients with a non-surgical option for the treatment of BCC. Methods: Nineteen veterans, each with at least one biopsy proven superficial or nodular BCC on the trunk or extremity, agreed to participate in our IRB-approved, prospective, non-randomized, open-label clinical trial. A total of 21 BCC were treated, after local anesthetization, using the 755-nm Alexandrite laser (Gentle-Lase, Candela Corporation) in a single session with a 4 mm margin. Treatment sites were re-biopsied approximately six weeks later. Results: Twenty-one of 21 treated BCC demonstrated complete histologic tumor resolution at 6-week follow-up. At six weeks, all patients had a scar, and some patients had associated crusting, scaling or ulceration. The high energy and absence of dynamic cooling in our study likely resulted in additional thermal damage to the tumors. Healing times and scar appearance were comparable to electrodesiccation and curettage sites. Limitations: Our study was limited by a small sample size, lack of a control group, and sampling of treatment sites with shave removal rather than complete excision. Conclusion: The 755-nm laser has vessel-selective properties and a greater depth of penetration compared to vascular selective lasers. Our study results suggest that the 755-nm Alexandrite laser may be an effective treatment for superficial and nodular BCC on the trunk and extremities. Further investigation is warranted.

Photodynamic therapy with methyl aminolevulinate (MAL-PDT) is a non-invasive therapy for superficial and nodular basal cell carcinoma (BCC). We performed an open-label trial to evaluate efficacy, safety, tolerability and cosmetic outcome of MAL-PDT in selected patients with superficial and nodular BCCs. Ninety-four superficial and 24 nodular BCCs in 69 patients were treated with 2 to 8 MAL-PDT sessions. Efficacy, safety, tolerability and cosmetic outcome were evaluated at months 1, 3, 6 and 12 after the last MAL-PDT treatment and then every 3 months. One patient discontinued the study for reasons unrelated to study procedures. Complete clinical regression was detected in 84/94 (89.4%) superficial BCCs, and 12/23 (52.2%) nodular BCCs one month after 2 MAL-PDT sessions. No further clinical improvement was observed in either superficial or nodular BCCs with treatment continuation up to a maximum of 8 MAL-PDT sessions. Adverse effects were limited to mild local skin reactions, and cosmetic outcome was rated as excellent or good. Recurrence was observed in 2/84 (2.4%) successfully treated superficial BCCs at 6 and 12 months after treatment discontinuation. Based on the efficacy, tolerability, cosmetic outcome and recurrence rate, our results support the use of MAL-PDT for treatment of superficial BCC and for selected cases of nodular BCC.

Surgical excision is the standard treatment for basal cell carcinoma (BCC), but it can be challenging in elderly patients and patients with comorbidities. The non-surgical guidelines procedures are usually regarded as monotherapy options. This quasi-experimental, non-randomized, comparative effectiveness study aims to evaluate the efficacy of a combined, conservative, non-surgical BCC treatment, and compare it to standard surgical excision. Patients with primary, non-ulcerated, histopathologically confirmed BCCs were divided into a conservative treatment (129 patients) and a standard surgery subgroup (50 patients). The conservative treatment consisted of ablative CO2 laser, cryosurgery, topical occlusive 5-fluorouracil, and imiquimod. The follow-up examinations were performed 3 months after remission, then every 3 to 6 months, and were extended with telephone follow-ups. Cosmetic-self assessment was recorded during a telephone follow-up. Subjects from the conservative subgroup presented a clearance rate of 99.11%, and a recurrence rate of 0.98%. No recurrences were recorded in the surgical group, nor during the telephone follow-up. There were no differences regarding adverse events (p > 0.05). A superior self-assessment cosmetic outcome was obtained using the conservative method (p < 0.001). This conservative treatment is suitable for elders and patients with comorbidities, is not inferior to surgery in terms of clearance, relapses, or local adverse events, and displays superior cosmetic outcomes.

As a variation of the curettage and destruction technique, cryosurgery can be used in place of electrodesiccation for the destructive component when managing superficial basal and squamous cell carcinomas. There are few studies, though, demonstrating the long-term cure rate associated with similar methods. This study seeks to determine the long-term cure rate associated with curettage and cryosurgery in the treatment of small, non-facial, superficial basal and squamous cell carcinomas. Sixty-nine patients with 100 non-facial tumors, ≤ 2 cm in diameter, consisting of superficial basal cell carcinoma, superficial nodular basal cell carcinoma with papillary dermal invasion, squamous cell carcinoma in situ, and squamous cell carcinoma with papillary dermal invasion were prospectively treated with curettage and cryotherapy, and subsequently evaluated at 1- and 5-year intervals. No tumor recurred after one year of follow-up, and one recurrence occurred within the 5-year interval, for a 99% recurrence-free endpoint. Six patients died of unrelated causes after one year, and before five years, and were thus lost to follow-up. Curettage and cryosurgery is a simple, highly effective, and reliable treatment method for select, low-risk non-melanoma skin cancers.

Local recurrence of clinically observed basal cell carcinomas following complete saucerization or punch removal with negative margins: Retrospective case series from 2010 to 2020