Nonsurgical Therapies for Non-Melanoma Skin Cancers

  • Radiation therapy:
    • Is often reserved for:
      • Patients unable or unwilling to undergo surgical treatment of primary lesions or
      • When clear margins cannot be obtained by Mohs or more extensive surgery
    • It is also widely accepted as adjuvant treatment of recurrent or histologically aggressive tumors:
      • Particularly those with perineural invasion
    • For high-grade NMSC with perineural involvement or invasion into bone:
      • Radiation therapy is generally recommended in conjunction with surgical excision
    • Radiation therapy can be further used as:
      • Adjuvant or palliative treatment for lymph node metastases
    • Disadvantages of radiation therapy include:
      • Acute and chronic radiation changes:
        • Dyspigmentation
        • Telangiectasia
        • Radiodystrophy
      • Higher recurrence rates in BCC
      • Lack of margin control
      • Increased number of treatment sessions
    • As radiation therapy can result in NMSC decades after exposure:
      • It should be used cautiously in young patients
    • It is also contraindicated in nevoid BCC
  • Topical therapies for superficial NMSC and AKs include:
    • 5% fluorouracil (5-FU)
    • Imiquimod creams
  • 5-FU:
    • Is an antineoplastic antimetabolite
  • Imiquimod:
    • Is a synthetic immune response modifier:
      • That enhances cell-mediated immune response:
        • Via the induction of proinflammatory cytokines
  • These topical therapies are most commonly used for:
    • AKs as well as for superficial BCCs and SCCs in situ when surgery or other treatment techniques are contraindicated or impractical
  • Topical 5-FU is not appropriate for:
    • Nodular BCC
    • It is not recommended for SCC due to high recurrence rates
  • Treatment regimens for AKs with 5-FU vary widely:
    • In general, 5-FU is applied to the affected area once or twice daily for a period ranging from 2 to 6 weeks:
      • Retreatment several months later:
        • Either with cryotherapy or other modalities, may be necessary
  • For the treatment of superficial BCC:
    • 5-FU can be applied daily to the tumor and several millimeters of surrounding skin for a period of at least 4 weeks:
      • After a 2- to 3-week after the treatment ended:
        • The area is then evaluated clinically for residual tumor
        • Biopsy is often indicated to ensure adequate therapy
      • Significant erythema, stinging, oozing, and crusting are often reported:
        • Especially with more aggressive treatment regimens
  • 5-FU:
    • Can be applied to an entire region, such as the face, chest, arms, or hands
  • Imiquimod therapy:
    • Is approved for the treatment of AKs and superficial BCC but should not be used for SCC
    • In general, less local skin reaction is reported compared to 5-FU
    • For AKs the cream is applied:
      • Two nonconsecutive days a week for 16 weeks
    • For superficial BCC:
      • The cream should be applied 5 nights a week for at least 6 weeks
      • After a 2- to 3-month respite, the lesion is evaluated either clinically or histologically (rebiopsy) to confirm adequate therapy
    • While imiquimod can also be used for nodular BCC:
      • The treatment duration requires 12 weeks:
        • The response is lower (76%) compared to a greater than 85% success rate for superficial BCC
    • Imiquimod is often well tolerated:
      • Causes minimal or no scarring, and is particularly useful for multiple lesions concentrated in one area
  • Photodynamic therapy (PDT):
    • Is another noninvasive method used for the treatment of AKs and superficial BCC
    • A photosensitizer (most commonly, aminolevulinic acid) is applied to the skin and activated with a light source
    • The tumor cells retain the photosensitizer for longer periods of time than normal cells:
      • Resulting in preferential killing
    • Cure rates for AKs are reported to be as high as 90%:
      • However, recurrence rates at 5 years for superficial and nodular BCC have been reported to be as high as 14% to 22% respectively
    • Side effects include:
      • Burning or stinging pain during the treatment and posttreatment periods
      • Erythema, swelling, and temporary hyper- or hypopigmentation
      • But overall the cosmetic results are superior in comparison to surgery or cryotherapy
    • Systemic PDT:
      • Has also been tested as a treatment for BCC and may be appropriate for individuals presenting with multiple lesions or nevoid BCC syndrome
  • Chemoprevention:
    • With low-dose oral retinoids has shown some promise in the prevention of SCC for chronically immunosuppressed patients who have undergone organ transplantation:
      • However, long-term therapy is needed as beneficial effects are often lost when these drugs are discontinued

#Arrangoiz #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncology #CASO #CenterforAdvancedSurgicalOncology #Miami #SkinCancer #BCC #SCC

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