https://www.thelancet.com/pdfs/journals/lancet/PIIS014067360961196X.pdf

Non-melanoma skin cancer

Topical photodynamic therapy (PDT) is used to treat nonmelanoma skin cancers, such as actinic keratoses, Bowen's disease, and basal cell carcinoma (superficial and nodular). This article presents up-to-date, practical, evidence-based recommendations on the use of topical PDT using 5-aminolevulinic acid or methyl aminolevulinate for the treatment (and prevention) of nonmelanoma skin cancers. A systematic literature review was conducted (using MEDLINE), and recommendations were made on the basis of the quality of evidence for efficacy, safety/tolerability, cosmetic outcome, and patient satisfaction/preference. Topical PDT is highly effective in the treatment of actinic keratoses, Bowen's disease, superficial and thin nodular basal cell carcinomas, with cosmesis typically superior to that achieved with existing standard therapies. PDT may also be a means of preventing certain nonmelanoma skin cancers in immunosuppressed patients.

Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: an international consensus

https://www.jidonline.org/article/S0022-202X(15)30127-5/pdf

Terahertz pulse imaging of ex vivo basal cell carcinoma.

Summary Topical photodynamic therapy (PDT) is effective in the treatment of certain non-melanoma skin cancers and is under evaluation in other dermatoses. Its development has been enhanced by a low rate of adverse events and good cosmesis. 5-Aminolaevulinic acid (ALA) is the main agent used, converted within cells into the photosensitizer protoporphyrin IX, with surface illumination then triggering the photodynamic reaction. Despite the relative simplicity of the technique, accurate dosimetry in PDT is complicated by multiple variables in drug formulation, delivery and duration of application, in addition to light-specific parameters. Several non-coherent and coherent light sources are effective in PDT. Optimal disease-specific irradiance, wavelength and total dose characteristics have yet to be established, and are compounded by difficulties comparing light sources. The carcinogenic risk of ALA-PDT appears to be low. Current evidence indicates topical PDT to be effective in actinic keratoses on the face and scalp, Bowen’s disease and superficial basal cell carcinomas (BCCs). PDT may prove advantageous where size, site or number of lesions limits the efficacy and ⁄ or acceptability of conventional therapies. Topical ALA-PDT alone is a relatively poor option for both nodular BCCs and squamous cell carcinomas. Experience of the modality in other skin diseases remains limited; areas where there is potential benefit include viral warts, acne, psoriasis and cutaneous T-cell lymphoma. A recent British Photodermatology Group workshop considered published evidence on topical PDT in order to establish guidelines to promote the efficacy and safety of this increasingly practised treatment modality.

https://www.bad.org.uk/library-media/documents/PDT%202002.pdf

Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group

Summary Background Basal-cell carcinoma (BCC) is the most common form of skin cancer and its incidence is still rising worldwide. Surgery is the most frequently used treatment for BCC, but large randomised controlled trials with 5-year follow-up to compare treatment modalities are rare. We did a prospective randomised controlled trial to compare the effectiveness of surgical excision with Mohs' micrographic surgery (MMS) for the treatment of primary and recurrent facial BCC. Methods Between Oct 5, 1999, and Feb 27, 2002, 408 primary BCCs (pBCCs) and 204 recurrent BCCs (rBCCs) in patients from seven hospitals in the Netherlands were randomly assigned to surgical excision or MMS. Randomisation and allocation was done separately for both groups by a computer-generated allocation scheme. Tumours had a follow-up of 5 years. Analyses were done on an intention-to-treat basis. The primary outcome was recurrence of carcinoma, diagnosed clinically by visual inspection with histological confirmation. Secondary outcomes were determinants of failure and cost-effectiveness. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN65009900. Findings Of the 397 pBCCs that were treated, 127 pBCCs in 113 patients were lost to follow-up. Of the 11 recurrences that occurred in patients with pBCC, seven (4·1%) occurred in patients treated with surgical excision and four (2·5%) occurred in patients treated with MMS (log-rank test χ 2 0·718, p=0·397). Of the 202 rBCCs that were treated, 56 BCCs in 52 patients were lost to follow-up. Two BCCs (2·4%) in two patients treated with MMS recurred, versus ten BCCs (12·1%) in ten patients treated with surgical excision (log-rank test χ 2 5·958, p=0·015). The difference in the number of recurrences between treatments was not significant for pBCC, but significantly favoured MMS in rBCC. In pBCC, Cox-regression analysis showed no significant effects from risk factors measured in the study. In rBCC, aggressive histological subtype was a significant risk factor for recurrence in the Cox-regression analysis. For pBCC, total treatment costs were €1248 for MMS and €990 for surgical excision, whereas for rBCC, treatment costs were €1284 and €1043, respectively. Dividing the difference in costs between MMS and surgical excision by their difference in effectiveness leads to an incremental cost-effectiveness ratio of €23 454 for pBCC and €3171 for rBCC. Interpretation MMS is preferred over surgical excision for the treatment of facial rBCC, on the basis of significantly fewer recurrences after MMS than after surgical excision. However, because there was no significant difference in recurrence of pBCC between treatment groups, treatment with surgical excision is probably sufficient in most cases of pBCC. Funding The Netherlands Organisation for Scientific Research ZonMW.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(08)70260-2.pdf

Surgical excision versus Mohs' micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years' follow-up

This article represents a planned regular updating of the previous British Association of Dermatologists guidelines for the management of basal cell carcinoma. These guidelines present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

https://www.bad.org.uk/library-media/documents/BCC_2008.pdf

Guidelines for the management of basal cell carcinoma

DEAR EDITOR, Telling a patient that they have cancer is conventionally undertaken face to face, and there are several government publications that stress that ‘how’ the patient is informed of their diagnosis is a crucial area. However, there are no official guidelines. Headlines such as ‘Staff at NHS Trust rebuked for breaking bad news to patients over the phone’ suggest that many people would not support using the telephone or a letter as a communication tool. We see approximately 1500 patients annually where skin cancer is a possible diagnosis. Bringing back every patient after biopsy is unworkable and, for those with benign or low-grade pathology, unnecessary. The uncertain delay before receiving the pathology result makes it difficult to plan follow-up for those with worrying tumours. Equally, those awaiting a communication regarding an appointment to discuss their results may find that the subsequent wait is filled with awful anticipation. Patients often ask for further information even before the biopsy has been performed, and also enquire when and how they will receive the histological diagnosis. This prompted us to explore methods of communication in more detail. This study formed part of N.C.’s MSc and received ethical approval through the Sheffield Hallam University ethics review group. Patients with suspected malignant melanoma or squamous cell carcinoma were recruited consecutively. When the possibility of a cancer diagnosis was raised, the clinicians, adhering to a single format, explained that following a biopsy the patient could choose to receive the diagnosis by telephone, by letter or face to face. We outlined potential pitfalls for each choice, stressing the problems of confidentiality and an inappropriate environment in which to receive the news (Fig. 1). They were offered the department’s leaflet on the implications of a cancer diagnosis, which includes information on further

How to convey a diagnosis of skin cancer: patient preferences

<h2>Abstract</h2> Multinucleated osteoclast-like melanocytes are a relatively common feature in malignant melanoma, however reported cases of benign melanocytic naevi with giant cells melanocytes are scarce. Herein, we present an unusual case of an intradermal melanocytic naevus with numerous benign giant cell melanocytes. A 42-year-old female presented with a small papule on the forehead which was excised. Histologically, the lesion was formed of an intradermal proliferation of benign melanocytes without junctional activity. The melanocytes were arranged in small nests and showed neither cytological atypia nor mitotic activity. There were numerous multinucleated osteoclast-like giant cells with abundant eosinophilic granular cytoplasm and several small open face nuclei. These multinucleated cells showed immune reactivity to melanocytic markers. This case represents a rarely described morphological pattern of a benign intradermal melanocytic lesion showing multiple benign giant cell melanocytes. Reporting such a case provides further evidence to support the presence of this morphological entity and would aid in further understanding its biology and clinical significance. 

G. B. Colver

Papers

Guidelines for the management of basal cell carcinoma

How to convey a diagnosis of skin cancer: patient preferences

Benign intradermal melanocytic naevus with osteoclast-like giant melanocytes: a case report of an unusual morphological pattern