Page 71 - IDF Journal 2023

and infection with human papilloma virus.
Surgical excision is usually the preferred first-line treatment for SCC but can
lead to significant scarring. Alternative treatments include conventional radiotherapy or brachytherapy using the beta emitter radioisotope Rhenium-188 (Rhenium-SCT®, Oncobeta, Munich) which is approved in Europe, South Africa and Australia for the treatment
of skin BCC and SCC. This treatment is applied directly to the lesion, and the radiation penetrates up to 3 mm depth, destroying cells to that level and saving the underlying tissues. This product is currently being evaluated in a Phase 4 Clinical Trial in London (NCT05135052).
Basal Cell Carcinoma
Basal Cell Carcinoma (BCC), also known as a rodent ulcer, is the most common cancer in humans. There are four types, nodular, superficial, morphoeic and pigmented. The latter is a diagnostic challenge because it resembles the much more aggressive and metastatic cancer, melanoma, so early differentiation of these cancers is essential.
Nodular BCC commonly presents with a pearly morphology, telangiectasia (spider veins), rolled edges, and central ulceration. Superficial BCC is typical
in younger patients where it presents
as pink or red scaly irregular plaques. Morphoeic BCC is prone to recurrence after treatment and can infiltrate cutaneous nerves leading to perineural spread. It presents as a waxy, skin coloured lesion and is typically observed in mid-facial sites.
Pigmented BCC may be nodular or superficial and can be brown, blue, or greyish in colour. It is differentiated from melanoma by the presence of pearly borders and telangiectasia. It is most common in darker skinned people, e.g., Hispanics and Asians.
A biopsy is ideally required to confirm BCC subtype and depth, and treatment can be tailored to the size, depth and location of the BCC. Surgical excision
is typically offered for nodular, infiltrative and morphoeic BCC, but many patients
refuse surgery when the BCC presents on the face as the scarring from surgery can be perceived as disfiguring. Reduced scarring can be achieved with well- defined nodular BCC and superficial BCC which can be treated with shave, curettage or cautery with no incisions
or stitching. Mohs surgery is a high- precision microscopically monitored form of surgery in which BCC tissue removed is rapidly analysed for the presence of cancer cells and the analysis informs the ongoing surgical excision. It is particularly useful for poorly defined BCC to ensure full margin removal, especially in areas close to critical structures, e.g., around the eyes. Radiotherapy is sometimes used for facial BCC, but requires weekly treatments for several weeks to be effective.
Photodynamic therapy is beneficial
with small, superficial BCC and is the treatment of choice for most superficial BCC because it causes minimal scarring and often results in a good cosmetic outcome. It is not appropriate in high-risk sites such as eye margins. Cryotherapy has a less favourable cosmetic outcome and is effective only with small superficial BCC.
Topical treatments are clearly a preferred alternative to the physical methods described above which are all administered in the clinic. Topical treatments that a patient can self- administer are much less costly to the healthcare system. Current topical treatments include imiquimod, which is effective only for small superficial BCC, requires 6-16 weeks of treatment
3-5 times per week, and long term follow up to check for recurrence. As described above, inflammatory responses are common. 5-fluorouracil cream is less effective than imiquimod, requiring twice daily administration.
At an IDF webinar, I presented data
on our own topical agent, a liposomal bleomycin formulation for treating BCC. This has been used successfully to treat large and deep nodular BCC without any adverse effects. It has also been used successfully in veterinary medicine for treatment of the equine skin malignancy sarcoid (Knottenbelt et al., 2018). The liposomal bleomycin treatment was extremely well tolerated and resulted high patient compliance and an excellent cure rate (Chopra et al., 2023, manuscript in preparation).
REFERENCE
Knottenbelt DC, Watson AH, Hotchkiss
JW, et al. A pilot study on the use of ultra- deformable liposomes containing bleomycin in the treatment of equine sarcoid. Equine Vet Educ. 2018; 32(5): 258-263.
Dr Sunil Chopra BSc FRCP
The london Dermatology Centre, 69 Wimpole Street, London
W1G 8AS
E: reception@the-dermatology- centre.co.uk
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