Basal cell carcinoma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

After the suspicious lesion is evaluated, the medical therapy is divided into low-risk and high-risk basal cell carcinoma patients. Medical therapy consists of surgery, radiation therapy, and follow-up for recurrence.

Basal Cell Carcinoma Medical Therapy

After the suspicious lesion is evaluated, the medical therapy is divided into low-risk and high-risk basal cell carcinoma patients.

The table below summarizes the characteristics in low-risk and high-risk lesions[1].

H&P Low Risk High Risk
Location/size Area L < 20 mm; Area M < 10 mm; Area H < 6 mm Area L ≥ 20 mm; Area M ≥ 10 mm; Area H ≥ 6 mm
Borders Well defined Poorly defined
Primary vs. recurrent Primary Recurrent
Immunosuppression (-) (+)
Site of prior radiation therapy (-) (+)
Subtype Nodular, superficial Aggressive growth pattern
Perineural involvement (-) (+)

Area H = “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips [cutaneous and vermilion], chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet

Area M = cheeks, forehead, scalp, neck, and pre-tibial area

Area L = trunk and extremities (excluding pre-tibial area, hands, feet, nail units, and ankles)


The algorithm below demonstrates a treatment protocol for low-risk lesions[2].

The algorithm below demonstrates a treatment protocol for high-risk lesions[3].

After the primary treatment, a follow-up is performed to evaluate for recurrence of the tumor.

The algorithm below demonstrates a follow-up protocol[4].

Other medical therapy techniques include the following:

  • Oral vismodegib - was approved by the FDA in January 2012 for adult patients with locally advanced basal cell carcinoma who are not candidates for surgery or radiation
  • Radiotherapy - used in elderly patients with extensive lesions when surgery is inappropriate
  • Topical photodynamic therapy - particularly for the management of superficial BCC that involves the application of a topical emulsion-based 5-aminolaevulinic acid
  • Fluorouracil - particularly for the management of multiple superficial BCC on the trunk and limbs
  • Imiquimod - particularly for the management of superficial BCC

The medical therapy for basal cell carcinoma is divided into:

  • Toipcal
  • Systemic

Topical therapy

  • Imiquimoid
    • It is an immunomodulatory agent that binds to toll-like receptor 7 and induces the release of pro-inflammatory cytokines including IFN-alpha, TNF-alpha and IL-12.
    • It is approved as a 5% cream for treatment of small (<7.25 cm²) superficial BCC and is applied nightly five times a week for six weeks.
    • The complete cure rate was around 80%.
  • Photodynamic therapy
    • The other available option for BCC is photodynamic therapy (PDT) with 5-amino levulinic acid or with its methyl ester plus red light.
    • The MAL cream is applied to the tumor and covered with an occlusive dressing for three hours.
    • The tumor cells then form increasing amounts of protoporphyrin IX, which is stimulated by irradiation with red light to form reactive oxygen species which are in turn cytotoxic.
    • It should be repeated after 1–4 weeks.
    • The achieved complete remission is expected to be 92%.
    • The main disadvantages of PDT are the pain during the irradiation and the local inflammatory reaction (erythema, erosions, pustules, and crusts).
  • 5-flurouracil
    • It is a cytostatic agent which is available as a 5% prescription cream that is designed to be applied twice daily for 3–12 weeks until erosions develop.

Systemic therapy

  • Hedgehog pathway inhibitors
    • vismodegib

References