ORLANDO – Despite a paucity of recently approved treatments for squamous cell carcinoma, you can use study findings from the past few years to refine your clinical approach, Dr. Suzanne Olbricht said.
"It would be nice if I had some new treatments to discuss, but I don't. So let's go through some recent studies," Dr. Olbricht said at the annual meeting of the Florida Society of Dermatologic Surgeons.
Photodynamic Therapy
Investigators, for example, found methyl aminolevulinate photodynamic therapy (MAL-PDT) superior to 5-fluorouracil and cryosurgery for squamous cell carcinoma in situ. In addition, ophthalmologists might start using more imiquimod to treat periorbital skin cancers based on outcomes of a recent case series, Dr. Olbricht said. Other findings support promise for the oral medications cetuximab and capecitabine.
The prospective, randomized study that bolsters use of MAL-PDT included 225 patients with biopsy-confirmed squamous cell carcinoma in situ (Arch. Dermatol. 2006;142:729-35). Researchers found an 80% complete response rate in the MAL-PDT–treated patients at 12 months, compared with a 69% rate with 5-fluorouracil and a 67% rate in patients treated with cryotherapy.
"MAL-PDT was judged [to have the] most acceptable cosmetic outcome," Dr. Olbricht said. She added that 5-fluorouracil is "still a good therapy if some patients prefer to do things at home."
This is a "large study that is worth thinking about," said Dr. Olbricht, chair of the department of dermatology at the Lahey Clinic in Burlington, Mass., and a member of the dermatology faculty at Harvard Medical School, Boston.
Photodynamic therapy (PDT) was associated with a 72% complete response in a smaller study of 30 patients with recurrent tumors of the head and neck (J. Drugs Dermatol. 2010;9:122-6).
These investigators described PDT as effective, tolerable, and associated with good cosmetic results for recurrent squamous cell carcinoma or basal cell carcinoma. One concern, Dr. Olbricht said, is "they did not describe how they did the PDT."
Imiquimod Therapy
Another noteworthy study supports imiquimod for periorbital skin lesions (Orbit 2010;29:83-7). Two patients in this case series had basal cell carcinoma of the eyelid, one had actinic keratosis, and another had intraepidermal squamous cell carcinoma (Bowen’s disease). A fifth patient presented with concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. All tumors regressed with a clinical cure at 6-9 months.
"It’s a short follow-up, but your ophthalmologic colleagues will be using imiquimod," Dr. Olbricht said.
Cetuximab and Capecitabine
Oral cetuximab (Erbitux, Imclone) was associated with a complete clinical response for a patient with organ metastases from cutaneous squamous cell carcinoma (Dermatol. Surg. 2010;36:2069-74). Keep two caveats in mind with a cetuximab treatment strategy, Dr. Olbricht said. First, it's expensive – costing approximately $30,000 for an 8-week series of infusions. Second, cetuximab is effective only for skin cancer patients who do not have a KRAS mutation.
Another treatment showing promise is capecitabine (Xeloda, Hoffmann La Roche), an oral 5-fluorouracil precursor. New lesion development was halted within 6 months for three patients with a history of more than one new squamous cell carcinoma occurrence per month for more than 3 years (Dermatol. Surg. 2009;35:1657-72). Dr. Olbricht noted that hand and foot erythema occurred, which "is supposedly well known with this oral medication."
A meeting attendee asked how Dr. Olbricht manages patients with chronic, multiple squamous cell carcinomas. "I probably have six or seven people for years who come in at least once a month for skin cancer," she replied. "I try to take care of what they have at that moment."
For example, she recently treated a man whose biggest clinical concern is skin cancer 7 years post kidney transplant. "We sent 12 specimens to pathology. We did two Mohs procedures on his face, two excisions on his legs, and the rest were probably electrodesiccation and curettage on his trunk."
"I know I would make more money if I treated each lesion at individual sessions ... but I think this is best approach to this kind of patient," Dr. Olbricht said.
Dr. Olbricht said she had no relevant disclosures.