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: Maneesha Nandimandalam, M.B.B.S.[2],Saarah T. Alkhairy, M.D.

Overview

After the suspicious lesion is evaluated, the medical therapy is divided based on low-risk and high-risk basal cell carcinoma patients. Medical therapy consists of topical and systemic therapy. Among topical therapy imiquimod, photodynamic therapy, 5-fluorouracil are included. Systemic therapy consists of sonic hedgehog pathway inhibitors like vismodegib, sonidegib.

Basal Cell Carcinoma Medical Therapy

Once the suspicious lesion is evaluated, the medical therapy is based upon the low-risk and high-risk basal cell carcinoma patients.

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

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.

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

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

The algorithm below demonstrates a follow-up protocol.

The medical therapy for basal cell carcinoma is divided into:

• Toipcal
• Systemic

Topical therapy

• Imiquimod
  • 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 for treatment of small superficial basal cell carcinoma 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 basal cell carcinoma is photodynamic therapy (PDT) with 5-amino levulinic acid(MAL) 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 photodynamic therapy are the pain during the irradiation and the local inflammatory reaction (erythema, erosions, pustules, and crusts).
• 5-fluorouracil
  • 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

• Sonic hedgehog pathway inhibitors(vismodegib, sonidegib)
  • They are markedly teratogenic and embryotoxic.
  • The commonest adverse effects of vismodegib include muscle cramps, hair loss, taste disturbances and weight loss.

Cryotherapy

• Small and superficial basal cell carcinoma is occasionally still treated with liquid nitrogen (–196°C) either with direct contact or using a spray.
• The wounds may heal with either hypopigmentation or scarring so making it a major disadvantage.