Eugênio R. A. Pimentel

Treatment of Cutaneous Tumors with Topical 5% Imiquimod Cream

INTRODUCTION There are various approaches to the treatment of cutaneous tumors; one of them is treatment with imiquimod, a synthetic toll-like receptor agonist with a low molecular weight that offers a topical, noninvasive, and non-surgical therapeutic option. The main objective of our study was to provide data on 89 patients who used a 5% imiquimod cream for the treatment of cutaneous tumors at the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas from 2003 to 2008. MATERIALS AND METHODS Here, we present our experience in the treatment of 123 cutaneous tumors of various types, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), Bowen’s disease, erythroplasia of Queyrat, Paget’s disease, and trichoepithelioma, with 5% imiquimod cream from 2003 to 2008 in the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas. Patients were divided into two separate groups according to their diagnosis and comorbidities; these comorbidities included epidermodysplasia verruciformis, xeroderma pigmentosum, albinism, basal cell nevus syndrome, Brooke-Spiegler syndrome, HIV, chronic lymphocytic leukemia, B-cell lymphoma, and kidney transplantation. Treatment duration, response to imiquimod, follow-up, recurrence, and local and systemic reactions associated with use of the drug were analyzed. Epidemiological data were obtained and cure rates were calculated. RESULTS The ratio of women to men was 1.28:1, and the mean age was 63.1 years. Tumors were located mainly on the face, back, trunk, and legs. For patients with comorbidities, the overall cure rate was 38%. These specific patients demonstrated cure rates of 83.5% for superficial BCC and 50% for Bowen’s disease. Aggressive BCC and superficial and nodular BCC did not present a good response to treatment. Trichoepitheliomas and nodular BCC showed a partial response, and erythroplasia of Queyrat showed a complete response. For patients without comorbidities, the overall cure rate was 73%. For these patients, the cure rates were 85.7% for superficial and nodular BCC, 88% for superficial BCC, 57% for Bowen’s disease, 50% for nodular BCC, and 50% for aggressive BCC. One SCC lesion demonstrated a complete response, and tumors caused by Paget’s disease and erythroplasia of Queyrat presented a partial response. None of the tumors considered as clinically cured recurred. Thirty-seven lesions demonstrated no response to imiquimod. Having a cutaneous comorbidity, high-risk tumors such as mixed aggressive BCC (sclerodermiform or micronodular), nodular BCC, or Bowen’s disease, and presenting no local reaction to imiquimod were considered as risk factors for a worse prognosis. We demonstrate that patients with no response to imiquimod, even when they demonstrated no local reaction, can undergo another cycle of six weeks of imiquimod treatment and show a complete response. The healing pattern led to good cosmetic outcomes, and the side effects were tolerable. CONCLUSIONS Our experience confirms imiquimod as an effective treatment option for several types of cutaneous tumors, especially in patients without the cutaneous comorbidities cited above and with low-risk tumors. Imiquimod has a relatively low cost compared to other therapeutic options and can be delivered via ambulatory care to patients with surgery contraindications, and its side effects are tolerable.

High numbers of human skin cancers express MMP2 and several integrin genes

Background:  Basal cell carcinomas (BCC), squamous cell carcinomas (SCC) and cutaneous malignant melanoma (MM) are solid skin cancers derived from different cell types, with different ability to metastasize. Several subtypes of integrins and matrix metalloproteinases (MMP) have been related to malignization and metastasis processes. This work aimed at a quantitative evaluation of skin cancers expressing eight integrins and MMP2 genes.

PTCH1 gene mutations in exon 17 and loss of heterozygosity on D9S180 microsatellite in sporadic and inherited human basal cell carcinomas

Background  Basal cell carcinomas (BCCs) are the most frequent human cancer that results from malignant transformation of basal cells in the epidermis. Gorlin syndrome is a rare inherited autosomal dominant disease that predisposes with multiple BCCs and other birth defects. Both sporadic and inherited BCCs are associated with mutations in the tumor suppressor gene PTCH1, but there is still uncertainty on the role of its homolog PTCH2.

Letter: Giant Superficial Basal Cell Carcinoma Treated with Cryosurgery

A 55-year-old Caucasian male patient was seen in our clinic for a large pruritic lesion on his chest, which slowly evolved over a period of 18 years. During all those years, the lesion had been treated as seborrheic dermatitis with topical steroids. Dermatologic examination revealed an erythematous, minimally infiltrated, and well-delimitated plaque measuring 18 13 cm on his chest. The center of the lesion was occasionally atrophic or covered with meliceric and hematic crust. The periphery of the lesion had a striking pearly appearance (Figure 1). The clinical diagnosis of superficial basal cell carcinoma (BCC) was confirmed by histopathologic analyses of five biopsies, representing distinct lesional sites and including the most infiltrated areas (Figure 2). For treatment sake, owing to its unusual size, the tumor was divided into several sections, each measuring about 9 cm. Diametrically opposed sections were treated monthly by cryosurgery with liquid nitrogen. Up to four sections were treated at a single visit. Two freezing-thawing cycles were delivered for each section, using open spray technique. A cryosurgical unit was used (Cry-Ac, Brymill Cryogenic Systems, Ellington, CT). Each cycle comprised 1minute freezing followed by 3-minute thawing. Whereas biopsies were taken using local anesthesia, cryosurgery was performed without anesthesia by patient’s own request. Treated areas evolved with blisters and crust and were treated with antibiotic ointment dressings. There were no systemic postoperative side effects. Complete reepithelialization was usually achieved within 6 weeks. Several sessions were needed to treat the whole tumor. Two months after the last treatment, clinical exam revealed only atrophic and hypopigmented areas, without signs of residual tumor. One year later, control biopsies (one for each quadrant) were performed demonstrating only cicatricial fibrosis. The patient has been under complete remission for 6 years (Figure 3).

Fatores preditivos do maior número de estádios na cirurgia micrográfica de Mohs para o tratamento do carcinoma espinocelular da cabeça

FUNDAMENTOS: Os carcinomas espinocelulares da pele da cabeca tem como opcao terapeutica mais segura a cirurgia micrografica de Mohs, que apresenta os menores indices de recidiva e a maxima preservacao tecidual. Caracteristicas dos carcinomas espinocelulares podem estar relacionadas a maior numero de estadios cirurgicos. OBJETIVO: Definir caracteristicas dos carcinomas espinocelulares que sejam preditoras de maior numero de estadios na cirurgia de Mohs. METODOS: Analise retrospectiva de 51 carcinomas espinocelulares da cabeca tratados pela cirurgia de Mohs para determinar fatores de risco de maior numero de estadios. Foram analisados limites clinicos, morfologia, recidiva, histologia e tamanho, relacionando-os ao numero de estadios cirurgicos. A analise estatistica foi realizada pelo teste exato de Fisher e regressao logistica multivariada. RESULTADOS: Os carcinomas recidivados tiveram tendencia a maior numero de estadios (p=0,081). Os tumores com limites imprecisos apresentaram tres vezes mais possibilidades de maior numero de fases na analise da razao de chances. Esse achado foi compativel com dados da literatura, apesar de nao ter sido estatisticamente significante. CONCLUSAO: Caracteristicas pre-operatorias dos carcinomas espinocelulares, como recidiva e limites imprecisos, apesar de nao preditivas, indicaram tendencia a maior numero de estadios na cirurgia micrografica de Mohs.

Indication guidelines for Mohs micrographic surgery in skin tumors

Mohs micrographic surgery is a technique used to excise skin tumors based on comprehensive surgical mapping, in which the surgeon removes the tumor, followed by a complete histological evaluation of the tumors margins. The correlation of the presence of a tumor in histological examinations and its precise location on the surgical map result in a complete removal of the tumor with maximum normal tissue preservation. The present article seeks to provide general practitioners and healthcare specialists with guidelines regarding recommendations for Mohs micrographic surgery to treat skin tumors, based on the most reliable evidence available in medical literature on the subject. This bibliographic review of scientific articles in this line of research was conducted based on data collected from MEDLINE/PubMed. The search strategy used in this study was based on structured questions in the Patient, Intervention, Control, and Outcome (PICO) format. MeSH terms were used as descriptors. The indications of this technique are related to recurrence, histology, size, definition of tumor margins, and location of tumors. These guidelines attempt to establish the indications of Mohs surgery for different types of skin tumors.

Carcinoma basocelular em localizações incomuns

The authors present five patients who develop basal cell carcinomas in sites this tumor rarely occurs. The aim is to report the rare location of this frequent cutaneous malignancy and to briefly discuss the concept of unusual location of basal cell carcinoma.

Risco de complicações durante a cirurgia dermatológica: protocolo das exéreses em fuso

FUNDAMENTOS: A cirurgia dermatologica e pratica comum no dia-a-dia do dermatologista, havendo portanto necessidade de estudos que demonstrem a seguranca do procedimento. OBJETIVO: Criacao de protocolo que avaliasse o risco de complicacoes durante e imediatamente apos a cirurgia dermatologica, sobretudo em pacientes com co-morbidades clinicas. METODOS: Foram realizadas 860 exereses em fuso no periodo de janeiro de 2001 a novembro de 2003, sendo todas protocoladas segundo algumas variaveis - como idade e sexo do paciente, tipo de lesao excisada, doencas associadas e uso de medicacoes, tamanho do fuso, tempo de cirurgia, tipo e quantidade de anestesico utilizado e afericao da pressao arterial -, correlacionando-as ao risco de complicacoes. RESULTADOS: Dos 860 pacientes operados, 64,6% nao apresentaram nenhuma complicacao; 34,6% apresentaram elevacao da pressao arterial sem repercussao clinica; 0,5% apresentaram sangramento importante que pode ser controlado; dois pacientes apresentaram hipotensao arterial. CONCLUSAO: A cirurgia dermatologica e muito segura, podendo ser realizada em consultorios ou ambulatorialmente, consistindo, na maioria dos casos, em procedimento pequeno e rapido, sendo o risco de complicacoes muito baixo.

Elastosis Perforans Serpiginosa

Elastosis perforans serpiginosa is an uncommon and chronic dermatosis characterized by transepidermal elimination of abnormal elastic fibers originating in the dermis. Diagnosis is based on clinical and histopathologic aspects. Treatment has included various modalities and cryotherapy is one of the effective options. Favored method includes the use of open spray timed spot freeze technique and one to two sessions are usually enough to treat some grouped papules.

Placing Preemptive Hemostatic Sutures before Incising Highly Vascularized Lesions

Most dermatologists are well trained to perform office-based skin surgery. Nevertheless, many of them do not perform biopsies when faced with highly vascularized lesions. Such reluctance is comprehensible because most skin surgical complications involve difficulties with hemostasis. Accordingly, dermatologists might refer those cases to a general surgeon, owing to a concern for excessive bleeding. Postponing biopsies may delay the histopathologic diagnosis of malignant tumors, increasing morbidity and patient dissatisfaction.