Managing Cutaneous Malignancies and Field Damage

During the first day of the APP Institute Dermatology 2024, Ted Lain, MD, MBA, FAAD, a board-certified dermatologist and chief medical officer of Sanova Dermatology, and Martha Sikes, DMSc, RPh, PA-C, an assistant professor in the physician assistant program at Emory University, provided an extensive update on the management of cutaneous malignancies and field damage, focusing particularly on non-melanoma skin cancers like basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). He emphasized the importance of following the European consensus-based guidelines, which he considers more comprehensive and recently updated.

For BCC, Dr Lain outlined the treatment protocols according to the stage of the disease. For early-stage (Stage 1) superficial basal cell cancers, particularly in low-risk areas, standard surgery with a margin of 3 to 4 mm is recommended. However, for patients who are not suitable candidates for surgery, topical treatments, such as Imiquimod 5%, 5-fluorouracil (5-FU), and photodynamic therapy (PDT) are viable options, although PDT is not yet approved in the United States. He also mentioned that more aggressive approaches like cryotherapy could be considered for older adult patients who are hesitant about invasive procedures. As the stage progresses, especially for high-risk nodular BCCs in critical areas or those with aggressive subtypes (e.g., micronodular, infiltrative, or metatypical), surgical excision with wider margins or Mohs micrographic surgery is advised. In advanced cases, hedgehog inhibitors or anti-PD1 agents may be considered.

When discussing SCC, Dr Lain focused on the primary management strategies. For low-risk cutaneous SCCs, surgical excision with 5-mm margins is standard, but for higher-risk tumors, Mohs surgery or excisions with larger margins are recommended. He pointed out that for SCC, the emphasis is more on surgical options rather than topical treatments, which are more commonly used in BCC.

Dr Lain then shifted to actinic keratosis (AK), a precursor to SCC, discussing the Olson scale used to grade the severity of AKs. Grade 1 AKs are lesions that are more easily felt than seen, while Grade 3 AKs are hyperkeratotic and can be challenging to differentiate from early SCCs, necessitating biopsy in some cases. He highlighted the importance of aggressive treatment of AKs, especially Grade 3 lesions, as they carry a higher risk of progressing to invasive SCC.

In terms of treatment modalities for AKs, cryotherapy has long been a staple, but Dr Lain emphasized the importance of adequate freeze times to achieve a sufficient clearance rate. He noted that a freeze time of at least 5 seconds is necessary to achieve around a 69% clearance rate, but longer freeze times of over 20 seconds can significantly improve outcomes. He also discussed the evolving risk of AKs progressing to SCC, referencing a study showing that the cumulative incidence of SCC in patients with AK over 10 years is approximately 17%, compared to 5.7% in the control group.

Dr Lain also addressed the importance of patient education, particularly in discussing the risks associated with untreated AKs. He recommended field therapy, which targets sun-damaged areas to reduce the risk of developing SCC. He mentioned the increasing prevalence of SCC in situ and invasive SCC, underlining the importance of early and comprehensive treatment.

When discussing topical treatments, Dr Lain mentioned newer therapies like tirbanibulin, a novel agent approved for AKs that requires only 5 days of application and is associated with minimal local skin reactions compared to traditional treatments like 5-FU or imiquimod. He also discussed the use of combination therapies, such as 5-FU with calcipotriol, which has shown superior efficacy in reducing AKs compared to 5-FU alone, although it is associated with higher local skin reactions.

In summary, this presentation highlighted the latest strategies for managing BCC, SCC, and AK, with an emphasis on following evidence-based guidelines, educating patients on the risks of untreated lesions, and considering both established and emerging treatment modalities to optimize patient outcomes.

For more meeting coverage, visit the APP Institute Dermatology 2024 newsroom.

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Reference
Lain E, Sikes M. Updates in cutaneous malignancies & field damage management. Presented at: APP Institute Dermatology; Aug 16–17, 2024; Virtual.