Cutting edge techniques provide options for skin cancer

New technologies for managing skin cancer were a topic of discussion at a scientific session at the American Society for Dermatologic Surgery’s 2015 annual meeting in Chicago in October. Seaver L. Soon, M.D., division of dermatology and dermatologic surgery at Scripps Clinic, La Jolla, Calif., was one of the moderators for the scientific discussion titled, “The Cutting Edge: New Technologies for Managing Skin Cancer.”

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Dr. Soon explains that the presentations in this session showed how far the medical community has come in surgical and non-surgical management of skin cancer. “Most exciting are neo-adjuvant treatments for skin cancer,” he says, “such as use of imatinib for dermatofibrosarcoma protuberans, and vismodegib for advanced basal cell carcinoma; these treatments give us an option to decrease tumor burden prior to definitive surgery for particularly advanced tumors, although we will learn how best to use them with more experience and longer term follow-up.”

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He notes novel treatments for keratinocyte carcinoma, including Nd:Yag laser for low-risk basal cell carcinoma, which nets acceptable cure rates and minimal morbidity. He also cites daylight photodynamic therapy (PDT) for actinic keratosis, which demonstrates equivalent efficacy with less patient morbidity compared to traditional PDT. Although surgical management remains the mainstay of skin cancer treatment, Dr. Soon says, “Medical therapies are an exciting addition that will hopefully improve outcomes that are important to patients, such as cosmesis, pain, and healing time.”

NEXT: tapping into available resources

Tapping into available resources

Dr. Soon has some suggestions on how dermatologists can best assess their patients’ skin cancers and advise on appropriate treatment options.

He cites the National Comprehensive Cancer Network (NCCN), which provides up-to-date clinical decision making pathways based on expert consensus and best evidence to guide appropriate evaluation and management as an important resource. Currently available guidelines for skin cancer include basal cell carcinoma, squamous cell carcinoma, dermatofibrosarcoma protuberans, Merkel cell carcinoma and melanoma.

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Dr. Soon says that, in the ASDS session, Siegrid Yu, M.D., from the University of California, San Francisco, presented a compelling argument for the consideration of sentinel lymph node biopsy in all patients presenting with Merkel cell carcinoma, assuming they are surgical candidates.

Obviously, one size doesn’t fit all. So, in what circumstances might some therapies and/or approaches be specifically recommended-or contraindicated? How can dermatologists recognize and manage complications, both of the disease itself and/or of the treatment modalities?

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Dr. Soon believes close clinical follow-up and multi-disciplinary management are key to identifying and managing complications from the disease and from therapy. “For smoothened inhibitors such as vismodegib and sonidegib,” he says, “muscle cramps are a common side effect that may result in treatment discontinuation. A case series recently reported that amlodipine 10 mg daily may be helpful in minimizing this adverse effect, although larger studies are necessary to validate this finding.” 

NEXT: Looking to the future

Looking to the future

Current knowledge certainly influences ongoing research. Dr. Soon sees new technologies are on the horizon, and can speculate on how current knowledge might influence treatment approaches in the years to come.

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“One of the most exciting developments in skin cancer treatment” not covered in the session, he explains, “is immune checkpoint inhibition [PD-1/PD-L1 and CTLA-4 inhibitors] initially born out of studies on melanoma, and now demonstrating positive outcomes in our most difficult patients with squamous cell carcinoma and Merkel cell carcinoma. Management of advanced skin cancer will increasingly be multi-disciplinary, with dermatologic surgeons assuming important roles in organizing management, as we are the first point of contact for many of these patients.”

Disclosure: Dr. Soon is an investigator for Genentech.