[Show abstract][Hide abstract] ABSTRACT: This is the protocol for a review and there is no abstract. The objectives are as follows:
To determine the diagnostic accuracy of diagnostic tests for the diagnosis of the keratinocyte skin cancers BCC and cSCC in adults.
Accuracy will be estimated separately according to the target condition and prior testing undergone by study participants, i.e., primary presentation and referred populations.
To estimate and compare the accuracy of diagnostic tests for the detection of any skin cancer.
Investigation of sources of heterogeneity
We will consider a range of potential sources of heterogeneity for investigation in each individual test review. These may vary between reviews but may include the following.
i. Population characteristics
general versus higher risk populations
ii. Index test characteristics
type of test or algorithm used for test interpretation within each 'group' of tests
expert versus generalist practitioner
diagnosis in person versus image-based diagnosis
the nature of and definition of criteria for test positivity
approaches to lesion preparation (e.g., use of keratolytics before exfoliative cytology or of oil for dermoscopy)
iii. Reference standard characteristics
reference standard used
whether histology-reporting meets pathology-reporting guidelines
use of excisional versus diagnostic biopsy
whether two independent dermatopathologists reviewed histological diagnosis
iv. Study quality
consecutive or random sample of participants recruited
index test interpreted blinded to the reference standard result
index test interpreted blinded to the result of any other index test
presence of partial or differential verification bias (whereby only a sample of those subject to the index test are verified by the reference test or by the same reference test with selection dependent on the index test result)
use of an adequate reference standard
overall risk of bias
We will examine the quality and quantity of research evidence available on the effectiveness of each index test and make recommendations regarding where further research might be required.
[Show abstract][Hide abstract] ABSTRACT: Background:
Ingenol mebutate (IngMeb) is a novel patient-applied topical field therapy for actinic keratosis.
To demonstrate the efficacy and safety of follow-up IngMeb field treatment of actinic keratoses (AKs) present at 8 weeks after initial treatment or emerging in a previously cleared field.
In this phase III, randomised, double-blind study in patients with 4-8 clinically visible AKs within a contiguous 25 cm(2) treatment area on the face or scalp, all patients were treated initially with IngMeb 0.015% gel for 3 consecutive days. If lesions were present in the field at 8 weeks, or emerged at week 26 or 44, patients were randomised (2:1) to follow-up IngMeb or vehicle gel for 3 consecutive days. Main outcome was complete clearance rates of AKs 8 weeks after randomisation.
Of 450 patients who received initial treatment with IngMeb, 61.6% demonstrated complete clearance at 8 weeks. Patients with AKs present at 8 weeks or emerging at 26 or 44 weeks were randomised to IngMeb (n = 134) or vehicle (n = 69). IngMeb achieved a higher complete clearance rate than vehicle 8 weeks after randomisation in AKs present at 8 weeks (46.7% vs. 18.4%, P = 0.001) and in emergent AKs (59.5% vs. 25.0%, P = 0.013). Based on those who completed 12 months follow-up (n = 340), the overall 12-month clearance rate was estimated at 50.0%. Follow-up IngMeb treatment was well tolerated.
This study demonstrated long-term benefit of IngMeb 0.015% gel for initial and follow-up therapy. This article is protected by copyright. All rights reserved.
British Journal of Dermatology 10/2015; DOI:10.1111/bjd.14222 · 4.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We read with interest the timely and important article by Nissen and colleagues (1) reporting a significant age-related decline in protoporphyrin IX (PpIX) formation following photodynamic therapy (PDT). As our society ages, studies such as this which aim to explore the relationship of age to the efficacy of various treatments and the underlying molecular mechanisms are increasingly of clinical and economic importance. We feel the age-related reduction in PpIX formation reported may not necessarily translate into clinical relevance. The suggestion of inferior PDT efficacy for treatment of basal cell carcinoma (BCC) in older patients is at odds with our own findings in a larger cohort of BCCs. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
British Journal of Dermatology 08/2015; DOI:10.1111/bjd.14080 · 4.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: While actinic keratoses (AKs) have a known association with cutaneous squamous cell carcinoma (SCC), the relation of actinic field change to SCC has not been quantified. This study investigated the presence of field change and AKs in renal transplant recipients (RTRs) and estimated SCC risk. May 2010 to October 2011, a dermatologist examined 452 white RTRs (mean age 53 years) at two hospitals in Manchester, UK, counting AKs and recording field change presence by body site and SCCs arising during the study period. Of the participants 130 (29%) had AKs at examination. In 60 (13%) RTR patients with AKs but no field change, 4 (7%) developed SCCs, compared with 15 (21%) of the 70 (15%) with AKs and field change. SCCs developed directly within field change areas in 11/15 (73%) RTRs. This study confirms that RTRs with widespread confluent actinic skin damage are at very high risk of SCC and should be monitored closely.
[Show abstract][Hide abstract] ABSTRACT: Basal cell carcinoma (BCC) is a common malignancy with a good prognosis in the majority of cases. However, some BCC patients develop a more advanced disease that poses significant management challenges. Such cases include locally advanced, recurrent or metastatic BCC, or tumours that occur in anatomical sites where surgical treatment would result in significant deformity. Until recently, treatment options for these patients have been limited, but increased understanding of the molecular basis of BCC has enabled potential therapies, such as hedgehog signalling pathway inhibitors, to be developed. A clear definition of advanced BCC as a distinct disease entity and formal management guidelines have not previously been published, presumably because of the rarity, heterogeneity and lack of treatment options available for the disease. Here we provide a UK perspective from a multidisciplinary group of experts involved in the treatment of complex cases of BCC, addressing the key challenges associated with the perceived definition and management of the disease. With new treatments on the horizon, we further propose a definition for advanced BCC that may be used as a guide for healthcare professionals involved in disease diagnosis and management.British Journal of Cancer advance online publication, 11 September 2014; doi:10.1038/bjc.2014.270 www.bjcancer.com.
British Journal of Cancer 09/2014; 111(8). DOI:10.1038/bjc.2014.270 · 4.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Gorlin syndrome is an autosomal dominant disorder, characterized by multiple early-onset basal cell carcinomas (BCCs) and jaw keratocysts. Through association studies in cohorts of sporadic BCC, nine genetic variants have previously been identified to increase the risk of BCC. The nine SNPs were genotyped by Taqman allelic discrimination in 125 individuals with Gorlin syndrome. Kaplan-Meier survival curves and Cox proportional-Hazard regression analysis were applied to determine the association between genotypes and age of first BCC in individuals with Gorlin syndrome. The p.(Arg151Cys) variant in MC1R (rs1805007) was associated with an earlier median age of onset of BCC of 27 years (95% CI: 20-34) compared with 34 years (95% CI: 30-40) for wild-type individuals (hazard ratio (HR)=1.64, 95% CI: 1.04-2.58, P=0.034). The risk allele of the variant at the chromosome 5p15 locus encompassing TERT-CLPTM1L (rs401681) was also associated with an earlier median onset of BCC, 31 years (95% CI: 28-37) compared with 41 years (95% CI: 32-48, HR=1.44, 95% CI: 1.08-1.93, P=0.014). In individuals with a risk allele at either rs1805007 or rs401681 the median time to BCC was 31 years of age (95% CI: 28-34) compared with 44 years of age (95% CI: 38-53) in wild-type individuals (HR=2.48, 95% CI: 1.47-4.17, P=0.0002). Our findings may have implications for future personalized risk estimates and BCC screening strategies in individuals with Gorlin syndrome.European Journal of Human Genetics advance online publication, 27 August 2014; doi:10.1038/ejhg.2014.167.
European journal of human genetics: EJHG 08/2014; 23(5). DOI:10.1038/ejhg.2014.167 · 4.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sattler and colleagues' paper exploring the factors underlying lack of patient adherence to sun protective measures (1) overlooks a potentially critical facet, that of patient preference. Shared decision-making and promotion of patient choice are requisite to good practice, as discussed in a recent editorial (2) and stipulated in the UK dermatology specialty training curriculum. (3) This is perhaps best illustrated in dermatology by the realm of emollients, where patient concordance with prescribed therapy is greater when patients are encouraged to select the emollient of their choice, with patients often preferring lighter cream-based emollients to greasier ointments. This article is protected by copyright. All rights reserved.
British Journal of Dermatology 05/2014; 171(6). DOI:10.1111/bjd.13136 · 4.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A novel, topically applied, short course therapy for actinic keratoses (AK) is now widely licensed following first approval in the USA in 2012. The active agent, ingenol mebutate, is a naturally occurring diterpenoid found in the plant Euphorbia peplus. AK, the most common premalignant dermatological pathology, is increasing in prevalence with increased UV radiation exposure and aging populations, and has the potential to progress to malignant disease. Various treatment modalities exist for AK and the choice for the clinician and patient is now extended with this novel treatment, which requires topical application for only 2 or 3 days, and has cosmetic and tissue-sparing advantages. Ingenol mebutate gel is used as a field-directed therapy, thereby potentially reducing perilesional subclinical AK.
Clinical Practice 05/2014; 11(3):295-306. DOI:10.2217/cpr.14.13
[Show abstract][Hide abstract] ABSTRACT: Interest is increasing in the use of sequential or combined therapeutic modalities for spot or area treatment of actinic keratoses (AKs) to achieve complete sustained remission. For multiple lesions in a contained area, topical treatment offers less discomfort, better cosmesis and greater patient convenience than destructive/ablative techniques. Twelve patients with multiple grade I and II AK lesions of the scalp (cases 1-10) or the dorsum of the hand (cases 11 and 12), most with a history of recurrence, were treated with Solaraze gel (3% diclofenac sodium in 2.5% hyaluronic acid) twice daily for 12 weeks, followed by a 2-week treatment-free interval, then Actikerall cutaneous solution (5-fluorouracil 5 mg/g and salicylic acid 100 mg/g) once daily for up to 6 weeks as required. Sequential treatment provided complete (clinical and histological) clearance in 8/10 male patients. Two patients with numerous lesions had partial clearance (significant improvement) and the remaining few lesions were treated with erbium laser. Both female patients achieved complete clinical clearance with sequential treatment. Solaraze/Actikerall were well tolerated. A case of contact dermatitis with Solaraze resolved after discontinuation and the patient progressed to treatment with Actikerall. Local application site reactions resolved upon treatment completion. Topical lesion-directed sequential treatment with Solaraze/Actikerall is a rational approach to treat patients with multiple AKs. Sequential treatment produces excellent clearance rates which are accompanied by relevant improvement in patients' quality of life.
Case Reports in Dermatology 05/2014; 6(2):164-8. DOI:10.1159/000365070
[Show abstract][Hide abstract] ABSTRACT: Actinic keratosis (AK) is a common skin disease seen in daily practice. It is associated with a risk of progression to invasive squamous cell carcinoma and can be regarded as a marker of increased risk for non-melanoma skin cancer. The use of a field-directed treatment approach reflects the need to initiate early treatment over an affected area to prevent tumour development and local recurrence. Candidate field-directed treatments require a mechanism of action compatible with an effect on field cancerisation, immediate and long-term efficacy against visible lesions and efficacy against subclinical AK. Applicability to large treatment areas, tolerability compatible with long-term use, utility in organ transplant patients and, ideally, evidence of extended long-term activity may also be desirable. We review the evidence of a role for topical diclofenac sodium 3% administered in a 2.5% hyaluronic acid gel (diclofenac/HA) as field-directed treatment. Diclofenac/HA directly targets AK pathophysiology through multiple mechanisms, including induction of apoptosis, inhibition of angiogenesis and reduced inflammation. Clearance of visible field cancerisation is safely and rapidly achieved with a 90-day treatment course in patients with affected areas of up to 50 cm(2) and is associated with a ≥75% reduction in target lesion number score in 85% and 91% of patients, respectively, at 30 days and 1 year post-treatment. Following treatment of AK in high-risk transplant patients, 45% remained free of lesions in the treatment area at 2 years post-treatment. We conclude that diclofenac/HA fulfils most criteria necessary to be considered an appropriate candidate for a field-directed treatment in AK.