neoadjuvant Tx LA skin

Mohs surgery is a specific type of surgery to remove different types of skin cancer by cutting away thin layers of skin until negative margins are obtained. For patients with locally advanced disease, however, this treatment modality is often not feasible while in others it can lead to functional or cosmetic defects or require complicated wound healing. To address this issue, there has been a growing interest to use neoadjuvant therapies to shrink skin cancers making them (more) suitable for Mohs surgery. During EADV 2024, Dr Aleksandar Krunic, Mohs surgeon at the Northwestern University in Chicago, provided an overview of the available data on the use of neoadjuvant therapy in patients with non-melanoma skin cancer.

Over the last decade, several new treatment options have emerged for patients with skin cancer. However, large clinical trials evaluating these new agents largely focused on patients with melanoma or patients with very advanced stages of non-melanoma skin cancer. Nevertheless, the number of anecdotal reports and case series evaluating neoadjuvant therapy in patients with non-melanoma skin cancer is accumulating. These reports have shown positive results with the use of neoadjuvant vismodegib in patients with basal cell carcinoma (BCC), with imatinib in patients with dermatofibrosarcoma protuberans and with imiquimod or immune checkpoint inhibitors in patients with sebaceous carcinomas.1 In addition to this, results of a phase II study showed a high rate of pathological complete responses with neoadjuvant cemiplimab in a cohort of patients with resectable cutaneous squamous-cell carcinoma (cSCC).2 Importantly, this study also showed a very low rate of disease recurrence (89% at 1 year), even in patients who did not obtain a major response to the treatment.2

The available data indicate that neoadjuvant therapy is an effective strategy to shrink tumors, making initially inoperable patients eligible for surgery and reducing the risk for functional or aesthetic defects after surgery in patients with an operable non-melanoma skin cancer in a challenging location. Furthermore, the short treatment course that is needed in the neoadjuvant setting leads to a low incidence of toxicity and a good treatment tolerance.

On a final note, Dr Krunic underscored the need for more dedicated clinical trials evaluating neoadjuvant therapies prior to Mohs surgery in patients with non-melanoma skin cancer. He therefore urged pharmaceutical companies to invest in these studies, or provide the necessary drugs to allow academic centers to conduct them.