PracticeUpdate: Dermatology - Winter 2018

EDITOR’S PICKS 15

The 9-Valent HPV Vaccine for Treatment of Squamous Cell Carcinomas JAMA Dermatology Take-home message

" Although this treatment modality appears promising,

• The authors of this study reported a case of a 90-plus-year-old patient who pre- sented with multiple large tumors on her lower leg, which were found to be basaloid squamous cell carcinomas (SCC). Due to her large tumor burden and age, surgery was not felt to be a viable treatment option, and the patient declined systemic chemotherapy. She was instead treated with two intramuscular doses of the 9-valent HPV vaccine 6 weeks apart, followed by four doses of diluted vaccine administered to the three largest tumors over a period of 8 months. Tumor regression was noted 2 weeks after the second intratumoral dose, and clinical resolution was demonstrated 11 months after the first intratumoral dose. At follow-up 24 months after the first vaccine administration, the patient had no evidence of recurrence. • Complete resolution of a large basaloid SCC tumor burden was achieved by treatment with systemic and intratumoral 9-valent HPV vaccine in a patient who was not a surgical candidate. Even tumors that were not directly injected resolved with no evidence of recurrence 24 months after initiation of treatment. Caitlyn T. Reed MD

additional research is required to assess its mechanism of action. "

Abstract IMPORTANCE Squamous cell carcinoma (SCC) is the second most common form of skin cancer, and its incidence is increasing. When surgical management is not an option, finding a safe and efficacious treatment is a challenge. Mounting evidence suggests that the human papilloma- virus (HPV) is involved in the pathogenesis of some SCCs. OBJECTIVE To assess whether the 9-valent HPV vaccine could be an effective treatment strategy for cutaneous SCC. DESIGN, SETTING, AND PARTICIPANTS A woman in her 90s with multiple, inoperable cutaneous basaloid SCCs was successfully treated at a university-based outpatient dermatology clinic with a combination of systemic and intratumoral delivery of the 9-valent HPV vaccine fromMarch 17, 2016, through February 27, 2017, and then fol- lowed up through May 21, 2018. MAIN OUTCOMES AND MEASURES Reduction in tumor size and number after a combination of systemic and intratumoral administration of the HPV vaccine. RESULTS All tumors resolved 11 months after the first intratumoral injection of the vaccine. The patient remained free of tumors at the end of follow-up. CONCLUSIONS AND RELEVANCE This is the first report, to our knowledge, of complete regres- sion of a cutaneous malignant tumor after combined systemic and direct intratumoral injec- tion of the 9-valent HPV vaccine. This report suggests that the HPV vaccine may have ther- apeutic utility for SCCs in patients who are poor surgical candidates, have multiple lesions, or defer surgery. Combined Systemic and Intratumoral Admin- istration of Human Papillomavirus Vaccine to Treat Multiple Cutaneous Basaloid Squamous Cell Carcinomas. JAMA Dermatol 2018 Jul 03;[EPub Ahead of Print], AJ Nichols, A Gonza- lez, ES Clark, et al. www.practiceupdate.com/c/70610

COMMENT By Stephen K. Tyring MD, PhD , Uyen Ngoc Mui MD and Ravi Patel MD T he majority of cutaneous squamous cell carcinoma (SCC) is successfully treated via surgical means. However,

associated with B-HPV types 5, 8, 15, 17, 20, 24, 36, and 38, whereas 9-valent HPV vaccinations protect against types 6, 11, 16, 18, 31, 33, 45, 52, and 58. Although this treatment modality appears prom- ising, additional research is required to assess its mechanism of action. In addi- tion, a clinical trial may be warranted to further assess safety and efficacy in a larger patient population.

high-risk, inoperable SCCs warrant alternative treatment modalities. The report by Nichols et al demonstrates the first case of complete resolution of multiple cutaneous SCCs via a combination of off-label systemic and intratumoral administration of 9-valent HPV vaccine. An immunocompetent 90-year-old woman presented due to multiple large, nontender tumors on her right leg. Biopsy and subsequent analysis determined the lesions to be primary basaloid SCC. Due to the patient’s advanced age and tumor burden, alternative treatment to sur- gery and radiotherapy was considered. The authors administered two doses of intramuscular 9-valent HPV vaccination followed by a total of four intratumoral HPV injections spanning the subsequent 8 months. Complete tumor regression was evident 11 months after the first intratumoral vaccination. No significant adverse events were noted. The authors surmise that the resolution of this patient’s basaloid SCC most likely reflects a multifactorial response involv- ing antiviral, antitumor, and immunologic effects of vaccination. Development of cutaneous SCC is most commonly

Dr. Tyring is Clinical Professor in the Departments of Dermatology, Microbiology/ Molecular Genetics and Internal Medicine at the University of Texas Health Science Center at Houston, Texas. Dr. Mui received her MD degree from the University of Texas Medical Branch. She is currently a Clinical Research Fellow at the Center for Clinical Studies under the direction of Dr. Stephen Tyring. Dr. Patel is a Fellow at the Center for Clinical Studies, Webster, Texas.

VOL. 2 • NO. 3 • 2018