Photodynamic therapy with methyl-5-aminolevulinate for basal cell carcinoma: A systematic review and meta-analysis

Basal cell carcinoma (BCC) is the most common type of non-melanoma skin cancer worldwide. Methyl-5-aminolevulinate (MAL) photodynamic therapy (PDT) is an effective and acceptable treatment for BCC. The purpose of this analysis was to compare the benefit and tolerability of MAL-PDT with other modalities for the treatment of BCC.

PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched from inception until 5 August 2019. Eligible studies were prospective and retrospective clinical trials of MAL-PDT for superficial and nodular BCC. At least one of the following outcomes were reported: complete response (CR) at 3 months and sustained at 12 months; recurrence at 12 months and sustained at 5 years; cosmetic outcome at ≥ 3 months; adverse events.

From 427 search results, 11 articles including seven randomized controlled trials (1339 patients; 1568 lesions) and one retrospective study (108 lesions) were eligible. CR was inferior with MAL-PDT versus surgery (3 months: Risk Ratio [RR]: 0.93, 95 % confidence interval [CI] 0.89-0.97, p = 0.002; 12 months: RR: 0.90, 95 % CI 0.85-0.95, p = 0.0002). Moreover, MAL-PDT had higher 12 months recurrence rate (RR: 10.43, 95 % CI 1.98-55.03, p = 0.006) and more toxicities (RR: 2.12, 95 % CI 1.46-3.09, p < 0.0001) in comparison with surgery. However, MAL-PDT cosmesis was superior to excisional surgery (RR: 1.99, 95 % CI 1.50-2.63, p < 0.00001). Additionally, MAL-PDT was associated with similar CR in comparison with 5-aminolaevulinic acid (ALA)-PDT and ALA nanoemulsion (BF-200 ALA)-PDT, but had higher recurrence rate at 12 months and worse cosmesis compared with BF-200 ALA-PDT, even though the differences were not statistically significant.

MAL-PDT might not be the best first-line treatment option for BCC, although cosmetic outcome could be good-to-excellent.