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Guideline Updates

NCCN Updates Clinical Practice Guidelines for Multiple Skin Cancers

October 07, 2019

The National Comprehensive Cancer Network (NCCN) recently released updated clinical practice guidelines for squamous cell skin cancer as well as for merkel cell carcinoma.

In the algorithm for clinical presentation of squamous cell skin cancer, a pathway for diagnosis and risk status was modified: “Clinically or radiographically concerning regional lymph nodes or Distant metastatic disease.”

The heading “Adjuvant Treatment” was removed throughout all algorithms in the guideline and the phrase “complete circumferential margin assessment” was replaced with “CCPDMA.” Similarly, the phrase “multidisciplinary tumor board consultation” was replaced with “multidisciplinary consultation” throughout the guideline.

Multiple changes were made to the algorithm for primary treatment of local, high-risk squamous cell skin cancer (if patient is immunosuppressed, consider modification or reduction of immunosuppression as appropriate). For non-surgical candidates, the guideline now lists systemic therapy as an option if curative radiotherapy is not feasible. The top pathway options for patients with positive margins after Mohs micrographic surgery or resection with CCPDMA were modified; the guideline now suggests re-resection if feasible, radiotherapy plus systemic therapy, or systemic therapy if curative radiotherapy is not feasible. The bottom pathway options for patients with positive margins after standard excision were also modified: Mohs micrographic surgery or resection with CCPDMA if feasible, or standard re-excision if CCPDMA is not feasible. Additionally, if residual disease is persistent and further surgery is not feasible, the guideline suggests radiotherapy plus systemic therapy or systemic therapy if curative radiotherapy is not feasible.

In the algorithm for primary treatment of inoperable disease, the same suggestions are listed. After primary treatment, the guideline now directs users to the follow-up algorithm.

A page for principles of systemic therapy was added to the guideline.

Similar modifications were made to the clinical practice guideline for merkel cell carcinoma. In the algorithm for lesions suspicious for skin cancer, “multidisciplinary consultation recommended” is now listed in the additional workup.

In the algorithm for primary and adjuvant treatment of clinical N0 disease and for sentinel lymph node-positive diagnosis, the guideline offers “clinical trial for adjuvant therapy preferred, if available” as an option.

The algorithm for follow-up visits featured multiple modifications. For local and/or regional disease, options now include clinical trial preferred if available; any combination or single use of systemic therapy, radiotherapy, and surgery; and best supportive care.

In the section for principles of systemic therapy, a bullet was added for local disease: “Recurrent locally advanced.” Under this bullet, a sub-bullet was added to consider pembrolizumab if curative surgery and curative radiotherapy are not feasible. The same sub-bullet was added for recurrent regional disease.—Zachary Bessette

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