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Guideline Updates

NCCN Updates Treatment Guideline for Type of Skin Cancer

November 04, 2019

The National Comprehensive Cancer Network (NCCN) released updates to its treatment guideline for basal cell skin cancer.

In the section for clinical presentation, workup, and risk status, the first statement now reads, “Lesion suspicious for skin cancer.” A pathway was added under risk status: initial presentation of advanced disease. This pathway directs readers to the section for treatment for recurrence or advanced disease.

The section for treatment for local, low-risk disease features a minor change. Under adjuvant treatment, the abbreviation “CCPDMA” is listed and defined in the footnotes as “complete circumferential peripheral and deep margin assessment.” This abbreviation is used throughout the guideline.

A variety of changes were made to the section for treatment for local, high-risk disease. Under primary treatment options, the options for non-surgical candidates are now radiotherapy or systemic therapy if curative radiotherapy is not feasible. “Adjuvant treatment” was changed to “additional treatment,” and these options were revised extensively. Listed in the algorithm for positive margins following Mohs micrographic surgery or resection with CCPDMA are multidisciplinary consultation to discuss options, followed by resection if feasible, radiotherapy, and systemic therapy if curative radiotherapy and/or curative surgery is not feasible.

For positive margins following standard excision with wider surgical margins and postoperative margin assessment and with linear or delayed repair, the guideline recommends Mohs micrographic surgery or resection with CCPDMA if feasible or standard re-excision if CCPDMA is not feasible. If residual disease is present and further surgery is not feasible, the recommendation is to consider multidisciplinary consultation to discuss options, followed by radiotherapy or systemic therapy if curative radiotherapy is not feasible.

In the section for follow-up and recurrence or advanced disease, a bullet was added under follow-up: consider imaging if clinical exam is insufficient for following disease. The options for recurrence or advanced disease were revised; the pathway for patients with nodal or distant metastases now lists multidisciplinary consultation to discuss options, followed by hedgehog pathway inhibitors (vismodegib and sonidegib), surgery, radiotherapy, and clinical trials.

In the section for principles of pathology, the first bullet under principles of biopsy reporting now reads, “Pathologic evaluation of skin biopsies is ideally performed by a dermatologist, pathologist, or dermatopathologist who is experienced in interpreting cutaneous neoplasms.”

Two significant changes were made to the section for principles of treatment for basal cell skin cancer. The fourth bullet now reads, “In patients with low-risk, superficial basal cell skin cancer, where surgery and radiotherapy are not feasible, therapies such as topical imiquimod, topical 5-fluorouracil, photodynamic therapy, or vigorous cryotherapy may be considered, even though the cure rates may be lower than with surgical treatment modalities.” The final bullet was also modified to read, “Systemic therapy may be considered for complicated cases of locally advanced disease if curative surgery and curative radiotherapy are not feasible. Systemic therapy may be considered for cases of nodal or distant metastatic disease, especially if surgery and radiotherapy are not feasible.”—Zachary Bessette

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