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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®)
Basal Cell
Skin Cancer
Version 1.2016
Continue
NCCN.org
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NCCN Guidelines Index
Basal Cell TOC
Discussion
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Version 1.2016 Panel Members
Basal Cell Skin Cancer
Roy C. Grekin, MD ϖ ¶UCSF Helen Diller FamilyComprehensive Cancer Center
Kenneth Grossman, MD, PhD †Huntsman Cancer Institute atthe University of Utah
Susan Higgins, MD, MS ф Yale Cancer Center/Smilow Cancer Hospital
Alan L. Ho, MD, PhD †Memorial Sloan Kettering Cancer Center
Karl D. Lewis, MD †University of Colorado Cancer Center
Daniel D. Lydiatt, DDS, MD ¶ ζFred & Pamela Buffett Cancer Center
Kishwer S. Nehal, MD ϖ ¶Memorial Sloan Kettering Cancer Center
Paul Nghiem, MD, PhD ϖFred Hutchinson Cancer Research Center/SeattleCancer Care Alliance
Elise A. Olsen, MD ϖ Duke Cancer Institute
Chrysalyne D. Schmults, MD ϖDana-Farber/Brigham and Women’s Cancer Center Massachusetts General Hospital Cancer Center
Aleksandar Sekulic, MD, PhD ϖMayo Clinic Cancer Center
Ashok R. Shaha, MD ¶ ζ
Memorial Sloan Kettering Cancer Center
Wade L. Thorstad, MD §Siteman Cancer Center at Barnes-Jewish Hospital and WashingtonUniversity School of Medicine
Malika Tuli, MD ϖSt. Jude Children’s Research Hospital/University of TennesseeHealth Science Center
Marshall M. Urist, MD ¶University of Alabama at BirminghamComprehensive Cancer Center
Timothy S. Wang, MD ϖThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins
Sandra L. Wong, MD, MS ¶University of MichiganComprehensive Cancer Center
John A. Zic, MD ϖ
Vanderbilt-Ingram Cancer Center
NCCN
Anita Engh, PhDKarin G. Hoffmann, RN, CCM Continue NCCN Guidelines Panel Disclosures
ϖ Dermatology ф Diagnostic/Interventional radiology¶ Surgery/Surgical oncologyζOtolaryngology≠ Pathology/Dermatopathology† Medical oncologyƿ Internal medicine§ Radiotherapy/Radiation oncology‡ Hematology/Hematology oncology
* Discussion Section Writing Committee
Christopher K. Bichakjian, MD/Chair ϖUniversity of MichiganComprehensive Cancer Center
Thomas Olencki, DO/Vice-Chair †The Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute
Sumaira Z. Aasi, MD ϖStanford Cancer Institute
Murad Alam, MD ϖ ¶ ζRobert H. Lurie Comprehensive CancerCenter of Northwestern University
James S. Andersen, MD ¶City of HopeComprehensive Cancer Center
Daniel Berg, MD ϖFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance
Glen M. Bowen, MD ϖHuntsman Cancer Instituteat the University of Utah
Richard T. Cheney, MD ≠
Roswell Park Cancer Institute
Gregory A. Daniels, MD, PhD ‡ ƿ
UC San Diego Moores Cancer Center
L. Frank Glass, MD ϖ ≠Moftt Cancer Center
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Clinical Trials: NCCN believes thatthe best management for any cancerpatient is in a clinical trial.Participation in clinical trials isespecially encouraged.
To nd clinical trials online at NCCNMember Institutions, click here:nccn.org/clinical_trials/physician.html.
NCCN Categories of Evidence andConsensus: All recommendationsare category 2A unless otherwisespecied.
See NCCN Categories of Evidenceand Consensus.
The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.
Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or
warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network®
. All rights reserved. The NCCN Guidelines and the illustrations herein maynot be reproduced in any form without the express written permission of NCCN. ©2015.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Basal Cell Skin Cancer Panel Members
Summary of the Guidelines Updates
Basal Cell Skin Cancer (BCC)
BCC Clinical Presentation, Workup, and Risk Status (BCC-1)BCC Primary and Adjuvant Treatments• Low Risk (BCC-2)
• High Risk (BCC-3)
BCC Follow-up and Recurrence (BCC-4)
BCC Risk Factors for Recurrence (BCC-A)
Principles of Treatment for Basal Cell Skin Cancer (BCC-B)
Principles of Radiation Therapy for Basal Cell Skin Cancer (BCC-C)
NCCN Guidelines Version 1.2016 Table of Contents
Basal Cell Skin Cancer
NCCN Guidelines Index
Basal Cell TOC
Discussion
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NCCN Guidelines Index
Basal Cell TOC
Discussion
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
UPDATES
NCCN Guidelines Version 1.2016 Updates
Basal Cell Skin Cancer
• Footnote “n” is new to this page: “Current FDA-approved hedgehog pathway inhibitors include vismodegib and sonidegib.”
• Footnote “o” is new to this page: “If no further skin cancers are identified in the first 2 years, then less frequent follow-up may be
appropriate.”
BCC-A• Footnote “1”:
Was added to “Area M <10 mm” under “Low Risk”, removed from “Area H ≥6 mm”, under “High Risk” and modied: “Location independent
of size may constitute high risk. in certain clinical settings.”
• Footnote “3” was revised: “Having morpheaform, basosquamous (metatypical), sclerosing, mixed inltrative, or micronodular features
is any portion of the tumor. In some cases basosquamous (metatypical) tumors may be prognostically similar to SCC. Clinicopathologic
consultation is recommended.”
Updates in Version 1.2016 of the NCCN Guidelines for Basal Cell Skin Cancer from Version 1.2015 include:
Basal Cell Skin Cancer
BCC-2• For “Primary treatment of low-risk basal cell skin cancer” under “Curettage and electrodesiccation”:Bullet 1 statement: “In non-hair bearing areas” revised: “Excluding terminal hair-bearing areas, such as scalp, pubic, axillary regions,
and beard area in men”.Bullet 2 statement: “If adipose reached, surgical excision should generally be performed”, an arrow was added pointing directly to
“Standard excision”.
BCC-3
• Under “Adjuvant Treatment”:
For “Standard excision” when margins are positive, a statement was modied: “If residual disease is present, and further surgery and RT
are contraindicated, consider multidisciplinary tumor board consultation (consider vismodegib a hedegehog pathway inhibitor or clinical
trials)”
For “Mohs or resection” as primary treatment when margins are positive, a statement was modied: “RT and/or multidisciplinary tumorboard consultation (consider a hedgehog pathway inhibitor or clinical trial)”
Footnote “n” added: “Current FDA approved hedgehog pathway inhibitors include vismodegib and sonidegib.”
BCC-4
• Under “Recurrence”:
“Regional” was removed and statement “Surgery and/or RT” was added to revised: “Nodal or distant metastases”
Statement revised: “Multidisciplinary tumor board consultation (consider a hedgehog pathway inhibitor vismodegib or clinical trials)”
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P i t d b F d N h 12/27/2015 8 56 35 PM F l l N t d f di t ib ti C i ht © 2015 N ti l C h i C N t k I All Ri ht R d
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Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
CLINICAL PRESENTATION WORKUP RISK STATUS
Suspicious lesion
• H&P
• Complete skin exam
• Biopsy
If more than supercial lesion,
inclusion of deep reticular
dermis preferreda
• Imaging studies as indicated for
suspicion of extensive diseaseb
Low riska
High riska,c
See Primary Treatment of Low-Risk
Basal Cell Skin Cancer (BCC-2)
See Primary Treatment of High-Risk
Basal Cell Skin Cancer (BCC-3)
aSee Risk Factors for Recurrence (BCC-A).bExtensive disease includes deep structural involvement such as bone, perineural disease, and deep soft tissue. If perineural disease is suspected, MRI is preferred.c Any high-risk factor places the patient in the high-risk category.
BCC-1
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Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
PRIMARY TREATMENTd ADJUVANT TREATMENT
Low-risk basal cell
skin cancer a,d
Curettage and electrodesiccation:
• Excluding terminal hair-bearing areas, such as scalp,pubic, axillary regions, and beard area in men
• If adipose reached, surgical excision should generally be
performed
or
Standard excision:
• If lesion can be excised with
4-mm clinical margins and
second intention healing,
linear repair, or skin grafte
or
RTf,g for non-surgical
candidates
Margins
Positive
Negative
Mohs or resection
with complete margin
assessmenth
or
Standard re-excision
for area L regionsi
or
RTffor non-surgical
candidatesSee Follow-up(BCC-4)
aSee Risk Factors for Recurrence (BCC-A).dSee Principles of Treatment for Basal Cell Skin Cancer (BCC-B).eClosures like adjacent tissue transfers, in which significant tissue rearrangement occurs, are best performed after clear margins are verified.f See Principles of Radiation Therapy for Basal Cell Skin Cancer (BCC-C).gRT often reserved for patients over 60 years because of concerns about long-term sequellae.hExcision with complete circumferential peripheral and deep margin assessment (CCPDMA) with frozen or permanent section is an alternative to Mohs surgery.i Area L = trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). (See BCC-A)
BCC-2
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Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
BCC-3
PRIMARY TREATMENTd ADJUVANT TREATMENT
High-risk basal cell
skin cancer a,c,d,j
Standard excision
Wider surgical margins
with linear or delayed
repair are recommended
when excising high-risk
tumors with standard
re-excisione
Mohs or
resection with
complete margin
assessmenth
or
RTf,g for non-surgical
candidates
k
Margins
Margins
Positive
Negative
Negative
Positivel
Mohs or resection
with complete
marginassessmenth
or
RTf
If residual disease is
present, and further
surgery and RT arecontraindicated,
consider
multidisciplinary
tumor board
consultation
(consider a hedgehog
pathway inhibitor n or
clinical trial) See
Follow-up
(BCC-4)
aSee Risk Factors for Recurrence (BCC-A).c Any high-risk factor places the patient in the high-risk category.dSee Principles of Treatment for Basal Cell Skin Cancer (BCC-B).eClosures like adjacent tissue transfers, in which significant tissue rearrangement occurs, are best performed after clear margins are verified.f See Principles of Radiation Therapy for Basal Cell Skin Cancer (BCC-C).gRT often reserved for patients over 60 years because of concerns about long-term sequellae.hExcision with complete circumferential peripheral and deep margin assessment (CCPDMA) with frozen or permanent section is an alternative to Mohs surgery.
jFor complicated cases, consider multidisciplinary tumor board consultation.kIf surgery and RT are contraindicated, consider multidisciplinary tumor board consultation and therapy.lNegative margins unachievable by Mohs surgery or more extensive surgical procedures.mIf large nerve involvement is suspected, consider MRI to evaluate extent and rule out base of skull involvement.nCurrent FDA-approved hedgehog pathway inhibitors include vismodegib and sonidegib.
If extensive
perineural
or large-nerve
involvementm
recommendadjuvant RTf
RTf
and/or
Multidisciplinary tumor board consultation
(consider a hedgehog pathway inhibitor n or
clinical trial)
or
ted by e a do a uc e o / / 0 5 8 56 35 o pe so a use o y ot app o ed o d st but o Copy g t © 0 5 at o a Co p e e s e Ca ce et o , c , g ts ese ed
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Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
FOLLOW-UP RECURRENCE
H&P
• Including complete skin exam
every 6-12 mo for lifeo
Patient education:
• Sun protection
• Self-examination
Local
Nodal or
distant metastases
Follow Primary Treatment Pathways (BCC-1)
BCC-4
kIf surgery and RT are contraindicated, consider multidisciplinary tumor board consultation and therapy.nCurrent FDA-approved hedgehog pathway inhibitors include vismodegib and sonidegib.oIf no further skin cancers are identified in the first 2 years, then less frequent follow-up may be appropriate.
Surgery and/or RTk
Multidisciplinary tumor board consultation
(consider a hedgehog pathway inhibitor n or
clinical trials)
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Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
BCC-A
H&P
Location/size
Borders
Primary vs. Recurrent
Immunosuppression
Site of prior RT
Pathology
Subtype
Perineural involvement
RISK FACTORS FOR RECURRENCE
Low Risk
Area L <20 mm
Area M <10 mm1
Area H <6 mm1
Well dened
Primary
(-)
(-)
Nodular, supercial2
(-)
High Risk
Area L ≥20 mm
Area M ≥10 mm
Area H ≥6 mm
Poorly dened
Recurrent
(+)
(+)
Aggressive growth pattern3
(+)
Area H = “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips [cutaneous and vermilion], chin, mandible, preauricular and postauricular
skin/sulci, temple, ear), genitalia, hands, and feet.
Area M = cheeks, forehead, scalp, neck, and pretibia.
Area L = trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles).
1Location independent of size may constitute high risk. 2Low risk histologic subtypes include nodular, superficial and other non-agressive growth patterns such as keratotic, infundibulocystic, and fibroepithelioma of Pinkus.3Having morpheaform, basosquamous (metatypical), sclerosing, mixed infiltrative, or micronodular features in any portion of the tumor. In some cases basosquamous (metatypical) tumors may be prognostically similar to SCC. Clinicopathologic consultation is recommended.
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Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
BCC-B
• The goal of primary treatment of basal cell skin cancer is the cure of the tumor and the maximal preservation of function and
cosmesis. All treatment decisions should be customized to account for the particular factors present in the individual case and
for the patient’s preference. Customary age and size parameters may have to be modied.
• Surgical approaches often offer the most effective and efcient means for accomplishing cure, but considerations of function,
cosmesis, and patient preference may lead to choosing radiation therapy as primary treatment in order to achieve optimal overallresults.
• In certain patients at high risk for multiple primary tumors, increased surveillance and consideration of prophylactic measures
may be indicated.
• In patients with low-risk, supercial basal cell skin cancer, where surgery or radiation is contraindicated or impractical, topical
therapies such as 5-uorouracil, imiquimod, photodynamic therapy (eg, aminolevulinic acid [ALA], pormer sodium), or vigorous
cryotherapy may be considered, even though the cure rate may be lower.
PRINCIPLES OF TREATMENT FOR BASAL CELL SKIN CANCER
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Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 1.2016, 10/26/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®.
NCCN Guidelines Index
Basal Cell TOC
Discussion
NCCN Guidelines Version 1.2016
Basal Cell Skin Cancer
BCC-C
PRINCIPLES OF RADIATION THERAPY FOR BASAL CELL SKIN CANCER
Tumor Diameter
<2 cm
Margins
1–1.5 cm1
Examples of Electron Beam Dose and Fractionation
64 Gy in 32 fractions over 6–6.4 weeks2
55 Gy in 20 fractions over 4 weeks
50 Gy in 15 fractions over 3 weeks
35 Gy in 5 fractions over 5 days
Dose and Field Size
≥2 cm 1.5–2 cm1 66 Gy in 33 fractions over 6–6.6 weeks55 Gy in 20 fractions over 4 weeks
Postoperative adjuvant 50 Gy in 20 fractions over 4 weeks
60 Gy in 30 fractions over 6 weeks
• Protracted fractionation is associated with improved cosmetic results.
• Radiation therapy is contraindicated in genetic conditions predisposing to skin cancer(eg, basal cell nevus syndrome, xeroderma pigmentosum) and connective tissue diseases (eg, scleroderma)
1When using electron beam, wider field margins are necessary than with orthovoltage x-rays due to the wider beam penumbra. Tighter field margins can be usedwith electron beam adjacent to critical structures (eg, the orbit) if lead skin collimation is used. Bolus is necessary when using electron beam to achieve adequatesurface dose. An electron beam energy should be chosen which achieves adequate surface dose and encompasses the deep margin of the tumor by at least thedistal 90% line. Appropriate medical physics support is essential.
2Electron beam doses are specified at 90% of the maximal depth dose (Dmax). Orthovoltage x-ray doses are specified at Dmax (skin surface) to account for the
relative biologic difference between the two modalities of radiation.
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NCCN Guidelines IndexNCCN Guidelines Version 1.2016
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NCCN Guidelines IndexBCC Table of Contents
Discussion
NCCN Guidelines Version 1.2016Basal Cell Skin Cancer
Unresectable Squamous Cell Carcinoma of the Skin. J Clin Oncol
2011;29:3419-3426. Available at:http://www.ncbi.nlm.nih.gov/pubmed/21810686.
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140. Brewster AM, Lee JJ, Clayman GL, et al. Randomized trial ofadjuvant 13-cis-retinoic acid and interferon alfa for patients withaggressive skin squamous cell carcinoma. J Clin Oncol 2007;25:1974-1978. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17513803.
141. Guthrie TH, Jr., Porubsky ES, Luxenberg MN, et al. Cisplatin-based chemotherapy in advanced basal and squamous cell carcinomasof the skin: results in 28 patients including 13 patients receiving
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