NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)

Basal Cell Skin Cancer Version 1.2015 NCCN.org

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Version 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

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NCCN Guidelines Version 1.2015 Panel Members Basal Cell Skin Cancer Christopher K. Bichakjian, MD/Chair ϖ University of Michigan Comprehensive Cancer Center Thomas Olencki, DO/Vice-Chair † The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Sumari Aasi, MD ϖ Stanford Cancer Institute Murad Alam, MD ϖ ¶ ζ Robert H. Lurie Comprehensive Cancer Center of Northwestern University James S. Andersen, MD ¶ City of Hope Comprehensive Cancer Center Daniel Berg, MD ϖ Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Glen M. Bowen, MD ϖ Huntsman Cancer Institute at the University of Utah Richard T. Cheney, MD ≠ Roswell Park Cancer Institute Gregory A. Daniels, MD, PhD ‡ ƿ UC San Diego Moores Cancer Center ϖ Dermatology ¶ Surgery/Surgical oncology ζOtolaryngology ≠ Pathology/Dermatopathology † Medical oncology ƿ Internal medicine § Radiotherapy/Radiation oncology ‡ Hematology/Hematology oncology * Writing Committee Member

NCCN Guidelines Index Basal Cell TOC Discussion

L. Frank Glass, MD ϖ ≠ Moffitt Cancer Center

Ashok R. Shaha, MD ¶ ζ Memorial Sloan Kettering Cancer Center

Roy C. Grekin, MD ϖ ¶ UCSF Helen Diller Family Comprehensive Cancer Center

Wade L. Thorstad, MD § Siteman Cancer Center at BarnesJewish Hospital and Washington University School of Medicine

Kenneth Grossman, MD, PhD † Huntsman Cancer Institute at the University of Utah Alan L. Ho, MD, PhD † Memorial Sloan Kettering Cancer Center

Malika Tuli, MD ϖ St. Jude Children’s Research Hospital/ University of Tennessee Health Science Center

Karl D. Lewis, MD † University of Colorado Cancer Center

Marshall M. Urist, MD ¶ University of Alabama at Birmingham Comprehensive Cancer Center

Daniel D. Lydiatt, DDS, MD ¶ ζ Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center

Timothy S. Wang, MD ϖ The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Kishwer S. Nehal, MD ϖ ¶ Memorial Sloan Kettering Cancer Center

Andrew E. Werchniak, MD ϖ Dana-Farber/Brigham and Women’s Cancer Center

Paul Nghiem, MD, PhD ϖ Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Elise A. Olsen, MD ϖ Duke Cancer Institute Clifford S. Perlis, MD, MBe ϖ ¶ Fox Chase Cancer Center

Sandra L. Wong, MD, MS ¶ University of Michigan Comprehensive Cancer Center John A. Zic, MD ϖ Vanderbilt-Ingram Cancer Center

Aleksandar Sekulic, MD, PhD ϖ Mayo Clinic Cancer Center NCCN Lauren Gallagher, RPh, PhD Maria Ho, PhD Karin G. Hoffmann, RN, CCM

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NCCN Guidelines Panel Disclosures

Version 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

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NCCN Guidelines Version 1.2015 Table of Contents Basal Cell Skin Cancer 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 Index Basal Cell TOC Discussion

Clinical Trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN Member Institutions, click here: nccn.org/clinical_trials/physician.html. NCCN Categories of Evidence and Consensus: All recommendations are category 2A unless otherwise specified. See NCCN Categories of Evidence and 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 may not be reproduced in any form without the express written permission of NCCN. ©2014. Version 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®1

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NCCN Guidelines Version 1.2015 Updates Basal Cell Skin Cancer

NCCN Guidelines Index Basal Cell TOC Discussion

Updates in Version 1.2015 of the NCCN Guidelines for Basal Cell Skin Cancer from Version 1.2014 include: Global Change Basal Cell and Squamous Cell Skin Cancers have been divided into two separate guidelines. Basal Cell Skin Cancer BCC-2 • For “Primary treatment of low-risk basal cell skin cancer”: Removed C&E and modified to: “Curettage and electrodesiccation” “Excision with POMA”modified to: “Standard excision with POMA: If lesion can be excised with 4 mm clinical margins and secondary intention healing, linear repair, or skin graft” • Under “Adjuvant Treatment” for “Margins” that are “Positive”: “Mohs or resection with CCPDMA” modified to: “Mohs or resection with CCPDMA complete margin assessment” “Re-excision with POMA for area L regions” modified to: “Standard re-excision with POMA for area L regions” Footnote “h” added: “Excision with complete circumferential peripheral and deep margin assessment (CCPDMA) with frozen or permanent section is an alternative to Mohs surgery.” • Box defining abbreviations removed: C&E= curettage and electrodessication; POMA= postoperative margin assessment; CCPDMA= complete circumferential peripheral and deep margin assessment with frozen or permanent section BCC-3 • For “Primary treatment of high-risk basal cell skin cancer”: “Excision with POMA” modified to: “Standard excision” with POMA ◊◊“Wider surgical margins with linear or delayed repair are recommended when excising high-risk tumors with POMA” modified to: “Wider surgical margins with linear or delayed repair are recommended when excising high-risk tumors with POMA standard re-excision ” “Mohs or resection with CCPDMA” modified to: “Mohs or resection with CCPDMA complete margin assessment”

Basal Cell Skin Cancer - cont BCC-3 (cont) • Under “Adjuvant Treatment”: “Standard excision”: For “Margins” that are “Positive”: “Mohs or resection with CCDPMA” modified to: “Mohs or resection with CCPDMA complete margin assessment” For “Margins” that are “Negative” statement added: “If extensive perineural or large-nerve involvement recommend adjuvant RT” For both “Standard excison” and “Mohs” negative margins the statement “If residual disease...” was bypassed and went directly to: “See Follow-up (BCC-3)” Box defining abbreviations removed: POMA= postoperative margin assessment; CCPDMA= complete circumferential peripheral and deep margin assessment with frozen or permanent section • Footnote “h” was added: “Excision with complete circumferential peripheral and deep margin assessment (CCPDMA) with frozen or permanent section is an alternative to Mohs surgery.” BCC-4 • Under “Recurrence”: “Regional or distant metastases” was divided into 2 pathways: “Regional” and Distant metastases For regional, the treatment option was revised from “Multidisciplinary tumor board consultation (consider vismodegib or clinical trials)” to:“Surgery and/or RT” For distant metastases, the treatment option was clarified as,“Multidisciplinary tumor board consultation (consider vismodegib or clinical trials)” • Footnote “k“ was added to this page: “If surgery and RT are contraindicated, consider multidisciplinary tumor board consultation and therapy.”

UPDATES Version 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

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NCCN Guidelines Version 1.2015 Basal Cell Skin Cancer CLINICAL PRESENTATION

WORKUP

NCCN Guidelines Index Basal Cell TOC Discussion RISK STATUS

Low riska

Suspicious lesion

See Primary Treatment of Low-Risk Basal Cell Skin Cancer (BCC-2)

• H&P • Complete skin exam • Biopsy If more than superficial lesion, inclusion of deep reticular dermis preferreda • Imaging studies as indicated for suspicion of extensive diseaseb

High riska,c

aSee Risk Factors for Recurrence (BCC-A). bExtensive disease includes deep structural involvement such as cAny high-risk factor places the patient in the high-risk category.

See Primary Treatment of High-Risk Basal Cell Skin Cancer (BCC-3)

bone, perineural disease, and deep soft tissue. If perineural disease is suspected, MRI is preferred.

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 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

BCC-1

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NCCN Guidelines Version 1.2015 Basal Cell Skin Cancer PRIMARY TREATMENTd

ADJUVANT TREATMENT

Curettage and electrodesiccation: • In non-hair–bearing areas • If adipose reached, surgical excision should generally be performed or Primary treatment of low-risk basal cell skin cancera,d

Standard excision: • If lesion can be excised with 4-mm clinical margins and second intention healing, linear repair, or skin grafte or

NCCN Guidelines Index Basal Cell TOC Discussion

Positive

Margins

Mohs or resection with complete margin assessmenth or Standard re-excision for area Li regions or RTf for non-surgical candidates

See Follow-up (BCC-4)

Negative

RTf,g for non-surgical candidates

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. fSee Principles of Radiation Therapy for Basal Cell Skin Cancer (BCC-C). gRT often reserved for patients over 60 y 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 iArea L = trunk and extremities (excluding pretibia, hands, feet, nail units, and ankles). (See BCC-A)

to Mohs surgery.

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 1.2015, 10/24_/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

BCC-2

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NCCN Guidelines Version 1.2015 Basal Cell Skin Cancer PRIMARY TREATMENTd Standard excision Wider surgical margins with linear or delayed repair are recommended when excising high-risk tumors with standard re-excisione

ADJUVANT TREATMENT

Positive Margins Negative

Primary treatment of high-risk basal cell skin cancera,c,d,j

or Negative Mohs or resection with complete margin assessmenth or

NCCN Guidelines Index Basal Cell TOC Discussion

Mohs or resection with complete margin assessmenth or RTf If extensive perineural or large-nerve involvementm recommend adjuvant RT

If residual disease is present, and surgery and RT are contraindicated, consider multidisciplinary tumor board consultation (consider vismodegib or clinical trials)

See Follow-up (BCC-4)

Margins Positivel

RTf

RTf,g for non-surgical candidatesk

aSee Risk Factors for Recurrence (BCC-A). cAny 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. fSee Principles of Radiation Therapy for Basal Cell Skin Cancer (BCC-C). gRT often reserved for patients over 60 y 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 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.

to Mohs surgery.

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 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

BCC-3

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NCCN Guidelines Version 1.2015 Basal Cell Skin Cancer FOLLOW-UP

H&P • Including complete skin exam every 6-12 mo for life Patient education: • Sun protection • Self-examination

kIf

NCCN Guidelines Index Basal Cell TOC Discussion

RECURRENCE

Local

Follow Primary Treatment Pathways (BCC-1)

Regional

Surgery and/or RTk

Distant metastases

Multidisciplinary tumor board consultation (consider vismodegib or clinical trials)

surgery and RT are contraindicated, consider multidisciplinary tumor board consultation and therapy.

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 1.2015, 10/24/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

BCC-4

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NCCN Guidelines Version 1.2015 Basal Cell Skin Cancer

NCCN Guidelines Index Basal Cell TOC Discussion

RISK FACTORS FOR RECURRENCE H&P

Low Risk

High Risk

Location/size

Area L