Journal of Clinical and Aesthetic Dermatology

APR 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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44 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 microscopically controlled surgery is preferred for excision of MCC using a peripheral excision margin of 1 to 2cm. SLNB is recommended as well as local radiotherapy. 46 Danish guidelines. For the management of MCC, the Danish guidelines recommend WLE as first-line treatment. Peripheral margins of 2 to 3cm are advised, as well as deep margins extending to the level of the deep fascia. MMS can be used alternatively if such surgical margins cannot be obtained. SLNB is advised to assist with tumor staging, chest x-ray to exclude the diagnosis of lung cancer, positron emission tomography (preferred) or computerized tomography of the chest and abdomen to rule out metastasis, and local adjuvant radiotherapy as a final measure to assist with curative treatment. 47 Short German guidelines. According to the Short German guidelines, WLE is preferred as first-line treatment for MCC. Peripheral margins of 3cm are recommended, secondary to this tumor's high risk of recurrence. If such margins cannot be obtained, MMS is advised. Also recommended are SLNB and radiotherapy to target the tumor and regional lymph nodes. Adjuvant chemotherapy can be used for palliative measures (Table 5). 48 CONCLUSION After thorough review of international guidelines, it is clear that variations exist among the medical societies. Although some organizations share similar guidelines for certain portions of NMSC management, there is a lack of consistency evident on direct comparison. The least consistency was noted for DFSP and MCC peripheral margin recommendations. In contrast, great consistency was evident for low- risk BCC and cSCC peripheral margin recommendations. Ample global recommendations are available for excision of BCC and cSCC in comparison to DFSP and MCC, likely attributable to a lack of patients available for clinical trials and chart review. Future research should be directed at creating unified, global guidelines for peripheral and deep surgical margins for these NMSCs, especially for the more aggressive histological subtypes. Finally, the guidelines are centered on evidence-based medicine and are meant to serve as a "guide." They should never replace clinical judgment to ensure delivery of the highest quality of patient care and best clinical outcomes. Table 5. Merkel cell carcinoma global guideline comparison of surgical margins 44,46–48 orGANizATioN PEriPHErAL MArGiNS DEEP MArGiNS NCCN Preferred: WLE -1–2cm Alternative: MMS (provided it does not interfere with SNLB when indicated) Level of investing fascial layer EDF Preferred: MMS -1–2cm Not specified Denmark Preferred: WLE -2–3cm Alternative: MMS Level of underlying fascia German Preferred: WLE -3cm Alternative: MMS Not specified European Dermatology Forum (EDF), National Cancer Care Network (NCCN), Mohs micrographic surgery (MMS), sentinel lymph node biopsy (SNLB), wide local excision (WLE) r E v i E W

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