NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
Merkel Cell Carcinoma
Version 1.2016
NCCN.org
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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
Merkel Cell Carcinoma
Christopher K. Bichakjian, MD/Chair ϖ
University of Michigan
Comprehensive Cancer Center
Roy C. Grekin, MD ϖ ¶
UCSF Helen Diller Family
Comprehensive Cancer Center
Thomas Olencki, DO/Vice-Chair †
The Ohio State University Comprehensive
Cancer Center - James Cancer Hospital
and Solove Research Institute
Kenneth Grossman, MD, PhD †
Huntsman Cancer Institute
at the University of Utah
Sumaira Z. 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
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
Aleksandar Sekulic, MD, PhD ϖ
Mayo Clinic Cancer Center
Ashok R. Shaha, MD ¶ ζ
Memorial Sloan Kettering Cancer Center
Wade L. Thorstad, MD §
Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine
Malika Tuli, MD ϖ
St. Jude Children’s Research Hospital/
University of Tennessee Health Science
Center
Daniel D. Lydiatt, DDS, MD ¶
Fred & Pamela Buffett Cancer Center
Marshall M. Urist, MD ¶
University of Alabama at Birmingham
Comprehensive Cancer Center
Kishwer S. Nehal, MD ϖ ¶
Memorial Sloan Kettering Cancer Center
Timothy S. Wang, MD ϖ
The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Paul Nghiem, MD, PhD ϖ
Fred Hutchinson Cancer Research Center/
Seattle Cancer Care Alliance
Elise A. Olsen, MD ϖ
Duke Cancer Institute
Chrysalyne D. Schmults, MD ϖ
Dana-Farber/Brigham and Women’s Cancer Center
Massachusetts General Hospital Cancer Center
L. Frank Glass, MD ϖ ≠
Moffitt Cancer Center
NCCN
Anita Engh, PhD
Karin G. Hoffmann, RN, CCM
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
Continue
Sandra L. Wong, MD, MS ¶
University of Michigan
Comprehensive Cancer Center
John A. Zic, MD ϖ
Vanderbilt-Ingram Cancer Center
ϖ Dermatology
ф Diagnostic/Interventional radiology
¶ Surgery/Surgical oncology
ζOtolaryngology
≠ Pathology/Dermatopathology
† Medical oncology
ƿ Internal medicine
§ Radiotherapy/Radiation oncology
‡ Hematology/Hematology oncology
* Discussion Section Writing Committee
NCCN Guidelines Panel Disclosures
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 Table of Contents
Merkel Cell Carcinoma
NCCN Merkel Cell Carcinoma Panel Members
Summary of the Guidelines Updates
Merkel Cell Carcinoma
Clinical Presentation, Preliminary Workup, Diagnosis, Additional Workup,
and Clinical Findings (MCC-1)
Primary and Adjuvant Treatment of Clinical N0 Disease (MCC-2)
Primary and Adjuvant Treatment of Clinical N+ Disease (MCC-3)
Treatment of Clinical M1 Disease (MCC-4)
Follow-up and Recurrence (MCC-5)
Principles of Pathology (MCC-A)
Principles of Radiation Therapy (MCC-B)
Principles of Excision (MCC-C)
Principles of Chemotherapy (MCC-D)
Staging (ST-1)
NCCN Guidelines Index
Merkel Cell Carcinoma 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. ©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 Guidelines Version 1.2016 Updates
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
Updates in Version 1.2016 of the NCCN Guidelines for Merkel Cell Carcinoma from Version 2.2015 include:
MCC-2
• Primary and Adjuvant Treatment: For management of the draining nodal basin, footnote "f" was added: "In the head and neck region,
risk of false-negative SLNBs is higher due to aberrant lymph node drainage and frequent presence of multiple SLN basins. If SLNB is not
performed or is unsuccessful, consider irradiating nodal beds for subclinical disease (See MCC-B)"
MCC-4
• Under "Treatment of Clinical M1 Disease": "Consider any of the following therapies or combinations of": footnote "n" was removed from the
1st bullet "Chemotherapy"and added to the 3rd bullet "Surgery".
MCC-5
• Footnote "p" was added: "As immunosuppressed patients are at high-risk for recurrence, more frequent follow-up may be indicated.
Immunosuppressive treatments should be minimized as clinically feasible."
MCC-B Principles of Radiation Therapy
• MCC-B page was divided into two pages, "Primary Tumor Site" and "Draining Nodal Basin" and extensively revised.
MCC-C Principles of Excision
• For "Surgical Approaches" the 2nd sub-bullet was revised: When tissue sparing is of critical importance, "Techniques for more exhaustive
histologic margin assessment may be considered (Mohs technique, modified Mohs, CCPDMA), provided they do not interfere with SLNB
when indicated."
• For "Reconstruction":
1st bullet was removed: "Immediate reconstruction is recommended in most cases."
The following bullet was amended: "It is recommended that any reconstruction involving extensive undermining or tissue movement be
delayed until negative histologic margins are verified, and SLNB is performed if indicated."
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
Merkel Cell Carcinoma
CLINICAL
PRESENTATION
Suspicious lesion
PRELIMINARY
WORKUPa
• H&P
• Complete
skin and
lymph node
examination
• Biopsyb
�Hematoxylin
and eosin
(H&E)
�Immunopanel
DIAGNOSIS
Merkel cell
carcinoma
ADDITIONAL
WORKUP
• Imaging studiesc
as clinically
indicated
• Consider
multidisciplinary
tumor board
consultation
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
CLINICAL FINDINGS
Clinical N0
See Primary and
Adjuvant Treatment
(MCC-2)
Clinical N+
See Primary and
Adjuvant Treatment
(MCC-3)
Clinical M1
See Treatment (MCC-4)
aThe value of baseline MCPyV (Merkel cell polomavirus) serology for prognostic significance and to track disease recurrence is being evaluated.
bSee Principles of Pathology (MCC-A).
cImaging (CT, MR, or PET-CT) may be useful to identify and quantify regional and distant metastases. Some studies indicate that PET-CT may be
preferred in
some clinical circumstances. If PET-CT is not available, CT or MRI may be used. Imaging may also be useful to evaluate for the possibility of a skin
metastasis from a noncutaneous primary neuroendocrine carcinoma (eg, small cell lung cancer), especially in cases where CK-20 is negative.
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®.
MCC-1
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRIMARY AND ADJUVANT TREATMENT OF CLINICAL N0 DISEASE
MANAGEMENT OF THE PRIMARY TUMOR:
Adjuvant radiation therapy to
the primary tumor sitei
or
Consider observation of the
primary tumor sitej
Wide local excisiond,e
Clinical N0
AND
MANAGEMENT OF THE DRAINING
NODAL BASIN:
Sentinel lymph node biopsy (SLNB)f,g
with appropriate immunopanelb
SLN
positive
• Consider
baseline imaging
if studies not
already performedh
SLN
negative
bSee
dSee
• Clinical trial preferred,
if available
• Multidisciplinary tumor
board consultation
• Node dissection and/or
radiation therapy to the
nodal basini
Observation
of the nodal basinj
or
Consider radiation therapy
to the nodal basin in highrisk patientsf,k,i
See
Follow-up
(MCC-5)
Principles of Pathology (MCC-A).
Principles of Excision (MCC-C). In selected cases in which complete surgical excision is not possible, surgery is refused by the patient, or surgery would result in
significant morbidity, radiation monotherapy may be considered (See Principles of Radiation Therapy [MCC-B]).
eSurgical margins should be balanced with morbidity of surgery. If appropriate, avoid undue delay in proceeding to RT. (See Principles of Excision MCC-C)
fIn the head and neck region, risk of false-negative SLNBs is higher due to aberrant lymph node drainage and frequent presence of multiple SLN basins. If SLNB is not
performed or is unsuccessful, consider irradiating nodal beds for subclinical disease (See MCC-B).
gSLNB is an important staging tool for regional control, but the impact of SLNB on overall survival is unclear.
hImaging (CT, MR, or PET-CT) may be useful to identify and quantify regional and distant metastases. Some studies indicate that PET-CT may be preferred in
some clinical circumstances. If PET-CT is not available, CT or MRI may be used.
iSee Principles of Radiation Therapy (MCC-B).
jConsider
observation of the primary site in cases where the primary tumor is small (eg, <1 cm) and widely excised with no other adverse risk factors such as LVI
(lymphovascular invasion) or immuneosuppression.
kConsider
RT when there is a potential for anatomic [eg, previous history of surgery including WLE (wide local excision)], operator, or histologic failure (eg, failure to
perform appropriate immunohistochemistry on SLNs) that may lead to a false-negative SLNB. Consider RT for profound immunosuppression.
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®.
MCC-2
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRIMARY AND ADJUVANT TREATMENT OF CLINICAL N+ DISEASE
Positive
Clinical N+
M0
• Multidisciplinary tumor
board consultation
• Node dissection and/or
radiation therapyi,l
M1
See Treatment of Clinical M1 Disease (MCC-4)
See Follow-up
(MCC-5)
Imaging studiesh
recommended
• Fine-needle
aspiration
(FNA) or core
biopsy
• Immunopanelb
Biopsy
positive
Negative
Consider
open
biopsy
Biopsy
negative
Follow appropriate Clinical N0 pathway (MCC-2)
bSee Principles of Pathology (MCC-A).
hImaging (CT, MR, or PET-CT) may be indicated
to evaluate extent of lymph node and/or visceral organ involvement. Some studies indicate that PET-CT
may be preferred in some clinical circumstances. If PET-CT is not available, CT or MRI may be used.
iSee Principles of Radiation Therapy (MCC-B).
lAdjuvant chemotherapy may be considered in select clinical circumstances; however, available retrospective studies do not suggest prolonged survival benefit
for adjuvant chemotherapy. (See Principles of Chemotherapy [MCC-D]).
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®.
MCC-3
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
TREATMENT OF CLINICAL M1 DISEASE
Clinical M1
Multidisciplinary tumor
board consultation
iSee Principles of Radiation Therapy (MCC-B).
mSee Principles of Chemotherapy (MCC-D).
nUnder highly selective circumstances, in the context
oSee Principles of Excision (MCC-C).
Clinical trial preferred if available
Best supportive care
(See Guidelines for NCCN Palliative
Care)
and
Consider any of the following
therapies or combinations of:
• Chemotherapym
• Radiation therapyi
• Surgeryn,o
See Follow-up (MCC-5)
of multidisciplinary consultation, resection of oligometastasis can be considered.
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®.
MCC-4
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
FOLLOW-UPa
Follow-up visitsp:
• Physical exam including
complete skin and complete
lymph node exam
Every 3–6 mo for 2 years
Every 6–12 mo thereafter
• Imaging studies as clinically
indicatedh
Consider routine imaging
for high-risk patients
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
RECURRENCE
Recurrence
Local
Individualized
treatment
Regional
Individualized
treatment
Disseminated
See Clinical M1
(MCC-4)
aThe value of baseline MCPyV serology for prognostic significance and to track disease recurrence is being evaluated.
hImaging (CT, MR, or PET-CT) may be useful to identify and quantify regional and distant metastases. Some studies indicate
that PET-CT may be preferred in some
clinical circumstances. If PET-CT is not available, CT or MRI may be used.
pAs immunosuppressed patients are at high risk for recurrence, more frequent follow-up may be indicated. Immunosuppressive treatments should be minimized
as clinically feasible.
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®.
MCC-5
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRINCIPLES OF PATHOLOGY
• Pathologist should be experienced in distinguishing MCC from cutaneous simulants and metastatic tumors.
• Synoptic reporting is preferred.
• Minimal elements to be reported include tumor size (cm), peripheral and deep margin status, lymphovascular invasion, and
extracutaneous extension (ie, bone, muscle, fascia, cartilage).
• Strongly encourage reporting of these additional clinically relevant factors (compatible with the American Joint Committee on Cancer
[AJCC] and the College Of American Pathologists [CAP] recommendations):
Depth (Breslow, in mm)
Mitotic index (#/mm2 preferred, #/HPF (High-power fields), or MIB-1 index)
Tumor-infiltrating lymphocytes (not identified, brisk, non-brisk)
Tumor growth pattern (nodular or infiltrative)
Presence of second malignancy (ie, concurrent squamous cell cancer [SCC])
• An appropriate immunopanel should preferably include CK20 and thyroid transcription factor-1 (TTF-1). Immunohistochemistry for
CK20 and most low-molecular-weight cytokeratin markers is typically positive with a paranuclear “dot-like” pattern. CK7 and TTF-1
(positive in >80% of small cell lung cancers) are typically negative.
• For equivocal lesions, consider additional immunostaining with neuroendocrine markers such as chromogranin, synaptophysin,
CD56, neuron-specific enolase (NSE), and neurofilament.
• SLNB evaluation should preferably include an appropriate immunopanel (ie, CK20 and pancytokeratins [AE1/AE3]) based on the
immunostaining pattern of the primary tumor, particularly if hematoxylin and eosin sections are negative, as well as tumor burden
(% of node), location of tumor (eg, subcapsular sinus, parenchyma), and the presence/absence of extracapsular extension.
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®.
MCC-A
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRINCIPLES OF RADIATION THERAPY: PRIMARY TUMOR SITE
DOSE RECOMMENDATIONS
Consider observation of primary site when primary
tumor is small (ie, <1 cm), widely excised, and without
other risk factors such as lymphovascular invasion or
immunosuppression
Previous resection
of primary MCC
Negative resection margins
50-56 Gy
Microscopically positive resection
margins
56-60 Gy
Grossly positive resection margins and
further resection not possible
No previous resection
of primary MCC
• Unresectable
• Surgery refused by patient
• Surgery would result in
significant morbidity
60-66 Gy
• Expeditious initiation of adjuvant therapy after surgery is preferred as delay has been associated with worse outcomes.
• All doses are at 2 Gy/day standard fractionation. Bolus is used to achieve adequate skin dose. Wide margins (5 cm) should be used, if possible, around the primary site.
If electron beam is used, an energy and prescription isodose should be chosen that will deliver adequate lateral and deep margins.
• Palliation: A less protracted fractionation schedule may be used in the palliative setting, such as 30 Gy in 10 fractions.
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®.
MCC-B
1 OF 2
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRINCIPLES OF RADIATION THERAPY: DRAINING NODAL BASIN
DOSE RECOMMENDATIONS
No SLNB or LN
dissection
SLN negative
SLNB without LN
dissection
Clinically evident lymphadenopathy
60-66 Gy1,2
Clinically node negative, but at risk for subclinical disease
46-50 Gy
RT not indicated, unless at risk for false-negative SLNB3,4
Observe
SLN positive5
After LN dissection with
multiple involved nodes and/or
extracapsular extension6
50-56 Gy
50-60 Gy
•Expeditious initiation of adjuvant therapy after surgery is preferred as delay has been associated with worse outcomes.
•All doses are at 2 Gy/day standard fractionation. A less protracted fractionation schedule may be used in the palliative setting,
such as 30 Gy in 10 fractions.
•Irradiation of in-transit lymphatics is often not feasible unless the primary site is in close proximity to the nodal bed.
1Lymph node dissection is the recommended initial therapy for clinically evident adenopathy, followed by postoperative RT if
2Shrinking field technique.
3Consider RT when there is a potential for anatomic (eg, previous WLE), operator, or histologic failure (eg, failure to perform
indicated.
appropriate immunohistochemistry on
SLNs) that may lead to a false-negative SLNB.
4In the head and neck region, risk of false-negative SLNB is higher due to aberrant lymphatic drainage and frequent presence of multiple SLN basins. If SLNB is
unsuccessful, consider irradiating draining nodal basin for subclinical disease.
5Microscopic nodal disease (SLN positive) is defined as nodal involvement that is neither clinically palpable nor abnormal by imaging criteria, and microscopically
consists of small metastatic foci without extracapsular extension.
6Adjuvant RT following lymph node dissection is only indicated for multiple involved nodes and/or the presence of extracapsular extension. Adjuvant RT following LN
dissection is generally not indicated for patients with low tumor burden on sentinel lymph node biopsy or with a single macroscopic clinically detected lymph node
without extracapsular extension.
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®.
MCC-B
2 OF 2
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRINCIPLES OF EXCISION
Goal:
• To obtain histologically negative margins when clinically feasible.
• Surgical margins should be balanced with morbidity of surgery. If appropriate, avoid undue delay in proceeding to radiation
therapy.
Surgical Approaches:
• It is recommended, regardless of the surgical approach, that every effort be made to coordinate surgical management such that
SLNB is performed prior to definitive excision.1 Excision options include:
Wide excision with 1- to 2-cm margins to investing fascia of muscle or pericranium when clinically feasible.
Techniques for more exhaustive histologic margin assessment may be considered (Mohs technique, modified Mohs,
CCPDMA),2,3 provided they do not interfere with SLNB when indicated.
Reconstruction:
• It is recommended that any reconstruction involving extensive undermining or tissue movement be delayed until negative
histologic margins are verified and SLNB is performed if indicated.
• If adjuvant radiation therapy is planned, extensive tissue movement should be minimized and closure should be chosen to allow
for expeditious initiation of radiation therapy.
1SLNB is an important staging tool and may contribute to regional control; the impact of SLNB on overall survival is unclear.
2If Mohs surgery is used, a debulked specimen of the central portion of the tumor should be sent for permanent vertical section microstaging.
3Modified Mohs = Mohs technique with additional permanent section final margin assessment; CCPDMA = complete circumferential and peripheral
margin assessment.
deep
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®.
MCC-C
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
PRINCIPLES OF CHEMOTHERAPY 1
Local Disease:
• Adjuvant chemotherapy not recommended unless clinical judgment dictates otherwise
Regional Disease:
• Adjuvant chemotherapy not routinely recommended as adequate trials to evaluate usefulness
have not been done, but could be used on a case-by-case basis if clinical judgment dictates
• Cisplatin ± etoposide
• Carboplatin ± etoposide
Disseminated Disease:
As clinical judgment indicates:
• Cisplatin ± etoposide
• Carboplatin ± etoposide
• Topotecan
• (CAV): Cyclophosphamide, doxorubicin (or epirubicin), and vincristine
1When
available and clinically appropriate, enrollment in a clinical trial is recommended. The literature is not directive regarding the specific chemotherapeutic agent(s)
offering superior outcomes, but the literature does provide evidence that Merkel cell carcinoma is chemosensitive, although the responses are not durable, and the
agents listed above have been used with some success.
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®.
MCC-D
NCCN Guidelines Version 1.2016 Staging
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
Staging
Table 1
American Joint Committee on Cancer (AJCC)
TNM Staging Classification for Merkel Cell Carcinoma
(7th ed., 2010)
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0
No evidence of primary tumor (e.g., nodal/metastatic presentation
without associated primary)
Tis In situ primary tumor
T1
Less than or equal to 2 cm maximum tumor dimension
T2
Greater than 2 cm but not more than 5 cm maximum tumor
dimension
T3
Over 5 cm maximum tumor dimension
T4
Primary tumor invades bone, muscle, fascia, or cartilage
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
cN0
Nodes negative by clinical exam* (no pathologic
node exam performed)
pN0 Nodes negative by pathologic exam
N1 Metastasis in regional lymph node(s)
N1a Micrometastasis**
* Clinical detection of nodal disease may be via inspection,
palpation, and/or imaging.
** Micrometastases are diagnosed after sentinel or elective
lymphadenectomy.
*** Macrometastases are defined as clinically detectable nodal
metastases confirmed by therapeutic lymphadenectomy or
needle biopsy.
**** In transit metastasis: a tumor distinct from the primary
lesion and located either (1) between the primary lesion
and the draining regional lymph nodes or (2) distal to the
primary lesion.
Distant Metastasis (M)
M0 No distant metastases
M1 Metastasis beyond regional lymph nodes
M1a Metastasis to skin, subcutaneous tissues or distant lymph nodes
M1b Metastasis to lung
M1c Metastasis to all other visceral sites
Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original and primary source for this information is the AJCC
Cancer Staging Manual, Seventh Edition (2010) published by Springer Science
+Business Media, LLC (SBM). (For complete information and data supporting
the staging tables, visit www.springer.com.) Any citation or quotation of this
material must be credited to the AJCC as its primary source. The inclusion of this
information herein does not authorize any reuse or further distribution without the
expressed, written permission of Springer SBM, on behalf of the AJCC.
N1b Macrometastasis***
N2 In transit metastasis****
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®.
Continue
ST-1
NCCN Guidelines Version 1.2016 Staging
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma TOC
Discussion
Staging
Table 1 (continued)
American Joint Committee on Cancer (AJCC)
TNM Staging Classification for Merkel Cell Carcinoma
(7th ed., 2010)
Stage 0
Tis
N0 M0
Stage IA
T1
pN0 M0
ANATOMIC STAGE/PROGNOSTIC GROUPS
Patients with primary Merkel cell carcinoma with no evidence
of regional or distant metastases (either clinically or
pathologically) are divided into two stages: Stage I for primary
tumors ≤ 2 cm in size and Stage II for primary tumors >2 cm in
size. Stages I and II are further divided into A and B substages
based on method of nodal evaluation. Patients who have
pathologically proven node negative disease (by microscopic
evaluation of their draining lymph nodes) have improved survival
(substaged as A) compared to those who are only evaluated
clinically (substaged as B). Stage II has an additional substage
(IIC) for tumors with extracutaneous invasion (T4) and negative
node status regardless of whether the negative node
status was established microscopically or clinically. Stage
III is also divided into A and B categories for patients with
microscopically positive and clinically occult nodes (IIIA) and
macroscopic nodes (IIIB). There are no subgroups of Stage IV
Merkel cell carcinoma.
Stage IIAT2/T3pN0
M0
Stage IIB
cN0
M0
Stage IICT4
N0
M0
Stage IIIA
Any T
N1a M0
Stage IIIB
Any T
N1b/N2 M0
Stage IV
Any T
Any N
M1
Stage IBT1
T2/T3 cN0 M0
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC
Cancer Staging Manual, Seventh Edition (2010) published by Springer Science+Business Media, LLC (SBM). (For complete information and data supporting the
staging tables, visit www.springer.com.) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of this information
herein does not authorize any reuse or further distribution without the expressed, written permission of Springer SBM, on behalf of the AJCC.
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®.
ST-2
NCCN Guidelines Version 1.2016
Merkel Cell Carcinoma
NCCN Guidelines Index
Merkel Cell Carcinoma 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®.