This selection from the NCCN Guidelines for Merkel Cell Carcinoma (MCC) focuses on areas impacted by recently emerging data, including sections describing MCC risk factors, diagnosis, workup, follow-up, and management of advanced disease with radiation and systemic therapy. Included in these sections are discussion of the new recommendations for use of Merkel cell polyomavirus as a biomarker and new recommendations for use of checkpoint immunotherapies to treat metastatic or unresectable disease. The next update of the complete version of the NCCN Guidelines for MCC will include more detailed information about elements of pathology and addresses additional aspects of management of MCC, including surgical management of the primary tumor and draining nodal basin, radiation therapy as primary treatment, and management of recurrence.

Basal cell carcinoma (BCC) of the skin is the most common cancer, with a higher incidence than all other malignancies combined. Although it is rare to metastasize, patients with multiple or frequently recurring BCC can suffer substantial comorbidity and be difficult to manage. Assessment of risk is a key element of management needed to inform treatment selection. The overall management of BCC primarily consists of surgical approaches, with radiation therapy as an alternate or adjuvant option. Many superficial therapies for BCC have been explored and continue to be developed, including topicals, cryosurgery, and photodynamic therapy. Two hedgehog pathway inhibitors were recently approved by the FDA for systemic treatment of advanced and metastatic BCC, and others are in development. The NCCN Guidelines for Basal Cell Skin Cancer, published in full herein, include recommendations for selecting among the various surgical approaches based on patient-, lesion-, and disease-specific factors, as well as guidance on when to use radiation therapy, superficial therapies, and hedgehog pathway inhibitors.

We reviewed 156 previously untreated patients with squamous cell carcinoma of the oral tongue staged T1 and T2 to determine the incidence of nodal metastasis, and if elective neck dissection affected local/regional control or survival. Patients were divided into two nonrandomized groups: group 1, intraoral glossectomy only (102 patients); and group 2, intraoral glossectomy plus neck dissection (54 patients). Analysis revealed no significant differences for tumor location, histologic differentiation, status of margins, or clinical appearance; however, perineural invasion significantly adversely affected survival and local/regional control. In group 1 patients, 16.5% subsequently developed cervical metastasis, and 20.4% of patients in group 2 had occult nodal disease. The survival and local/regional control for group 1 patients subsequently developing nodes was 33% and 50%, respectively. The survival and local/regional control for group 2 patients with occult metastasis was 55% and 91%, respectively. We believe elective neck dissection is indicated for early staged oral tongue cancer.

Surgeons must emphasize and document the likelihood and consequences of this devastating complication to all patients undergoing surgery in this area. Risk management goals include a thorough and timely examination and careful and thoughtful surgical approaches. However, patient rapport and bedside manner may be the only protection the surgeon has from litigation arising from this complication.