皮膚基底細(xì)胞癌2022.v2-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)BasalCellSkinCancerersionMarchVersion2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexChrysalyneD.Schmults,MD,MS/Chair??Dana-Farber/BrighamandWomen’senterRachelBlitzblau,MD,PhD/ViceChair§DukeCancerInstituteSumairaZ.Aasi,MD?StanfordCancerInstituteMuradAlam,MD,MBA,MSCI??ζRobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityJamesS.Andersen,MD??CityofHopeNationalMedicalCenterBrianC.Baumann,MD§SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineJeremyBordeaux,MD,MPH?CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussignstitutePei-LingChen,MD,PhD≠M(fèi)offittCancerCenterRobertChin,MD,PhD§UCLAJonssonComprehensiveCancerCenterCarloM.Contreras,MD?TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteDominickDiMaio,MD≠Fred&PamelaBuffettCancerCenternesPanelDisclosuresJessicaM.Donigan,MD?HuntsmanCancerInstituteattheUniversityofUtahJeffreyM.Farma,MD?FoxChaseCancerCenterKarthikGhosh,MDTCancerCenterRoyC.Grekin,MD??UCSFHelenDillerFamilyComprehensiveCancerCenterKellyHarms,MD,PhD?UniversityofMichiganRogelCancerCenterAlanL.Ho,MD,PhD?MemorialSloanKetteringCancerCenterJohnNicholasLukens,MD§AbramsonCancerCenterattheUniversityofPennsylvaniaTheresaMedina,MD?UniversityofColoradoCancerCenterKishwerS.Nehal,MD??MemorialSloanKetteringCancerCenterPaulNghiem,MD,PhD?FredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceKellyOlino,MD?YaleCancerCenter/SmilowCancerHospitalSooPark,MD?UCSanDiegoMooresCancerCenterTejeshPatel,MD?≠St.JudeChildren’sResearchHospital/UniversityofTennesseeHealthScienceCenterIgorPuzanov,MD,MSCI?RoswellParkComprehensiveCancerCenterJeffreyScott,MD,MHS?TheSidneyKimmelComprehensiveCancerCenteratJohnHopkinsAleksandarSekulic,MD,PhD?MayoClinicCancerCenterAshokR.Shaha,MD?ζMemorialSloanKetteringCancerCenterDivyaSrivastava,MD?UTSouthwesternSimmonsComprehensiveCancerCenterValenciaThomas,MD?TheUniversityofTexasYaohuiG.Xu,MD,PhD?UniversityofWisconsineCancerCenterMehranYusuf,MD§O'NealComprehensiveCancerCenteratUABenPhDMcCulloughRNBSBDermatologyTInternalmedicine?MedicaloncologyζOtolaryngology≠Pathology/Dermatopathology?Reconstructivesurgery§Radiotherapy/Radiationoncology?Surgery/Surgicaloncology*DiscussionSectionWritingCommitteeVersion2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexlievesthatthebestmanagementforlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceandsusAllrecommendationsotherwisedNCategoriesofEvidenceandConsensus.aryoftheGuidelinesUpdatesicalPresentationWorkupandRiskStatusBCCTreatmentforLocalLowRiskBasalCellSkinCancerBCCTreatmentforLocalHighRiskBasalCellSkinCancerBCCeorAdvancedDiseaseBCCPrinciplesofPathology(BCC-A)StratificationtoDetermineTreatmentOptionsforLocalBCCBasedonRiskFactorsforRecurrence(BCC-B)PrinciplesofTreatment(BCC-C)PrinciplesofRadiationTherapy(BCC-D)PrinciplesofSystemicTherapy(BCC-E)TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexersionoftheNCCNGuidelinesforBasalCellSkinCancerfromVersioninclude?TheDiscussionsectionhasbeenupdatedtoreflectthechangesinthealgorithm.ersionoftheNCCNGuidelinesforBasalCellSkinCancerfromVersionincludenicalPresentationpFootnoteerevised:Forrarecasesthatpresentwithregionalordistantmetastaticdiseaseatdiagnosis,treatasnodalordistantmetastasespathwayonBCC-4.Imagingmodalityandtargetedareashouldbeatthediscretionofthetreatingteambasedonthesuspectedextentofdisease(ie,local,regional,metastatic).pFootnotegadded:Imagingmodalityandtargetedareashouldbeatthediscretionofthetreatingteambasedonthesuspectedextentofdisease(ie,local,regional,metastatic).Histologicconfirmationisoftensufficienttodiagnoselocalrecurrence,butMRIcanbeconsideredtoassessextentoflocaldisease.Fornodalordistantmetastasis,histologicanalysisand/orCTimagingcanbeemployedforconfirmationandtogaugeextentofdisease.BCC-2?Categoryheaderrevised:Locallow-riskbasalcellskincancer.?PrimaryTreatmentofLocallow-riskbasalcellskincancerpFirstoption,Curettageandelectrodesiccation(C&E):?Firstbulletrevised:Excludingterminalhair-bearingareas,suchasthescalp,pubicandaxillaryregions,andbeardareainmenmales.?Secondbulletrevised:Ifadiposereached,tumorappearstoextendbeyondthedermis,surgicalexcisionshouldgenerallybeperformedratherthanC&E.pSecondoptionrevised:Standardexcisionwith4-mmclinicalmarginsandpostoperativemarginassessment.Tissuerearrangement(eg,flapreconstruction,extensiveundermining)shouldnotbeundertakenuntilclearmarginsareidentifiedand(secondintentionhealing,linearrepair,orskingraftareacceptable).?AdditionalTreatmentofLocallow-riskbasalcellskincancerpFollowingpositivemargins,optionrevised:MohsmicrographicsurgeryorresectionwithCCPDMAotherformsofperipheralanddeepenfacemarginassessment(PDEMA).(AlsopageBCC-3)PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexersionoftheNCCNGuidelinesforBasalCellSkinCancerfromVersionincludeBCC-2(continued)?Footnotekrevised:Excisionwithcompletecircumferentialperipheralanddeepmarginassessment(CCPDMA)PDEMAwithpermanentsectionanalysisorintraoperativefrozensectionanalysisisanalternativetoMohsmicrographicsurgery.SeePrinciplesofPDEMATechnique(SCC-G).(AlsopageBCC-3A)?Footnotesremoved:pClosureslikeadjacenttissuetransfers,inwhichsignificanttissuerearrangementoccurs,shouldnotbeperformeduntilclearmarginsareverified.(AlsopageBCC-3A)pRTisoftenreservedforpatientsolderthan60yearsbecauseofconcernsaboutlongtermsequelae.(AlsopagesBCC-3AandBCC-4)?Footnotesadded:pFootnotei:Inpatientswithsuperficialbasalcellskincancer,therapiessuchastopicalimiquimod,topical5-fluorouracil,photodynamictherapy,orcryotherapymaybeconsidered,thoughcureratesareapproximately10%lowerthansurgicaltreatmentmodalities.JansenMHE,etal.JInvestDermatol2018;138:527-533.DrewBA,etal.DermatolSurg2017;43:1423-1430.pFootnotel:Fortumorsoncheeks,forehead,scalp,neck,andpretibiathatare<6mmindepthandconfinedtothedermis,C&EmaybeconsideredasanalternativeprimarytreatmentoptionifMohs,resectionwithPDEMA,andstandardexcisionarenotfeasibleduetopatientcomorbidities.SeeRiskFactorsforRecurrence(BCC-B).BCC-3?Categoryheaderrevised:Localhigh-riskbasalcellskincancer.?PrimaryTreatment:pFirstoptionrevised:MohsmicrographicsurgeryorresectionwithCCPDMAotherformsofPDEMA.pSecondoptionrevised:Standardexcisionwithwidersurgicalmarginsandpostoperativemarginassessmentandwithsecondintentionhealing,linearrepair,ordelayedrepairskingraft.?AdditionalTreatment,followingPositivemargins,firstoptionrevised:MohsmicrographicsurgeryorresectionwithCCPDMAotherformsofPDEMA,iffeasibleorStandardre-excisionifCCPDMAPDEMAnotfeasible.BCC-3A?Footnotesrevised:pFootnotel:Fortumorsoncheeks,forehead,scalp,neck,andpretibiathatare<6mmindepthandconfinedtothedermis,C&EmaybeconsideredasanalternativeprimarytreatmentoptionifMohsmicrographicsurgery,resectionwithCCPDMAPDEMA,andstandardexcisionarenotfeasibleduetopatientcomorbidities.SeeRiskFactorsforRecurrence(BCC-B).pFootnotem:Forcomplicatedcases(eg,locallyadvanced,wherehighchanceofsurgicalcureisinquestion),considermultidisciplinaryconsultation...pFootnoteq:ThereareconflictingdataaboutthevalueofadjuvantRTfollowingmargin-negativesurgicalexcision,particularlyafterMohssurgery.?Footnotesremoved:pWhenMohsmicrographicsurgerywithmarginassessmentisbeingperformedandthepreoperativebiopsyisconsideredinsufficientforprovidingallthestaginginformationrequiredtoproperlytreatthetumor,submissionofthecentralspecimenforverticalparaffin-embeddedpermanentsectionsordocumentationofstagingparametersinMohsreportisrecommended.pNegativemarginsunachievablebyMohsmicrographicsurgeryormoreextensivesurgicalprocedures.UPDATESVersion2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexersionoftheNCCNGuidelinesforBasalCellSkinCancerfromVersioninclude?RecurrenceorAdvancedDiseasepNodalordistantmetastasespathwayrevised:PrimaryorrecurrentNnodalordistantmetastases?OptionfollowingPrimaryorrecurrentnodalmetastasesrevised:Multidisciplinaryconsultationtoconsideroneormoreofthefollowingoptions:SurgeryorIfsurgeryisnotfeasiblethenRTorsystemictherapy.–Bulletadded:Cemiplimab-rwlcpPathwayadded:Distantmetastases?FollowingDistantmetastasespathway,optionsadded:Multidisciplinaryconsultationtoconsider:Systemictherapy,HHI,Vismodegib,Cemiplimab-rwlcorRTorsurgeryforlimitedmetastaticdiseaseorPalliationandbestsupportivecare.?Footnotesadded:Cemiplimab-rwlcisrecommendedforpatientswithlocallyadvancedormBCCpreviouslytreatedwithanHHIorforwhomanHHIisnotappropriate.?Footnotetadded:Underhighlyselectivecircumstances,inthecontextofmultidisciplinaryconsultation,resectionoflimitedmetastasescanbeconsidered.BCC-A?PrinciplesofBiopsyReporting,secondbulletrevised:Clinicalinformationtobesubmittedonbiopsyrequisitionincludespatientdemographics,clinicaldiameteroflesion,anatomiclocation,andpriortreatmentoflesion.Additionalhelpfulfeaturestoincludeareclinicaldiameteroflesion,andriskfactorssuchasimmunosuppression,andhistoryofRT,orsolidorgantransplantation.?PrinciplesofExcisionReportingpThirdbulletrevised:Minimalreportingelementstobereportedforallsurgicalspecimensincludehistologicsubtypeofbasalcellcarcinoma(BCC),invasionoftumorbeyonddeepreticulardermis,presenceorabsenceofperineuralinvasion(ifinvolvingnervebelowdermisoriflargestnerveinvolvedis>0.1mmincaliber)andangiolymphaticinvasion,andperipheralanddeepmarginstatus.pFourthbulletrevised:ForMohsexcisions,reportingoftheseelementsisalsoencouraged.Asdepthofinvasion(inmm)maynotbereliablyascertainedonMohsspecimens,anatomiclevelofinvasioncanbereported.Submissionofacentralsectionoftissueattheareaofdeepestinvasionforpermanentsectionevaluationmaybeconsideredtoevaluateanddocumenthigh-riskfeaturesthatwerequestionableorambiguousonMohssections.Sincedepthofinvasion(inmm)maynotbeascertainedontangentiallycutMohsspecimens,anatomiclevelofinvasionshouldbereported.Frozenorpermanentsectionanalysisoftheclinicaltumorspecimenmaybeundertakenifneededforcompletereportingoffeaturesassociatedwithpoorprognosis.?Footnote3added:MorganFC,RuizES,KariaPS,etal.BrighamandWomen'sHospitaltumorclassificationsystemforbasalcellcarcinomaidentifiespatientswithriskofmetastasisanddeath.JAmAcadDermatol2021;85:582-587.BCC-B?HighRisk,Location/size,thirdrowrevised:"Maskareas”offace(centralface,eyelids,eyebrows,periorbital,nose,lips[cutaneousandvermilion],chin,mandible,preauricularandpostauricularskin/sulci,temple,andear),genitalia,hands,andfeetHead,neck,hands,feet,pretibia,andanogenital(anysize).?Footnote3revised:Thisareaconstituteshighriskbasedonlocation,independentofsize.Narrowexcisionmarginsduetoanatomicandfunctionalconstraintsareassociatedwithincreasedrecurrencerateswithstandardhistologicprocessing.CompletemarginassessmentsuchaswithMohsmicrographicsurgery/CCPDMAorPDEMAisrecommendedforoptimaltumorclearanceandmaximaltissueconservation...UPDATESVersion2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexersionoftheNCCNGuidelinesforBasalCellSkinCancerfromVersioninclude?Secondbulletrevised:Surgicalapproachesoftenofferthemosteffectiveandefficientmeansforaccomplishingcure,butconsiderationsoffunction,cosmesis,andpatientpreference,andperformancestatusmayleadtochoosingRTasprimarytreatmentinordertoachieveoptimaloverallresults.?Fifthbulletrevised:WhenMohsmicrographicsurgerywithmarginassessmentisbeingperformedandthepreoperativebiopsyisconsideredinsufficientforprovidingallthestaginginformationrequiredtoproperlytreatthetumor,submissionofthecentralspecimenforverticalparaffin-embeddedpermanentsectionsordocumentationofstagingparametersinMohsreportisrecommended.BCC-D?GeneralPrinciplespNewbulletadded:Isotope-basedbrachytherapycanbeaneffectivetreatmentforcertainsitesofdisease,particularlyontheheadandneck.pFifthbulletrevised:Thereareinsufficientlong-termefficacyandsafetydatatosupporttheroutineuseofradioisotopeorelectronicsurfacebrachytherapy.BCC-E?ApproachpFirstbulletrevised:SystemictherapymaybeconsideredforlocallyadvancedlaBCCandmBCC...pFourthbullet,Systemictherapyoptionsinclude:?Firstbulletrevised:HedgehogpathwayinhibitorsHHIs(ie,vismodegib,sonidegib).–Firstsub-bulletrevised:DuetofrequencyofintolerablesideeffectsassociatedwithhedgehogpathwayinhibitorsHHIs...–Secondsub-bulletrevised:HedgehogpathwayinhibitorsHHIsmaybeconsideredfordiffuseBCCformation(eg,GorlinsyndromeTheapproachforpatientswithdiffuseBCCformation(eg,Gorlinsyndrome,orothergeneticformsofmultipleBCC),hedgehogpathwayinhibitorsmaybeconsidered.HedgehogpathwayinhibitorsHHIsarenotapprovedforGorlinsyndrome;however,theyareeffectivebasedonarandomizedcontrolledtrial.–Thirdsub-bulletrevised:CurrentFDA-approvedhedgehogpathwayinhibitorsHHIsincludevismodegibandsonidegib.VismodegibisFDAapprovedforthetreatmentofadultswithmBCCorwithlocallyadvancedlaBCCthathasrecurredfollowingsurgery,orthosewhoarenotcandidatesforsurgeryorandwhoarenotcandidatesforRT.SonidegibisFDAapprovedforthetreatmentofadultspatientswithlocallyadvancedlaBCCthathasrecurredfollowingsurgeryorRT,orthosewhoarenotcandidatesforsurgeryorRT.SonidegibisnotFDAapprovedforthetreatmentofadultswithmBCC.?Secondbulletrevised:Cemiplimab-rwlcisrecommendedforpatientswithlocallyadvancedlaBCCormBCCpreviouslytreatedwithanhedgehogpathwayinhibitor[HHI]orforwhomanHHIisnotappropriate.?Footnote1added:DummerR,GuminksiA,GutzmerR,etal.Long-termefficacyandsafetyofsonidegibinpatientswithadvancedbasalcellcarcinoma:42-monthanalysisofthephaseIIrandomized,double-blindBOLTstudy.BrJDermatol2020;182:1369-1378.?Footnote2added:TangJY,etal.Inhibitionofthehedgehogpathwayinpatientswithbasal-cellnevussyndrome:finalresultsfromthemulticenter,randomized,double-blind,placebocontrolled,phase2trial.LancetOncol2016;17:1720-1731.PrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexWORKUPCWORKUPPRESENTATIONincanceraincanceraHPybc?ybcDIAGNOSISRISKSTATUSryskBasalCellSkinCancerBCCfryhskBasalCellSkinCancerBCCpresentationofregionalordistantImagingstudiesofareasofinterestasindicatedforseaseseasedegforRecurrenceorAdvancedDiseaseBCC-4)aFormoreinformation,seeAmericanAcademyofDermatologyAssociation.bSeePrinciplesofPathology(BCC-A).cSeeRiskFactorsforRecurrence(BCC-B).dExtensivediseaseincludesdeepstructuralinvolvementsuchasbone,perineuraldisease,anddeepsofttissue.Ifperineuraldiseaseissuspected,MRIwithcontrastispreferred.Ifbonediseaseissuspected,CTwithcontrastispreferredunlesscontraindicated.eForrarecasesthatpresentwithregionalordistantmetastaticdiseaseatdiagnosis,treatasnodalordistantmetastasespathwayonBCC-4.fAnyhigh-riskfactorplacesthepatientinthehigh-riskcategory.gImagingmodalityandtargetedareashouldbeatthediscretionofthetreatingteambasedonthesuspectedextentofdisease(ie,local,regional,metastatic).Histologicconfirmationisoftensufficienttodiagnoselocalrecurrence,butMRIcanbeconsideredtoassessextentoflocaldisease.Fornodalordistantmetastasis,histologicanalysisand/orCTimagingcanbeemployedforconfirmationandtogaugeextentofdisease.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.BCC-1Curettageandelectrodesiccation(C&E):nuntilclearmarginsareidentified(secondintentionhealing,NegativelinearrepairorskingraftaremarginsblePrintedbyMinTangon3/26/20229:56:11AM.ForCurettageandelectrodesiccation(C&E):nuntilclearmarginsareidentified(secondintentionhealing,NegativelinearrepairorskingraftaremarginsblerdexPRIMARYTREATMENThADDITIONALTREATMENTLocallow-riskbchbchi?Excludingterminalhair-bearingareas,suchasthescalp,candaxillaryregionsandbeardareainmales?Iftumorappearstoextendbeyondthedermis,surgicalexcisionshouldgenerallybeperformedratherthanC&ErformsofperipheralRadiationtherapy(RT)jfornon-surgicalcandidateshSeeFollow-up(BCC-4)bSeePrinciplesofPathology(BCC-A).cSeeRiskFactorsforRecurrence(BCC-B).hSeePrinciplesofTreatment(BCC-C).iInpatientswithsuperficialbasalcellskincancer,therapiessuchastopicalimiquimod,topical5-fluorouracil,photodynamictherapy,orcryotherapymaybeconsidered,thoughcureratesareapproximately10%lowerthanforsurgicaltreatmentmodalities.JansenMHE,etal.JInvestDermatol2018;138:527-533.DrewBA,etal.DermatolSurg2017;43:1423-1430.jSeePrinciplesofRadiationTherapy(BCC-D).kPDEMAwithpermanentsectionanalysisorintraoperativefrozensectionanalysisisanalternativetoMohs.SeePrinciplesofPDEMATechnique(SCC-G).lFortumorsoncheeks,forehead,scalp,neck,andpretibiathatare<6mmindepthandconfinedtothedermis,C&EmaybeconsideredasanalternativeprimarytreatmentoptionifMohs,resectionwithPDEMA,andstandardexcisionarenotfeasibleduetopatientcomorbidities.SeeRiskFactorsforRecurrence(BCC-B).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.BCC-2Version2.2022,03/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.gerynotfeasiblehmPrintedbyMinTangon3/26/20229:56:11AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.gerynotfeasiblehmrdexPRIMARYTREATMENThADDITIONALTREATMENTLocalhigh-riskrbcrbcfhmMultidisciplinaryconsultationtodiscussoptions:?RTj?Systemictherapyo?RTj?SystemictherapyoifcurativeRTand/orcurativermsrmsinvolvement,b,pconsideradjuvantinvolvement,b,pconsideradjuvantRTh,j,qrdexcisionwithwidersurgicalmarginsnandpostoperativemarginassessmentandsecondintentionhealing,linearDEMAkliffeasibleDEMAkliffeasibleEMAklnotEMAklnotfeasibleIfresidualdiseaseispresent,andfurthersurgeryisnotfeasible,considermultidisciplinaryconsultationto?SystemictherapyoifcurativeRTnotfeasiblem?RTj?Systemictherapyoif?RTj?SystemictherapyoifcurativeRTnotfeasiblemootnotesonBCCANote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTria