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Skin Cancer

Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure the following steps are completed.

Pretreatment evaluation:

  • A full history and physical examination with a complete skin examination and lymph node examination if needed
  • A biopsy to confirm a diagnosis of cancer
  • An evaluation by the members of a skin cancer team

Additional possible measures may be taken:

  • Evaluation of the lungs to check for spread
  • Imaging of the primary tumor and the neck
  • Maybe a PET-CT for advanced cancers
  • Pretreatment medical clearance and optimization of medical conditions

Then your doctor will recommend a course of treatment for you, depending on a number of factors. Like with all cancers in the head and neck, there are three general options to consider:

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma, Non-Melanoma Skin Cancers, or Merkel Cell Carcinoma to decide on the appropriate treatment course.5, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. 6, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. 7Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.  If these NCCN Guidelines® are not followed, they will discuss it with you and explain why your situation might be special.

Because surgical removal of skin cancer is usually the first line treatment, there are a few important points to know about different methods of surgical removal of skin cancers.

Methods of Surgical Excision for Skin Cancers6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

  • Cryosurgery: This involves destroying a skin lesion by freezing it off. This works quite well for non-cancerous lesions, and a dermatologist might use it for very small basal cell and squamous cell carcinomas of the skin that do not invade deeply. The problems with doing this for skin cancer are that there is no way to assess details of the cancer or determine whether all of the cancer was eliminated.
  • Curettage and electrodessication: This involves scraping off and burning the lesion. This works well for non-cancerous lesions, and a dermatologist might use it for very small basal cell and squamous cell carcinomas of the skin that do not invade deeply. The problems with doing this for skin cancer are that there is no way to assess details of the cancer or determine whether all of the cancer was eliminated.
  • Wide local excision: A surgeon removes the cancer completely, along with a rim of normal-appearing tissue around the tumor. This method is used if a nice rim of normal tissue can be taken without distorting the appearance of the face. It can be done with a little numbing medicine in the office, or under general anesthesia (with you completely asleep). In this case, the surgeon will send some tissue at the edge to see if all of the cancer was removed. Once the lesion is removed, the surgeon can reconstruct the area. Sometimes the reconstruction might be delayed to a later date so the pathologist can check if more of the margins should be removed to make sure the cancer is out.
    • When doing a wide excision for melanoma, the NCCN recommends a certain sized margin of resection, depending on the thickness of the melanoma. Keep in mind that for the head and neck region, the margins may be modified to avoid distortion of certain parts of the face.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.  
Tumor Thickness Recommended Clinical Margins
  • In situ
  • 0.5 cm
  • ≤ 1.0 mm
  • 1.0 cm
  • 1.01 to 2 mm
  • 1 to 2 cm
  • 2.01 to 4 mm
  • 2.0 cm
  • > 4 mm
  • 2.0 cm
  • Mohs’ micrographic surgery: This technique is used mainly for NMSC by a dermatologist who has special training in this technique. It can also be considered for merkel cell carcinoma according to the current NCCN Guidelines for Merkel Cell Carcinoma.7Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. It is not used for melanoma.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.
    • This technique is particularly useful for skin cancers on the face because it allows the surgeon to remove all of the cancer (with negative margins) while sparing as much normal face as possible.
    • The surgeon uses numbing medicine and does this in the office. Basically, the lesion, along with a small margin, is removed with a knife. The margin is carefully mapped out. The surgeon then acts as a pathologist and looks at the entire margin for any signs of residual cancer. If there is any cancer on the margin, the surgeon is able to use the map he or she created to remove cancer from the areas that still have cancer. This will be repeated until all of the margins are negative for signs of cancer. In some cases, the dermatologist will get negative margins all around the cancer on the skin but leave some cancer in the deep areas. Then the dermatologist will send you to a surgeon who can remove the rest of the deeper cancer and reconstruct the area that was removed.

Treatment for Basal Cell Skin Cancers5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

The main goal in the treatment of basal cell cancers (BCC) is to cure them while maintaining as much normal appearance and facial function as possible. Keep this in mind when your doctor discusses treatment options with you.

The treatment recommendations for BCC of the skin depend on the risk that it will come back. NCCN® uses the following guidelines to put you into low-risk or high-risk categories:5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

71_Hzone

Shaded area represents Area H (higher-risk region of the face). White area represents Area M. Cancers in the H zone can invade important structures more easily and are more likely to recur (perhaps due to less aggressive surgical removal or difficulty in getting negative margins).

 

Low Risk

High Risk

Location and Size Area M < 10 mmArea H < 6 mm Area M > 10 mmArea H > 6 mm
Borders Borders well defined Borders poorly defined
First time Cancer or Recurrent in this Area First time BCC in this area Recurrent BCC in this area
Immune System Suppressed No Yes
Site of Radiation Therapy in the past No Yes
Subtype Nodular, superficial Aggressive growth pattern
Invasion in or near nerves No Yes

Modified with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org.  NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

For low-risk BCC, the main treatment options are:

  • Curettage and electrodessication
  • Excision with assessment of margins. If the margins are positive, the area should be removed again with assessment of margins, or radiation should be considered.
  • Radiation therapy for people not fit for surgery

For high-risk BCC, the treatment options are:

  • Excision with assessment of margins. If the margins are positive, the area should be removed again with assessment of margins, or radiation should be considered.
  • Mohs or resection with complete margin assessment all around the tumor. Then radiation therapy should be recommended if the margins are still positive or if there is a great deal of invasion in/around nerves.
  • Radiation therapy for people not fit for surgery

For superficial and low risk BCC, if surgery or radiation is not the best option, then certain creams, phototherapy and aggressive cryotherapy might be considered.5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

If the basal cell carcinoma has spread to lymph nodes in the region or somewhere else in the body, then your team of doctors should meet and discuss the best options for you.

Treatment of Squamous Cell Carcinoma of the Skin5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

The main goal in the treatment of squamous cell skin cancers is to cure them while maintaining as much normal appearance and facial function as possible. Keep this in mind when your doctor discusses treatment options with you.

The treatment recommendations for SCC of the skin depend on the risk that it will come back. NCCN uses the following guidelines to put you into low-risk or high-risk categories:5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

71_Hzone

Shaded area represents Area H (higher-risk region of the face). White area represents Area M. Cancers in the H zone can invade important structures more easily and are more likely to recur (perhaps due to less aggressive surgical removal or difficulty in getting negative margins).

 

Low Risk

High Risk[NM1] 

Location and Size Area M < 10 mmArea H < 6 mm Area M > 10 mmArea H > 6 mm
Borders Borders well defined Borders poorly defined
First time Cancer or Recurrent in this Area First time SCC in this area Recurrent SCC in this area
Immune System Suppressed No Yes
Site of Radiation Therapy in the past or Long-term inflammation site No Yes
Rapidly growing tumor No Yes
Nerve related symptoms No Yes
Differentiation Well or Moderately Differentiated Poorly Differentiated
Subtype Other Adenoid, Adenosquamous, desmoplastic
Depth (thickness) < 2 mm or Clark I, II, III > 2 mm or Clark IV, V
Invasion in or near nerves No Yes

Modified with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org.  NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

For low-risk SCC, the main treatment options are:

  • Curettage and electrodessication can be used in areas without hair. If the curettage is going down into the fat, then your doctor should probably change to an excision.
  • Excision with assessment of margins. If the margins are positive, then the area should be removed again with assessment of margins, or radiation should be considered.
  • Radiation therapy for people not fit for surgery

For high-risk SCC, the treatment options are:

  • Excision with assessment of margins. If the margins are positive, then the area should be removed again with assessment of margins, or radiation should be considered.
  • Mohs or wide resection with complete margin assessment all around the tumor. Then radiation therapy should be recommended if the margins are still positive, or if there is significant invasion in/around nerves.
  • Radiation therapy for people not fit for surgery

Finally, if you have lymph nodes that are biopsied and found to be positive, you need to have that region treated. Lymph nodes can be found in the neck, on one or both sides, or within the parotid salivary gland.

For squamous cell skin cancer spread to any lymph nodes:

  • Before treating the lymph, your doctor will get some imaging to see the extent of neck disease and make sure the cancer has not spread to other parts of your body as well. If the neck disease can be removed, you will get a neck dissection (or a parotidectomy if the lymph nodes are in the parotid gland). Then you will either get no further treatment, radiation or (if the lymph nodes show spread of cancer outside of the node or if all of the lymph node disease could not be removed) your doctor might recommend chemotherapy with radiation.

Treatment of Malignant Melanoma of the Skin6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

Treatment for malignant melanoma should be carried out by a team that is up to date on the latest advances in the treatment of melanoma. NCCN treatment recommendations are broken down by stage, and are summarized below.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

The NCCN Guidelines for Patients With Melanoma can help you understsand treatment recommendations for certain skin cancer types.9 Rubin AI, Chen EH, Ratner D. Basal Cell Carcinoma. N Engl J Med. 2005;353:2262-2269.

  • Stage 0 (in situ melanoma): Treatment should involve wide excision (surgical removal).
  • Stage 1A (0.75 mm thick): Treatment should involve wide excision (surgical removal).
  • Stage 1A (0.76 to 1 mm thick): Treatment should involve wide excision (surgical removal). Your doctor might also consider sentinel lymph node biopsy.
  • Stage 1B (and ≤ 0.75  mm thick): Treatment should involve wide excision (surgical removal).
  • Stage 1B (and 0.76 – 1 mm thick): Treatment should involve wide excision (surgical removal) along with a discussion about sentinel lymph node biopsy. If an SLNB is done and it is negative, then it is okay to just observe, or enter into a clinical trial. If an SLNB is done and it is positive, then you go to the Stage III treatment.
  • Stage 2 (no evidence of spread to lymph nodes): Treatment should involve wide excision (surgical removal) along with a discussion about sentinel lymph node biopsy.
    • For Stage 2a, if an SLNB is done and it is negative, then it is okay to observe, or you might be recommended to a clinical trial.
    • For Stage 2b or 2c, if an SLNB is done and it is negative, the recommendations are to observe, give interferon-alfa or you might be recommended to a clinical trial.
    • If an SLNB is done and it is positive, then you need to move on to Stage 3 treatment.
  • Stage 3 (positive lymph nodes):
    • For Stage 3 based on cancerous lymph nodes found by your doctor before starting any treatment, the recommended course of action is wide excision of the primary tumor and a lymph node dissection (parotidectomy or neck dissection, depending on where the lymph nodes are positive). This should be followed by observation, clinical trial, or interferon-alfa. You doctor may also considerradiation to the lymph node region.
    • For Stage 3 based on a positive SLNB, the options are a parotidectomy/neck dissection or clinical trial. Then either observation, interferon-alfa or a clinical trial would be the next steps.
    • For Stage 3 because of in-transit metastases (which are tumor deposits in the lymph channels of the skin between the primary tumor and the closest neck lymph node basin) there are a number of options.  In general, for in-transit metastases, you should be treated at a center that has specialists in advanced melanoma treatment, and you should consider enrolling in a clinical trial.  Treatment options can include complete surgical excision of the metastatic tumor if possible, or other local treatments such as biologic injections, local ablation, topical creams, or even radiation in some situations.  There are also some medication infusion options, or biologic/chemotherapy options that could be considered.  Following treating all apparent tumor, either observation, interferon-alfa or a clinical trial would be the next steps.
  • Stage 4 (metastatic melanoma): For malignant cutaneous melanoma spread to a distant site, you should have an extensive discussion with your team of doctors. Surgical removal of the melanoma is an option if it is limited, or some whole body treatment might be considered.

Treatment of Merkel Cell Carcinoma7Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

  • Merkel Cell Carcinoma that has not spread to any lymph nodes (N0) or throughout the body (M0): If there are no evident nodes in the neck or parotid gland, and there has been no prior surgical excision, there are two options:
    • Sentinel lymph node biopsy followed by wide local excision
      • If the SLNB is negative, your doctor will either observe or give you radiation.
      • If the SLNB is positive, you should receive a tumor board consultation and a neck dissection or parotidectomy, with or without radiation. After surgery, a clinical trial is the preferred treatment if it is available.
  • Merkel Cell Carcinoma that has spread to the lymph nodes (N+): Before treating the lymph nodes, your doctor will perform some imaging to see the extent of neck disease and make sure the cancer has not spread to other parts of your body as well. You should receive a tumor board consultation and lymph node dissection or parotidectomy with or without radiation.
  • Metastatic (M1) Merkel Cell Carcinoma to the body: If there is spread to other parts of the body (M1), then your team of doctors should meet and discuss the best treatment option for you personally.
  • Recurrent Merkel Cell Carcinoma: If there is recurrent Merkel cell cancer (the cancer has come back after being treated in the past), your team of doctors should meet and discuss the best treatment option for you personally.
References

1 Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United State: Incidence. J Am Academy of Dermatology. 1994;30:774.

2 American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.

3 Albores-Saavedra J, Batich K, Chable-Montero F, Sagy N, Schwartz AM, Henson DE. Merkel cell carcinoma demographics, morphology, and survival based on 3870 cases: a population based study. J Cutan Pathol. 2010:37:20-27.

4 LeBoit PE, Burg G, Weedon D, Sarasain A. (Eds.): World Health Organization. Classification of Tumours. Pathology and Genetics of Skin Tumours. IARC Press: Lyon 2006.

5 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

7 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

8 Referenced with permission from the NCCN Guidelines for Patients®: Melanoma V.1.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed July 2, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

9 Rubin AI, Chen EH, Ratner D. Basal Cell Carcinoma. N Engl J Med. 2005;353:2262-2269.

10 Walling HW, Fosko SW, Geraminejad PA, Whitaker DC, Arpey CJ. Aggressive basal cell carcinoma: Presentation, pathogenesis, and management. Cancer and Metastasis Reviews. 2004;23(3-4):389-402.

11 Hollestein LM, de Vries E, Nijsten T. Trends of cutaneous squamous cell carcinoma in the Netherlands: Increased incidence rates, but stable relative survival and mortality 1989-2008. European Journal of Cancer. 2012;48(13):2046-2053.

12 Lardar T, Shea SM, Sharfman W, Liegeois N, Sober AJ. Improvements in the Staging of Cutaneous Squamous-Cell Carcinoma in the 7th Edition of the AJCC Cancer Staging Manual. Annals of Surgical Oncology. 2010;17(8):1979-1980.

13 Cockburn M, Peng D, Key C. Chapter 12: Melanoma. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

14 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Chapter 31: Melanoma of the Skin. P329.

15 Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD.

16 Agelli M, Clegg LX. Epidemiology of primary Merkel cell carcinoma in the United States. J Am Acad Dermatol. 2003;49:832-41.

17 Engels EA, Frisch M, Goedert JJ, Biggar RJ, Miller RW. Merkel cell carcinoma and HIV infection. The Lancet. 2002;359(9305):497-498.

18 Buell JF, Trofe J, Hanaway MJ, et al. Immunosuppresion and Merkel cell cancer. Transplant Proc. 2002;34(5):1780-1.

19 Penn I, First MR. Merkel cell carcinoma in organ recipients: report of 41 cases. Transplantation. 1999;68(11):1717-21.

20 Young JL, Ward, KC, Ries LAG. Chapter 30: Cancers of Rare Sites. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

21 Albores-Saavedra J, Batich K, Chable-Montero F, Sagy N, Schwartz AM, Henson DE. Merkel cell carcinoma demographics, morphology, and survival based on 3870 cases: a population based study. J Cutan Pathol. 2010:37:20.

22 Wang TS, Byrne PJ, Jacobs LK, Taube JM. Merkel Cell Carcinoma: Update and Review. 2011 Seminars in Cutaneous Medicine and Surgery: 30(1):48-56.