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Treatment Option Overview

    continued...

    In the absence of adequately powered, prospective, randomized clinical trials, the following questions remain:[4,12,21,24][Level of evidence: 3iiiDiii]

    • Should every positive SLN biopsy be followed routinely by completion nodal surgery and/or radiation therapy?
    • Are outcomes demonstrably improved by routinely adding radiation if node surgery reveals tumor in multiple nodes and/or extracapsular extension and/or lymphovascular invasion?
    • Should patients with MCCs smaller than 1 cm routinely undergo sentinel lymph node dissection (SLND)?
    • Should patients with negative or omitted nodal work-up routinely undergo local or local-regional radiation therapy?
    • Should immunohistochemical staining techniques be used to identify micrometastases in nodes, and is micrometastatic disease in nodes clinically relevant?

    At present, the primary role of lymph node surgery is for staging and guiding additional treatment.

    Based on a small number of retrospective studies, therapeutic dissection of the regional nodes after a positive SLND appears to minimize but not totally eliminate the risk of subsequent regional node recurrence and in-transit metastases.[4,21,24][Level of evidence: 3iiiDiii] There are no data from prospective randomized trials demonstrating that definitive regional nodal treatment with surgery improves survival.

    Radiation Therapy

    Because of the aggressive nature of MCC, its apparent radiosensitivity, and the high incidence of local and regional recurrences (including in-transit metastases after surgery alone to the primary tumor bed), some clinicians have recommended adjuvant radiation therapy to the primary site and nodal basin. Nodal basin radiation in contiguity with radiation to the primary site has been considered, especially for patients with larger tumors, locally unresectable tumors, close or positive excision margins that cannot be improved by additional surgery, and those with positive regional nodes, especially after SLND (stage II).[10,11,14,15,25][Level of evidence: 3iiiDiii] Several small, retrospective series have shown that radiation plus adequate surgery improves local-regional control compared to surgery alone, [2,5,26,27,28,29] whereas other series did not show the same results.[4,8][Level of evidence: 3iiiDiii]

    In the absence of adequately powered, prospective, randomized clinical trials, the following questions remain:[4,8,9,12,21,24,26,30,31,32,33,34][Level of evidence: 3iiiDiii]

    • Should every positive SLN biopsy be followed routinely by completion nodal surgery and/or radiation therapy?
    • Are outcomes demonstrably improved by routinely adding radiation only if nodal surgery reveals tumor in multiple nodes and/or extracapsular extension and/or lymphovascular invasion?
    • Should all or just certain patients with negative or omitted nodal work-up receive local or local-regional radiation routinely?
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