Cutaneous disease
· Basal cell carcinoma
o Defer when possible
o If advanced and/or symptomatic requiring therapy sooner, consider hedgehog inhibitors
· Squamous cell carcinoma
o Consider deferring wide local excision (WLE) or Mohs by 8-12 weeks, or consider topical options for early stage disease (e.g., imiquimod)
o If advanced and/or symptomatic requiring therapy sooner, consider neoadjuvant non-surgical therapy (e.g., cemiplimab) to allow deferral past peak incidence of pandemic
· Melanoma (detailed report can be found in the NCCN COVID-19 working group14)
o Melanoma in situ
§ Delay WLE of melanoma in situ for at least 3 months
o T1 melanoma
§ Delay WLE for up to 3 months or consider excision in office/outpatient setting
o Sentinel lymph node biopsy (SLNB)
§ Offer for melanoma >1 mm thickness, but defer SLNB for T1b melanoma (0.8-1.0 mm with or without ulceration), unless high risk features are evident (e.g., lympho-vascular invasion, very high mitotic rate, young patient age [≤40 years])
o T3/T4 melanomas should take priority over T1/T2 melanomas
§ Delay SLNB for up to 3 months, unless WLE in the OR is planned, in which case case WLE/SLNB may be performed at the same time
o Stage III (regional nodal) Melanoma
§ As per current NCCN guidelines15, defer completion lymph node dissection following a positive SLNB, and perform regional nodal ultrasound surveillance (if radiologic expertise available) or other imaging surveillance (CT, FDG PET-CT, MRI), as appropriate
§ Defer therapeutic neck dissection in the setting of clinically palpable regional nodes, and offer neoadjuvant systemic therapy immune checkpoint blockade or BRAF/MEK inhibitors instead
· The NCCN Melanoma Panel does not consider neoadjuvant therapy as a superior option to surgery followed by systemic adjuvant therapy for stage III melanoma15, but available data suggests this is a reasonable resource-conserving option during the COVID-19 outbreak
§ Metastatic resections (stages III and IV) should be placed on hold unless the patient is critical/symptomatic and patients should continue systemic therapy
o Merkel cell carcinoma
§ Favor primary radiation therapy
§ Consider starting immunotherapy for locally advanced/locoregional recurrent disease