Table 9.

Updated treatment algorithm for Merkel cell carcinoma [13–15].

Stages I and II (localized disease)
(i) Wide local excision with SLNB. If SLN positive, complete  LN dissection if feasible. If not, nodal radiotherapy
(ii) Wide excision and prophylactic lymph node dissection
(iii) Wide excision of the primary tumor, alone or combined  with adjuvant radiotherapy
(iv) Mohs micrographic surgery can be used if feasible
(v) Excision followed by postoperative adjuvant radiotherapy  to primary ± nodal regions
Stage III (regional disease)
(i) Wide local excision plus LN dissection if feasible. If not,  radiation therapy to primary and nodal regions
(ii) Adjuvant chemotherapy is controversial but may be  considered in selected fit high-risk patients
Stage IV (distant disease)
(i) Palliative care with or without surgery, radiotherapy, and  chemotherapy

LN: lymph node; SLN: sentinel lymph node; SLNB: sentinel lymph node biopsy.