Focused Review © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 12 Number 3 | March 2014 434 Abstract Merkel cell carcinoma (MCC) is a rare malignancy of the skin, and prospective randomized clinical studies on management and treatment are very limited. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MCC provide up-to-date, best evidence–based, and consensus-driven management pathways with the purpose of providing best care and outcomes. Multidisci- plinary management with consensus treatment recommendations to individualize patient care within the framework of these guide- lines is optimal. The University of Michigan multidisciplinary MCC program uses NCCN Guidelines in the management and treatment of its patients. This article discusses 4 patient presentations to high- light the implementation of the NCCN Guidelines for MCC at the University of Michigan. (J Natl Compr Canc Netw 2014;12:434–441) Despite its rarity, the increasing incidence and ag- gressive nature of MCC have brought attention on this disease and revealed a wide variability in the treatment and management of patients diagnosed with this malig- nancy. Patients with MCC may have very different work- up, treatment, and follow-up depending on the institu- tion, physician, and specialty providing their care. These inconsistencies highlight the importance of having best evidence–based treatment guidelines. Unfortunately, prospective randomized clinical trials are extremely lim- ited because of the rarity of the disease, necessitating that guidelines be based on best available evidence and ex- pert consensus opinion. Multidisciplinary management to establish consensus recommendations for individu- alizing patient care within the framework of evidence- based guidelines constitutes the optimal treatment model within the existing limitations. This article discusses the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MCC, including the importance of multidisciplinary management, and highlights the im- plementation of these guidelines in the multidisciplinary MCC program at the University of Michigan (UM). Background MCC is rarely clinically suspected. The most common presentation is a nondistinctive, rapidly growing, as- ymptomatic, red-purple–colored nodule. 2 MCC occurs most frequently on sun-exposed skin of the head and neck (29.0%–45.3%) and extremities (21.0%–50.0%), followed by the trunk (4.7%–23.0%) and other sun-pro- tected areas. 2–5 Immunosuppression from HIV, chronic lymphocytic leukemia, and certain immunosuppressant From the Departments of a Dermatology, b Surgery, c Otolaryngology, d Radiation Oncology, e Internal Medicine, and f Pathology, University of Michigan Health System, Ann Arbor, Michigan. Submitted September 23, 2013; accepted for publication December 9, 2013. The authors have disclosed that they have no fnancial interests, arrangements, affliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. Correspondence: Jennifer L. Schwartz, MD, University of Michigan Health System, 1910 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0314. E-mail: jennschw@med.umich.edu NCCN Guidelines Implementation in the Multidisciplinary Merkel Cell Carcinoma Program at the University of Michigan Jennifer L. Schwartz, MD a ; Sandra L. Wong, MD b ; Scott A. McLean, MD, PhD c ; James A. Hayman, MD d ; Christopher D. Lao, MD, MPH e ; Jeffrey H. Kozlow, MD b ; Kelly M. Malloy, MD c ; Carol R. Bradford, MD c ; Marcus L. Frohm, MD a ; Douglas R. Fullen, MD a,f ; Lori Lowe, MD a,f ; and Christopher K. Bichakjian, MD a Merkel cell carcinoma (MCC), diagnosed primarily in the elderly white population, is an uncommon, clinically aggressive cutaneous malignancy with a high rate of local, regional, and distant recurrence. During the last 2 decades of the 20th century, the incidence of MCC more than tripled, a trend that is expected to continue with an increasingly aging population. 1