Peri-Neural Invasion: When is Referral for Radiotherapy Mandatory?

How should GPs manage a report of peri-neural invasion (PNI) in non-melanoma skin cancer? Close to 3,000 GPs have attended the Professional Certificate of Skin Cancer Medicine course that I teach around Australia each year. It is always of interest to me that many don’t fully appreciate the importance of  PNI when reported in BCC or SCC biopsy or excision.

This paper from Gupta et al is highly instructive. How should GPs manage a report of PNI in NMSC?

  1. My default standard is that any report of PNI should lead to referral for radiotherapy. However, we can get a bit more specific than that:
  2. Any patient with clinically apparent neurological symptoms in association with NMSC (motor or sensory changes) must be referred for multidisciplinary care: these clinical symptoms indicate involvement of large nerves which will likely need extensive surgery and radiotherapy
  3. Most patients with PNI associated with NMSC are asymptomatic so we need to do a simple risk assessment:

Any patient with a low risk NMSC and when the PNI is limited to the body of the tumour itself, and to small nerves is unlikely to benefit from radiotherapy – you might still seek an opinion though, depending on your confidence, experience and access to services

If the pathology report indicates PNI outside the body of the tumour, if larger nerves are involved, if the tumour is invading the dermis, if the tumour is recurrent, and if the subtype is aggressive (eg poorly differentiated SCC, sclerosing BCC etc), then referral for radiotherapy is mandatory.

David Wilkinson

Click here to download the full paper

Learn more about skin cancer medicine in primary care at the next Skin Cancer Certificate Courses:

Skin Cancer Certificate Courses in Australia

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