Merkel cell carcinoma of the head and neck: a retrospective case series

Mohs Micrographic Surgery for Facial Merkel Cell Carcinoma

BACKGROUND

Merkel cell carcinoma (MCC) is a rare malignant cutaneous tumor with frequent metastases. They often appear in the face where cosmetic and functional outcome is critical. Mohs micrographic surgery (MMS) is a controlled intervention that optimizes negative margins without sacrificing tissue.

OBJECTIVE

A comprehensive assessment of outcomes of MMS-treated facial MCC will help guide clinicians in surgical and medical management.

METHODS & MATERIALS

Retrospective review identified facial MCC cases treated with MMS at a single institution from January 2005 to August 2020. Tumor characteristics and outcomes were recorded and descriptive and predictive analyses were performed.

RESULTS

34 cases were reviewed with a mean followup of 34.4 months. The most common sites were the forehead, cheek-jaw region, and nasal ala. 2 (5.9%) patients had local recurrence by a mean of 4.3 months. No documented variables were significantly associated with local recurrence. 8 (23.5%) patients had progression to metastasis by a mean of 9.4 months. Younger age at biopsy and surgery, male sex, and intraoperative detection of in-transit disease were significantly associated with progression to metastasis.

CONCLUSIONS

In summary, the tissue-sparing approach of MMS may be beneficial for MCC in cosmetically and functionally sensitive facial locations as it preserves tissue without compromising outcomes.

Head and Neck Merkel Cell Carcinoma: A 12-Year Single Institutional Experience

Background

Merkel cell carcinoma (MCC) is an aggressive malignancy of presumed neuroendocrine origin. Most case series of MCC are limited by low case numbers and are not specific to head and neck tumours. The purpose of this study was to provide a focused review of head and neck MCC diagnosis and management in a single Irish institution.

Methods

Patient's demographics, tumour characteristics, pathological diagnosis, surgical treatment, adjuvant treatment, subsequent management and clinical course were collected. Estimates of progression-free MCC survival rates were calculated by the Kaplan–Meier statistical model. A Pearson product-moment correlation coefficient examined the association between surgical margins and disease-free follow-up.

Results

In total, 11 patients were treated for head and neck MCC with a mean age of 79.6 years (range = 69–91 years). The mean average follow-up duration of patients was 18.3 months. Of the cohort, 18% (n=2) had a sentinel node biopsy (SLNB). A selective neck dissection was subsequently performed in 18% (n=2). In total, 72% (n=8) of patients received adjuvant radiotherapy. Median disease-specific survival was 15 months for the SLNB group and 17 months for the non-SLNB group, not statistically significant (p=0.23). There was no significant association between surgical margins and disease-free follow (p=0.65).

Conclusions

Our case series adds to a limited body of evidence of head and neck MCC. Surgery remains the treatment priority in localized disease, with an increasing role of SLNB for accurate prognostication and staging. Early management of stage I disease results in moderate long-term disease-free survivability.

Merkel Cell Carcinoma, the Impact of Clinical Excision Margins and Mohs Micrographic Surgery on Recurrence and Survival: A Systematic Review

BACKGROUND

When treating Merkel cell carcinoma (MCC), the relation between wide local excision (WLE) margin and recurrence or survival is unclear. Mohs micrographic surgery (MMS) is an alternative surgical option for MCC, but it is unknown whether the local recurrence rate differs between MMS and WLE.

OBJECTIVE

To systematically assess the available literature to determine the recurrence and survival rates when treating MCC with MMS and different clinical excision margins.

MATERIALS AND METHODS

The MEDLINE, EMBASE, and CENTRAL databases were searched. Two independent reviewers selected studies that defined clear excision margins and either recurrence or survival. When possible, individual cases were extracted from case series and included in the analyses. Other studies were reviewed narratively.

RESULTS

Overall, 1108 studies were identified; of which, 19 case series (168 cases) and 12 cohort studies were eligible. None of the cohort studies showed significant differences in recurrence or survival for either excision margins or MMS. Equally, logistic and Cox regression analyses of the case series revealed no significant differences in recurrence or survival between different excision margins and MMS.

CONCLUSION

Synthesis of the available data does not indicate differences in recurrence and/or survival rates for MCC between different clinical excision margins and MMS.

Mohs Micrographic Surgery Versus Wide Local Excision in the Treatment of Merkel Cell Carcinoma: A Systematic Review

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins. However, Mohs micrographic surgery (MMS) offers a potential advantage over WLE because of its ability of sparing healthy tissue and assessing 100% of margins.

OBJECTIVE

To systematically evaluate the surgical modalities for the treatment of MCC.

MATERIALS AND METHODS

Eligible articles were identified using MEDLINE, Scopus, EMBASE, and Cochrane Library. All available studies investigating surgical treatment of MCC with WLE or MMS were considered.

RESULTS

Forty studies met the inclusion criteria. Thirty-one studies described patients treated with WLE, 3 with MMS, and 6 with either WLE or MMS. Subgroup analysis of Stage I MCC showed recurrence rates similar in both surgical modalities with local recurrence rate of 6.8% for WLE versus 8.5% for MMS (p = .64) and a regional recurrence rate of 15.2% for WLE versus 15.3% for MMS (p = .99).

CONCLUSION

Overall WLE cases were at a higher stage at presentation. Subgroup analysis showed that MMS is not inferior to WLE excision for the treatment of Stage I MCC and is a reasonable option for anatomic locations where tissue sparing is important.

Effect of the COVID-19 Pandemic on Delayed Skin Cancer Services

The COVID-19 pandemic has presented a unique set of challenges to cancer care centers around the world. Diagnostic and treatment delays associated with lockdown periods may be expected to increase the total number of avoidable skin cancer deaths. During this unprecedented time, dermatologists have been pressed to balance early surgical interventions for skin cancer with the risk of viral transmission. This article summarizes evidenced-based recommendations for the surgical management of cutaneous melanoma, keratinocyte cancer, and Merkel cell carcinoma during the COVID-19 pandemic. Additional long-term studies are required to determine the effect of COVID-19 on skin cancer outcomes.

Should Sentinel Lymph Node Biopsy Status Guide Adjuvant Radiation Therapy in Patients With Merkel Cell Carcinoma?

Purpose

Radiation of the draining lymph node basin remains controversial for Merkel cell carcinoma, particularly in the era of sentinel lymph node biopsy (SLNB).

Methods and Materials

Based on a 20-year experience using SLNB-guided adjuvant radiation therapy (RT), we conducted a retrospective review of clinically node-negative patients testing 2 hypotheses: (1) whether nodal RT could be safely omitted in SLNB-negative Merkel cell carcinoma and (2) whether the excised primary site should always be radiated. Clinically node-positive patients were excluded.

Results

Among 57 clinically node-negative patients who underwent SLNB and wide local excision (WLE), 42 (74%) had a negative SLNB, and 15 (26%) had a positive SLNB. At a median follow-up of 43 months (range, 5-182), SLNB-negative patients irradiated to the primary site had improved 4-year disease-specific survival (100% vs 65%, P = .008), local recurrence-free survival (100% vs 76%, P = .009), and distant recurrence-free survival (100% vs 75%, P = .008), but not overall survival (87.5% vs 57.7%, P = .164) compared with SLNB-positive patients receiving comprehensive RT. Among SLNB-negative patients treated with WLE only, 67% (6/9) had a disease relapse, half of which were local relapses (33%).

Conclusions

In this single-institution retrospective review, after negative SLNB and WLE, RT given only to the primary site provided 100% disease control without a need for nodal RT. Among SLNB-negative patients who had WLE, omission of postoperative primary-site RT was associated with 67% cancer relapse, of which half was local.

The clinical significance of cytokeratin 20 staining pattern in Merkel cell carcinoma

In the present study, to identify the clinical significance of the cytokeratin (CK) 20 staining pattern in Merkel cell carcinoma (MCC), we retrospectively analyzed the major clinicopathological and immunohistochemical characteristics of 12 cases of MCC. Typical dot-like pattern was seen in eight of our patients, while four patients showed peripheral staining pattern. Interestingly, all cases of MCC with dot-like CK20 tumor cells occurred in the head and neck region, while those with peripheral CK20 pattern tended to be located in other lesions (forearm, knee, or buttock): The difference of frequency in the head and neck regions was statistically significant. Dot-like CK20 staining pattern may therefore be resulted from ultraviolet exposure. Additionally, although without significance, metastasis was more frequent in those with dot-like CK20 than in peripheral CK20 staining: All patients with peripheral CK20 pattern had complete remission by surgical excision with or without radiation therapy. CK20 staining pattern may be a novel predictor of prognosis.

Surgical Management of Merkel Cell Carcinoma

The incidence of Merkel cell carcinoma (MCC) continues to increase. Understanding of MCC biology has advanced rapidly, with current staging providing valuable prognostic information. MCC treatment often is multidisciplinary. Surgery remains an important component in the staging and treatment, most commonly involving wide excision of the cancer and sentinel lymph node biopsy. Lymphadenectomy is used to treat nodal disease. Radiotherapy enhances locoregional control and possibly survival. Systemic therapies, in particular novel immunotherapies, may be promising in the treatment of advanced or recurrent and metastatic disease.

Management of regional metastatic disease in cutaneous malignancy of the head and neck. 3. Merkel cell carcinoma

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes.

Merkel cell carcinoma of the eyelid: A review

Merkel cell carcinoma (MCC) is a rare, aggressive tumor of both epithelial and neuroendocrine origin, which carries a mortality rate of up to 40%. MCC tumors typically present as painless, expanding nodules on the sun-exposed skin areas of older, white patients. Eyelid and periocular tumors comprise approximately 2.5% of all cases of MCC and may be mistaken for chalazia or basal cell carcinomas. Immunosuppression is a significant risk factor, particularly in solid-organ-transplant recipients, patients with chronic lymphocytic leukemia, and patients with HIV. Sentinel lymph node biopsy is often used for accurate staging of head and neck MCC. Treatment includes wide local excision, commonly with the addition of radiotherapy for improved locoregional disease control. Historically, adjuvant chemotherapy had been reserved for metastatic disease, but immunotherapy and targeted chemotherapies are currently being investigated for use in primary disease. The clinical characteristics of all available published cases of eyelid MCC are summarized in this article.

Demographics and outcomes of stage I and II Merkel cell carcinoma treated with Mohs micrographic surgery compared with wide local excision in the National Cancer Database

BACKGROUND

The optimal surgical approach (wide local excision [WLE] vs Mohs micrographic surgery [MMS]) for treating Merkel cell carcinoma (MCC) is yet to be determined.

OBJECTIVE

To compare survival outcomes in patients with early-stage MCC treated with MMS versus with WLE.

METHODS

A retrospective review of all cases in the National Cancer Database (NCDB) of MCC of clinical stage I or II MCC treated with WLE or MMS was performed.

RESULTS

A total of 1795 cases of stage I or II MCC who underwent WLE (n = 1685) or MMS (n = 110) were identified. There was no difference in residual tumor on surgical margins between the 2 treatment groups (P = .588). On multivariate analysis, there was no difference in overall survival between the treatment modalities (adjusted hazard ratio, 1.02; 95% confidence interval, 0.72-1.45; P = .897). There was no difference in overall survival between the 2 groups on propensity score-matched analysis.

LIMITATIONS

Disease-specific survival was not reported, as these data are not available in the National Cancer Database.

CONCLUSIONS

MMS appears to be as effective as WLE in treating early-stage MCC.

[Care of Merkel cell carcinoma and role of the radiotherapy]

Merkel cell carcinoma is a rare neuro-endocrine tumor of skin with a poor prognosis. Data available in literature are scarce. Current treatment for locoregional disease is based on combined treatment by surgery and radiotherapy. However these treatments are controversial. The aim of the present review is to sum up the different available studies and to compare national and international guidelines.

A systematic review of patients with Merkel cell carcinoma of the head and neck and a negative sentinel lymph node biopsy

Background

A negative sentinel lymph node biopsy (SLNB) from patients with head and neck Merkel cell carcinoma (HNMCC) may allow the patient to avoid further adjunctive therapies. However, there is considerable regional variability of lymphatic drainage from primary sites involving the head and neck, and Merkel cell carcinoma (MCC) has aggressive biologic behavior.

Objective

The primary aim of this systematic review was to document the incidence of regional recurrence and mortality from HNMCC patients after a negative SLNB.

Methods

A systematic search of the English literature was conducted via Ovid Medline and Embase from inception until 2013 and the Cochrane Central Register of Controlled Trials from 1991 to January 2014.

Results

Twenty-three studies, with a total of 81 patients matched the inclusion criteria. The incidence of regional recurrence from the entire cohort was 12.3%, and there was a 5% mortality rate. The mean follow-up time, excluding the 30 patients who did not have individual follow-up times specified, was 32.8 months.

Limitations

This review included studies had variable follow-up durations and treatments for MCC.

Conclusions

Despite negative pathologic staging of the neck using SLNB in HNMCC patients, there is still a high incidence of regional recurrence and mortality, over a short follow-up period.

•

Merkel cell carcinoma is an aggressive neoplasm.

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Patients with a negative sentinel lymph node biopsy from head and neck Merkel cell carcinoma showed a high incidence of future regional lymph node involvement.

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In this context, a negative sentinel lymph node biopsy is not necessarily reassuring for the patient or the clinician.

Management of early stage cutaneous Merkel cell carcinoma of the head and neck

Merkel cell carcinoma (MCC) is a rare but aggressive skin cancer of neuroendocrine origin. As a result, few large studies have been published, and we know of even fewer on disease of the head and neck alone. The most appropriate way to manage patients with early local disease and no sign of metastases neck is controversial. We reviewed management of early cutaneous MCC of the head and neck in 8 hospitals in the United Kingdom over 12 years between 1999 and 2011 (the largest head and neck series in Europe to date), and identified 39 patients (19 men and 20 women) with early disease according to a well recognised classification. A total of 24 patients had stage Ia disease, 11 had stage Ib disease, and 4 were unclassified. Five of those with stage Ia disease developed regional metastases and 7 with stage Ib disease developed regional recurrence. The 2-year overall survival for stage Ia and Ib disease was 62% and 27%, respectively. Our study shows that prognosis is poor after conservative surgical management of stage I disease. Management of the neck is still controversial, and a meta-analysis of all the published data is needed to establish best practice statistically.

Secondary merkel cell carcinoma manifested in the parotid

Background. Merkel cell carcinoma of the head and neck is a rare and aggressive malignant tumour. Both the dermatological and surgical colleagues should be aware of this entity as lesions usually present on sun exposed areas of the skin such as the head and neck. Main Observation and Treatment. A 69-year-old male originally presented to the maxillofacial surgery department with a growing lesion on the left eyebrow. Histological analysis confirmed Merkel cell carcinoma and consequently surgical excision was carried out. A follow-up PET/CT scan 2 years later demonstrated a hotspot in the left parotid gland. Fine needle aspiration and cytology revealed Merkel cell carcinoma. A subtotal parotidectomy left side with ipsilateral selective neck dissection levels I to III was carried out. Conclusions. Potential secondary Merkel cell carcinoma in the head and neck region should be taken into account when planning short- and long-term follow up for previously diagnosed patients. This followup should involve both dermatological and surgical colleagues.

Neuroendocrine tumours of the head and neck: anatomical, functional and molecular imaging and contemporary management

Neuroendocrine tumours (NETs) of the head and neck are rare neoplasms and can be of epithelial or non-epithelial differentiation. Although the natural history of NETs is variable, it is crucial to establish an early diagnosis of these tumours as they can be potentially curable. Conventional anatomical imaging and functional imaging using radionuclide scintigraphy and positron emission tomography/computed tomography can be complementary for the diagnosis, staging and monitoring of treatment response. This article describes and illustrates the imaging features of head and neck NETs, discusses the potential future role of novel positron-emitting tracers that are emerging into clinical practice and reviews contemporary management of these tumours. Familiarity with the choice of imaging techniques and the variety of imaging patterns and treatment options should help guide radiologists in the management of this rare but important subgroup of head and neck neoplasms.

Benefits of combined modality treatment of Merkel cell carcinoma of the head and neck: single institution experience

BACKGROUND

There is ongoing debate surrounding the roles of surgery and adjuvant radiotherapy in the management of primary and recurrent Merkel cell carcinoma of the head and neck. This study assessed the influence of local excision, margin status, adjuvant radiotherapy and chemotherapy on locoregional recurrence and survival.

METHOD

A retrospective review of 54 consecutive cases of head and neck Merkel cell carcinoma at a single institution.

RESULTS

Median disease-specific survival time was 120 months. Forty-four per cent of patients developed locoregional recurrence. Combined treatment with surgery and locoregional radiotherapy improved diseasespecific survival. Radiotherapy was associated with longer time to recurrence and regional recurrence. Irradiation of the regional nodes improved regional control, irrespective of clinical status. Margin-negative excision was not associated with improved local control. Combined modality treatment of recurrent disease resulted in a four-fold improvement of local control, but small numbers prevented this trend from reaching statistical significance.

CONCLUSION

Surgical excision of the primary disease and clinically involved regional nodes, plus adjuvant radiotherapy to the surgical bed and regional nodes are recommended for all patients with Merkel cell carcinoma of the head and neck, irrespective of clinical status. Recurrent disease should be aggressively treated with combined modality treatment.

Evidence-based management of primary and localized Merkel cell carcinoma: a review

BACKGROUND

Merkel cell carcinoma is a rare and often lethal cutaneous neuroendocrine malignancy with a tendency for early and frequent locoregional and distant metastasis and relapses. It is a tumor of the elderly and immunosuppressed, which most often appears on sun-exposed areas of the body. There is growing interest in characterization of the disease and the best approach to its management. Despite the lack of prospective randomized clinical trials, treatment is evolving.

OBJECTIVE

To provide an updated review of the most current and relevant data concerning the surgical (± radiological) management of Merkel cell carcinoma, including the role of Mohs micrographic surgery.

METHODS

Using relevant MeSH terms, we performed a review of the literature on the above subjects from 1981 to 2011.

RESULTS AND CONCLUSION

For primary tumors without evidence of organ metastases, surgical excision should be the primary therapy. Owing to the high rate of local metastases, a safety margin of at least 2 cm should be considered. In situations where small, localized tumors and/or special locations necessitate a smaller safety margin, compensation by complete histological examination of the excision margins and perhaps adjuvant radiation therapy should be undertaken. The literature states that benefits of Mohs micrographic surgery (over wide local excision) include tissue conservation and identification of tumors that may require extremely wide excision margins. The majority of data to date supports the use of Mohs surgery in the treatment of Merkel cell carcinoma.

A practical update of surgical management of merkel cell carcinoma of the skin

The role of surgeons in the treatment of Merkel cell carcinoma (MCC) of the skin is reviewed, with respect to diagnosis and treatment. Most of the data in the literature are case reports. Surgery is the mainstay of treatment. A wide local excision, with sentinel node (SLN) biopsy, is the recommended treatment of choice. If SLN is involved, nodal dissection should be performed; unless patient is unfit, then regional radiotherapy can be given. Surgeons should always refer patients for assessment of the need for adjuvant treatments. Adjuvant radiotherapy is well tolerated and effective to minimize recurrence. Adjuvant chemotherapy may be considered for selected node-positive patients, as per National Comprehensive Cancer Network guideline. Data are insufficient to assess whether adjuvant chemotherapy improves survival. Recurrent disease should be treated by complete surgical resection if possible, followed by radiotherapy and possibly chemotherapy. Generally results of multimodality treatment for recurrent disease are better than lesser treatments. Future research should focus on newer chemotherapy and molecular targeted agents in the adjuvant setting and for gross disease.

Merkel cell carcinoma of the head and neck: a single institutional experience

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy occurring mostly in older immunocompromized Caucasian males. A growing incidence of MCC has been reported in epidemiological studies. Treatment of MCC usually consists of surgical excision, pathological lymph node evaluation, and adjuvant radiotherapy. This paper reports the experience of a single tertiary center institution with 17 head and neck Merkel cell carcinoma patients. Median followup for the cohort was 37.5 months. After five years, recurrence-free survival, disease specific survival, and overall survival were 85%, 90%, and 83%, respectively. Our limited data support the use of adjuvant radiotherapy. We also report two cases of MCC located at the vestibule of the nose and two cases of spontaneous regression after diagnostic biopsy. About 40% of our patients were referred to our center for surgical revision and pathological lymph node evaluation. Increased awareness of MCC and an interdisciplinary approach are essential in the management of MCC.

Multidisciplinary management in Merkel cell carcinoma

Herein, the authors describe the experience with the treatment of Merkel cell carcinoma (MCC) and review the literature regarding MCC treatment regimens. Nine patients underwent treatment due to stage I, II, or III MCC. The median follow up was 39 months. In five cases, tumors were excised with skin margins of >2 cm, and skin margins were <2 cm in four patients. Local adjuvant radiotherapy (RT) was given to four patients, while three patients underwent local lymphadenectomy (LAD). Local recurrence occurred in four patients who did not undergo RT (among them three patients had excision margins <2 cm) after a mean time of 9 months. Despite retreatment, two of those patients developed metastases. Recurrence-free survival after primary therapy was achieved: (a) in three patients with stage I and II MCC treated surgically with excision margins <2 cm combined with RT or wide excision >2 cm alone and (b) in two patients with stage III MCC treated with wide excision and LAD combined with local and regional RT. A review of the literature supports the following recommendations: (a) excision with adequate margins combined with RT; (b) LAD with regional RT in cases of lymph node involvement; and (c) sentinel lymph node biopsy in patients without clinically suspicious lymph nodes.

Merkel cell carcinoma. Case report

BACKGROUND

Merkel cell carcinoma (MCC) is a rare aggressive skin tumour affecting mainly older and immuno suppressed individuals (see our review on MCC in this volume).

AIM

This is a case report describing our first experience with Merkel cell carcinoma in an elderly woman on chemo therapy for lymphoma and it covers the diagnosis, treatment and outcome.

METHODS

We did a radical excision of the soft tissue in the tumor area in conjunction with total paroditectomy and resection of the body of the zygomatic bone by radical block neck dissection. The skin defect was reconstructed myocutaneous free flap by a plastic surgeon.

RESULTS AND CONCLUSION

At 12 months follow-up, the MCC had not recurred.

Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Begolka WS, Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Merkel cell carcinoma. A review

BACKGROUND

Merkel cell carcinoma (MCC) is a rare potentially fatal skin tumour affecting older mainly white people and younger immunosuppressed individuals. While uncommon, the incidence is increasing relative to melanoma and with twice the lethality. The benign appearance of the tumour usually on exposed skin parts, contrasting with its extensive microscopic invasion, can delay timely diagnosis. Recurrent MCC is currently attributed to the recently discovered Merkel cell polyomavirus This brief review of MCC covers the history, epidemiology,etiology,clinical and histological features, treatment and prognosis.

METHODS

Literature search using PubMed and search words Merkel cell carcinoma (MCC), etiology, treatment for the years 1972 to 2010.

RESULTS AND CONCLUSION

Merkel cell carcinoma is a rare malignancy with uncertain prognosis. Due to the uncommon occurrence and dearth of randomized studies, there is no agreement on optimal treatment. The tumor has only recently been included in the international classification of tumors (NCCN). The treatment approaches found to be best are radical surgery of primary tumor, drainage of lymph node extension and possibly adjuvant loco-regional radiotherapy. The basis of successful treatment however, remains prevention regular dermatological examination in immunosuppressed patients and early initiation of combination therapy, based on radical surgery supplemented by radiotherapy and palliative chemotherapy in the last resort.

Adjuvant prophylactic regional radiotherapy versus observation in stage I Merkel cell carcinoma: a multicentric prospective randomized study

BACKGROUND

The treatment of stage I Merkel cell carcinoma (MCC) usually includes wide local excision (WLE) combined with irradiation of the tumor bed (ITB). No randomized study has ever been conducted in MCC. The purpose of this study was to assess the efficacy and safety of prophylactic adjuvant radiotherapy on the regional nodes.

PATIENTS AND METHODS

In this randomized open controlled study, patients for a stage I MCC treated by WLE and ITB were randomly assigned to regional adjuvant radiotherapy versus observation. Overall survival (OS) and probability of regional recurrence (PRR) were primary end points. Progression-free survival (PFS) and tolerance of irradiation were secondary end points.

RESULTS

Eighty-three patients were included before premature interruption of the trial, due to a drop in the recruitment mainly due to the introduction of the sentinel node dissection in the management of MCC. No significant improvement in OS (P = 0.989) or PFS (P = 0.4) could be demonstrated after regional irradiation, which, however, significantly reduced the PRR (P = 0.007) with 16.7% regional recurrence rate in the observation arm versus 0% in the treatment arm. The treatment was well tolerated.

CONCLUSION

The adjuvant regional irradiation significantly decreased the PRR in MCC, but benefit in survival could not be demonstrated.

Radiation monotherapy as regional treatment for lymph node-positive Merkel cell carcinoma

BACKGROUND

: Merkel cell carcinoma (MCC) is an aggressive cutaneous malignancy with a high risk of lymph node involvement. To the authors' knowledge, few data have been published to date regarding the optimal regional therapy for lymph node-positive patients. This cohort study was performed to analyze the outcomes of patients with lymph node-positive MCC treated with lymph node irradiation as definitive therapy compared with completion lymphadenectomy (CLND).

METHODS

: Fifty patients with lymph node involvement of MCC at presentation and adequate follow-up data were included in this analysis. Forty-three of these patients were enrolled and followed prospectively. Twenty-six patients presented with microscopic lymph node disease, and 24 patients presented with palpable lymph node involvement.

RESULTS

: Regional control for patients with microscopically involved lymph nodes was 100% regardless of treatment modality-definitive lymph node irradiation (n = 19) or CLND +/- radiotherapy (n = 7) with median follow-up of 18 months. Patients with clinically positive lymph nodes had 2-year regional recurrence-free survival rate of 78% and 73% in the definitive lymph node irradiation (n = 9) and CLND +/- radiotherapy (n = 15) groups, respectively (P = .8) with a median follow-up of 16 months.

CONCLUSIONS

: To the best of the authors' knowledge, the current study is the largest series published to date of radiation monotherapy as regional treatment for lymph node-positive MCC. Lymph node irradiation alone to positive regional lymph nodes was found to confer an excellent regional control rate that was comparable to CLND for both microscopic and palpable lymph node disease. There was no difference noted with regard to overall survival. Given their similar efficacy, the choice between these lymph node therapies may be based on the clinical scenario and anticipated side effect profiles. Cancer 2010. (c) 2010 American Cancer Society.

Nonmelanoma skin cancer of the head and neck I: histopathology and clinical behavior

Non-Melanoma skin cancer (NMSC) is the most commonly encountered malignancy in almost every area of practice, but the cases that present to an Otolaryngology practice will be advanced in nature. The major subtypes of NMSC include basal cell carcinoma, squamous cell carcinoma, dermatofibrosarcoma protuberans, merkel cell carcinoma, and adnexal malignancies. In this review, we present the epidemiology, histology, clinical presentation and management of these major subtypes. Further, we present background on multimodality treatment for NMSC lesions that have become metastatic from their primary site and an introduction to the behavior and treatment of NMSC lesions in patients who have received organ transplants. Understanding the clinical behavior of advanced NMSC is essential knowledge for a general Otolaryngologist.

Merkel cell carcinoma in a young pregnant woman

SUMMARY

We present a 27-year-old pregnant woman with Merkel cell carcinoma on the forehead. In early pregnancy, the lesion was excised as an epidermal cyst. It was only after recurrence that a diagnosis of Merkel cell carcinoma was made. Sentinel-node biopsy, excision with 2 cm margins and reconstruction with free microvascular radial forearm flap was carried out, and the patient received postoperative radiotherapy. No evidence of recurrence or disease progression was found 24 months after surgery.

Analysis of Radiation Therapy for the Control of Merkel Cell Carcinoma of the Head and Neck Based on 36 Cases and a Literature Review

Merkel cell carcinoma (MCC) is a rare and aggressive epidermal cancer. We conducted a retrospective study and literature review to investigate the impact that radiation therapy has on local, regional, and distant control as part of the oncologic management of MCC of the head and neck and to further elucidate the role of radiation therapy with regard to regional control for the clinically uninvolved neck. We reviewed all registered cases of head and neck MCC that had occurred at four institutions from January 1988 through December 2005. Treatment and outcomes data were collected on patients with American Joint Committee on Cancer stage I, II, and III tumors. Local, regional, and distant control rates were calculated by comparing variables with the Fisher exact test; Kaplan-Meier analysis was used to report actuarial control data. Stage I to III head and neck MCC was identified in 36 patients— 22 men and 14 women, aged 43 to 97 years (mean: 71.6) at diagnosis. Patients with stage I and II tumors were combined into one group, and their data were compared with those of patients with stage III tumors. Twenty-sixpatients(72%) had clinical stage I/II disease and 10 patients (28%) had clinical stage III disease. Median follow-up was 41 months for the stage I/II group and 19 months for the stage III group. Based on examination at final follow-up visits, local recurrence was seen in 7 of the 36 patients (19%), for a local control rate of 81 %. The 2-year actuarial local control rate for all stages of MCC was 83%; by treatment subgroup, the rates were 95% for those who had undergone radiation therapy to the primary site and 69%) for those who had not— a statistically significant difference(p = 0.020). Based on information obtained at final follow-ups, 10 of the 36 patients (28%) experienced a regional recurrence, for a regional control rate of 72%. The 2-year actuarial regional control rate among all patients was 70%; by subgroup, rates were 82%) for patients who had undergone regional node radiation therapy and 60% for those who had not— not a statistically significant difference (p = 0.225). Nine patients (25%) overall developed a distant metastasis, for a distant control rate of 75%. Salvage therapies included chemotherapy and/or radiation therapy to the metastatic site, but neither had any significant effect on survival. Regardless of treatment, the Kaplan-Meier survival curves leveled off at 30 months with 82% survival for the stage I/II group and at 19 months with 60% survival for the stage III group. We conclude that radiation therapy to the primary tumor site (either following resection or definitively) results in a local control rate of more than 90% in patients with head and neck MCC. We also found a trend toward improved regional control of the clinically negative neck with the addition of radiation therapy.

Merkel cell carcinoma of the face: an analysis of 16 cases in the Japanese

BACKGROUND

There is no agreement regarding a staging system and optimal treatment of Merkel cell carcinoma. Some centres have reported results from larger series of patients, but these do not include Asian or Japanese centres.

OBJECTIVE

The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC of the face in the Japanese and to study its management and outcome using the staging system described by Clark et al.

METHODS

We report our experiences with 16 cases between 1991 and 2004. Patients and tumour characteristics, treatment variables and outcome were analysed.

RESULTS

The follow-up periods ranged from 1 to 180 months. The average was 32.6 months and the median was 17.5 months. The relapse-free survival for all patients was 51% at 2 years. The relapse-free survival was 80% for the patients with Stage I and 33% with Stage II at 2 years.

CONCLUSION

This staging system was suggested to reflect prognosis although the number of patients in this series was small. Sentinel lymph node biopsy should be considered to determine the accurate nodal staging, and patients with MCC of the head and neck may be treated according to the revised staging system by Clark et al.

A comparison of merkel cell carcinoma and melanoma: results from the california cancer registry

INTRODUCTION

Melanoma and Merkel cell carcinoma (MCC) are both aggressive skin malignancies associated with immunosuppression and possible UV exposure. Both tumors get similar surgical treatment; however, MCC is a relatively rare tumor in which less is known about prognosis and clinical behavior.

METHODS

The California Cancer Registry (CCR), a population-based registry, was reviewed from the years 1988-2003. Merkel cell carcinoma and melanoma were compared with relation to gender, age, ethnicity, disease stage, site, and survival.

RESULTS

A total of 113,187 cases of melanoma and 1,878 cases of MCC were identified in the CCR. Though both cancers are more common in men than in women, MCC had a higher incidence in men than melanoma (63% vs 57% p < 0.005). MCC occurs in the more elderly, with 73.6% of cases occurring in people over 70 years. In contrast, 69% of melanoma cases occurred in people younger than 70 years (p < 0.005). MCC shows a predilection for the head and neck compared to melanoma (47% vs 25.8%) Additionally, melanoma occurs more frequently on the trunk than MCC (30% vs 8.7%). Finally, the 10-year cumulative survival is lower for MCC than for melanoma (17.7% vs 61.3%, p < 0.005).

CONCLUSION

Many clinicians assume MCC and melanoma behave similarly. However, MCC occurs in an older population, more frequently on the head and neck, in a higher percentage of men. Additionally, MCC has a higher rate of regional metastasis and thus may have more of a benefit from regional staging procedures. Overall, MCC has a worse prognosis.

A comprehensive review of the treatment of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distant metastases. The etiology of MCC remains unknown. It usually occurs in sun-exposed areas in elderly people, many of whom have a history of other synchronous or metachronous sun-associated skin lesions. The outcome for most patients with MCC is generally poor. Surgery is the mainstay of treatment. The role of adjuvant therapy has been debated. However, data from recent development support a multimodality approach, including surgical excision of primary tumor with adequate margins and sentinel lymph node dissection followed by postoperative radiotherapy in most cases, as current choice of practice with better locoregional control and disease-free survival. Patients with regional nodal involvement or advanced disease should undergo nodal dissection followed by adjuvant radiotherapy and, perhaps, systemic platinum-based chemotherapy in most cases.

Merkel Cell Carcinoma of the Eyelid

PURPOSE

To evaluate the clinical and histopathologic characteristics of Merkel cell carcinoma (MCC) of the eyelid.

DESIGN

Retrospective case series and literature review.

PARTICIPANTS

Three consecutive patients with MCC of the eyelid who were referred to the Ocular Oncology Unit of Leiden University Medical Center, Netherlands.

METHODS

Clinical records and histopathologic material of patients with eyelid MCC were reviewed. The clinical presentation and treatment were evaluated.

MAIN OUTCOME MEASURES

Clinical and histopathologic description of eyelid MCC, with histologic proof of spontaneous regression of the tumor.

RESULTS

Three patients with MCC of the eyelid were included. Diagnosis was made by pathologic investigation and immunohistochemistry (S100, cytokeratin 20, epithelial membrane antigen, chromogranin). Two of the patients showed histologically proven complete spontaneous regression after nonradical excision of the tumor. After local excision, none of the MCCs demonstrated local recurrence, without regional or distant metastases. Mean clinical follow-up was 50 months.

CONCLUSIONS

Nonocular MCC is known to recur in 66% of patients and to be lethal in almost 33%. Merkel cell carcinoma of the eyelid is a rare malignancy that can not be recognized clinically. Clinical differential diagnosis must be made with a chalazion, and histopathologic differential diagnosis must be made with small cell carcinomas. Close follow-up of these patients is advised because of the potential high recurrence rate and lymphatic spread. The immunologic phenomenon of spontaneous regression points out the importance of the immune system in this disease.

Merkel cell carcinoma of the head and neck: is adjuvant radiotherapy necessary?

BACKGROUND

Controversy exists regarding the optimal management of patients with Merkel cell carcinoma. The primary aim of this study was to determine whether combined treatment with surgery and radiotherapy improves outcome in a multi-institutional cohort of patients with Merkel cell carcinoma of the head and neck. The secondary aims were to determine by stage, which patients derive benefit from combined therapy and to identify predictors for survival on multivariable analysis.

METHODS

A retrospective analysis of 110 patients with Merkel cell carcinoma of the head and neck was performed. Data were collected from 3 tertiary care institutions (Westmead Hospital, Sydney, Australia; Princess Margaret Hospital, Toronto, Canada; Royal Prince Alfred Hospital, Sydney). There were 78 males and 32 females, median age was 70 years, and mean follow-up of survivors was 2.3 years. Sixty-six patients underwent combined treatment, and 44 patients had either surgery or radiotherapy alone. Analysis by stage was performed using 2 staging systems.

RESULTS

Local and regional control at 5 years was 84% and 69%, respectively. Combined treatment improved both local (p = .009) and regional control (p = .006). Overall and disease-specific survival at 5 years was 49% and 62%, respectively. Combined treatment was associated with significantly better disease-free survival on univariable analysis (p = .013) When analyzed by stage, patients with stage IIb (primary >1 cm, node negative) disease who underwent combined treatment had improved disease-free (p = .005) and disease-specific survival (p = .035). Predictors of survival on multivariable analysis were age >70 years (HR 6.19, p < .001), primary tumor size >1 cm (HR 7.55, p < .001), number of nodal metastases divided into none, <or= 2 and >2 (HR 3.71 per stratum, p < .001). When analyzed with age and disease stage, treatment modality trended toward significance as a predictor of disease-specific (p = .081) and overall survival (p = .076). Disease stage was the most powerful independent predictor on Cox regression (HR 5.43 per stratum, p < .001).

CONCLUSIONS

Merkel cell carcinoma is an aggressive cutaneous malignancy. Age and disease stage are the most important predictors of survival. Combined surgery and radiotherapy improves both locoregional control and disease-free survival. Patients with stage II disease appear to derive the greatest benefit from adjuvant radiotherapy, including improved disease specific survival.

Predictors of survival and recurrence in the surgical treatment of merkel cell carcinoma of the extremities

PURPOSE

Merkel cell carcinoma (MCC) is a rare and aggressive malignancy that originates within the extremities in about 40% of cases. Treatment approaches to this tumor have not been standardized. The purpose of this study was to examine treatment approaches to extremity MCC and to determine predictors of recurrence and patient survival.

METHODS

A retrospective review of 38 consecutive patients with surgically treated extremity MCC was performed. Patient demographics, histologic tumor stage and location and pre-existing malignancies were recorded. Patients were treated by wide-local excision (WLE) or Mohs' technique. Clinically negative regional lymph nodes were either observed (n = 16) or staged with elective lymphadenectomy or sentinel lymph node dissection (SLND) (n = 17), and clinically positive nodes underwent therapeutic node dissection (n = 5). Adjuvant radiotherapy (n = 21) and chemotherapy (n = 6) were noted, as well as time to tumor recurrence and overall patient survival. Predictors of recurrence and survival were analyzed using Kaplan-Meier method and log rank test.

RESULTS

There was no difference in local recurrence rates when comparing Mohs' technique to WLE for the treatment of primary tumors. Although there was no survival advantage to lymph node dissection, lymph node status was effective in predicting the risk of regional recurrence. Radiation reduced the local recurrence rate (HR = 0.29, 95% CI [0.10, 0.85]), but did not lead to improved overall survival.

CONCLUSION

Margin-negative excision of the MCC remains the mainstay of treatment. Surgical staging, preferably with SLND, identifies patients that may develop regional recurrence. This study further supports the important role of adjuvant radiation therapy in improving locoregional tumor control in the patients with MCC.