A Merkel cell tumor of the eyelid

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.

Merkel Cell Carcinoma of the Eyelid

A case of Merkel cell carcinoma of the eyelid of an 85-year-old woman is presented. We define the essential morphological features of this much-debated neuroendocrine cutaneous tumor and its clinical and morphobiological peculiarities, with particular reference to its location in the palpebral region.

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.

Eyelid Merkel Cell Carcinoma: Report of Three Cases

PURPOSE

To present three cases of Merkel cell carcinoma, a primary cutaneous neuroendocrine tumor that arises from Merkel cells, and to describe their clinical features, diagnosis, and management.

METHODS

Case series.

RESULTS

In only one case, the disease was clinically recognized. In the others, the diagnosis was confirmed by histology, and chalazion was initially suspected in one of them. Surgery was performed in all patients, and there was no evidence of metastatic disease.

CONCLUSIONS

The rarity of eyelid Merkel cell carcinoma and the fact that it can simulate benign entities frequently lead to difficulties in diagnosis and a delay in the establishment of suitable therapy.

Merkel cell tumor of the eyelid and the cytologic aspect in fine-needle aspirates: report of a case

We describe one case of Merkel cell tumor (MCT) of the eyelid diagnosed by fine-needle aspiration (FNA). The main cytologic features were: isolated cells, loose cohesive sheets, and rosette-like structures in a hematic background. The cells were round to ovoid and very uniform. Chromatin was finely granular and frequent mitotic figures were observed. Under close scrutiny small faintly stained juxtanuclear "caps" were seen. A strong dot-like positivity for CK22 and NFP was observed in the position corresponding to the "caps." NSE positivity was diffuse, although a weak dot-like positivity was seen in some cells. S-100 was negative. Both the cytologic features and the immunocytologic profile of Merkel cell tumor are very characteristic. FNA enables an early and confident diagnosis of this aggressive tumor and an early planning of surgery.

Merkel cell carcinoma of the eyelid and periocular tissues

Five patients had eyelid and periocular Merkel cell carcinoma. The tumor was located on the left lower eyelid in two patients, the left upper eyelid in one patient, the right upper eyelid in one patient, and was metastatic to the right outer canthus in one patient. The mean duration of symptoms was approximately four months. The diagnosis of Merkel cell carcinoma was not suspected clinically in any of the four primary eyelid cases, but was only established on histopathologic examination of biopsy specimens. Light microscopy disclosed carcinoma with small primitive cells in all five tumor biopsy specimens. Immunohistochemical studies showed neuron-specific enolase and keratin and transmission electron microscopy demonstrated neurosecretory granules typical for Merkel cell carcinoma. All five patients in this study were treated with wide surgical excision of the eyelid tumors with intraoperative frozen-section monitoring of the margins of resection. The left lower eyelid Merkel cell carcinoma spread to the preauricular lymph node in one patient. This patient subsequently died of metastatic Merkel cell carcinoma. One patient with metastatic right outer canthus Merkel cell carcinoma received radiotherapy (6,550 cGy). Eyelid Merkel cell carcinoma has the potential for recurrence and metastatic spread. We recommend lifetime follow-up for patients treated for eyelid Merkel cell carcinoma.

The Merkel cell and associated neoplasms in the eyelids and periocular region

Merkel cells are clear oval cells in the epidermis and outer root sheaths of hair follicles, which are probably of epithelial origin, share ultrastructural features with neuroendocrine cells, and are found in association with touch receptors. In the eyelid, they occur singly in the epidermis and external root sheaths of hairs and eyelashes, and in specialized touch spots alternating with eyelashes. Their typical electron microscopical and antigenic features include dense-core granules, intranuclear rodlets, spinous processes, and a positive reaction for specific cytokeratins, epithelial membrane antigen, neuron-specific enolase, chromogranin and synaptophysin. Merkel cell carcinoma probably develops from precursor cells which give rise to keratinocytes and Merkel cells, and nearly one out of ten Merkel cell carcinomas occur in the eyelid and periocular region. They tend to be bulging lesions near the lid margin of elderly patients, reddish in color, and erythematous with telangiectatic vessels. The diagnosis is based on the frequent presence of neurofilaments and paranuclear aggregates of intermediate filaments in addition to features typical of normal Merkel cells. The tumor often mimics lymphoma or undifferentiated carcinoma and frequently invades lymphatic vessels. One third of Merkel cell carcinomas recur, almost two thirds give rise to regional node metastases, and up to one half metastasize widely and result in death. Initial treatment should be prompt and aggressive, with wide resection and routine postoperative irradiation. Although metastatic lesions often respond to radiation therapy and cytostatic drugs, these treatments are mainly of palliative value.

Primary neuroendocrine carcinoma of the eyelid, immunohistochemical and ultrastructural study

Primary neuroendocrine carcinomas of the skin were recognized as distinctive neoplasms and clinicopathologic information on their location on the eyelids have been reported. The authors present one case of primary neuroendocrine carcinoma occurring on the right lower lid in a 73-year-old woman. The clinical history, light and electron microscopic findings as well the results of an immunohistochemical study are described. The ultrastructural study demonstrated the characteristic membrane-bound dense-core neurosecretory granules. Immunoreactivity for neuron-specific enolase, keratin filaments, epithelial membrane antigen and calcitonin were observed and are strongly suggestive of a neuroendocrine differentiation in a neoplasm of epithelial origin. Various hypothesis concerning the origin of this tumor are discussed on the basis of the immunohistochemical findings. The authors also provide a brief review of the literature.

[Clinical aspects and therapy of Merkel cell tumor--report of 4 personal cases and review of the literature]

Four cases of Merkel cell tumor located in the face or on the trunk are presented. In a literature review 339 cases were found and analysed. The Merkel cell tumor is a neuroendocrine tumor of the skin derived from the Merkel cells. It is located most often in the face and neck area. Typically, it is an exophytic node, has a red-blue color and measures 25 mm in diameter on the average. Since it is metastasizing it is a malignant tumor. Regional node metastases were found in 27%, local recurrences occur in 51%, and distant metastases were seen in 32% of the cases. The best therapy is excision with wide margins as is the rule for a malignant skin tumor. While the tumor reacts to radiotherapy, chemotherapy seems to be of no help.

Merkel cell carcinoma of the eyelid

The clinical and pathological features of two Merkel cell carcinomas of the eyelid skin are reported. Both tumours occurred in the upper lid in elderly women and enlarged rapidly to form smooth, round nodules which projected from the lid surface anterior to the grey line. In one case the primary excision biopsy was followed by a wider excision in 1982, and the patient has been free from recurrence or metastases in the intervening period. In the second more recent case, the tumour was inadequately excised in 1984 and the lid was treated by radiotherapy: this patient is at present free from recurrence. Histological examination of each tumour revealed an identical morphology - characterised by the presence of uniform polyhedral cells with multiple nucleoli lying in nests and lobules within the dermis: mitotic figures were prominent. Immunohistochemical studies showed the cells to react positively with antisera against neurone-specific enolase, epithelial membrane antigen and met-enkephalin. Electron microscopy revealed only rare neuroendocrine granules in one tumour, and numerous granules in the other. Intranuclear rodlets were not identified and there was paucity of cell membrane attachment modifications.