Multiple Primary Cancers Associated with Merkel Cell Carcinoma in Queensland, Australia, 1982–2011

Patient Characteristics and Outcomes in Clinically Misdiagnosed Patients With Merkel Cell Carcinoma

INTRODUCTION

Merkel cell carcinoma (MCC) is a rare aggressive cutaneous neuroendocrine carcinoma characterized by poor outcomes. MCC morphology is nonspecific and mimics that of other skin lesions, resulting in misdiagnosis and delayed treatment. This study aims to describe survival outcomes of patients with MCC who were clinically misdiagnosed.

METHODS

Patients diagnosed with MCC were identified using a single-institution retrospective database. Demographics, tumor characteristics, and diagnostic features were evaluated. The Kaplan-Meier method was used to estimate overall survival and recurrence-free survival.

RESULTS

Out of 109 patients with MCC, 96 (88.1%) were initially misdiagnosed based on clinical examination before histopathological confirmation of MCC. Common misdiagnoses included basal cell carcinoma (n = 32, 29.4%), squamous cell carcinoma (n = 23, 21.1%), and benign cyst (n = 21, 19.3%). Misdiagnosed patients had a larger median tumor size of 1.8 cm, whereas correctly diagnosed patients had a median tumor size of 1.5 cm. Patients with correct initial diagnosis tended to have negative nodal disease (87.5% versus. 50.0%) and early-stage disease (stage I-II: 76.9% versus. 44.7%). Patients who were misdiagnosed had a lower median overall survival compared to those who were not (74.6 mo versus. 120.6 mo, P = 0.414). Median recurrence-free survival among those who were misdiagnosed was 52.6 mo, whereas it was not reached in the correctly diagnosed group (P = 0.068).

CONCLUSIONS

The nonspecific appearance of MCC poses diagnostic challenges in nonacademic health care settings. Given that patients who were clinically misdiagnosed had worse survival, heightened awareness of MCC and early referral to tertiary medical centers are crucial to ensuring optimal patient outcomes for this rare disease.

How Strong Is the Link Between Merkel Cell Carcinoma and the Occurrence of Other Skin Cancer Types? A Meta-Analysis

This meta-analysis presents findings from nine studies involving 4626 cases of primary Merkel cell carcinoma (MCC), aimed at evaluating the relationship between primary MCC and the incidence of a second skin cancer. The analysis reveals a significant association, with a calculated risk ratio of 2.97 (95% CI, 1.70-5.19, p = 0.0001), indicating that individuals diagnosed with primary MCC are nearly three times more likely to develop the second skin cancer compared to patients with other second cancers. Among the second skin cancers analysed, basal cell carcinoma (BCC) showed the highest risk (0.69, 95% CI 0.35-1.37), followed by squamous cell carcinoma (SCC) (0.45, 95% CI 0.23-0.90) and melanoma (0.31, 95% CI 0.19-0.50). While geographic analysis showed that patients in Northern Europe have a non-significant 1.7-fold increased likelihood of developing the second skin cancer relative to those in North America (USA), where the likelihood of developing the second skin cancer is significantly lower at 0.7 times. The results underscore the importance of implementing enhanced surveillance and preventive strategies for individuals at increased risk. By identifying these associations, we may improve the early detection of the second skin cancer in patients with MCC.

Double Primary Cancers of Earlobe Merkel Cell Carcinoma and Lung Adenocarcinoma

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine carcinoma with a high rate of metastasis. MCC is rarely suspected during clinical examination, thus requiring biopsy to establish a pathologic diagnosis. In addition, MCC sometimes occurs in double primary cancers. Although there have been reviews on double primary cancers, only a few cases involving MCC have been described. Herein, we report a case of a 54-year-old female patient who presented to our clinic with a diagnosis of earlobe MCC following an excisional biopsy performed by another clinic. Further evaluation, including chest imaging, revealed a mass in the lung. The patient underwent a wide excision of the right earlobe, and video-assisted thoracic surgery on the lung. Pathology confirmed MCC in the right earlobe and adenocarcinoma in the lung. The patient underwent postoperative adjuvant chemotherapy followed by radiotherapy. Up to this point, 3 years after the surgery, there has been no evidence of recurrence.

Risk of Multiple Primary Cancers in Patients With Merkel Cell Carcinoma: A SEER-Based Analysis

Importance

The risk of subsequent primary cancers after a diagnosis of cutaneous Merkel cell carcinoma (MCC) is not well established.

Objective

To evaluate the risk of subsequent primary cancers after the diagnosis of a first primary cutaneous MCC.

Design, Setting, and Participants

This cohort study analyzed data from 17 registries of the Surveillance, Epidemiology, and End Results (SEER) Program from January 1, 2000, to December 31, 2019. In all, 6146 patients diagnosed with a first primary cutaneous MCC were identified.

Main Outcomes and Measures

The primary outcome was the relative and absolute risks of subsequent primary cancers after the diagnosis of a first primary MCC, which were calculated using the standardized incidence ratio (SIR; ratio of observed to expected cases of subsequent cancer) and the excess risk (difference between observed and expected cases of subsequent cancer divided by the person-years at risk), respectively. Data were analyzed between January 1, 2000, and December 31, 2019.

Results

Of 6146 patients with a first primary MCC diagnosed at a median (IQR) age of 76 (66-83) years, 3713 (60.4%) were men, and the predominant race and ethnicity was non-Hispanic White (5491 individuals [89.3%]). Of these patients, 725 (11.8%) developed subsequent primary cancers, with an SIR of 1.28 (95% CI, 1.19-1.38) and excess risk of 57.25 per 10 000 person-years. For solid tumors after MCC, risk was elevated for cutaneous melanoma (SIR, 2.36 [95% CI, 1.85-2.97]; excess risk, 15.27 per 10 000 person-years) and papillary thyroid carcinoma (SIR, 5.26 [95% CI, 3.25-8.04]; excess risk, 6.16 per 10 000 person-years). For hematologic cancers after MCC, risk was increased for non-Hodgkin lymphoma (SIR, 2.62 [95% CI, 2.04-3.32]; excess risk, 15.48 per 10 000 person-years).

Conclusions and Relevance

This cohort study found that patients with MCC had an increased risk of subsequently developing solid and hematologic cancers. This increased risk may be associated with increased surveillance, treatment-related factors, or shared etiologies of the other cancers with MCC. Further studies exploring possible common etiological factors shared between MCC and other primary cancers are warranted.

Incidence of cutaneous melanoma and Merkel cell carcinoma in patients with primary cutaneous B-cell lymphomas: A population study of the SEER registry

Introduction

The increased incidence of cutaneous melanoma (CM) and Merkel cell carcinoma (MCC) in patients with hematologic malignancies (HM) is well established. While the risk of CM has been assessed in some subtypes of HM including cutaneous T-cell lymphoma, the incidence in patients with primary cutaneous B-cell lymphoma (PCBCL) has not been interrogated.

Methods

Here we evaluated the standardized incidence ratio (SIR) of CM and MCC in 5,179 PCBCL patients compared to approximately 1.5 billion individuals in the general population using the Surveillance, Epidemiology and End Results (SEER) database. Among patients with PCBCL, we identified subgroups that were at increased risk for CM or MCC as a second primary cancer.

Results

We found 36 cases of CM in the PCBCL cohort (SIR, 1.35; 95% CI, 0.94–1.86), among which SIR was significantly elevated for non-Hispanic White patients compared to the general population (SIR, 1.48; 95% CI, 1.03–2.06). Males had a significantly increased risk of developing CM after a diagnosis of PCBCL (SIR, 1.60; 95% CI, 1.10–2.26). We found that males in the age group of 50–59 were at increased risk for CM development (SIR, 3.02; 95% CI, 1.11–6.58). Males were at increased risk of CM 1–5 years after PCBCL diagnosis (SIR, 2.06; 95% CI, 1.18–3.34). Patients were at greater risk of developing MCC within 1 year of diagnosis of PCBCL (SIR, 23.60; 95% CI, 2.86–85.27), particularly in patients who were over the age of 80 (SIR, 46.50; 95% CI, 5.63–167.96). Males aged 60–69 with PCBCL, subtype marginal zone, were also at increased risk for MCC (SIR, 42.71; 95% CI, 1.08–237.99).

Conclusion

There is an increased incidence of CM in White, middle-aged males within 5 years of diagnosis of PCBCL and an increased risk of MCC in elderly patients within 1 year of PCBCL diagnosis. These data suggest that certain subgroups of patients with PCBCL may require more rigid surveillance for CM and MCC.

Unique presentation of Merkel cell tumour affecting the hand

Merkel cell carcinoma (MCC) is a rare and highly aggressive skin cancer which most commonly occurs on the head and neck. A limited number of cases of MCC of the hand have been reported in the English literature. We describe a case of MCC of the hand in a man in his late 60s. The lesion presented on the dorsum of the left fifth digit, with metastasis to the left axillary lymph nodes. The primary lesion grew rapidly over a span of 3 months. The patient was treated with two courses of neoadjuvant nivolumab, amputation of the digit and left axillary lymph node resection followed by radiotherapy to the left hand and left axilla. He continues to follow-up for radiotherapy treatment 3 months postoperatively.

Merkel Cell Carcinoma: An updated review of pathogenesis, diagnosis, and treatment options

Merkel cell carcinoma is a rare neuroendocrine carcinoma that typically appears in sun-exposed areas of the elderly. It has a poor prognosis and with its incidence projected to increase, it is vital for dermatologists to remain up to date with recent updates in this malignancy's pathogenesis and treatment. In the past few decades Merkel cell carcinoma's pathogenesis, more specifically its relation to the Merkel cell polyomavirus, has sparked further interest in the study of this carcinoma. Most cases are attributed to malignant transformation secondary to the Merkel cell polyomavirus, with a minority derived from DNA damage resulting from ultraviolet radiation. Investigators have also determined that there are immunologic influences in the development and prognosis of Merkel cell carcinoma, as individuals with HIV, solid organ transplants, and lymphoproliferative malignancies are at a greater risk of developing this carcinoma. Also, this immunologic link carries treatment value, as immunologic therapies are currently being investigated. This article provides a comprehensive review of the epidemiology and pathogenesis of Merkel cell carcinoma as well as the current treatments available and clinical trials underway. We also touch upon the updated National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology in respect to its diagnosis and recommended treatment modalities.

Metastatic Merkel cell carcinoma and malignant melanoma in a single sentinel lymph node

Merkel cell carcinoma (MCC) and malignant melanoma are aggressive skin cancers that usually arise in sun-exposed parts of the body. This report describes an 85-year-old man who underwent a wide local excision and sentinel lymph node biopsy for primary MCC and was subsequently found to have metastatic MCC and malignant melanoma within the left inguinal sentinel lymph node. Dual diagnoses of aggressive cutaneous carcinomas, although rare, may become more common in regions of high ultraviolet exposure and an ageing population. Currently, there are no guidelines for treating synchronous MCC and melanoma, however, immunotherapy with PD-1 inhibitors and anti-CTLA-4 receptor antagonists have shown therapeutic effect against these two cancers and should be considered in treatment planning.

Simultaneous renal clear cell carcinoma and primary clear cell carcinoma of the liver: A case report

RATIONALE

Double primary clear cell carcinomas of the liver (PCCCL) and kidney are extremely rare; moreover, there have been no reported cases of adrenal metastasis from primary clear cell tumors of the liver.

PATIENT CONCERNS

A 47-year-old male patient was admitted to our clinic with space-occupying lesions in the left kidney and liver during a regular medical examination.

DIAGNOSES

The tumors in the kidney and liver were diagnosed as primary clear cell carcinoma by histopathological examination.

INTERVENTIONS

The patient subsequently underwent nephron-sparing surgery of the left kidney and radical partial excision of the right liver lobe by laparoscopic surgery. Transcatheter arterial chemoembolization (TACE) was performed for the patient 2 weeks after tumor resection. One month after the operation, the patient started adjuvant therapy with sorafenib (400 mg twice per day orally). However, follow-up CT imaging revealed a solid mass measuring 1.9 × 2.0 × 2.0 cm in the right adrenal gland at 2 months postoperatively, and then the patient underwent radiofrequency ablation (RFA) for the right adrenal tumor.

OUTCOMES

The patient remained cancer free for 2 years following the diagnosis despite early right adrenal metastasis.

LESSONS

Hepatocyte immunostaining is sufficient for the diagnosis of PCCCL.

Monoclonal Antibodies in Dermatooncology-State of the Art and Future Perspectives

Monoclonal antibodies (mAbs) targeting specific proteins are currently the most popular form of immunotherapy used in the treatment of cancer and other non-malignant diseases. Since the first approval of anti-CD20 mAb rituximab in 1997 for the treatment of B-cell malignancies, the market is continuously booming and the clinically used mAbs have undergone a remarkable evolution. Novel molecular targets are constantly emerging and the development of genetic engineering have facilitated the introduction of modified mAbs with improved safety and increased capabilities to activate the effector mechanisms of the immune system. Next to their remarkable success in hematooncology, mAbs have also an already established role in the treatment of solid malignancies. The recent development of mAbs targeting the immune checkpoints has opened new avenues for the use of this form of immunotherapy, also in the immune-rich milieu of the skin. In this review we aim at presenting a comprehensive view of mAbs' application in the modern treatment of skin cancer. We present the characteristics and efficacy of mAbs currently used in dermatooncology and summarize the recent clinical trials in the field. We discuss the side effects and strategies for their managing.

Prognostic Significance of "Nonsolid" Microscopic Metastasis in Merkel Cell Carcinoma Sentinel Lymph Nodes

Our recent work regarding Merkel cell carcinoma sentinel lymph node (SLN) metastasis found that "solid" pattern microscopic metastasis conferred worse prognosis than the "nonsolid" ones. The goals of the present study were to (1) compare the prognostic significance/outcomes of 2 diagnostic groups-patients with a nonsolid pattern of SLN metastasis and those with diagnostically negative SLN biopsies (SLNB), and (2) evaluate the durability of SLN metastasis after extensive sectioning. Five-level, step-wise sectioning at 250-μm intervals was performed in all SLN blocks with an immunohistochemical stain for CK20 on all levels. The presence and pattern of metastases were recorded and analyzed as were corresponding patient and tumor parameters. Median follow-up durations for all patients (n=38), positive SLNB (n=16) and negative SLNB (n=22) groups were 56.3, 50.4, and 66.8 months, respectively. Overall survival (OS) and disease-specific survival (DSS) did not differ between the 2 diagnostic groups (OS P=0.65, DSS P=0.37) but did differ by immune status (immunocompetent vs. immunosuppressed, OS P=0.03, DSS P=0.005) and primary tumor category (OS P<0.0001, DSS P=0.001). On deeper sectioning, all 16 diagnostically positive SLNB continued to show nonsolid microscopic metastasis, and 32% (7/22) diagnostically negative SLNB revealed nonsolid metastasis. DSS was worse for sinusoidal-pattern metastasis versus all others (P=0.02). Five of 38 patients (13%) died of disease; the only immunocompetent patient had sinusoidal-pattern metastasis discovered in a diagnostically negative SLNB. Our data suggest that outcome for nonsolid metastasis is similar to that of negative SLNB with the exception of the sinusoidal pattern, which was associated with worse outcome. Larger studies are warranted to quantify and compare microscopic metastatic tumor burden by pattern and confirm whether the sinusoidal pattern confers an intermediate prognostic risk between solid and other nonsolid microscopic metastases.

Human polyomaviruses and cancer: an overview

The name of the family Polyomaviridae, derives from the early observation that cells infected with murine polyomavirus induced multiple (poly) tumors (omas) in immunocompromised mice. Subsequent studies showed that many members of this family exhibit the capacity of mediating cell transformation and tumorigenesis in different experimental models. The transformation process mediated by these viruses is driven by viral pleiotropic regulatory proteins called T (tumor) antigens. Similar to other viral oncoproteins T antigens target cellular regulatory factors to favor cell proliferation, immune evasion and downregulation of apoptosis. The first two human polyomaviruses were isolated over 45 years ago. However, recent advances in the DNA sequencing technologies led to the rapid identification of additional twelve new polyomaviruses in different human samples. Many of these viruses establish chronic infections and have been associated with conditions in immunosuppressed individuals, particularly in organ transplant recipients. This has been associated to viral reactivation due to the immunosuppressant therapy applied to these patients. Four polyomaviruses namely, Merkel cell polyomavirus (MCPyV), Trichodysplasia spinulosa polyomavirus (TSPyV), John Cunningham Polyomavirus (JCPyV) and BK polyomavirus (BKPyV) have been associated with the development of specific malignant tumors. However, present evidence only supports the role of MCPyV as a carcinogen to humans. In the present review we present a summarized discussion on the current knowledge concerning the role of MCPyV, TSPyV, JCPyV and BKPyV in human cancers.

Activation of IL-8 and its participation in cancer in schizophrenia patients: new evidence for the autoimmune hypothesis of schizophrenia

To investigate the autoimmune mechanisms of schizophrenia, we explored the relationship between schizophrenia and cancer using gene expression data of peripheral blood mononuclear cells from GSE27383 datasets. Gene screening and enrichment analysis using Gene Set Enrichment Analysis were applied to identify possible connections between schizophrenia and cancer. Real-time PCR (quantitative PCR), Western blotting and immunohistochemistry were performed on the brain tissue from both schizophrenia patients and normal controls. The genes for IL-8, as well as PTGS2, TPR, JUN, CXCL1, CXCL3, CXCL5 and PARD3 were highly expressed in schizophrenia patients. Cancer and chemokine signaling pathways were enriched in the schizophrenic group, related to the high expression of IL-8. Increased expression of IL-8 was further confirmed by quantitative PCR, Western blotting and immunohistochemistry results. Our results suggest that IL-8 may participate specifically in the pathophysiological changes that occur in schizophrenia. Additionally, our findings provide novel evidence supporting the autoimmune hypothesis of schizophrenia.

A case series and literature review of Merkel cell carcinoma metastasizing to pancreas

BACKGROUND

Merkel cell carcinoma is a rare aggressive tumor arising from the mechanoreceptors of the epidermis with a relative higher mortality rate stage for stage than melanoma. Microscopically, the cells appear similar to small cell lung cancer, but they specifically stain positive for CK20 and are negative for TTF-1. It is rarely known to metastasize to the pancreas.

AIMS

To report four cases of Merkel cell carcinoma metastasizing to pancreas and compare them to previously reported patients.

METHODS

We performed a retrospective review of all patients who underwent endoscopic ultrasound with fine-needle aspiration (EUS-FNA) for a suspected pancreatic lesion between January 2004 and December 2012. We reviewed other reported cases with a literature search using PubMed, Embase, and Scopus.

RESULTS

Four male patients with mean age of 66 years were found to have metastatic disease in the pancreas on average 29 months after initial diagnosis of MCC. Two cases were diagnosed with EUS-FNA and two with PET-CT. Three patients had multifocal pancreatic involvement which has not been previously described. All four patients died within 3-9 months following tumor spread to the pancreas. Merkel cell carcinoma rarely metastasizes to the pancreas with only 10 cases being described in the medical literature.

CONCLUSIONS

EUS-FNA is an effective tool that can be utilized in diagnosing pancreatic masses. Differentiating metastatic pancreatic tumors, especially Merkel cell carcinoma from primary pancreatic tumor is useful as systemic therapy is an option in pancreatic adenocarcinoma, but is ineffective in metastatic Merkel cell carcinoma.

The role of Merkel cell polyomavirus and other human polyomaviruses in emerging hallmarks of cancer

Polyomaviruses are non-enveloped, dsDNA viruses that are common in mammals, including humans. All polyomaviruses encode the large T-antigen and small t-antigen proteins that share conserved functional domains, comprising binding motifs for the tumor suppressors pRb and p53, and for protein phosphatase 2A, respectively. At present, 13 different human polyomaviruses are known, and for some of them their large T-antigen and small t-antigen have been shown to possess oncogenic properties in cell culture and animal models, while similar functions are assumed for the large T- and small t-antigen of other human polyomaviruses. However, so far the Merkel cell polyomavirus seems to be the only human polyomavirus associated with cancer. The large T- and small t-antigen exert their tumorigenic effects through classical hallmarks of cancer: inhibiting tumor suppressors, activating tumor promoters, preventing apoptosis, inducing angiogenesis and stimulating metastasis. This review elaborates on the putative roles of human polyomaviruses in some of the emerging hallmarks of cancer. The reciprocal interactions between human polyomaviruses and the immune system response are discussed, a plausible role of polyomavirus-encoded and polyomavirus-induced microRNA in cancer is described, and the effect of polyomaviruses on energy homeostasis and exosomes is explored. Therapeutic strategies against these emerging hallmarks of cancer are also suggested.

An increased risk of non-Hodgkin lymphoma and chronic lymphocytic leukemia in US patients with Merkel cell carcinoma versus Australian patients: A clinical clue to a different mechanism of pathogenesis?

The US and Queensland populations both demonstrate an increased risk of secondary malignancies following the diagnosis of Merkel cell carcinoma (MCC). A recent Queensland study failed to demonstrate a significantly increased risk of developing non-Hodgkin lymphoma (NHL) or chronic lymphocytic leukaemia (CLL) in these patients. In contrast, using the US Surveillance, Epidemiology, and End Results database, we demonstrate there is an increased risk in CLL and NHL following the diagnosis of MCC in the USA. We hypothesise that this difference may be a result of a differing pathogenesis.

Risk of second cancers in merkel cell carcinoma: a meta-analysis of population based cohort studies

The risk of second cancers in Merkel cell carcinoma (MCC) remains uncertain since risk estimates vary worldwide. The global MCC population is growing and there is a demand for better knowledge of prognosis of this disease. The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE search engines were searched for the relevant literature between January 1999 and September 2014 by use of explicit search criteria. The main outcome was second malignancies associated with MCC patients measured by standardized incidence ratios (SIRs) or other estimates of risks. Five papers fulfilled the inclusion criteria and reported SIRs of second cancer in MCC which varied from 1.07 to 2.80. Performing meta-analysis using random effects model revealed that there was an increased risk for second malignancies due to MCC (SIR, 1.52; 95% CI, 1.10–2.11). There was a significant increase in risk for malignant melanoma (SIR, 3.09; 95% CI, 2.02–4.73) as compared to all common second malignancies among the studies. Updated knowledge about risk of second malignancies in MCC will help in better assessment of the disease prognosis and will help in optimizing the medical and surgical treatment, radiotherapy, follow-up, and surveillance procedures.