The use of VP16 and cisplatin in the treatment of Merkel cell carcinoma

Merkel cell carcinoma of the thigh: case report and review of the literature

BACKGROUND

Merkel cell carcinoma (MCC) is a kind of cutaneous neuroendocrine cancer with a poor prognosis. It is characterized by a high rate of recurrence and metastases, including distant metastases and regional nodal metastases. Clinically, MCC often manifests as obvious single painless hard nodules visible in sun irradiation of diameter <2 cm and not uncommonly >2 cm, with rapid growth and metastases, especially lymph node metastases. Due to the aspecific nature of MCC, it is often confused with other skin cancers. Exploring different treatments of MCC is necessary.

CASE PRESENTATION

The current study describes the case of an 86-year-old retired man, who presented with a 2.5×2.0×1.2 cm red nodule on the right thigh, which was initially diagnosed as subcutaneous small cell cancer. Upon histological and immunohistochemical analysis, the tumor was consistent with a diagnosis of MCC.

RESULTS

Antiangiogenic therapy combining endostar and apatinib was administered and a partial response achieved after 2.0 months of treatment, and 6.5 months of progression-free survival was achieved. Overall survival was 13.0 months.

CONCLUSION

We believe that antiangiogenic therapy is an extremely effective treatment for MCC, especially for patients who cannot tolerate chemotherapy and radiotherapy.

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: critical review with guidelines for multidisciplinary management

Merkel cell carcinoma (MCC) is a relatively rare cutaneous malignancy that occurs predominantly in the older white population. The incidence of MCC appears to have tripled during the past 20 years; an increase that is likely to continue because of the growing number of older Americans. The pathogenesis of MCC remains largely unknown. However, ultraviolet radiation and immunosuppression are likely to play a significant pathogenetic role. Many questions currently remain unanswered regarding the biologic behavior and optimal treatment of MCC. Large, prospective, randomized studies are not available and are unlikely to be performed because of the rarity of the disease. The objective of this review was to provide a comprehensive reference for MCC based on a critical evaluation of the current data. The authors investigated the importance of sentinel lymph node biopsy as a staging tool for MCC to assess the status of the regional lymph node basin and to determine the need for additional therapy to the lymph node basin. In an attempt to standardize prospective data collection with the intention to define prognostic indicators, the authors also present histopathologic profiles for primary MCC and sentinel lymph nodes. The controversies regarding the appropriate surgical approach to primary MCC, the use of adjuvant radiation therapy, and the effectiveness of adjuvant chemotherapy were examined critically. Finally, the authors have provided treatment guidelines based on the available evidence and their multidisciplinary experience.

Merkel cell cancer of the skin

Merkel cell carcinoma (MCC) is a rare malignant cutaneous tumor of the elderly with rapidly growing skin nodules found predominantly on sun-exposed areas of the body. The vast majority of patients present with localized disease, while up to 30% have regional lymph node metastases. Despite local excision and the incidence of local recurrence, regional lymph node metastases and distant metastases is high and usually occurs within 2 years of primary diagnosis. The optimal treatment for patients with MCC remains unclear. The best outcome is achieved with multidisciplinary management including surgical excision of primary tumor with adequate margins and post-operative radiotherapy (RT) to control local and regional disease. Patients with regional nodal metastases should be treated with lymph node dissection plus RT. Adjuvant chemotherapy (CT) should be considered as part of the initial management. In case of metastatic disease CT based on regimens used for small-cell lung cancer is the standard treatment of care.

Merkel cell carcinoma of skin: diagnosis and management strategies

Merkel cell carcinoma (MCC) of the skin is a rare form of cutaneous malignancy of neuroendocrine origin with a propensity to affect predominately elderly patients in sun-exposed areas. The tumour has an extremely aggressive growth pattern with the potential to seed into the dermal lymphatics at an early stage as well as spread to nodes and distant sites. Successful outcomes can be achieved with early diagnosis and a multidisciplinary approach to management. Patients with MCC should be carefully staged to exclude distant metastatic disease. Treatment should be approached with both the primary site and the lymph nodes in mind. The primary site should be excised with clear margins, followed by postoperative radiotherapy to the primary site and affected nodes. Addition of chemotherapy to patients perceived to be at high-risk of distant recurrence (e.g. those with involved nodes) has been considered, but evidence supporting this approach is relatively scant. This treatment strategy needs to be approached with caution in the elderly because of the risk of myelosuppression. An aggressive treatment approach is warranted at the first attempt to treat MCC as treatment for recurrent disease is less likely to be successful.

Treatment of Merkel Cell Carcinoma

PURPOSE

The purpose of this study was to evaluate the treatment of Merkel cell carcinoma.

MATERIALS AND METHODS

We reviewed 85 cases of Merkel cell carcinoma. There were 68 males and 17 females. The majority of cases involved head and neck sites (48%), followed by the extremities (38%) and trunk (14%). Sixty-seven percent of the patients had stage I disease that was localized to the skin of origin at presentation. Twenty-five percent and 8% were stage II (nodal metastasis) and stage III (distant metastasis), respectively. Surgical intervention included local or wide local excision +/- nodal dissection (68%), radical resection +/- nodal dissection (22%), and amputation (4%). Five patients (6%) underwent biopsy only because of metastatic disease or unresectability at presentation. Fifty-one percent received adjuvant therapy consisting of external beam radiation therapy and/or combination chemotherapy.

RESULTS

With an average follow-up time of 39.5 months, 12% had persistent disease and 40% had recurrent disease. The median time to recurrence was 8 months with a mean of 10.6 months. Although the addition of adjuvant therapy did not affect survival, the recurrence rate was 32.5% for surgery +/- adjuvant radiation therapy +/- chemotherapy as compared with 52.7% for surgery-only patients. Although the 40.7% recurrence rate for patients receiving surgery and adjuvant radiation therapy was approximately the same as for patients receiving surgery and adjuvant chemotherapy (40%), the effect of systemic chemotherapy on recurrence is less clear as a result of the small number of patients who received such therapy. Although tumor size and site of presentation were not observed to be statistically significant in overall survival, significant differences were observed based on sex and tumor stage. For females, the median survival time was 96 months (mean, 94.5 months) compared with 63 months (mean, 76.8 months) for males. This difference was significant (P < 0.01). Patients presenting with low-stage (stage I) disease had a significant (P < 0.01) survival benefit when compared with high-stage individuals (stages II and III). The 5-year actuarial survival rates were 68% and 42%, respectively.

CONCLUSION

In this retrospective study, surgery remains the primary modality for Merkel cell carcinoma, and adjuvant radiation therapy +/- systemic chemotherapy reduces local recurrence. Female patients and those who present with early-stage disease appear to have a better prognosis.

Merkel cell carcinoma--current therapeutic options

Merkel cell carcinoma (MCC) is a rare, highly malignant skin tumour of neuroendocrine origin that occurs predominantly in elderly people in sun-exposed areas. It exhibits high levels of radiosensitivity and chemosensitivity both in vivo and in vitro. A variety of adverse prognostic factors have been identified which allow more aggressive therapy to be delivered to patients who are at higher risk of recurrence. The most powerful prognostic factor is the presence of nodal secondaries. Local disease should be excised, but there is some controversy over how wide the margins should be. Wide resection margins are not required provided postoperative radiotherapy is used. In the event of inoperable disease, patient refusal of surgery or frailty, radiotherapy can be used as the sole treatment modality, with a high likelihood of achieving local control. Patients with involved nodes have a higher risk of distant disease. Traditionally, involved nodes have been managed with resection but, currently, there are protocols exploring the use of synchronous chemoradiotherapy as definitive treatment. Although adjuvant chemotherapy has been used in this setting to reduce the risk of distant metastases, its role still remains under investigation. The presence of distant disease carries a grave outlook with responses to chemotherapy occurring frequently, albeit of short duration.

Is there a diminishing role for surgery for Merkel cell carcinoma of the skin? a review of current management

Merkel cell carcinoma is a highly malignant skin tumour that must be managed in a multidisciplinary forum. Excisional biopsy of the primary is recommended and this should be followed by postoperative radiotherapy to the primary site, in-transit areas and the draining lymph nodes. The tumour is quite radiosensitive and radiation doses of the order of 50 Gy offer high levels of local control. Resection margins of 3 cm are not required provided postoperative radiotherapy is used. In the event of inoperable disease, patient refusal of surgery or a frail patient, radiotherapy should be used as the sole treatment modality, with high likelihood of achieving local control. Patients with involved nodes have a higher risk of distant disease. Traditionally, involved nodes have been managed with resection but, currently, there are protocols exploring the use of synchronous chemoradiotherapy as definitive treatment. Although adjuvant chemotherapy has been used in this setting to reduce the risk of distant seeding, the benefits at this stage have not been confirmed conclusively. The presence of distant disease carries a grave outlook and responses to chemotherapy occur frequently, but are usually shortlived.

Chemotherapy in neuroendocrine/Merkel cell carcinoma of the skin: case series and review of 204 cases

PURPOSE

To study the use of chemotherapy for Merkel cell carcinoma (MCC) of the skin.

PATIENTS AND METHODS

Twenty-five cases of MCC were treated at the London Regional Cancer Center between 1987 and 1997. Thirteen cases treated with chemotherapy were reviewed with 191 cases from the literature.

RESULTS

At presentation, 24 patients had localized skin lesions (stage I) and one had locoregional involvement (stage II). Among the nine cases with recurrent nodal disease, six had chemotherapy as a component of salvage treatment. They were all free of disease at a median of 19 months (range, 12 to 37 months). In contrast, two patients who had salvage radiotherapy alone died of disease. Overall survival (OS) and disease-free survival (DFS) were 59% and 43%, respectively, at two years. Median OS and DFS were 29 months (range, 1 to 133 months) and 9 months (range, 1 to 133 months), respectively. Nodal disease developed in 12 (50%) of 24 patients with stage I disease, and distant metastases developed in six (25%) of 24. Including those from the literature, there were 204 cases treated with chemotherapy. Cyclophosphamide/doxorubicin (or epirubicin)/vincristine combination +/- prednisone was the most commonly used chemotherapy regimen (47 cases), with an overall response rate of 75.7% (35.1% complete, 35. 1% partial, and 5.4% minor responses). Etoposide/cisplatin (or carboplatin) was the next most commonly used regimen (27 cases), with an overall response rate of 60% (36% complete and 24% partial responses). The difference in response rate was not statistically significant (P =.19). Among the 204 cases, there were seven (3.4%) toxic deaths.

CONCLUSION

Chemoradiation for locally recurrent or advanced disease may be an option for patients with a good performance status.

Oral etoposide for Merkel cell carcinoma in patients previously treated with intravenous etoposide

We describe three patients with advanced Merkel cell carcinoma who were treated with etoposide given orally for recurrent regional lymph node involvement 18 to 30 months after exposure to etoposide given intravenously. Etoposide given orally (100 mg/day) was given for 10 to 14 consecutive days and repeated every 21 to 28 days for a median of three courses (range: two to four). Toxicity was minimal and mainly hematologic. Two patients showed a complete response and one a partial response, all of very rapid onset. All three patients are alive 6, 9, and 42 months from the start of oral treatment. Two remain progression free, and one had a recurrence 1 month after completion of chemotherapy. We suggest that orally administered etoposide, a topoisomerase II inhibitor, has a strong antitumor effect in advanced Merkel cell carcinoma, even in patients previously treated parenterally with the same drug. This action may be explained by the greater dependence of the drug's efficacy on the duration of administration rather than the dose intensity.

Chemotherapy for patients with locally advanced or metastatic Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma (MCC) is a highly malignant skin neoplasm. Regional lymph node and distant metastasis occur in 20-52% of patients. The role of chemotherapy in the treatment of patients with this rare tumor is unclear.

METHODS

An exhaustive analysis of the literature (1980-1995) describing chemotherapy for patients with locally advanced or metastatic MCC was performed. All available published medical records (n = 101 patients) were entered in a database. In addition, data on six additional patients given chemotherapy during this time frame in Lyon, France, were included in the database.

RESULTS

For the 107 patients, the overall objective response rate to first-line chemotherapy was 61% (61 of 101 evaluable patients). The response rate was 57 % (41 of 72) for patients with metastasis and 69% (20 of 29) for patients with locally advanced tumors. No clinical parameter was found to be correlated to response to chemotherapy. A high rate of toxic death during first-line treatment (n = 7.7%) was reported for these patients. The median overall survival from the date of chemotherapy initiation was 9 months for patients with metastasis and 24 months for patients with locally advanced tumors. The projected overall survival at 3 years was 17% for patients with metastasis and 35% for patients with locally advanced tumors. Progression after first-line chemotherapy was associated with significantly worse survival for patients with metastasis. Rates of response to second-line (n = 33) and third-line (n = 10) chemotherapy were 45% and 20%, respectively.

CONCLUSIONS

MCC is chemosensitive but rarely chemocurable in patients with metastasis or locally advanced tumors. A high incidence of toxic death due to chemotherapy is reported in the literature.

The natural history and management of Merkel cell carcinoma of the skin: a review of 22 patients treated at the Royal Marsden Hospital

Merkel cell carcinoma is a rare skin malignancy, which primarily affects the elderly. Currently, there is only limited data on the natural history of this condition and no consensus on its optimum management. We have reviewed the natural history and management of 22 patients with Merkel cell carcinoma, who were treated at the Royal Marsden Hospital between 1985 and 1994. The median age at diagnosis was 75 years (range 55-96), with the head and neck region being the most common site of disease (nine patients: 41%). Seventeen patients (77%) presented with skin disease, three (14%) with regional lymphadenopathy and two (9%) with metastatic disease. Of the Stage I patients, 41% developed local recurrence postoperatively at a median time to relapse of 12 months. Those with head and neck disease had the highest risk of local recurrence, which occurred in 62.5% of this group. Stage I patients also had a high risk of disease progression, with 53% developing regional lymphadenopathy or visceral metastases. The median survival for all disease stages was 47 months. The treatment of unresectable primary or recurrent disease with radiotherapy led to valuable long term control in four of nine patients treated. Six courses of chemotherapy were administered; one brief complete response was observed, occurring in a patient treated with cyclophosphamide, vincristine and doxorubicin. The data in this study confirms the predilection for the elderly and the aggressive nature of Merkel cell carcinoma, with only four of 17 Stage I patients remaining disease free. To clarify the role of adjuvant postoperative radiotherapy and to establish the appropriate use of chemotherapy in metastatic spread of this rare malignancy will require further studies with multicentre cooperation.

Merkel cell carcinoma. Diagnosis and treatment

BACKGROUND

Merkel cell carcinoma is an uncommon malignancy of the skin that often portends a poor prognosis. Since its first description by Toker in 1972, a plethora of case reports and articles regarding the etiopathogenesis and treatment have been published spanning multiple medical and surgical disciplines. Much confusion still exists regarding the diagnosis and treatment of this ominous tumor.

OBJECT

Through extensive review of the medical, surgical, and pathological literature, to collate the observations of multiple investigators and summarize these findings.

METHODS

Articles from journals of multiple subspecialties were carefully reviewed with particular emphasis placed on epidemiology, prognosis, histology, immunohistochemistry, electron microscopy, tumor origin, treatment, and work-up of Merkel cell carcinoma.

RESULTS

Merkel cell carcinoma is an aggressive malignant neoplasm. Local recurrence develops in 26-44% of patients despite therapy. Up to three-fourths of patients eventually develop regional nodal metastases with distant metastases occurring in one-third of all patients. Reported overall 5-year survival rates range from 30% to 64%.

CONCLUSION

Treatment recommendations unfortunately are based more on anecdotal than scientific data because of the rarity of the tumor and its recognized high risk. Most authors recommend wide local excision of the primary lesion and regional lymph node resection if lymph nodes are palpable followed by x-irradiation of both the postsurgical bed and lymph node basin. The role of elective lymph node resection in the absence of clinically positive nodes remains controversial.

Further insights into the natural history and management of primary cutaneous neuroendocrine (Merkel cell) carcinoma

PURPOSE

Primary cutaneous neuroendocrine (Merkel cell) carcinoma is a rare neoplasm with aggressive behavior but potential for response to radiotherapy and chemotherapy. Optimal treatment regimens are evolving based on reports of case series and a growing understanding of the natural history.

METHODS AND MATERIALS

A retrospective analysis of 34 cases treated at two Australian Institutions over 13 years is presented, focusing on clinical features and response to therapy.

RESULTS

The aggressive nature of this neoplasm is confirmed by the local recurrence rate of 22% following surgical excision, the development of regional node metastases in 76%, and of distant metastases in 70%. Overall median survival was 24 months with 65% of patients succumbing to metastatic disease. An association with B cell malignancies and immunosuppressive therapy is noted, with these patients having a poorer outcome, and one spontaneous remission was observed. Radiation therapy produced responses in 21 of 30 measurable sites (11 complete, 10 partial), and in 11 sites irradiated prophylactically there was only one infield relapse (9%). Responses to chemotherapy were observed in 8 of 20 applications (40%), particularly carboplatin and etoposide given in the setting of regional node disease.

CONCLUSION

In this poor prognosis tumor, further investigation of adjuvant radiotherapy and chemotherapy is warranted, as responsiveness of recurrent disease is confirmed. Immunological factors appear important in the natural history, and their manipulation may offer additional therapeutic options.

Merkel cell carcinoma of the head and neck

Merkel cell carcinoma is a rare cutaneous tumour that typically arises in the head and neck area of elderly patients. The tumour often follows an aggressive course with frequent local recurrences and (regional) metastases, especially when localized above the clavicles. Five patients with a Merkel cell carcinoma of the head and neck, treated in our institute since 1984, are presented, illustrating the need for radical initial treatment consisting of surgery and radiotherapy, and showing how rapidly progressive the disease can be. Four of the five patients were cured of disease by a combination of surgery and radiotherapy.

Merkel cell carcinoma and iodine-131 metaiodobenzylguanidine scan

Two cases of Merkel cell carcinoma, a neuroendocrine neoplasia of the skin, investigated with iodine-131 metaiodobenzylguanidine (131I-mIBG) scintigraphy, are reported. Uptake in the tumor was evident only in 1 case. The possible diagnostic and therapeutic role of 131I-mIBG in patients with this rare neoplasm is discussed.

Merkel cell carcinoma of the labial mucosa. An immunohistochemical and ultrastructural study with a review of the literature on oral Merkel cell carcinomas

Merkel cell carcinoma is a rare cutaneous neuroendocrine tumor that occurs predominantly in the head and neck region of older patients. An 88-year-old white man had an erythematous, umbilicated tumor on his lower lip, which on histopathologic examination showed solid sheets of infiltrating basaloid round cells with a high mitotic index. Globular, paranuclear immunostaining for low-molecular-weight cytokeratins (Nos. 8, 18, and 19) and neurofilament was observed. On ultrastructural examination, the tumor cells demonstrated paranuclear whorls of intermediate filament aggregates and occasional electron-dense granules. This unique cytokeratin- and neurofilament-staining pattern with coexpression enabled the Merkel cell carcinoma to be differentiated from other small cell malignant tumors that included metastatic neuroendocrine carcinomas from other regions. The follow-up 1 year after surgery and radiation showed that the patient remained disease free. Review of the literature revealed 11 cases of oral Merkel cell carcinomas with a predilection for the labial mucosa of older men. The mode of treatment and the clinical course of these cases are also presented, with an update on therapeutic management of Merkel cell carcinomas.

Primary neuroendocrine carcinoma of the skin. Clinicopathologic study of 18 cases

The clinical and pathologic features of primary neuroendocrine carcinoma of the skin in 18 elderly patients are reported. The carcinomas arose in the dermis and subcutaneous tissues, particularly on the head and the upper extremities. One tumor occurred in an irradiated area. Using Gould's clinicopathologic classification, we have found four trabecular types, eleven intermediate cell types, and two small cell types. One tumor could not be classified. Other noteworthy pathologic features were association with invasive squamous cell carcinoma, lentiginous melanocytic hyperplasia, and presence of intratumoral melanocytes. Immunoreactivity for cytokeratins (56 kD), neurofilaments, neuron-specific enolase, and epithelial membrane antigen was observed. The paranuclear globular staining pattern of cytokeratins and neurofilaments was conspicuous. The ultrastructural features revealed paranuclear intermediate filament aggregates (fibrous bodies), neurosecretory granules, and cell junctions. In two metastatic tumors, high levels of catecholamines were found. The trabecular types were characterized by localized disease and a good prognosis. The patients with the small cell types died of distant metastases. Postoperative radiotherapy seemed to reduce the rate of local recurrences.