Merkel cell carcinoma and HIV infection

[Frequent and rare dermatological diseases in HIV patients]

HIV patients develop a variety of infectious and non-infectious diseases of the skin and mucous membranes. Some of these serve as indicator diseases for a weakening immune system. While none of the dermatological complications is pathognomonic, conditions such as oral hairy leukoplakia, herpes zoster, thrush, and eosinophilic folliculitis should make physicians consider the possibility of underlying HIV disease. Moreover, one has to consider HIV if these skin diseases take an atypical or severe course, or if they do not respond properly to appropriate medication. Frequent and rare dermatoses occurring in HIV infection are discussed.

Merkel Cell Carcinoma: Assessing the Effect of Wide Local Excision, Lymph Node Dissection, and Radiotherapy on Recurrence and Survival in Early-Stage Disease—Results From a Review of 82 Consecutive Cases Diagnosed Between 1992 and 2004

BACKGROUND

Wide surgical excision, lymph node dissection, and radiotherapy have been used with varying efficacy in the management of early-stage Merkel cell carcinoma.

METHODS

Records of 82 patients with early-stage Merkel cell carcinoma between 1992 and 2004 were reviewed.

RESULTS

Forty-two patients developed a recurrence, and 44 died during the study period. Twenty-nine patients presented with regional lymph node disease, which was independently associated with diminished survival (hazard ratio [HR], 4.08; 95% confidence interval [CI], 1.55-10.75; P = .005). Lymphadenectomy was independently associated with prolonged disease-free survival (median, 28.5 vs. 11.8 months; HR, .46; 95% CI, .22-.94; P = .034) but not overall survival (P = .25). Margin-negative excision of the primary tumor (60 of 73) was not significantly associated with either prolonged disease-free survival (median, 16 vs. 14 months) or overall survival (median, 54 vs. 34 months). Forty-eight patients received radiotherapy: 36 to the primary site and 31 to the regional lymph nodes. Radiotherapy to both sites was associated with a longer median time to first recurrence (primary site, 24.2 vs. 11.8 months; regional lymph nodes, 46.2 vs. 11.3 months) and survival (primary site, 53.9 vs. 45.7 months; regional lymph nodes, 103.1 vs. 34.2 months). Administration of any radiotherapy was significantly associated with a prolonged time to first recurrence (HR, .39; 95% CI, .20-.75; P = .004) and survival (HR, .39; 95% CI, .18-.82; P = .013) on the Cox regression multivariate analyses.

CONCLUSIONS

Adjuvant radiotherapy to the primary site after surgical excision is recommended in early-stage disease. Involved regional lymph nodes should be treated with radiotherapy with or without lymphadenectomy.

HIV and skin cancer

AIDS produces profound alterations in normal immunity. Impaired cellular immunity permits new tumor formation as evidenced by the solid-organ transplant literature. The weakened cellular immune system of HIV-infected patients resembles in some ways the iatrogenic immunosuppression in solid-organ transplant recipients. This article summarizes what is known about skin cancer in the solid-organ transplant population and compares the immunodysregulation of HIV infection with the iatrogenic immunosuppression following solid-organ transplantation.

Merkel cell carcinoma and multiple primary cancers

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine tumor of the skin for which causative factors remain largely unknown. The site-specific risks of multiple primary cancers associated with MCC, which may provide insight into etiologic influences, have not been quantified in large population-based studies. We estimated the long-term risk of subsequent primary tumors after a first primary MCC (1,306 patients) and the risk of second primary MCC following other first primary cancers (2,048,739 patients) within 11 population-based cancer registries which report to the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (1986-2002). Patients with first primary MCC were at significantly increased risk of developing a subsequent cancer [standardized incidence ratio (SIR), 1.22; 95% confidence intervals (95% CI), 1.01-1.45; observed (O = 122)], with significant excesses restricted to the first year after diagnosis (SIR, 1.71; 95% CI, 1.21-2.33; O = 39). Significantly elevated site-specific risks were observed for cancers of salivary gland (SIR, 11.55; 95% CI, 2.32-33.76; O = 3), biliary sites other than liver and gallbladder (SIR, 7.24; 95% CI, 1.46-21.16; O = 3), and non-Hodgkin lymphoma (SIR, 2.56; 95% CI, 1.23-4.71; O = 10). Nonsignificantly increased risks of 2-fold or higher were seen for chronic lymphocytic leukemia, and cancers of the small intestine and brain. A significantly increased 1.36-fold risk (95% CI, 1.19-1.55; O = 221) of MCC as a second primary malignancy was observed among patients with all other first primary cancers taken together. In particular, significant 3- to 7-fold excesses of MCC followed multiple myeloma (SIR, 3.70; 95% CI, 1.01-9.47; O = 4), chronic lymphocytic leukemia (SIR, 6.89; 95% CI, 3.77-11.57; O = 14), non-Hodgkin lymphoma (SIR, 3.37; 95% CI, 1.93-5.47; O = 16), and malignant melanoma (SIR, 3.05; 95% CI, 1.74-4.95; O = 16). Although enhanced medical surveillance may play a role, increased reciprocal risks suggest that MCC may share etiologic influences with other malignancies. Heightened awareness of the associations of lymphohematopoietic malignancies with MCC may facilitate early clinical recognition.

The Toker Tumor

Primary neuroendocrine carcinoma of the skin is a relatively rare tumor that was first described by Cyril Toker in 1972. Since the seminal paper by Toker based on simple morphologic observations and detailed clinical correlation, our understanding of the clinical, morphological, and biological attributes of these lesions has grown exponentially with their increased awareness by pathologists and clinicians as well as with the many contributions of modern diagnostic techniques. The present review focuses principally on the various morphologic appearance that these tumors are able to adopt, the role of modern special techniques for diagnosis, and the conditions that need to be considered in their differential diagnosis.

No evidence of Epstein-Barr virus association with Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive tumor of cutaneous neuroendocrine cells with a reported 13-fold increased incidence in immunocompromised patients, raising the possibility that it is driven by an oncogenic virus. Additionally, Merkel cell hyperplasia is seen in the Epstein-Barr virus (EBV)-driven process oral hairy leukoplakia, and EBV is known to be involved in the pathogenesis of several other malignancies.

OBJECTIVE

We tested the hypothesis that EBV is involved in MCC.

METHODS

We employed EBV-encoded RNA in situ hybridization (ISH), lytic EBV ISH, latent membrane protein 1 immunohistochemistry, and BamH1Z leftward reading frame 1 immunohistochemistry to detect and localize EBV in paraffin sections of MCC from five patients as well as seven other cutaneous tumors and positive controls for EBV infection.

RESULTS

Positive controls reacted appropriately. However, there was no evidence of latent or lytic EBV in any of the MCC biopsies or other cutaneous tumors.

CONCLUSION

Our findings suggest that EBV is not associated with MCC.

Merkel cell tumour of the external ear. Report of a case

Merkel cells carcinoma (MCC) is an uncommon skin lesion, considered a malignancy of the neuroendocrine system, which is found mainly in elderly people. Its incidence is highly correlated with sun exposure or immunodeficiency syndromes. MCC is often an aggressive tumour with high tendency for local recurrence, lymph node involvement and distant metastasis. To our best knowledge 20 cases originated from the auricle have been described, 2 of them arising from external ear canal. The authors report a case of the ear canal characterized by two others synchronous tumours and the occurrence of a malignant high grade lymphoma, in which contribute of the pathologist was essential for a critical review. MCC diagnosis is not always easy for its pathological and clinical features and it should always be considered in presence of lymphoma. A multidisciplinary approach is basic.

Merkel cell carcinoma (primary cutaneous neuroendocrine carcinoma): An overview on management

Merkel cell carcinoma is an uncommon but aggressive primary cutaneous neuroendocrine (small cell) carcinoma. There is ongoing debate regarding the optimal treatment of this disease. The early literature comprised small institutional studies with inherent weaknesses. Recent data have emerged from larger studies, including those from Australian institutions, that adds support to a multimodality approach as best practice. Despite this, the outcome for patients with unfavourable disease remains poor and in most series 25-30% of patients die as a direct result of Merkel cell carcinoma. The head and neck is the commonest site for presentation (50-60%) and wide excision (2-3 cm) of the primary lesion is usually recommended, although achieving this is often difficult within functional and cosmetic constraints. All clinically node-negative patients should be considered candidates for elective nodal treatment and those with clinical nodal disease should undergo nodal dissection and adjuvant radiotherapy. Recent evidence suggests that patients treated with surgery and adjuvant locoregional radiotherapy experience a better disease-free survival compared with those undergoing surgery alone. The role of platinum-based chemotherapy is evolving. The aim of this article is to discuss relevant issues in the management of a patient with Merkel cell carcinoma.

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

Background

Merkel cell carcinoma (MCC) is an unusual primary neuroendocrine carcinoma of the skin. MCC is a fatal disease, and patients have a poor chance of survival. Moreover, MCC lacks distinguishing clinical features, and thus by the time the diagnosis is made, the tumour usually have metastasized. MCC mainly affects sun-exposed areas of elderly persons. Half of the tumours are located in the head and neck region.

Methods

MCC was first described in 1972. Since then, most of the cases reported, have been in small series of patients. Most of the reports concern single cases or epidemiological studies. The present study reviews the world literature on MCC. The purpose of this article is to shed light on this unknown neuroendocrine carcinoma and provide the latest information on prognostic markers and treatment options.

Results

The epidemiological studies have revealed that large tumour size, male sex, truncal site, nodal/distant disease at presentation, and duration of disease before presentation, are poor prognostic factors. The recommended initial treatment is extensive local excision. Adjuvant radiation therapy has recently been shown to improve survival. Thus far, no chemotherapy protocol have achieved the same objective.

Conclusion

Although rare, the fatality of this malignancy makes is important to understand the etiology and pathophysiology. During the last few years, the research on MCC has produced prognostic markers, which can be translated into clinical patient care.

Merkel cell carcinoma: a clinicopathological study of 11 cases

OBJECTIVE

To report our 12-year experience with Merkel cell carcinomas (MCCs) from a clinical and pathological point of view.

SUBJECTS AND SETTING

Eleven MCCs were diagnosed at our institution between 1991 and 2002.

METHODS

A retrospective clinical, histopathological and immunohistochemical study was performed. Age, gender, location, size, stage, treatment and follow-up data were collected. Histopathological pattern and immunohistochemical study with CAM 5.2, cytokeratin 20 (CK20), CK7, Ber EP4, neurofilaments, synaptophysin, chromogranin, S100 protein, p53 protein, CD117, leucocyte common antigen (LCA) and Ki-67 were accomplished.

RESULTS

Six females and five males with a mean age of 82 years were identified. Tumours were located on the face (n = 6), extremities (n = 3) and trunk (n = 1). At diagnosis, one patient was in stage Ia, six in stage Ib, three in stage II and one in stage III. All but one patient experienced wide surgical excision of the tumour. Additional treatment consisted of lymph node dissection in two patients, radiotherapy in four patients and systemic chemotherapy in one patient. Local recurrence developed in five patients. Three patients died because of MCC after 14 months of follow-up. Intermediate-size round cell proliferation was found in all cases. Additional small-size cell pattern and trabecular pattern were observed in seven and six cases, respectively. Eccrine and squamous cell differentiation were found in three cases. A dot-like paranuclear pattern was observed in all cases with CAM 5.2 and neurofilaments, and in 89% of cases with CK20. Seventy-five per cent of cases reacted with Ber EP4, chromogranin and synaptophysin, 70% with p53, 22% with S100 protein, 55% with CD117 and none with LCA. Ki-67 was found in 75% of tumoral cells on average. Fifty per cent of MCCs reacted with CK7 and showed eccrine differentiation areas.

CONCLUSIONS

MCC is an aggressive neuroendocrine tumour of the elderly. Wide surgical excision is the recommended treatment. Lymph node dissection, adjuvant radiotherapy and chemotherapy decrease regional recurrences but have not been demonstrated to increase survival. Immunohistochemically, MCC is an epithelial tumour with neuroendocrine features.

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.

Merkel cell carcinoma and multiple basal cell carcinoma in an African albino woman with HIV infection

A 25-year-old HIV-infected African albino woman developed an aggressive Merkel cell carcinoma on her face and at least 10 basal cell carcinomas, mainly on sun-exposed parts of her body. HIV infection, immune deficiency and sun exposure are known risk factors for the development of Merkel cell carcinoma. Chemotherapy and radiotherapy were only temporarily successful. She died shortly after surgery was performed to remove the tumour.

Merkel cell carcinoma: changing incidence trends

BACKGROUND

The objective of this study was to define the incidence trends of Merkel cell carcinoma (MCC), a rare and aggressive cutaneous malignancy.

MATERIALS AND METHODS

All cases of MCC of the skin between 1986 and 2001 were identified using the surveillance, epidemiology, and end results (SEER) program. Overall age-adjusted, gender-specific, age-specific, stage-specific, and regional incidence rates were calculated. All rates are per 100,000 and age-adjusted to the 2000 US standard population. Estimated annual percent change (EAPC) was calculated using a linear least squares model.

RESULTS

A total of 1,124 cases of MCC were identified in the SEER registries. The rate of MCC increased from 0.15 cases per 100,000 in 1986 to 0.44 cases per 100,000 in 2001. The EAPC for the time period was 8.08%. This was statistically significant (95% CI: 6.29, 9.90, P-value < 0.05). Age-specific incidence (5-year age groups) were highest in the elderly, 4.28 per 100,000 in the 85+ age group.

CONCLUSIONS

MCC incidence rates have increased threefold over the 1986-2001 period. Rates are highest in the elderly population. Further etiologic studies and identification of high-risk populations are warranted.

Merkel cell carcinoma of the head and neck

Merkel cell carcinoma (MCC) is a rare neuroendocrine neoplasm of the skin. The tumor most frequently affects elderly patients, with a preference for the head and neck. Incidence rates increase with sun exposure and after immunosuppression and organ transplantation. A significant proportion of MCC have been reported to occur in intimate association with malignant epithelial neoplasms. The genetic mechanisms underlying the development and tumor progression of MCC are poorly understood, sharing pathogenetic mechanisms with other neoplasms of neural crest derivation. MCC has a propensity for spreading to regional lymph nodes, either at presentation or as a first site of relapse. Sentinel lymph node positivity is helpful in predicting the risk of recurrence or metastasis in patients with MCC. Complete surgical resection is the mainstay of treatment of the primary tumor. Tumor resections are recommended to include a 2-3-cm tumor-free margin around the primary lesion when possible, but this is often difficult to achieve in the head and neck, where Mohs micrographic surgery has proved to be effective. The role of adjuvant radiation therapy is controversial. The role of adjuvant chemotherapy in diminishing the risk of subsequent systemic recurrence in patients with positive nodes remains undefined. Overall response rates to combination chemotherapy for surgically unresectable distant metastatic disease are generally high, although responses are transient. Overall survival of head and neck MCC at 5 years postoperatively ranks between 40% and 68%. MCC has a high incidence of locoregional recurrences, but even after a locoregional failure, a substantial proportion of patients achieve long-term disease-free survival. Finally, factors generally associated with survival are the stage of disease at presentation, distant recurrence usually being the most adverse predictor of survival.

Merkel cell carcinoma: report of seven cases

Merkel cell carcinoma (MCC) is an infrequent, highly malignant, primary skin tumor derived from neuroendocrine cells. Most MCCs occur in elderly individuals, on sun-exposed areas of the body, with the head and neck being the most common sites. We present 7 patients (2 male and 5 female, age 45-80 years) suffering from MCC and treated between 1993 and 2000. All tumors were located on the head and neck and varied from 0.9 to 2.3 cm in size. Five of the patients had stage II disease, 1 patient had stage Ia disease and 1 patient had stage III disease. Six of the patients had positive regional lymph nodes. All patients had local excision of the tumor. Six of them also had lymph node dissection and in 5 of them a superficial parotidectomy was performed. Five patients received adjuvant radiotherapy and 3 of them also received chemotherapy. Local and cervical lymph node recurrence was observed in only 1 patient. Metastases occurred in 5 patients. One patient died within 10 days for other reasons. The patient with the stage III tumor had a survival of 7 months. The other 5 patients had survivals varying from 15 to 54 months. MCC is a skin tumor with very poor prognosis and high recurrence and metastatic rates. Its treatment is still under discussion. Radical excision of the tumor is the main method of treatment. Selective lymph node dissection is suggested. Superficial parotidectomy seems necessary, especially if the tumor is on the auricle. Adjuvant radio- and chemotherapy may extend survival in case of small-size tumors.