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Lugowska I, Becker JC, Ascierto PA, Veness M, Blom A, Lebbe C, Migliano E, Hamming-Vrieze O, Goebeler M, Kneitz H, Nathan P, Rutkowski P, Slowinska M, Schadendorf D, Piulats JM, Petrelli F, van Akkooi ACJ, Berruti A. Merkel-cell carcinoma: ESMO-EURACAN Clinical Practice Guideline for diagnosis, treatment and follow-up. ESMO Open 2024; 9:102977. [PMID: 38796285 PMCID: PMC11145756 DOI: 10.1016/j.esmoop.2024.102977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 05/28/2024] Open
Abstract
•This ESMO Clinical Practice Guideline provides key recommendations for managing Merkel-cell carcinoma (MCC). •Recommendations are based on available scientific data and the multidisciplinary group of experts’ collective opinion. •The guideline covers clinical and pathological diagnosis, staging and risk assessment, treatment and follow-up. •Algorithms for the management of locoregional and inoperable/metastatic disease are provided. •A multidisciplinary team with a high level of expertise in MCC should diagnose and make decisions about therapy.
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Affiliation(s)
- I Lugowska
- Department of Early Phase Clinical Trials, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - J C Becker
- Department of Translational Skin Cancer Research, German Cancer Consortium (DKTK), University Hospital of Essen, Essen; Department of Translational Skin Cancer Research, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - P A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - M Veness
- Sydney Medical School, The University of Sydney, Sydney; Department of Radiation Oncology, Westmead Hospital, Sydney, Australia
| | - A Blom
- CARADERM Network, Department of General and Oncologic Dermatology, Université Paris-Saclay, UVSQ, EA4340-BECCOH, AP-HP, Ambroise-Paré Hospital, Boulogne-Billancourt
| | - C Lebbe
- Université de Paris Cite, Paris; Dermato-Oncology and CIC Department, AP-HP Hôpital Saint Louis, Paris; INSERM U976, Paris, France
| | - E Migliano
- Department of Plastic and Regenerative Surgery, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - O Hamming-Vrieze
- Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - H Kneitz
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - P Nathan
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw
| | - M Slowinska
- Department of Dermatology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - D Schadendorf
- Department of Dermatology, Westdeutsches Tumorzentrum (WTZ), University Hospital Essen, Essen; German Cancer Consortium (DKTK), Partner Site Essen & NCT-West Campus Essen & University Alliance Ruhr, Research Center One Health, Essen, Germany
| | - J M Piulats
- Medical Oncology Department, Institut Català d'Oncologia (ICO), Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), CIBEROnc, Universitat de Barcelona, Barcelona, Spain
| | - F Petrelli
- Oncology Unit, Azienda Socio Sanitaria Territoriale (ASST) Bergamo Ovest, Treviglio, Italy
| | - A C J van Akkooi
- Department of Melanoma and Surgical Oncology, Melanoma Institute Australia, Sydney; Faculty of Medicine and Health, University of Sydney, Sydney; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - A Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Medical Oncology Unit, University of Brescia, ASST Spedali Civili, Brescia, Italy
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Daha C, Brătucu E, Moisă H, Prunoiu VM, Simion L. Luarea deciziilor terapeutice în carcinomul cu celule Merkel – punctul de vedere al chirurgului oncolog. ONCOLOG-HEMATOLOG.RO 2023. [DOI: 10.26416/onhe.62.1.2023.7745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Survival outcomes and epidemiology of Merkel cell carcinoma of the lower limb and hip: A Surveillance, Epidemiology, and End Results analysis 2000-2018. JAAD Int 2022; 7:13-21. [PMID: 35243404 PMCID: PMC8873923 DOI: 10.1016/j.jdin.2021.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 11/21/2022] Open
Abstract
Background Merkel cell carcinoma of lower limb and hip skin is a rare skin tumor that has a high recurrence rate. Objective To assess epidemiology and survival outcomes of the lower limb and hip Merkel cell carcinoma, which are less addressed in the literature. Methods The Surveillance, Epidemiology, and End Results database was searched for all cases of skin Merkel cell carcinoma between 2000 and 2018. Demographic and clinicopathologic features were compared between lower limb and other skin localizations using the t test or χ2 test. The overall survival (OS) of lower limb Merkel cell carcinoma was calculated using the Kaplan-Meier method. Subgroups were compared using the log rank test. Multivariate cox regression was used to identify independent prognostic factors. Results In total, 976 patients were identified. The mean age was 72.7 years. The median OS was 68 months, better than that of other localizations. Older age, regional lymph node, and distant metastasis were associated with low OS. Surgery with >1-cm margins, when associated with radiotherapy, had the best OS. Age, tumor size, lymph node status, presence of metastasis, and treatment sequence were identified as independent prognostic factors. Conclusion Lower limb and hip Merkel cell carcinomas have better OS than tumors in other skin localizations. In this dataset, the best OS was ensured using surgery with >1-cm margins and adjuvant radiotherapy.
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Lamberti G, Andrini E, Siepe G, Mosconi C, Ambrosini V, Ricci C, Marchese PV, Ricco G, Casadei R, Campana D. Lymph node ratio predicts efficacy of postoperative radiation therapy in nonmetastatic Merkel cell carcinoma: A population-based analysis. Cancer Med 2022; 11:4204-4213. [PMID: 35485165 DOI: 10.1002/cam4.4773] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/02/2021] [Accepted: 09/24/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND After radical resection of a nonmetastatic Merkel cell carcinoma (M0 MCC), postoperative radiation therapy (RT) is recommended as it improves survival. However, the role of RT in specific subgroups of M0 MCC is unclear. We sought to identify whether there is a differential survival benefit from RT in specific M0 MCC patient subgroups. METHODS M0 MCC patients from the Surveillance, Epidemiology, and End Results (SEER) database registry were collected. The best prognostic age, tumor size, and lymph node ratio (LNR, ratio between positive lymph nodes and resected lymph nodes) cutoffs were calculated. The primary endpoint was overall survival (OS). RESULTS A total of 5644 M0 MCC patients (median age 77 years, 62% male) were included: 4022 (71%) node-negative (N0) and 1551 (28%) node-positive (N+). Overall, 2682 patients (48%) received RT. Age > 76.5 years, tumor size >13.5 mm, and LNR >0.215 were associated with worse OS. RT was associated with longer OS in the M0 MCC, N0, and N+ group and independently associated with a 25%, 27%, and 26% reduction in the risk for death, respectively. RT benefit on survival was increased in tumor size >13.5 mm in the N0 group and LNR >0.215 in the N+ group. No OS benefit from RT was observed in T4 tumors (N0 and N+ groups). CONCLUSIONS RT was associated with improved survival in M0 MCC, irrespective of the nodal status. LNR >0.215 is a useful prognostic factor for clinical decision-making and for stratification and interpretation of clinical trials.
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Affiliation(s)
- Giuseppe Lamberti
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy
| | - Elisa Andrini
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy
| | - Giambattista Siepe
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Mosconi
- NET Team Bologna - ENETS Center of Excellence, Bologna, Italy.,Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valentina Ambrosini
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Ricci
- NET Team Bologna - ENETS Center of Excellence, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paola Valeria Marchese
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy
| | - Gianluca Ricco
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy
| | - Riccardo Casadei
- NET Team Bologna - ENETS Center of Excellence, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Davide Campana
- Department of Experimental Diagnostic and Specialized Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Division of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,NET Team Bologna - ENETS Center of Excellence, Bologna, Italy
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Ferini G, Valenti V, Puliafito I, Illari SI, Marchese VA, Borzì GR. Volumetric Modulated Arc Therapy Capabilities for Treating Lower-Extremity Skin Affected by Several Merkel Cell Carcinoma Nodules: When Technological Advances Effectively Achieve the Palliative Therapeutic Goal while Minimising the Risk of Potential Toxicities. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121379. [PMID: 34946324 PMCID: PMC8703259 DOI: 10.3390/medicina57121379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 12/25/2022]
Abstract
The peculiar and rare clinical condition below clearly requires a customized care approach in the context of personalized medicine. An 80-year-old female patient who was subjected in 2018 to surgical removal of a cutaneous Merkel cell carcinoma (MCC) nodule located on the posterior surface of the left thigh and to three subsequent palliative radiotherapy treatments developed a fourth relapse in October 2020, with fifteen nodular metastases located in the left thigh and leg. Since the overall macroscopic disease was still exclusively regionally located and microscopic spread was likely extended also to clinically negative skin of the thigh and leg, we performed an irradiation of the whole left lower extremity. For this purpose the total target (65.5 cm) was divided into three sub-volumes. Dose prescription was 30 Gy in 15 daily fractions. A sequential boost of 10 Gy in 5 daily fractions was planned for macroscopic nodules. Plans were calculated by means of volumetric modulated arc therapy (VMAT) with the field overlap technique. Thanks to this, we obtained a homogeneous dose distribution in the field junction region; avoidance structures were delineated in the central part of the thigh and leg with the aim of achieving an optimal superficial dose painting and to reduce bone exposure to radiation. This case study demonstrates that VMAT allows for a good dose coverage for circumferential cutaneous targets while sparing deeper organs at risk. A reproducible image-guided set-up is fundamental for an accurate and safe dose delivery. However, local treatments such as radiotherapy for very advanced MCC of the lower extremities might have limited impact due to the high probability of systemic progression, as illustrated in this case. Radiation is confirmed as being effective in preventing MCC nodule progression toward skin wounding.
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Affiliation(s)
- Gianluca Ferini
- REM Radioterapia srl, Via Penninazzo 11, I-95029 Viagrande, CT, Italy; (V.V.); (V.A.M.)
- Correspondence: ; Tel.: +39-095-78-94-581
| | - Vito Valenti
- REM Radioterapia srl, Via Penninazzo 11, I-95029 Viagrande, CT, Italy; (V.V.); (V.A.M.)
| | - Ivana Puliafito
- Medical Oncology Unit, Mediterranean Institute of Oncology, I-95029 Viagrande, CT, Italy;
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Cheraghlou S, Agogo GO, Girardi M. Evaluation of Lymph Node Ratio Association With Long-term Patient Survival After Surgery for Node-Positive Merkel Cell Carcinoma. JAMA Dermatol 2019; 155:803-811. [PMID: 30825411 PMCID: PMC6583886 DOI: 10.1001/jamadermatol.2019.0267] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/12/2019] [Indexed: 12/18/2022]
Abstract
Importance Merkel cell carcinoma (MCC) carries the highest mortality rate among cutaneous cancers and is rapidly rising in incidence. Identification of prognostic indicators may help guide patient counseling and treatment planning. Lymph node ratio (LNR), the ratio of positive lymph nodes to the total number of examined lymph nodes, is an established prognostic indicator in other cancers. Objectives The primary objective was to evaluate the association between LNR and patient survival after surgery for node-positive MCC. The secondary objective was to evaluate whether the survival rates associated with adjuvant therapies vary by patient LNR status. Design, Setting, and Participants Retrospective cohort study of patients with node-positive MCC treated with surgery and lymphadenectomy. We queried the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) registry for patient records. Data originated from 2004 through 2017 for the NCDB and from 1973 through 2016 for the SEER registry. The SEER registry comprises a population-based US cohort while cases from the NCDB include all reportable cases from Commission on Cancer-accredited facilities and represents approximately 70% of all newly diagnosed cancers in the United States. All data analysis took place between August 1, 2018, and February 11, 2019. Exposures The ratio of positive lymph nodes to the total number of examined lymph nodes, LNR, was stratified into quartiles. Main Outcomes and Measures Overall survival (NCDB) and disease-specific survival (SEER). Results We identified 736 eligible cases in the NCDB and 538 eligible cases in the SEER registry. Among these 1274 patients, the mean (SD) age was 71.1 (11.5) years, and 401 (31.5%) were women. After controlling for clinical and tumor factors including AJCC N staging, patient LNR of 0.07 to 0.31 (hazard ratio [HR], 1.37; 95% CI, 1.03-1.81) and greater than 0.31 (HR, 2.84; 95% CI, 2.10-3.86) was associated with significantly worse survival than an LNR less than 0.07. Univariate supplementary analysis performed in the SEER data set revealed a similar association of LNR with disease-specific survival. For patients with an LNR greater than 0.31, treatment with surgery and adjuvant chemoradiation therapy was associated with improved survival compared with surgery and adjuvant radiation therapy alone (HR, 0.61; 95% CI, 0.38-0.97), while this was not found for patients with an LNR of 0.31 or lower (HR, 0.93; 95% CI, 0.65-1.33). Conclusions and Relevance For lymph node-positive MCC, LNR offers a potentially prognostic metric alongside traditional TNM staging that may be useful for both patient counseling and treatment planning after surgery.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - George O. Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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Petrelli F, Ghidini A, Torchio M, Prinzi N, Trevisan F, Dallera P, De Stefani A, Russo A, Vitali E, Bruschieri L, Costanzo A, Seghezzi S, Ghidini M, Varricchio A, Cabiddu M, Barni S, de Braud F, Pusceddu S. Adjuvant radiotherapy for Merkel cell carcinoma: A systematic review and meta-analysis. Radiother Oncol 2019; 134:211-219. [PMID: 31005218 DOI: 10.1016/j.radonc.2019.02.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 01/31/2023]
Abstract
Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous malignancy with a high propensity for local recurrence and regional and distant metastases. The main treatment is surgery with narrow excision margins and draining nodes, plus or minus adjuvant radiotherapy (RT) on the surgical bed and/or lymph nodes. We performed a systematic review and meta-analysis of the benefits of adjuvant RT in MCC treatment. PubMed, EMBASE, and the Cochrane Library were systematically searched to identify relevant studies published before September 2018. Prospective trials and retrospective series comparing adjuvant RT vs. no RT in resected primary MCCs were included. Primary endpoint was to evaluate the outcomes of MCC patients who received adjuvant RT in term of overall survival (OS) and disease-free survival (DFS). Hazard ratios (HRs) for OS and DFS were aggregated according to a fixed or random effect model. Secondary endpoints were local, locoregional, and distant DFS. A total of 17,179 MCCs across 29 studies were analysed. There was a significant difference in OS between the RT and no RT arms (HR = 0.81, 95%CI 0.75-0.86, P < 0.001). There was also a significant difference in DFS in favour of adjuvant RT (HR = 0.45, 95%CI 0.32-0.62, P < 0.001). Adjuvant RT improved locoregional DFS and local DFS but not distant DFS (HR = 0.3, 95%CI 0.22-0.42; HR = 0.21, 95%CI 0.14-0.33, and HR = 0.79, 95%CI 0.49-1.14, respectively). Meta-regression analysis showed that high Newcastle-Ottawa scale scores, stage I-II MCCs, shorter follow-up durations, size >2 cm, and being of a younger age were associated with increased OS. This systematic review and meta-analysis suggests a survival and DFS benefit for postoperative radiation of MCCs. Intermediate stage MCCs derive the maximum benefit with local and regional relapses reduced by 80% and 70%, respectively. Conversely, distant metastases were not significantly prevented.
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Affiliation(s)
- Fausto Petrelli
- Medical Oncology Unit, ASST Bergamo Ovest, Treviglio, Italy.
| | | | - Martina Torchio
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Italy
| | - Natalie Prinzi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Italy
| | | | | | | | | | | | | | | | | | | | | | - Mary Cabiddu
- Medical Oncology Unit, ASST Bergamo Ovest, Treviglio, Italy
| | - Sandro Barni
- Medical Oncology Unit, ASST Bergamo Ovest, Treviglio, Italy
| | - Filippo de Braud
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Italy
| | - Sara Pusceddu
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Italy
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van Veenendaal LM, van Akkooi ACJ, Verhoef C, Grünhagen DJ, Klop WMC, Valk GD, Tesselaar MET. Merkel cell carcinoma: Clinical outcome and prognostic factors in 351 patients. J Surg Oncol 2018; 117:1768-1775. [DOI: 10.1002/jso.25090] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/04/2018] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Cees Verhoef
- Departement of Surgical Oncology; Erasmus MC Cancer Institute; Rotterdam The Netherlands
| | - Dirk Jan Grünhagen
- Departement of Surgical Oncology; Erasmus MC Cancer Institute; Rotterdam The Netherlands
| | - W. Martin C. Klop
- Departement of Head and Neck Surgery and Oncology; Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Gerlof D. Valk
- Departement of Endocrine Oncology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Margot E. T. Tesselaar
- Departement of Medical Oncology; Netherlands Cancer Institute; Amsterdam The Netherlands
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9
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van Veenendaal LM, Madu MF, Tesselaar MET, Verhoef C, Grünhagen DJ, van Akkooi ACJ. Efficacy of isolated limb perfusion (ILP) in patients with Merkel cell carcinoma (MCC): A multicenter experience. Eur J Surg Oncol 2017; 43:2157-2162. [PMID: 28802661 DOI: 10.1016/j.ejso.2017.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/20/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare and potentially aggressive neuroendocrine tumor of the skin, with a propensity for locoregional metastases. In two expert referral centers, isolated limb perfusion (ILP) is used to obtain locoregional control in selected locoregionally advanced MCC patients. This study describes our experience. METHOD Patients who underwent ILP for MCC were analyzed. ILP was performed with melphalan and tumor necrosis factor (TNF) combination therapy. Depending on the institution, either a normothermic or a hyperthermic temperature regimen was used. Baseline characteristics, toxicity data, locoregional progression-free survival (LPFS) and overall survival (OS) were assessed. RESULTS Four males and 6 females with a median age of 78 years (IQR 61-84 years) were included. Four patients underwent ILP for upper extremity disease and 6 for lower extremity disease. All patients received combination therapy with Melphalan and TNF, one patient with the addition of interferon-gamma. No signs of systemic toxicity were present post-ILP. Severe locoregional toxicity (compartment syndrome) occurred in 1 patient and 1 elderly patient with extensive atherosclerosis had to undergo transfemoral amputation due to critical ischemia. Eight patients could be included for response evaluation. The overall response rate (ORR) was 87.5% with a complete response (CR) rate of 62.5%. Two long-term responses of 53 months and 71 months were observed. Median LPFS was 5 months and median OS was 54 months. CONCLUSION ILP shows a high CR rate that can be durable. Therefore, ILP should be considered an effective treatment modality for locally advanced MCC.
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Affiliation(s)
- L M van Veenendaal
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, NL-1066 CX Amsterdam, The Netherlands
| | - M F Madu
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, NL-1066 CX Amsterdam, The Netherlands
| | - M E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, NL-1066 CX Amsterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, NL-3075 EA Rotterdam, The Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, NL-3075 EA Rotterdam, The Netherlands
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, NL-1066 CX Amsterdam, The Netherlands.
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Antic D, Jelicic J, Vukovic V, Pupic G, Milovanovic Z, Mihaljevic B. Concomitant chronic lymphocytic leukemia and Merkel cell carcinoma. DERMATOL SIN 2015. [DOI: 10.1016/j.dsi.2014.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Sentinel lymph node biopsy for head and neck Merkel cell carcinoma: A preliminary study. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 132:77-80. [DOI: 10.1016/j.anorl.2015.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Risk of second cancers in merkel cell carcinoma: a meta-analysis of population based cohort studies. J Skin Cancer 2014; 2014:184245. [PMID: 25574398 PMCID: PMC4276678 DOI: 10.1155/2014/184245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/22/2014] [Indexed: 02/07/2023] Open
Abstract
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.
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Garibyan L, Cotter SE, Hansen JL, Noell C, Dorosario A, O'Farrell DA, Devlin PM, Wang LC. Palliative treatment for in-transit cutaneous metastases of Merkel cell carcinoma using surface-mold computer-optimized high-dose-rate brachytherapy. Cancer J 2014; 19:283-7. [PMID: 23867506 DOI: 10.1097/ppo.0b013e31829e3566] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The objective of this study was to evaluate the palliative treatment benefit of surface-mold computer-optimized high-dose-rate brachytherapy (SMBT) for in-transit cutaneous metastases of Merkel cell carcinoma (MCC). METHODS Ten patients with in-transit cutaneous MCC metastases were treated with SMBT at the Dana-Farber/Brigham & Women's Cancer Center between 2006 and 2012. RESULTS The median age at diagnosis was 76 years (range, 63-87 years). Seven patients had in-transit metastases on the lower extremities (70%), 2 patients on the head and neck (20%), and 1 patient on an upper extremity (10%). A total of 152 metastatic MCC lesions were treated with SMBT. All SMBT-treated lesions resolved clinically within a few weeks of therapy. The median follow-up was 34 months (range, 22-85 months). Two of 152 treated lesions recurred during the study period for a local control rate of 99%. Eight patients (80%) developed additional in-transit metastases outside the original SMBT fields. Five of these 8 patients underwent additional SMBT. At study conclusion, 3 patients (30%) are alive without disease, 3 patients (30%) are alive with disease, and 4 patients (40%) died of MCC. DISCUSSION Surface-mold computer-optimized high-dose-rate brachytherapy offers effective and durable palliation for cutaneous metastases of MCC, although it does not appear to alter disease course.
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Affiliation(s)
- Lilit Garibyan
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 21202, USA.
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Marchesi A, Parodi PC, Brioschi M, Sileo G, Marchesi M, Vaienti L. Giant Merkel cell carcinoma of the lower limb: case report and review of the literature. J Cutan Med Surg 2014; 17:351-5. [PMID: 24067857 DOI: 10.2310/7750.2013.12121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine malignancy that usually grows rapidly at the head and neck. Giant forms at the lower limbs are rarely reported and usually affect patients in the eighth decade or older. METHODS We report the case of a 60-year-old man who presented with a giant MCC on his right thigh. We managed this case by applying the 2012 updated guidelines and reviewed all cases of giant MCC of the lower limbs reported in the literature. RESULTS At the 4-month follow-up, the patient showed complete remission. CONCLUSION Giant forms of MCC are still treated as typical cases of MCC, when these patients show a very poor prognosis. In young and adult people, such as our case, wide surgical excisions, sentinel lymph node biopsy in clinically negative node cases, radiotherapy of the regional drain area, and a strict follow-up should be routinely performed to improve patients' survival.
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Becker JC, Assaf C, Vordermark D, Reske SN, Hense J, Dettenborn T, Seitz O, Grabbe S. Brief S2k guidelines--Merkel cell carcinoma. J Dtsch Dermatol Ges 2013; 11 Suppl 3:29-36, 31-8. [PMID: 23734895 DOI: 10.1111/ddg.12015_6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Jürgen C Becker
- Division of General Dermatology, Graz University Hospital, Graz, Austria.
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Hasan S, Liu L, Triplet J, Li Z, Mansur D. The role of postoperative radiation and chemoradiation in merkel cell carcinoma: a systematic review of the literature. Front Oncol 2013; 3:276. [PMID: 24294591 PMCID: PMC3827544 DOI: 10.3389/fonc.2013.00276] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 10/25/2013] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE A systematic review of the literature was undertaken to investigate whether adjuvant radiotherapy and/or chemotherapeutics offered any additional benefit than surgery alone in the treatment of Merkel Cell Carcinoma (MCC). METHODS A PubMed, MEDLINE search was conducted between 1995 and 2013, to identify reported cases of surgically treated MCC followed by either observation, radiation, or chemoradiation. Patient demographics and outcomes were recorded and compared in a systematic fashion. RESULTS Thirty-four studies (n = 4475) were included. The median age was 73 years, median follow up was 36 months and there was a 1.5:1 ratio of men to women. All 4475 patients had surgery, 1975 had no further treatment, 1689 received postoperative RT, and 301 received postoperative chemoRT. The most common site was face/head/neck, 47.8%. Stage 1 was the most common clinical stage at diagnosis (57%). Three-year local control was 20% (median 10%) in the observation cohort, compared to 65% (62%) with postoperative RT, and 67% (75%) with postoperative chemoRT; these findings were statistically significant (P < 0.001). Recurrence was found to be 38% (60%) in the observation cohort, compared to 23% (20%) with postoperative RT (P < 0.001). Three-year overall survival (OS) was found to be 56% (57%) in the observation cohort, compared to 70% (78%) with postoperative RT and 73% (76%) with postoperative chemoRT (P < 0.001). The observation cohort had a median OS of 44 months compared with 64 months (P < 0.001) in the postoperative RT cohort. There was no statistically significant difference in any parameters assessed between postoperative radiation and postoperative chemoradiation arms. CONCLUSION The comprehensive collection of retrospective data suggests a survival and control benefit for postoperative radiation in MCC. No differences were noted between adjuvant radiation and chemoradiation. This analysis indicates the need for prospective trials with patients stratified by known prognostic factors.
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Affiliation(s)
- Shaakir Hasan
- College of Osteopathic Medicine, Nova Southeastern University , Fort Lauderdale, FL , USA
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Abstract
Merkel cell carcinoma (MCC) is a rare, clinically aggressive cutaneous neuroendocrine neoplasm with a high mortality rate. Though the etiology is not precisely known, Merkel cell polyomavirus DNA has been found recently in a large percentage of MCC tumors. Other suggested risk factors include sun exposure, immunosuppression, and a history of prior malignancy. Work up of patients with MCC most notably includes nodal staging via clinical examination or sentinel lymph node biopsy. The prognosis for most patients with MCC is poor, and the rarity of MCC precludes the prospective, randomized clinical trials necessary to elucidate optimum treatment protocols. Most published data support the use of a multimodality approach centered around surgical excision with negative margins, sentinel lymph node biopsy to establish the presence or absence of nodal metastases, adjuvant radiothearpy to decrease the risk of recurrence, and systemic chemotherapy in the case of widespread disease.
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Kouzmina M, Leikola J, Böhling T, Koljonen V. Positive sentinel lymph node biopsy predicts local metastases during the course of disease in Merkel cell carcinoma. J Plast Surg Hand Surg 2013; 47:139-43. [DOI: 10.3109/2000656x.2012.736386] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A practical update of surgical management of merkel cell carcinoma of the skin. ISRN SURGERY 2013; 2013:850797. [PMID: 23431473 PMCID: PMC3570924 DOI: 10.1155/2013/850797] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/30/2012] [Indexed: 01/08/2023]
Abstract
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.
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Santamaria-Barria JA, Boland GM, Yeap BY, Nardi V, Dias-Santagata D, Cusack JC. Merkel cell carcinoma: 30-year experience from a single institution. Ann Surg Oncol 2012. [PMID: 23208132 DOI: 10.1245/s10434-012-2779-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare cutaneous malignancy. Few single-institution series have been reported. METHODS Review of MCC patients treated at our institution between 1980 and 2010. Patient, tumor, and treatment variables were analyzed to determine MCC-specific outcomes. RESULTS We identified 161 patients with MCC. There was a 2.5-fold increase in cases over the last decade. Median length of follow-up was 36 months. Stage at diagnosis was I in 35 %, II in 21 %, IIIa in 12 %, IIIb in 23 %, and IV in 9 %. The 5-year MCC-specific survival rates were 87, 63, 42, and 0 % for stages I, II, III, and IV, respectively. Death from the disease occurred in 10 % of patients with T1 and in 50 % with larger lesions. One-third of patients presented with nodal disease. Sentinel lymph node biopsy (SLNB) identified micrometastases in 9 out of 27 (33 %) early-stage patients. Recurrence developed in 56 % of SLNB-positive and 39 % of SLNB-negative patients. Half of patients recurred after a median time of 9 months. Proportions of first recurrence location were distant (52 %), nodal (27 %), and local (21 %). Adjuvant treatments did not improve recurrence or survival rates. One-third of patients died of the disease. CONCLUSIONS SLNB identifies micrometastasis in one-third of early-stage patients. Negative SLNB may predict for improved but not necessarily favorable outcome. Initial tumor size and clinical nodal disease predict for poor outcome. High recurrence rates warrant the development of more effective adjuvant therapies, and better markers of recurrence and treatment response for MCC are needed.
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Affiliation(s)
- Juan A Santamaria-Barria
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, YAW 7B, 55 Fruit Street, Boston, MA 02114, USA
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Lim CS, Whalley D, Haydu LE, Murali R, Tippett J, Thompson JF, Hruby G, Scolyer RA. Increasing tumor thickness is associated with recurrence and poorer survival in patients with Merkel cell carcinoma. Ann Surg Oncol 2012; 19:3325-34. [PMID: 22820936 DOI: 10.1245/s10434-012-2509-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous neuroendocrine tumor usually occurring on sun-exposed skin in elderly patients. Clinical and pathologic factors associated with disease progression and mortality in patients with MCC are poorly defined. Recently, it has been reported that p63 expression in primary MCC is strongly associated with clinical outcome. METHODS MCC patients diagnosed between July 1, 1993 and July 31, 2009 were identified from the surgical pathology records of the Sydney South West Area Health Service. Clinical, pathologic, treatment, and survival data were obtained and immunohistochemical analyses for p53, p63, and Ki-67 were performed. The associations of clinical and pathologic features with disease-free and disease-specific survival were analyzed. RESULTS Ninety-five patients were identified (67 males, 28 females; median age at diagnosis of primary MCC 76 [range, 42-93] years). Increasing primary tumor thickness was significantly associated with poorer disease-free survival (5-year survival 18 % in tumors >10 mm thick compared with 69 % for patients with tumors ≤10 mm thick, p = 0.002) and disease-specific survival (5-year survival 74 % in tumors >10 mm thick compared with 97 % for patients with tumors ≤10 mm thick, p = 0.006). There was a strong positive correlation between the Ki-67 index (proportion of Ki-67-positive tumor nuclei) and tumor thickness (r = 0.39, n = 45, p = 0.008). Positive staining for p63 in MCC was infrequent (9 % of primary MCC) and showed no significant association with disease outcome. CONCLUSIONS Tumor thickness is significantly associated with disease-free survival in MCC. We recommend that primary tumor thickness be routinely recorded in the pathology reports of patients with primary MCC.
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Affiliation(s)
- Cathy S Lim
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Abstract
PURPOSE OF REVIEW Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine carcinoma of the skin demonstrating a high propensity of recurrence and metastasis. Its 5-year disease-specific survival rate is only about 60%. Although MCC is still regarded as a very rare tumor entity, its incidence is rapidly increasing. In this regard, the American Cancer Society estimated almost 1500 new cases in the United States in 2008. RECENT FINDINGS The newly identified Merkel cell polyomavirus (MCV) has been found associated to most MCC cases. Nevertheless, the distinct molecular pathogenesis of MCC and its link to MCV is not yet fully understood. Moreover, the impact of MCV positivity on the course of disease and prognosis of MCC patients is controversially discussed. SUMMARY This review summarizes recent findings on MCC pathogenesis with a special emphasis on the impact of MCV, presents an overview of clinical aspects, and discusses treatment options.
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Fields RC, Busam KJ, Chou JF, Panageas KS, Pulitzer MP, Allen PJ, Kraus DH, Brady MS, Coit DG. Recurrence after complete resection and selective use of adjuvant therapy for stage I through III Merkel cell carcinoma. Cancer 2011; 118:3311-20. [PMID: 22072529 DOI: 10.1002/cncr.26626] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Revised: 08/29/2011] [Accepted: 08/29/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine neoplasm whose natural history is poorly understood. Here, the authors describe their experience with a large cohort of patients who were treated at a single institution to describe patterns of recurrence after curative therapy. METHODS Review of a prospective database was performed. Patient-related, tumor-related, and treatment-related variables were recorded, and the site and timing of initial recurrence were recorded. Factors associated with receipt of adjuvant therapy and recurrence were determined. RESULTS In total, 364 patients with stage I through III MCC who underwent complete resection were identified. Adjuvant local radiation therapy (RT), lymph node RT, and chemotherapy were received selectively by 23%, 23%, and 15% of patients, respectively. Factors associated with the receipt of adjuvant therapy included younger age, primary tumor features (larger size, lymphovascular invasion [LVI], positive margin excision), and increasing pathologic stage. With median follow-up of 3.6 years, 108 patients (30%) developed a recurrence, including 11 local recurrences (3%), 12 in-transit recurrences (3%), 43 lymph node recurrences (12%), and 42 distant recurrences (12%). Clinically involved lymph nodes, primary tumor LVI, and a history of leukemia/lymphoma were predictive of recurrence. The majority of recurrences (80%) occurred in patients who had clinically involved lymph nodes or patients who did not undergo pathologic lymph node evaluation. CONCLUSIONS A low recurrence rate in patients with clinically lymph node-negative MCC was achieved with adequate surgery (including sentinel lymph node biopsy) and the selective use of adjuvant RT for high-risk tumors. In contrast, patients with clinically lymph node-positive MCC had significantly higher rates of recurrence, especially distant recurrence. The authors concluded that contemporary natural history studies are critical in designing treatment pathways and clinical trials for MCC.
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Affiliation(s)
- Ryan C Fields
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Ghadjar P, Kaanders JH, Poortmans P, Zaucha R, Krengli M, Lagrange JL, Özsoy O, Nguyen TD, Miralbell R, Baize A, Boujelbene N, Collen T, Scandolaro L, Untereiner M, Goldberg H, Pesce GA, Anacak Y, Friedrich EE, Aebersold DM, Beer KT. The Essential Role of Radiotherapy in the Treatment of Merkel Cell Carcinoma: A Study From the Rare Cancer Network. Int J Radiat Oncol Biol Phys 2011; 81:e583-91. [DOI: 10.1016/j.ijrobp.2011.05.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 05/12/2011] [Accepted: 05/15/2011] [Indexed: 10/18/2022]
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Rush Z, Fields RC, Lee N, Brownell I. Radiation therapy in the management of Merkel cell carcinoma: current perspectives. EXPERT REVIEW OF DERMATOLOGY 2011; 6:395-404. [PMID: 23565121 PMCID: PMC3615640 DOI: 10.1586/edm.11.40] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine neoplasm with a propensity for metastatic spread. When managing MCC, surgical excision is often the initial treatment. As MCC is generally radiosensitive, many institutions include adjuvant radiation therapy (RT) in their standard treatment protocols. In the absence of prospective randomized clinical trials, a number of retrospective reports suggest that adjuvant RT can improve local and regional recurrence rates. Here, we provide an overview of recent studies on the use of RT in MCC treatment and explore the limits of the current knowledge. Ultimately, the benefits and risks associated with using RT in the treatment of MCC remain poorly described and merit more rigorous investigation.
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Affiliation(s)
- Zoe Rush
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Ryan C Fields
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Isaac Brownell
- Dermatology Branch, Center for Cancer Research, NCI, NIH, Building 10, Magnuson Clinical Center, Room 12N246, 10, Center Dr., Bethesda, MD 20892-1908, USA
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Veness M, Foote M, Gebski V, Poulsen M. The Role of Radiotherapy Alone in Patients With Merkel Cell Carcinoma: Reporting the Australian Experience of 43 Patients. Int J Radiat Oncol Biol Phys 2010; 78:703-9. [DOI: 10.1016/j.ijrobp.2009.08.011] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 08/12/2009] [Accepted: 08/13/2009] [Indexed: 12/01/2022]
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Veness M, Howle J. Patients with clinically node negative extremity Merkel cell carcinoma: The importance of identifying and treating patients with microscopic nodal metastases. Australas J Dermatol 2010; 51:274-8. [DOI: 10.1111/j.1440-0960.2010.00702.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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