Merkel cell carcinoma in South East Scotland, 1993– 2003

Epidemiology of Merkel Cell Polyomavirus Infection and Merkel Cell Carcinoma

Merkel cell polyomavirus (MCPyV) is a ubiquitous virus replicating in human dermal fibroblasts. MCPyV DNA can be detected on healthy skin in 67−90% of various body sites, and intact virions are regularly shed from the skin. Infection occurs early in life, and seropositivity increases from 37 to 42% in 1- to 6-year-olds to 92% in adults. Merkel cell carcinoma (MCC) is a rare but very aggressive neuroendocrine tumor of the skin. It develops mainly on sun-exposed areas as a fast-growing, reddish nodule. Two MCC entities exist: about 80% of MCC are MCPyV-associated. Tumorigenesis is driven by viral integration into the host genome and MCPyV oncogene expression. In MCPyV-negative MCC, UV radiation causes extensive DNA damage leading to the deregulation of the cell cycle. In recent decades, MCC incidence rates have increased worldwide, e.g., in the United States, from 0.15 in 1986 to 0.7/100,000 in 2016. Risk factors for the development of MCC include male sex, older age (>75 years), fair skin, intense UV exposure, and immunosuppression. Projections suggest that due to aging populations, an increase in immunosuppressed patients, and enhanced UV exposure, MCC incidence rates will continue to rise. Early diagnosis and prompt treatment are crucial to reducing high MCC morbidity and mortality.

Mohs Micrographic Surgery Versus Wide Local Excision in the Treatment of Merkel Cell Carcinoma: A Systematic Review

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins. However, Mohs micrographic surgery (MMS) offers a potential advantage over WLE because of its ability of sparing healthy tissue and assessing 100% of margins.

OBJECTIVE

To systematically evaluate the surgical modalities for the treatment of MCC.

MATERIALS AND METHODS

Eligible articles were identified using MEDLINE, Scopus, EMBASE, and Cochrane Library. All available studies investigating surgical treatment of MCC with WLE or MMS were considered.

RESULTS

Forty studies met the inclusion criteria. Thirty-one studies described patients treated with WLE, 3 with MMS, and 6 with either WLE or MMS. Subgroup analysis of Stage I MCC showed recurrence rates similar in both surgical modalities with local recurrence rate of 6.8% for WLE versus 8.5% for MMS (p = .64) and a regional recurrence rate of 15.2% for WLE versus 15.3% for MMS (p = .99).

CONCLUSION

Overall WLE cases were at a higher stage at presentation. Subgroup analysis showed that MMS is not inferior to WLE excision for the treatment of Stage I MCC and is a reasonable option for anatomic locations where tissue sparing is important.

Merkel cell carcinoma of the head and neck in the south-east of England

Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine malignancy of the skin. Its incidence is increasing with half of cases involving the head and neck. To the best of our knowledge, few large studies have been published in the UK, and to date this is the largest reported series of head and neck MCC. We retrospectively reviewed the outcomes of patients with MCC in three hospitals in the south-east of England over a 12-year period (2008-2019). Diagnosis was based on histological data following biopsy. Overall survival and disease-specific survival were calculated using Kaplan-Meier and log-rank tests. Fifty-eight patients met the inclusion criteria (24 stage I, 22 stage II, 9 stage III, and 3 unclassified). Median disease-free survival was 36 months (95% CI 0 to 77.2) and median overall survival 50 months (95% CI 29.9 to 70). Overall five-year survival was 34.4% (95% CI 17% to 52%) with two-year survival at 62% (95% CI 48% to 76%). Five-year disease-free survival was 26.7% (95% CI 17 to 52%) with two-year disease-free survival at 54% (95% CI 40% to 68%). To date, this is the largest UK based study reporting overall and disease-free survival associated with MCC of the head and neck. Half the patients presented late, and surgery was the mainstay of treatment, augmented by adjuvant radiotherapy. There is a need to better stratify patients at risk of developing metastatic disease, with the use of sentinel lymph node biopsy and positron-emission tomography-computed tomography (PET-CT), as immunotherapy and targeted agents are now available to treat advanced disease.

Management of regional metastatic disease in cutaneous malignancy of the head and neck. 3. Merkel cell carcinoma

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes.

Merkel cell carcinoma: Epidemiology, pathogenesis, diagnosis and therapy

Merkel cell carcinoma (MCC) is a rare and aggressive skin cancer with a neuroendocrine phenotype. Incidence varies according to the geographic regions but is overall increasing. Different risk factors have been identified namely advanced age, immunosuppression, and ultraviolet light exposure. An association between MCC and polyomavirus infection is known. However, the exact mechanism that leads to carcinogenesis is yet to be fully understood. Surgery when feasible is the recommended treatment for localized disease, followed by adjuvant radiation or chemoradiation. In the metastatic setting, chemotherapy has been the standard treatment. However, two recently published trials with immune checkpoint inhibitors in first and second line showed promising results with a tolerable safety profile and these might become the standard therapy shortly. Somatostatin receptors are expressed in many MCC but such expression is not associated with disease severity. Presently there are no biomarkers predictive of response that could help to better select patients to these new therapies, and additional research is essential.

Merkel cell carcinoma: Epidemiology, prognosis, therapy and unmet medical needs

Merkel cell carcinoma (MCC) is a rare skin cancer that is associated with Merkel cell polyomavirus infection in most cases. Incidence rates of MCC have increased in past decades. Risk factors for MCC include ultraviolet light exposure, immunosuppression and advanced age. MCC is an aggressive malignancy with frequent recurrences and a high mortality rate, although patient outcomes are generally more favourable if the patient is referred for treatment at an early stage. Although advances have been made recently in the MCC field, large gaps remain with regard to definitive biomarkers and prognostic indicators. Although MCC is chemosensitive, responses in advanced stages are mostly of short duration, and the associated clinical benefit on overall survival is unclear. Recent nonrandomised phase 2 clinical trials with anti-PD-L1/PD-1 antibodies have demonstrated safety and efficacy; however, there are still no approved treatments for patients with metastatic MCC. Patients with advanced disease are encouraged to participate in clinical trials for treatment, indicating the largely unmet need for durable, safe treatment within this population.

Treatment of Merkel cell carcinoma of the head and neck: a systematic review

BACKGROUND

Merkel cell carcinoma (MCC) is a rare and aggressive neurocutaneous malignancy that frequently arises in sun-exposed areas of the head and neck. Standard therapy focuses on wide local excision (WLE) with adjuvant locoregional radiotherapy. However, treatment is often complicated by concerns for cosmesis and for preservation of the head and neck neurovasculature.

OBJECTIVE

To explore treatment-related outcomes of the head and neck MCC.

METHODS

A MEDLINE and Google Scholar search was performed for studies focusing on the head and neck MCC treatment.

RESULTS

The search terms produced 100 articles. Seventeen studies met eligibility/screening criteria, yielding 868 patients. Three of the 6 relevant studies found a significant difference in disease-free survival (DFS) between surgery and surgery plus adjuvant radiation. Two studies found no difference in DFS or overall survival (OS) in patients receiving chemotherapy. Two studies found no difference in DFS between radiotherapy and surgery with adjuvant radiation. No difference in OS was found between WLE and Mohs surgery.

CONCLUSION

In an uncomplicated head and neck MCC, treatment with surgery and adjuvant radiotherapy is effective in increasing survival and reducing recurrence. Radiotherapy alone may be appropriate for inoperable regions. Primary chemotherapy seems to have a limited role; however, few studies explored this treatment modality.

Management of early stage cutaneous Merkel cell carcinoma of the head and neck

Merkel cell carcinoma (MCC) is a rare but aggressive skin cancer of neuroendocrine origin. As a result, few large studies have been published, and we know of even fewer on disease of the head and neck alone. The most appropriate way to manage patients with early local disease and no sign of metastases neck is controversial. We reviewed management of early cutaneous MCC of the head and neck in 8 hospitals in the United Kingdom over 12 years between 1999 and 2011 (the largest head and neck series in Europe to date), and identified 39 patients (19 men and 20 women) with early disease according to a well recognised classification. A total of 24 patients had stage Ia disease, 11 had stage Ib disease, and 4 were unclassified. Five of those with stage Ia disease developed regional metastases and 7 with stage Ib disease developed regional recurrence. The 2-year overall survival for stage Ia and Ib disease was 62% and 27%, respectively. Our study shows that prognosis is poor after conservative surgical management of stage I disease. Management of the neck is still controversial, and a meta-analysis of all the published data is needed to establish best practice statistically.

Merkel cell carcinoma in Western Australia: a population-based study of incidence and survival

BACKGROUND

Merkel cell carcinoma (MCC) is an uncommon but aggressive cutaneous skin cancer. Even with the appropriate treatment, MCC is prone to recurrence, and metastases are common. Exposure to ultraviolet radiation has been suggested as contributing towards the development of MCC. MCC has not been extensively investigated in Australia, even though Australia has the highest incidence of sun-related cancers in the world.

OBJECTIVES

To describe the demographics and determine trends of incidence and survival of MCC cases in Western Australia (WA).

METHODS

All reported invasive cases of MCC incident between 1 January 1993 and 31 December 2007 were extracted from the WA Cancer Registry. Age-adjusted incidence rates for MCC were calculated using direct standardization to the U.S. standard 2000 population. Cause-specific survival was investigated using Kaplan-Meier and Cox proportional hazards analysis. results: Two hundred and fifteen cases were confirmed by pathological review as being definite cases of MCC. Patients were mainly males (65%) and elderly (median age 77 years). Standardized age-adjusted incidence rates were higher in men (1·0/100,000) than in women (0·63/100,000) and higher in older ages (15·5/100,000 in the 85+year age group) than younger ages (0·1/100,000 in the 30-34 year age group). Five-year cause-specific survival was 64%.

CONCLUSIONS

Incidence of MCC in WA is the highest reported in the literature. In addition, MCC has worse survival than melanoma. The high rates and demographic and anatomical distribution are consistent with sun exposure playing a causal role.

Updated Review of the Pathogenesis and Management of Merkel Cell Carcinoma

Background:

Merkel cell carcinoma is a rare, aggressive, malignant cutaneous tumor of the elderly or immunosuppressed individuals that usually appears on sun-exposed areas of the body. Its pathogenesis is still debated, and, currently, no standardized treatment exists.

Objective:

To provide a current updated review of the most relevant data concerning the pathogenesis and management of Merkel cell carcinoma.

Methods:

Using relevant MeSH terms, we performed a review of the literature on these subjects from 1980 to June 2009.

Results and Conclusion:

The current management of Merkel cell carcinoma is based on surgical excision as the majority of patients present with localized disease, whereas up to 30% have regional lymph node metastases. In these cases, the best outcome is achieved with multidisciplinary management that includes radiotherapy. Chemotherapy is part of the treatment in advanced cases and is mandatory for distant metastatis. Given that a recent work showed the presence of a previously unknown polyomavirus, which the authors called Merkel cell polyomavirus, the therapeutical approach to Merkel cell carcinoma could be reconsidered in the future.

Rare skin cancer: a population-based cancer registry descriptive study of 151 consecutive cases diagnosed between 1980 and 2004

BACKGROUND

There are few epidemiological data available on rare skin cancer, including Merkel cell carcinoma, Paget's disease, adnexal carcinoma, and sarcoma. We conducted this study to investigate the epidemiology of rare skin cancer diagnosed in the department of Doubs from 1980 to 2004.

METHODS

Data were collected from a population-based cancer registry from 1980 to 2004. Diagnosis was based on the 3(rd) edition of the International Classification of Diseases for Oncology. The incidence rates were standardized on world population.

RESULTS

One hundred and fifty one patients were investigated (88 women and 63 men). Median age for the diagnosed disease was 63 years. The standardized incidence rate was 0.82/100 000 person-year (95% CI = 0.68-0.96) and increased from 0.25 in 1980-1984 to 1.50 in 2000-2004. Fifty nine cases (39%) were sarcomas, 35 (23%) adnexal carcinomas, 27 (18%) Merkel cell carcinoma and 27 (18%) Paget's disease. The standardized incidence rates were 0.37/100 000 (0.27-0.47) for sarcomas, 0.16 (0.10-0.22) for adnexal tumors, 0.13 (0.08-0.18) for Merkel cell carcinoma, and 0.15 (0.09-0.21) for Paget's disease.

CONCLUSIONS

Our results based on a population-based cancer registry showed an increase of the standardized incidence rate for all types of rare skin tumors. These results may be useful when considering the growing interest in rare diseases in identifying risk factors and planning scientific research programmes.