Merkel cell carcinoma arising in the head and neck: optimizing therapy

Surgical Management of Merkel Cell Carcinoma

The incidence of Merkel cell carcinoma (MCC) continues to increase. Understanding of MCC biology has advanced rapidly, with current staging providing valuable prognostic information. MCC treatment often is multidisciplinary. Surgery remains an important component in the staging and treatment, most commonly involving wide excision of the cancer and sentinel lymph node biopsy. Lymphadenectomy is used to treat nodal disease. Radiotherapy enhances locoregional control and possibly survival. Systemic therapies, in particular novel immunotherapies, may be promising in the treatment of advanced or recurrent and metastatic disease.

Primary Treatment Selection for Clinically Node-Negative Merkel Cell Carcinoma of the Head and Neck

OBJECTIVE

Merkel cell carcinoma practice guidelines recommend sentinel lymph node biopsy after wide local excision for the initial management of clinically node-negative disease without distant metastases (cN0M0). Despite guideline publication, treatment selection remains variable. We hypothesized that receipt of guideline-recommended care would be more common in patients evaluated at academic centers and institutions with high melanoma case volumes and that such therapy would be associated with improved overall survival.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

The National Cancer Database from 2004 to 2015.

METHODS

A total of 3500 patients were included. We utilized Kaplan-Meier analysis and logistic and Cox proportional hazard regressions. Survival analysis was performed on inverse probability-weighted cohorts.

RESULTS

There has been a trend toward evaluation at academic programs at a rate of 1.58% of patients per year (95% CI, 1.06%-2.11%) since 2004. However, the percentage of patients receiving guideline-compliant primary tumor excision and lymph node evaluation has plateaued at approximately 50% since 2012. Guideline-compliant surgical management was more commonly provided to patients evaluated at academic programs than nonacademic programs but only when those institutions had a high melanoma case volume (odds ratio, 2.01; 95% CI, 1.62-2.48). Receipt of guideline-compliant primary tumor excision and lymph node evaluation was associated with improved overall survival (hazard ratio, 0.70; 95% CI, 0.64-0.76).

CONCLUSION

Facility factors affect rates of receipt of guideline-compliant initial surgical management for patients with node-negative Merkel cell carcinoma. Given the survival benefit of such treatment, patients may benefit from care at hospitals with high melanoma case volumes.

Merkel cell carcinoma of the forehead area: a literature review and case report

BACKGROUND

Merkel cell carcinoma (MCC) is an uncommon, aggressive malignancy of the skin, mostly affecting head and neck area in elderly white patients. Between head/neck sites, face accounts for 61% and forehead accounts for 17% of all face MCCs.

PURPOSE

We here present a literature review MCC cases arising in the forehead area, published in the English literature in the period 1987-2018, and report a personal observation with a late diagnosis and a treatment out of the current recommendations. The aims of this paper are to provide an up-to-date on MCC arising in the forehead area and to raise awareness about misdiagnosis of this type of lesion mimicking arteriovenous malformations (AVM).

MATERIAL AND METHOD

Literature review was performed on PubMed and Medline database and "Merkel cell carcinoma (MCC)," "forehead" and "MCC forehead location" were the terms the authors searched for. Patients' data have been drawn from descriptions of single cases and of short case series reports. For each case, data were collected about clinical characteristics, treatment modalities and outcomes. The study has been limited to the clinical features of the disease, excluding etiologic/pathogenic aspects.

RESULTS

Twenty-five patients with forehead MCC have been identified, coming from 20 sources. Nineteen presented a locoregional disease and 6 had an advanced pathology. TNM classification was reported in only two cases lacking for the other available data. Patients presented at mean age of 66 years with solitary or multiple nodules or dome-shaped/hemispherical mass, rarely ulcerated. Mean size of tumors was 1.13 cm of max diameter. Previous or concurrent malignancies or immune-hematologic disorders (AIDS) were often associated. At first investigation, lesion was often mistaken for other malignant or benign processes and, then, diagnosis was generally late. Some type of preoperative biopsy was performed in 3 patients, while the others had only a postoperative microscopic study of specimen. Initial treatment consisted in 6 cases (24%) in a not further specified about extent and width of margins local excision of the primary lesion, while a wide resection was reported in only 3 cases (12%). Surgical treatment of involved lymph-nodes was performed in 3 cases (12%). Six patients underwent radiotherapy for locoregional or distant recurrences. Mortality and overall survival rate at five years were 28% and 24%, respectively. Spontaneous regression was observed in 3 patients (12%).

CASE REPORT

Personal observation concerned an 82-year-old woman presenting with a forehead periorbital 5 × 5 cm red-bluish mass. The erythematous lesion was erroneously diagnosed as hemangioma on the base of color, the absence of any signs of malignancy, an angio CT indicating a hypervascular tissue and a FNA cytology (FNAC) lacking of malignant cells. The mass was excised as a benign lesion with about 1 cm margins extent without searching larger edges. Postoperative radiotherapy was offered to the patient after histology report, but she refused. After 4 months from surgery, she had a parotid metastasis and died from the illness in spite of platinum-based chemotherapy.

CONCLUSIONS

This study confirms the aggressiveness of forehead MCC, comparable with that of other face similar tumors. Personal case suggests that the deceitful benign feature of lesion may mimic an AVM and that FNAC may be misleading and diagnostic failure worsen prognosis. Our experience suggests that in the face smaller than 2-3 cm margins resection may increase the risk of locoregional recurrence. Therefore, postoperative wide-field irradiation should be ever delivered, after forehead MCC surgery, not only when clear margins are unattainable or involved with tumor, but also when negative microscopic edges are documented and residual cancer is thought not persist in the tumor bed. Orbit irradiation seems to be not dangerous for the eye.

The role of postoperative radiation and chemoradiation in merkel cell carcinoma: a systematic review of the literature

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.

Merkel cell carcinoma

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.

Skin cancer of the head and neck

The majority of skin cancers of the head and neck are nonmelanoma skin cancers (NMSC). Basal cell carcinoma and squamous cell carcinoma are the most frequent types of NMSC. Malignant melanoma is an aggressive neoplasm of skin, and the ideal adjuvant therapy has not yet been found, although various options for treatment of skin cancer are available to the patient and physician, allowing high cure rate and excellent functional and cosmetic outcomes. Sunscreen protection and early evaluation of suspicious areas remain the first line of defense against skin cancers.

[Merkel cell carcinoma: a presentation of 5 cases and a review of the literature]

Merkel cell carcinoma is an unusual, aggressive skin tumour, with a tendency to recurrence after its surgical extirpation. Five cases of tumours in the cervicofacial region seen at our Centre in the last five years are presented, along with a review of the literature, focusing on its etiopathogeneis, approach and treatment.

Primary Merkel cell carcinoma of the parotid gland

Primary Merkel cell carcinoma (MCC) is a neuroendocrine tumor that typically affects older whites. It usually originates in the dermis, but in rare instances it has arisen in other primary sites, including the oral mucosa and the parotid gland. Explanations for the presence of MCC in these atypical locations have included theories of malignant transformation and neuroendocrine migration. We describe the case of a 35-year-old white woman who had an MCC in the parotid gland and no evidence of any other primary cutaneous lesion. A left superficial parotidectomy with facial nerve preservation was performed, and a histologic diagnosis of MCC was made. Positron-emission tomography was negative for other lesions, and postoperative radiation therapy was administered for local control. To the best of our knowledge, this is only the sixth case of a primary MCC of the parotid gland to be reported in the English-language literature; of these 6 patients, ours was by far the youngest. Otolaryngologists should be familiar with this rare but potentially fatal neoplasm.

Merkel cell carcinoma in a young pregnant woman

SUMMARY

We present a 27-year-old pregnant woman with Merkel cell carcinoma on the forehead. In early pregnancy, the lesion was excised as an epidermal cyst. It was only after recurrence that a diagnosis of Merkel cell carcinoma was made. Sentinel-node biopsy, excision with 2 cm margins and reconstruction with free microvascular radial forearm flap was carried out, and the patient received postoperative radiotherapy. No evidence of recurrence or disease progression was found 24 months after surgery.

Merkel cell carcinoma of the face: an analysis of 16 cases in the Japanese

BACKGROUND

There is no agreement regarding a staging system and optimal treatment of Merkel cell carcinoma. Some centres have reported results from larger series of patients, but these do not include Asian or Japanese centres.

OBJECTIVE

The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC of the face in the Japanese and to study its management and outcome using the staging system described by Clark et al.

METHODS

We report our experiences with 16 cases between 1991 and 2004. Patients and tumour characteristics, treatment variables and outcome were analysed.

RESULTS

The follow-up periods ranged from 1 to 180 months. The average was 32.6 months and the median was 17.5 months. The relapse-free survival for all patients was 51% at 2 years. The relapse-free survival was 80% for the patients with Stage I and 33% with Stage II at 2 years.

CONCLUSION

This staging system was suggested to reflect prognosis although the number of patients in this series was small. Sentinel lymph node biopsy should be considered to determine the accurate nodal staging, and patients with MCC of the head and neck may be treated according to the revised staging system by Clark et al.

A Case of Merkel Cell Carcinoma: Treated with Wide Excision and Adjuvant Radiotherapy

Merkel cell carcinoma is a rare aggressive primary cutaneous neuroendocrine skin cancer arising from the basal epidermis. Although the majority of patients with non-melanoma skin cancer are cured by local treatment, patients with Merkel cell carcinoma have a poor outcome characterized by locoregional and distant relapse. No standard treatment protocol for Merkel cell carcinoma exists. But, there is mounting evidence that combined treatment, incorporating adjuvant radiotherapy, improves the outcome (locoregional control and disease-free survival) compared with surgery alone in most patients. Herein we report a case of Merkel cell carcinoma treated with wide local excision and post-operative radiotherapy.

Merkel cell carcinoma arising in the ear canal

A case of rare tumor, Merkel cell carcinoma, located in the ear canal of a 25-year-old woman is presented. A polypoid tumor mass was extirpated, and tympanoplasty was done at the first operation, whereas at the second operation, all the bones of the ear canal were removed. Epitympanum and cavum were filled with tumor, and the tumor mass was removed in toto. The histopathology and immunohistochemical staining characteristics of tumor confirmed the presence of Merkel cell tumor. Postoperatively, radiation therapy to the tumor bed was completed. There was no clinical or radiographic evidence of recurrence or metastasis of Merkel cell tumor for 3 years.

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 of the head and neck: is adjuvant radiotherapy necessary?

BACKGROUND

Controversy exists regarding the optimal management of patients with Merkel cell carcinoma. The primary aim of this study was to determine whether combined treatment with surgery and radiotherapy improves outcome in a multi-institutional cohort of patients with Merkel cell carcinoma of the head and neck. The secondary aims were to determine by stage, which patients derive benefit from combined therapy and to identify predictors for survival on multivariable analysis.

METHODS

A retrospective analysis of 110 patients with Merkel cell carcinoma of the head and neck was performed. Data were collected from 3 tertiary care institutions (Westmead Hospital, Sydney, Australia; Princess Margaret Hospital, Toronto, Canada; Royal Prince Alfred Hospital, Sydney). There were 78 males and 32 females, median age was 70 years, and mean follow-up of survivors was 2.3 years. Sixty-six patients underwent combined treatment, and 44 patients had either surgery or radiotherapy alone. Analysis by stage was performed using 2 staging systems.

RESULTS

Local and regional control at 5 years was 84% and 69%, respectively. Combined treatment improved both local (p = .009) and regional control (p = .006). Overall and disease-specific survival at 5 years was 49% and 62%, respectively. Combined treatment was associated with significantly better disease-free survival on univariable analysis (p = .013) When analyzed by stage, patients with stage IIb (primary >1 cm, node negative) disease who underwent combined treatment had improved disease-free (p = .005) and disease-specific survival (p = .035). Predictors of survival on multivariable analysis were age >70 years (HR 6.19, p < .001), primary tumor size >1 cm (HR 7.55, p < .001), number of nodal metastases divided into none, <or= 2 and >2 (HR 3.71 per stratum, p < .001). When analyzed with age and disease stage, treatment modality trended toward significance as a predictor of disease-specific (p = .081) and overall survival (p = .076). Disease stage was the most powerful independent predictor on Cox regression (HR 5.43 per stratum, p < .001).

CONCLUSIONS

Merkel cell carcinoma is an aggressive cutaneous malignancy. Age and disease stage are the most important predictors of survival. Combined surgery and radiotherapy improves both locoregional control and disease-free survival. Patients with stage II disease appear to derive the greatest benefit from adjuvant radiotherapy, including improved disease specific survival.

Adjuvant Radiation Therapy Is Associated With Improved Survival in Merkel Cell Carcinoma of the Skin

Purpose

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy. Because of the absence of randomized studies, the real benefit of adjuvant radiation therapy in MCC is unclear. The aim of this study was to better define the role of adjuvant radiation therapy in the management of MCC.

Methods

The Surveillance, Epidemiology, and End Results (SEER) survey from the National Cancer Institute was queried from 1973 through 2002. Retrospective analysis was performed. The end point of the study was overall survival.

Results

There were 1,665 cases of MCC in the SEER registry. Presentation by stage were 55% stage I, 31% stage II, and 6% stage III. Eight percent of the cases could not be staged because of incomplete data. Surgical intervention was a component of therapy in 89% of the cases (n = 1,487). The median survival for the entire cohort was 49 months, and median follow-up was 40 months. Adjuvant radiation was a component of therapy in 40% of the surgical cases. The median survival for those patients receiving adjuvant radiation therapy was 63 months compared with 45 months for those treated without adjuvant radiation. The use of radiation was associated with an improved survival for patients with all sizes of tumors, but the improvement with radiation use was particularly prominent when analyzing those patients with primary lesions larger than 2 cm.

Conclusion

The use of adjuvant radiation therapy is associated with improved survival in patients with MCC. Prospective evaluation of adjuvant radiation therapy in this setting is warranted.

Metastatic disease to the parotid gland

OBJECTIVES

The purpose of this study was to review the clinico-pathologic findings and outcome of patients with metastasis to the parotid lymph nodes and gland.

METHODS

Retrospective study. Thirty-four out of 520 patients with a parotid mass treated at our institution met the criteria for this study. Age, gender, clinical findings, histopathology, treatment. and outcome were analyzed.

RESULTS

Twenty-three patients had metastases to parotid lymph nodes from a squamous cell carcinoma of the skin, seven from a cutaneous malignant melanoma after a mean interval of 15 months, two from a ductal breast carcinoma, one with a metastatic disease from a rhabdomyosarcoma of the lower limb, and one from a Merkel cell carcinoma. The 5-year cause-specific and absolute survival for squamous cell carcinoma was 64% and 48% respectively and 71% and 57% for malignant melanomas.

CONCLUSIONS

Metastatic disease to the parotid gland is mostly caused by squamous cell carcinoma. Despite combined treatment modalities long-term survival remains poor.

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.

Primary neuroendocrine carcinoma of inguinal lymph node

Ninety-seven percent of neuroendocrine carcinomas are located in the gastrointestinal tract or in the bronchopulmonary tree. Inguinal lymph nodes as the primary tumor site for neuroendocrine carcinoma represent a very unusual location, and have only been described in 2 patient series in the literature. A 64-year-old, previously healthy, Caucasian female presented with a 2-month history of an enlarged inguinal lymph node on the right side. The removed lymph node showed histological and immunohistochemical characteristics of neuroendocrine differentiation (positive for synaptophysin, cytokeratin 20, neuron-specific enolase and chromogranin A). Although extensive investigations including repeated CT and NMR scans, classical endoscopy, wireless capsule endoscopy of the small intestine, octreotide- and MIBG scintigraphy were performed, no other primary tumor was found. Furthermore, there was no evidence of Merkel cell carcinoma on dermatological examinations. A possible explanation for the presence of neuroendocrine carcinomas within the lymph nodes is malignant transformation of preexisting intranodal epithelial nests, which have previously been described in lymph nodes located close to the salivary glands, thyroid gland, breast tissue and pancreas. Since the surgical removal of the affected lymph node, the patient has now been disease-free for 42 months. We therefore consider our case to represent a primary undifferentiated neuroendocrine carcinoma in an inguinal lymph node.

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.

Successful targeted radiotherapy with 90Y-DOTATOC in a patient with Merkel cell carcinoma. A Case Report

Merkel cell carcinomas (MCC) belong to the family of neuroendocrine tumors. In addition to other markers, they express somatostatin receptors. They are uncommon, highly malignant skin tumors with an aggressive clinical course. They develop in sun-exposed areas of the skin, mostly in elderly patients. In addition to frequent locoregional recurrences, there is a high incidence of distant metastases. Treatment is stage dependent and consists of operation and chemo- and/or radiotherapy, respectively. The advanced age of patients often impedes adequate therapy. (90)Y-DOTATOC is a novel radiolabeled somatostatin analogue containing the active octapeptide of somatostatin. It is very well tolerated and offers the option of treating somatostatin receptor-positive tumors by targeted radiotherapy. We report the case of an 83-year-old woman with recurrent MCC of the left cheek. The primary tumor and several relapses were treated with surgery and locoregional radiotherapy. After the 3rd relapse, she was treated 4 times with (90)Y-DOTATOC and two complete remissions were achieved. The fourth administration after the 2nd relapse was ineffective and conventional chemotherapy was started. There were no side effects of the (90)Y-DOTATOC. We conclude that due to its good tolerability, (90)Y-DOTATOC therapy should be evaluated further as a new therapy for somatostatin receptor-positive MCC.

[Merkel cell carcinoma]

Merkel cell carcinoma is a neuroendocrine tumor of the skin, originating from neuroendocrine cells. A case report of Merkel cell carcinoma, discovered in a 77-Year-old woman, was diagnosed and confirmed on a biopsy. Diagnostic and therapeutic orientations of this unusual but malignant tumor are described.

Merkel cell carcinoma

Merkel cell carcinoma is a rare cutaneous neoplasm most commonly affecting the head and neck of elderly white patients. Even with treatment, Merkel cell carcinoma has a strong propensity toward local recurrence, lymphatic spread, and distant metastasis. Because of its rarity and the subsequent lack of well-controlled clinical trials, no single standard of care exists for the treatment of this aggressive tumor. In our institution, primary lesions are excised with wide margins or by Mohs' micrographic surgery. After local removal, the excision site is treated locally with external radiation therapy. Sentinel lymph node mapping and biopsy are performed. Patients with tumor within a sentinel lymph node undergo lymph node dissection and radiation to the lymphatic basin. Adjuvant chemotherapy is offered to high-risk patients with local disease and to patients with metastases. Patients with distant metastases are treated with a combination of salvage chemotherapy and radiation therapy.

Primary and metastatic cancer of the parotid: comparison of clinical behavior in 232 cases

OBJECTIVES/HYPOTHESIS

Parotid malignancy may develop as a primary cancer of salivary tissue or by metastatic involvement of parotid lymph nodes. The aim of the study was to compare the clinical behavior of primary and metastatic parotid cancers by analyzing patterns of treatment failure and clinical outcomes.

STUDY DESIGN

Retrospective review of clinical and pathologic data prospectively accessioned onto a computerized database.

METHODS

A prospectively documented series of 232 parotidectomies carried out for treatment of cancer from 1988 to 1999 was reviewed. There were 177 male and 55 female patients with a median age of 65 years (age range, 17-97 y). Median follow-up time was 4 years. Pathological groups included 54 patients with primary parotid cancer, 101 with metastatic cutaneous squamous cell carcinoma, 69 with metastatic melanoma, and 8 with other metastatic cancers.

RESULTS

Neck nodes were clinically positive in 12 patients with primary cancer, 24 patients with squamous cell carcinoma, 16 with melanoma, and 2 with other metastatic malignancies. Conservative parotidectomy, preserving the main trunk of the facial nerve, was performed in 185 patients, and 47 patients had a radical parotidectomy sacrificing the facial nerve. There were 54 therapeutic and 110 elective neck dissections. Adjuvant radiotherapy was given to 39 patients with primary cancer, 86 with squamous cell carcinoma, 50 with melanoma, and 8 in the other metastatic group (78% of the patients in the series). Local control rates at 5 years in the four groups were 86%, 75%, 94%, and 100%, respectively (P <.01). Survival rates at 5 years were 77%, 65%, 46%, and 56%, respectively (P <.01).

CONCLUSIONS

The pattern of parotid malignancy is unique in Australia because of the high incidence of skin cancer, which can metastasize to the parotid gland. Metastatic cutaneous malignancy predominates. The pattern of failure and outcome varied depending on histological findings. Local failure occurred most often in metastatic squamous cell carcinoma, whereas patients with melanoma had the highest incidence of distant spread.

Merkel cell carcinoma: a clinical, histopathologic, and immunohistochemical review

Merkel cell carcinoma is a rare aggressive neoplasm, with about 400 cases diagnosed in the United States each year. Among the cutaneous-derived neoplasms, it is the most deadliest, with a higher mortality rate than melanoma. Although the classic clinical presentation as a rapidly growing papule in a sun-exposed site of an elderly patient is not specific, certain histopathologic and ancillary pathologic features allow for its discrimination in most cases. Herein, we review the etiology, pathogenesis, clinical, and pathologic attributes as well as the staging treatment and prognosis of this important public health menace.

Merkel cell carcinoma--a retrospective analysis of 17 cases

OBJECTIVE

To report clinical experience with the rare neuroendocrine Merkel cell carcinoma of the skin.

SUBJECTS AND SETTING

Seventeen patients with Merkel cell carcinoma of the skin treated at the Departments of Dermatology and ENT, Krankenhaus Dresden-Friedrichstadt, Dresden, Germany, during the years 1984-2000 were evaluated.

METHODS

A retrospective analysis was performed. Age and sex distribution, clinical data and therapy were collected. Outcome measures including overall survival, tumour-free survival and relapse-free survival were determined.

RESULTS

Six male and 11 female patients with an age range of 68-90 years (mean age 73.3 years) were identified. The primary tumour localization was head and neck region (n = 8), upper limbs (8), lower limbs (1). Twelve patients presented in tumour stage I, three in stage II and one in stage III. First line therapy was complete surgical excision with wide margins in 16 patients followed by loco-regional radiation in 12 of 16 cases. In 16 patients follow up data were available. After primary treatment complete response was achieved in 14 of 16 patients (87.5%), two patients had a partial response. The median of relapse-free survival was 44 weeks [mean +/- standard deviation: (44 +/- 118) weeks]. The median of overall survival was 102 weeks [mean +/- standard deviation: (137 +/- 94) weeks]. Three patients with a PR after primary treatment had a median overall survival of only 48 weeks [mean +/- standard deviation: (51 +/- 20) weeks].

CONCLUSIONS

Primary surgical treatment with wide excision combined with radiotherapy seems to be a reasonable first-line treatment but prospective controlled multicentre trials are necessary for validation.

Mohs micrographic surgery of a papillary eccrine adenoma

BACKGROUND

Papillary eccrine adenoma (PEA) is a rare benign sweat gland neoplasm first described by Rulon and Helwig in 1977. Although these lesions typically behave in a benign fashion, PEA's on the volar surfaces may demonstrate more aggressive biologic behavior. Additionally, aggressive digital papillary adenomas (ADPA) may histologically simulate PEAs and behave in a more malignant fashion.

OBJECTIVE

To present a case report of a patient with an incompletely excised PEA that was successfully extirpated using Mohs micrographic surgery (MMS).

METHODS

A 51-year-old black woman was evaluated for the treatment of an incompletely excised PEA located on the dorsum of her left hand at the base of the thumb. Mohs micrographic surgery was felt to be the ideal treatment choice because of incomplete prior resections, ill-defined clinical borders, the need for conservative surgical excision to preserve sensory and motor function of the left hand, and the previously reported more aggressive nature of this tumor when located on volar surfaces. The patient underwent a two-stage, six section micrographically controlled excision using the fresh tissue technique.

RESULTS

Complete resection of the PEA without significant damage to neurovascular structures.

CONCLUSION

This case demonstrates the increasingly important role MMS is playing in the surgical management of a wide variety of cutaneous tumors. To our knowledge, this is the first time MMS has been used in the resection of a PEA.

Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management

In the United States more than 100,000 people are living with solid organ transplants. The intense immunosuppressive regimens necessary for prolonged survival of allografts significantly increase the rates of both internal and cutaneous malignancies in recipients of solid organ transplants. Skin cancer is the most common cancer in patients after transplantation. Because of the early onset and high tumor burden in transplant recipients, dermatologists have significant challenges in managing the treatment of these patients. This article describes the epidemiology and clinical presentation of skin cancer during posttransplantation immunosuppression, discusses pathogenic cofactors, and reviews the optimal management for mild and severe skin cancer in transplant recipients.