Clinical Case 010

A middle aged drover from central NSW is referred to the Oncology Department by the GP. He recently attended an educational session on skin cancer and remembers that surgery for BCC can be disfiguring around the eyes. He wonders if radiotherapy might be the best way to manage this lesion.

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how would you manage this man?

I would ask for a biopsy of the lesion as it does not look like a BCC, but rather a Merkel Cell Carcinoma

what outcome are you expecting?

I am expecting that the histopathology report will describe blue (rather than purple) neuroendocrine-like cells, without palisading and without keratin formation

discuss the appropriateness of surgery for this lesion

After an excisional biopsy, no further surgery is required. The frequency of local recurrence after complete excision is high (>70%) due to common satellite lesions, while it is substantially less after high dose radiotherapy (<20%)

discuss the appropriateness of radiotherapy for this lesion

Radiotherapy is the mainstay for this condition and should cover the primary site with a very large margin, as well as covering all the draining neck nodes. Nodal recurrence has a very poor prognosis, similar to a metastatic recurrence. In maximally treated patients (TROG trial), the 3-year OS, local-regional control, and distant control are nearly identical. Marginal failures are the rule when small fields are used. The primary dose should be 60Gy/30Fx and the uninvolved nodes should receive 50Gy/25Gy. Radiotherapy for this lesion will be problematic because of its position and the risk to the upper eyelid.

discuss the appropriateness of chemotherapy for this lesion

There is no data to support the use of chemotherapy outside of the palliative management of metastatic disease. It is tolerated, but not of any demonstrable benefit.

Discuss the aetiology of this condition

In 2008, a novel polyomavirus (Merkel cell polyoma virus, MCPyV) was first reported in MCC tumor specimens, a finding subsequently confirmed in other laboratories. High levels of viral DNA and clonal integration of the virus in MCC tumors have also been reported along with expression of certain viral antigens in MCC cells and the presence of antiviral antibodies. Not all cases of MCC appear to be associated with Merkel cell polyomavirus infection.

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Attribution

Bachmann et al. World Journal of Surgical Oncology 2005 3:58 doi:10.1186/1477-7819-3-58