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Case History

image A 78-year-old woman presents with a 6-month history of a red nodule on her forearm which has enlarged to >2 cm in diameter. Excision biopsy reveals Merkel's cell tumour with image2 mm excision margins.

How should this patient be further assessed?

How should the primary site be managed?

What adjuvant treatment should be considered?

What is the prognosis?

How should recurrent disease be managed?


How should this patient be further assessed?

image The patient needs to be further assessed to determine the extent of the disease. There is no widely accepted staging system for Merkel's cell carcinoma or a standardized classification based on prognosis. Either the American Joint Committee on Cancer1 staging system for cancer or the TNM staging (see Table 46.1) can be used for staging purposes. However, it is commonly staged according to clinical presentation as follows:2

  • Stage IA: Primary tumour image2 cm with no evidence of spread to lymph nodes or distant sites.

  • Stage IB: Primary tumour ≥2 cm with no evidence of spread to lymph nodes or distant sites.

  • Stage II: Regional node involvement but no evidence of distant metastases.

  • Stage III: Presence of systemic metastases beyond the regional lymph nodes.

Table 46.1TNM staging for Merkel's cell carcinoma

Further assessment includes investigations to determine whether there is lymph node involvement. Identification of disease in the sentinel lymph node basin will provide information about prognosis and also identifies the draining lymph node bed for surgery and any adjuvant radiotherapy.

The sentinel lymph node is the hypothetical first lymph node reached by micro metastasizing cancer cells from a primary tumour. Sentinel lymph node biopsy is carried out by injecting blue dye and a harmless radioactive substance around the primary tumour several hours prior to the biopsy. During the biopsy, the surgeon inspects the lymph nodes for staining and uses a Geiger counter (which detects α and β radiation) to assess which lymph nodes have taken up the radioactive substance. The node(s) which take up the dye are designated the sentinel lymph node(s) and the surgeon can then remove these for histopathological examination. Often a frozen section will be carried out to detect neoplasia, and if positive further lymph node dissection may be done. The advantage of sentinel lymph node biopsy is that it can avoid the need for large lymph node dissections, thus reducing the risk of ...

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