Merkel cell carcinoma with bone metastasis: a case report

 A case of Merkel cell carcinoma with bone metastasis is described. The patient, who had a history of Merkel cell carcinoma of the skin in the right cheek, had spontaneous pain in the right thigh. At the initial visit, the right hip range of motion was slightly limited, but there was no gait disturbance or abnormality in the radiographs of the right hip. However, the pain gradually increased and caused gait disturbance. The patient underwent surgical treatment. A bipolar type of femoral prosthesis was implanted into the femur, and sampling of cancellous bone was performed at the time of osteotomy. Pathological examination showed the findings of Merkel cell carcinoma. Merkel cell carcinoma is a rare malignant tumor of the skin, which usually occurs on the head, neck, or extremities and metastasizes to the lymph nodes. Although osseous involvement often occurs in the adjacent facial bones through direct invasion, distant osseous metastasis appears to be extremely rare. Received: November 12, 2001 / Accepted: April 18, 2002     

Appendicular Schwannoma Presenting as Acute Appendicitis

Merkel cell carcinoma is an uncommon, aggressive neuroendocrine tumour of the skin. At presentation regional lymph nodes are involved in approximately one third of the patients. In this report a patient is presented in whom merkel cell carcinoma presented as a solitary lymph node metastasis with an unknown primary skin lesion. The diagnosis of unknown primary merkel cell carcinoma including the use of immunohistochemical markers and treatment options based on data from the literature are discussed.     

Merkel Cell Carcinoma of the Foot: Case Report and Review of the Literature

Merkel cell carcinomas are rare neuroendocrine tumors of the skin with highly malignant behavior. These tumors arise from Merkel cells, which are slowly adapting type 1 mechanoreceptors that occur in hair follicles and the basal layer of the epidermis. Merkel cell carcinomas are typically located in the dermis and frequently extend into the subcutaneous fat and lymphatics. This case report describes the magnetic resonance imaging and pathologic findings, surgical treatment, and postoperative results with review of the literature for Merkel cell carcinoma involving the foot of a 72-year-old man with a 2-month history of a painless, enlarging mass that interfered with his ability to wear a shoe.     

Intraoperative lymphatic mapping and sentinel lymph node biopsy for Merkel cell carcinoma

BACKGROUND: Merkel cell carcinoma is a rare cutaneous neoplasm which commonly spreads to the regional lymph nodes. The feasibility of identifying the sentinel node in patients with clinically node-negative Merkel cell carcinoma was evaluated. METHODS: Sentinel lymphatic mapping was performed in 18 patients with stage 1 Merkel cell carcinoma using the combination of isosulphan blue dye and 99mTc-radiolabelled sulphur colloid. Patients with tumour metastasis in the sentinel node underwent complete dissection of the remainder of the lymph node basin. RESULTS: Eighteen patients underwent removal of 35 sentinel nodes. Two patients demonstrated metastatic disease in the sentinel lymph nodes; complete dissection of the involved nodal basin revealed no additional positive nodes suggesting that the sentinel lymph node had been identified. The node-negative patients received no further surgical therapy, with no evidence of recurrent disease in the sentinel nodal basin at a median of 7 months' follow-up. CONCLUSION: Sentinel node biopsy is feasible in patients with Merkel cell carcinoma. It can be used to stage patients and provides important prognostic information. In those with subclinical nodal disease, it may direct early regional lymphadenectomy but the effect of such surgery on survival remains unclear.     

Lymph node metastasis within the pectoralis major muscle in breast cancer--a case report

We report herein, a case of a 75 year old woman with breast cancer in whom lymph node metastasis within the pectoralis major muscle was found. The breast mass measured 10 X 6 cm, and its overlying skin was red and edematous, suggesting inflammatory carcinoma. An extended radical mastectomy was performed and the lesion was histologically confirmed to be solid-tubular carcinoma with regional lymph node involvement. In the pectoralis major muscle, where lymph nodes do not usually exist, one positive metastatic lymph node and another metastatic lymph node-like nodule were histopathologically confirmed. To our knowledge, no other such case has ever been reported, yet the possibility of lymph nodes existing in the pectoralis major muscle, albeit rare, should nevertheless be considered in the treatment of breast cancer.     

Lymph node metastasis within the pectoralis major muscle in breast cancer—A case report—

We report herein, a case of a 75 year old woman with breast cancer in whom lymph node metastasis within the pectoralis major muscle was found. The breast mass measured 10×6 cm, and its overlying skin was red and edematous, suggesting inflammatory carcinoma. An extended radical mastectomy was performed and the lesion was histologically confirmed to be solid-tubular carcinoma with regional lymph node involvement. In the pectoralis major muscle, where lymph nodes do not usually exist, one positive metastatic lymph node and another metastatic lymph node-like nodule were histopathologically confirmed. To our knowledge, no other such case has ever been reported, yet the possibility of lymph nodes existing in the pectoralis major muscle, albeit rare, should nevertheless be considered in the treatment of breast cancer.     

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.     

A Meta-analysis of the Prognostic Significance of Sentinel Lymph Node Status in Merkel Cell Carcinoma

BACKGROUND: Merkel cell carcinoma is an aggressive cutaneous neoplasm with a high propensity to metastasize to lymph nodes. OBJECTIVE: The objective of this study was to determine the prognostic significance of sentinel lymph node status in patients with Merkel cell carcinoma. METHODS: A meta-analysis of case series of patients with Merkel cell carcinoma managed with sentinel lymph node biopsy was performed. RESULTS: Forty of 60 patients (67%) had a biopsy-negative sentinel lymph node; 97% of this group had no recurrence at 7.3 months median follow-up. Twenty patients (33%) had a biopsy-positive sentinel lymph node; 33% of this group experienced local, regional, or systemic recurrence at 12 months median follow-up. Risk of recurrence or metastasis was 19-fold greater in biopsy-positive patients (odds ratio, 18.9; p = 0.005). None of 15 biopsy-positive patients who underwent therapeutic lymph node dissection experienced a regional recurrence; 3 of 4 who did not receive therapeutic lymphadenectomy experienced regional recurrence. CONCLUSION: Sentinel lymph node positivity is strongly predictive of a high short-term risk of recurrence or metastasis in patients with Merkel cell carcinoma. Therapeutic lymph node dissection appears effective in preventing short-term regional nodal recurrence. Aggressive adjuvant treatment should be considered for patients with positive sentinel lymph nodes.     

Basal Cell Carcinoma Metastatic to Parotid Gland

Metastasis from basal cell carcinoma of the skin is very rare with cases being documented in the lymph nodes, lung, bone and parotid gland. The main histopathological differential diagnosis is the locally arising basal cell adenocarcinoma from which it is difficult to distinguish by morphology and routine immunohistochemistry. Approximately 85 % of all reported metastatic basal cell carcinomas arise in the head and neck region. Here we present a case of basal cell carcinoma of the skin of the left lateral canthus of the eye which metastasized to the intraparotid lymph nodes with infiltration of the adjacent parotid parenchyma. More awareness and vigilance is required on the part of the reporting pathologist to consider metastasis in the presence of a parotid tumour. Features favouring metastasis include history of primary cutaneous basal cell carcinoma, histological similarity to the primary lesion and absence of any demonstrable direct extension from the skin lesion. We also review the literature on metastatic basal cell carcinoma and discuss the need for adequate follow up in high risk patients.     

Merkel cell carcinoma of the skin. 2 clinical cases

Merkel cell carcinoma of the skin is a tumor generally found in elderly people. This neoplasm involves primarily the dermis; it is locally aggressive often metastatizing to the lymph nodes and, sometimes, diffusely in the body. It must be considered in the diagnostic approach of the cutaneous neoplastic nodules. The clinical, histologic and ultrastructural features of two cases are presented and compared with previously reported examples.     

Merkel's tumor. Some comments and the authors' personal cases]

The clinical features of 7 cases of primary neuroendocrine carcinoma of the skin (Merkel cell tumor) are reported. This cancer arises in the dermis and subcutaneous tissues of elderly individuals. Natural history is characterized by local recurrences (30%), regional lymph node metastases (65%) and distant metastases (40%). Surgery is the elective treatment, chemotherapy and radiotherapy resulted in only short-term palliative response.     

Bronchial carcinoma and the lymphatic sump: the importance of bronchoscopic findings

The lymphatic sump of Borrie is an important area of regional node metastasis in each lung. The sump area is of increased importance on the right side, since bilobectomy has been recommended to ensure complete removal of lymphatic disease in patients with lower or middle lobe carcinoma. The role of bronchoscopy in assessing lymphatic metastasis of bronchial carcinoma was investigated in 42 patients at the North Carolina Memorial Hospital. Because of the high incidence of associated lymphatic metastases, bilobectomy is indicated for right lower or middle lobe lesions observed at bronchoscopy. Simple lobectomy may be utilized when bronchoscopic findings are negative and when there is no involvement of the lymph nodes of the sump of Borrie at the time of operation. If there is gross nodal involvement of the lymphatic sump, pneumonectomy will be required.     

Ex vivo comparison of radiological and histological evaluation of early metastatic lesions of pelvic lymph nodes from carcinoma of the bladder or prostate

To study the limitations of lymphangiography in the detection of early lymphatic spread of pelvic malignancies, we evaluated 587 lymph nodes from 23 patients with stages pN0 to 2 carcinoma of the bladder or prostate. Pelvic lymphadenectomy was performed 5 to 10 days after bipedal lymphangiography. Excised lymph nodes were separated one by one and an x-ray of each node was taken (lymphnodegram). The individual lymphnodegram was compared to the histological findings. Interpretations of lymphnodegrams from all 17 nodes with metastases were positive in 5, suspicious in 1, negative in 9 and radiolucent in 2. False negative judgments occurred chiefly because metastatic foci were microscopic. Two lymph nodes without metastasis were interpreted as positive for disease because of fat replacement of the nodes. These results indicated that lymphangiography is not suitable for the detection of early lymphatic metastases of carcinoma of the bladder or prostate.     

Adenocarcinoma occurring from a sigmoid colostomy 20 years after Hartmann's procedure for rectal cancer: A case report

IntroductionCancer arising from the stoma is relatively rare. There is no established surgical procedure for stomal cancer. Furthermore, when a subcutaneous lymphovascular invasion occurs, there is no consensus on whether lymph node dissection along the lymph flow is required. We diagnosed colorectal cancer 20 years after radical resection of rectal cancer.Presentation of caseWe encountered a 70-year-old man who had undergone Hartmann's procedure for rectal cancer 20 years before consultation. Colonoscopy revealed a 30-mm-sized sub-pedunculated polyp with a base at the stoma, and a well-differentiated adenocarcinoma was detected. Approximately 30 mm of the intestinal tract, including the stoma and skin in contact with the tumor, was resected. Pathological examination revealed submucosal invasive cancer with infiltration into the resected skin dermis and invasion of lymphatic vessels under the mucosa. Surgical margins were negative.DiscussionIt is thought that several causes overlap for stomal cancer, although a clear cause of occurrence is yet to be identified. However, as no established surgical procedure exists, the necessity for resection of the lymph nodes without exposure appears indisputable. Although it was reported that skin or subcutaneous metastasis in colorectal cancer is generally regarded as a symptom of systemic metastasis, opinions on the subcutaneous dissection margin of stomal cancer are rarely discussed.ConclusionStomal cancer can be observed macroscopically without colonoscopy. Patients and staff engaged in stoma care should be fully aware that continuous observation of the stoma is necessary even after rectal cancer surveillance is complete.     

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater

BACKGROUND/PURPOSE: Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted. METHODS: From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated. RESULTS: The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively). CONCLUSIONS: Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.     

Results of radical treatment of stage IIIa non-small-cell carcinoma of the lung

From 1979 to 1987, 907 patients with non-oat cell carcinoma of the lung were subjected to thoracotomy: of these, 685 (75.5%) underwent radical resection of the lung tumour. The 230 stage IIIa patients were studied in this paper. These were divided into three groups. First group: 93 patients with only local parietal or mediastinal spread without involvement of the mediastinal lymph nodes (T3N0-1M0); the 5-year survival of this group was 35% (44.1% when the ribs and muscles were not affected). A second group of 118 patients had tumour spreading to the mediastinal lymph nodes, but without local involvement (T1-2N2M0): this group had a 5-year survival of 22.3%. The 5-year survival was better in patients without metastases in the subcarinal lymph nodes than in patients with them (23.76% versus 12.89%). Skipping of lymphatic levels was frequent: 37% of patients with metastasis to mediastinal lymph nodes did not have metastases in the lymph nodes of the lung; 10% of tumours removed by lobectomy had metastases in the lymph nodes of the residual lobe. The third group with parietal and lymphatic mediastinal invasion (T3N2M0) had a poor survival (13.5% at 5 years). The author concludes that it is possible to achieve an acceptable 5-year survival in selected cases with metastasis to mediastinal lymph nodes: when the CT scan demonstrated mediastinal lymph nodes larger than 1.5 cm, mediastinoscopy was carried out and, if positive, the patient was judged inoperable.     

Predictive pathological factors of lymph nodes involvement in the squamous cell carcinoma of the penis

Objectives:To evaluate the predictive role ofprimary tumor histopathological features inpredicting inguinal lymph nodes involvement inpatients with penile squamous cell carcinoma.Material and methods:We retrospectivelyanalysed pathological records from 30consecutive patients who underwent penectomyfor invasive squamous cell carcinoma of thepenis. All histological specimens were reviewedby the same pathologist. We considered thefollowing histological parameters: histologicalgrading, growth pattern, deph invasion, tumourthickness, nuclear grading, poorlydifferentiated cancer rate, vascular andlymphatic embolization, eosinophilic andmononuclear infiltration and pathologicalstage.Results:Lymph nodes involvement occurred in 5patients who underwent `early' lymphadenectomyand in other 4 ones during oncologicalsurveillance. Lymph nodes metastasis resultedsignificantly correlated with histologicalgrading (p = 0.005), lymphatic (p = 0.005) andvenous (p = 0.02) embolization, corporacavernosa (p = 0.03) and urethra (p = 0.03)infiltration. Histological grading andlymphatic embolization were independentpredictive variables of lymph nodes involvement(p = 0.02).Conclusions:The histological grading andlymphatic embolization have to be considered asimportant parameters to select patients withpenile squamous cell carcinoma to undergo an`early' lymphadenectomy.     

The risk factors for the presence of pelvic lymph node metastasis in penile squamous cell carcinoma patients with inguinal lymph node dissection

Objective

To evaluate factors in penile squamous cell carcinoma predictive of pelvic lymph node metastasis and survival.

Materials and methods

Data were collected and analyzed retrospectively in 146 patients with squamous cell carcinoma of penis who underwent bilateral inguinal lymph node dissection in our center between January 1998 and April 2011. Variables recorded included serum squamous cell carcinoma antigen, primary tumor p53 immunoreactivity, histological grade, pathological tumor stage, lymphatic or vascular invasion, absent/unilateral or bilateral inguinal lymph node involvement, number of metastatic inguinal lymph nodes, presence of extracapsular growth and lymph node density.

Results

Seventy patients had inguinal lymph node metastasis (LNM). Of these, 33 (47.1 %) had pelvic LNM. Primary tumor strong p53 expression, lymphatic or vascular invasion, involvement of more than two inguinal lymph nodes and 30 % or greater lymph node density were significant predictors of pelvic LNM. Primary tumor strong p53 expression (odds ratio [OR] 5.997, 95 % confidence intervals [CI] 1.615–22.275), presence of extracapsular growth (OR 2.209, 95 % CI 1.166–4.184), involvement of more than two inguinal lymph nodes (OR 2.494, 95 % CI 1.086–5.728) and pelvic lymph node involvement (OR 18.206, 95 % CI 6.807–48.696) were independent prognostic factors for overall survival.

Conclusions

Primary tumor expression of p53, lymphatic or vascular invasion, number of metastatic inguinal lymph nodes and lymph node density were all predictors of pathologic pelvic lymph node involvement. Patients with pelvic LNM had an adverse prognosis, with a 3-year overall survival rate of approximately 12.1 %. Pelvic lymph node dissection should be considered in these cases.     

Scrofuloderma of the lower extremity treated with wide resection: a case report and review of the literature.

Scrofuloderma is tuberculosis of subcutaneous tissue that ulcerates and drains through the overlying skin. It most commonly occurs in the neck from a cervical lymph node source. Although such lymphatic spread is the usual clinical picture, there are sporadic reports in the literature of direct hematogenous seeding of subcutaneous tissue forming a tuberculoma, or "cold abscess." Definitive diagnosis requires the identification of Mycobacterium tuberculosis within the suspect lesion. Surgical intervention is necessary in any draining lesion and should be accompanied by appropriate antituberculous chemotherapy. Accounts of bone and joint involvement are numerous, but the orthopedic surgeon must also be aware of the soft-tissue manifestations of tuberculosis and the indications for surgery. We report on an immunocompromised patient who presented with a rare case of scrofuloderma of the lower extremity, which was treated with wide resection.     

Lymphoscintigraphy with sentinel lymph node biopsy in cutaneous Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy characterized by an aggressive clinical behavior with high rates of locoregional and systemic recurrence. Regional disease and distant metastases are associated with poor prognosis. Despite a predisposition of MCC to spread via the lymphatics, prophylactic lymph node dissection in the absence of clinically apparent lymph node involvement is controversial. The value of lymphoscintigraphy in cutaneous melanoma is established in lesions with ambiguous lymphatic drainage patterns. When used with sentinel lymph node biopsy (SLNB), it can identify subjects with occult regional node metastasis. The authors present 2 patients with MCC who underwent regional node staging with lymphoscintigraphy-directed SLNB. Both patients had sentinel nodes that were positive for metastatic disease. In patients with MCC, minimally invasive regional node staging SLNB may be useful in limiting the sequelae of routine lymphadenectomies. Whether early identification and treatment of patients with occult regional node disease can influence survival in MCC is not known.