Radiation sensitivity of merkel cell carcinoma cell lines

: Merkel cell carcinoma (MCC), being a small cell carcinoma, would be expected to be sensitive to radiation. Clinical analysis of patients at our center, especially those with macroscopic disease, would suggest the response is quite variable. We have recently established a number of MCC cell lines from patients prior to radiotherapy, and for the first time are in a position to determine their sensitivity under controlled conditions.     

Cisplatin-based chemotherapy for merkel cell carcinoma of the skin

PURPOSE: Merkel cell carcinoma (MCC), a rare tumor of the skin with aggressive behavior, is usually fatal when advanced disease is present. The role of chemotherapy (CT) in the treatment of patients with MCC is unclear. METHODS: Over 15 years, 9 patients with locally advanced or metastatic disease were treated with carboplatin (CBDCA) (300 mg/m(2) of AUC 5 on Day 1) and etoposide (VP-16) (100 mg/m(2) on Days 1-3) every 3 weeks. As second-line CT, cisplatin (CDDP) (60-100 mg/m(2)), ifosfamide (IFO) (3-5 g/m(2)) and epirubicin (EPI) (30-50 mg/m(2)) were utilized. RESULTS: Of the 3 patients who received adjuvant therapy, one achieved complete response after 108+ months with second-line chemotherapy and radiotherapy, despite a brief relapse; 2 patients remain disease-free after 84+ and 108+ months. Of the 6 patients with locally advanced or metastatic disease who were treated with first-line chemotherapy, one (16.6 percent) achieved a complete response and 3 (50 percent) achieved partial response, for an overall response rate of 66.6 percent. Two patients (one with complete and one with partial response) received subsequent radiotherapy, following which complete response was achieved. Of the 2 complete responders, one patient remains disease-free after 56+ months. The median overall survival from the time of initial diagnosis for the whole group was 56 months (range 15-114 months); the median overall survival from the initiation of chemotherapy was 18 months (range 6-108+). Local recurrences and soft tissue metastases responded better than visceral metastases. Patients with partial response and no response had rapid disease progression and fatality, despite second-line chemotherapy and/or radiotherapy. CONCLUSION: MCC appears to be chemosensitive but can progress rapidly with fatal outcomes. Although the rarity of these tumors precludes randomized trials, a common treatment plan should be utilized by those treating MCC. This may allow some conclusions regarding the optimum treatment of patients with MCC to be drawn in the future.     

Characterisation of four merkel cell carcinoma adherent cell lines

We have previously described the establishment of a number of cell lines from Merkel cell carcinoma (MCC), also known as small cell cancer of the skin or neuroendocrine carcinoma of the skin. These cells, all of which grew as suspension cultures, were found to resemble small cell lung cancer (SCLC) lines types 1, 2 and 3 by their morphology and growth characteristics. We now report 4 more MCC cell lines which resemble the SCLC type 4 cell lines in that they grow as adherent monolayers. These MCC lines would belong to the variant subgroup as they no longer express most neuroendocrine markers, grow at low cell density and have population doubling times of 1–5 days in contrast to the MCC suspension lines which have doubling times of 6–12 days. MCC 14/1 and MCC 14/2 were established from the same metastatic node and would appear to represent 2 clones of the tumour which differ in morphology, histochemical markers and DNA content. We present details of the morphology, DNA content and immunohistochemistry of these 4 lines and com-pare their growth patterns with those of SCLC and MCC lines which grow in suspension. © 1995 Wiley-Liss, Inc.     

Antibodies to merkel cell polyomavirus T antigen oncoproteins reflect tumor burden in merkel cell carcinoma patients

Merkel cell polyomavirus (MCPyV) is a common infectious agent that is likely involved in the etiology of most Merkel cell carcinomas (MCC). Serum antibodies recognizing the MCPyV capsid protein VP1 are detectable at high titer in nearly all MCC patients and remain stable over time. Although antibodies to the viral capsid indicate prior MCPyV infection, they provide limited clinical insight into MCC because they are also detected in more than half of the general population. We investigated whether antibodies recognizing MCPyV large and small tumor-associated antigens (T-Ag) would be more specifically associated with MCC. Among 530 population control subjects, these antibodies were present in only 0.9% and were of low titer. In contrast, among 205 MCC cases, 40.5% had serum IgG antibodies that recognize a portion of T-Ag shared between small and large T-Ags. Among cases, titers of T-Ag antibodies fell rapidly (～8-fold per year) in patients whose cancer did not recur, whereas they rose rapidly in those with progressive disease. Importantly, in several patients who developed metastases, the rise in T-Ag titer preceded clinical detection of disease spread. These results suggest that antibodies recognizing T-Ag are relatively specifically associated with MCC, do not effectively protect against disease progression, and may serve as a clinically useful indicator of disease status.     

Frequent occurrence of RASSF1A promoter hypermethylation and merkel cell polyomavirus in merkel cell carcinoma

Merkel cell carcinoma (MCC) is one of the most aggressive cancers of the skin. It has recently been reported that integration of a Merkel cell polyomavirus (MCPyV) in receptor tyrosine phosphates type G (PTPRG) gene occurs in MCC, and that viral infections are associated with epigenetic silencing of tumor suppressor genes (TSG) in cancer. To examine whether a correlation between TSG inactivation and viral infection can be found in MCC, we investigated the promoter hypermethylation of RASSF1A, TP73, PTPRG, FHIT, and CDKN2A and the presence of MCPyV and SV40 in 98 MCC by PCR. Hypermethylation of RASSF1A was frequently found in 42 of 83 (51%) of MCC. Methylation of CDKN2A was present in 9 of 41 (22%) of MCC. Hypermethylation of TP73 (0%), PTPRG (4%), and FHIT (0%) was infrequent in MCC. Interestingly, MCPyV was found in 90 of 98 (92%) MCC, however, no SV40 signal was detected. No correlation between TSG hypermethylation and viral infection was found. Our results show frequent hypermethylation of RASSF1A and the presence of MCPyV in primary MCC, and that these events may contribute to the pathogenesis of MCC. © 2009 Wiley‐Liss, Inc.     

Sentinel lymph-node biopsy compared to axillary lymph-node dissection for axillary staging in breast cancer patients.

AIMS: The purpose of this study was to evaluate the feasibility of sentinel lymph-node biopsy in breast cancer patients at our institution and to compare the results of sentinel node (SN) biopsy to standard axillary lymph-node dissection (ALND). METHODS: In a retrospective study the percentage of lymph-node positive patients and the number of micrometastases in 165 breast cancer patients following SN biopsy was compared to 195 patients who underwent ALND of level I and II without SN biopsy. The SN was identified using a combination of vital blue dye and a radiolabelled colloid. RESULTS: Patients and tumour characteristics were comparable between both groups. SN biopsy found no significant difference in the number of node positive T1 cancer patients (SN group: 31/108 (28.7%) -- ALND group: 21/92 (22.8%)) and T2 tumours (SN group: 27/57 (47.4%) -- ALND group: 49/103 (47.6%)) between both groups. Micrometastases were more frequently found in the SN group when compared to the ALND group (six of 70 positive nodes) (P=0.04). CONCLUSION: SN biopsy may be as accurate as standard axillary lymph-node dissection for the evaluation of the axillary lymph-node status in breast cancer patients. Copyright Harcourt Publishers Limited.     

Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients.

AIM: The aim was to identify a subset of breast cancer patient with positive sentinel nodes (SNs) for whom secondary axillary clearance would be unnecessary.METHODS: Between March 1999 and May 2001, 288 patients with T0-T2 breast cancer less than 3cm in diameter had SN detection either by a colorimetric method or using a combined technique. SNs were stained with haematoxylin and eosin (H&E). For all negative SNs, serial sections and immunochemistry (IHC) were performed. All patients with positive SNs underwent a complete axillary lymph node dissection. One hundred and twenty patients were SN positve.RESULTS: Non-sentinel node positivity (NSNP) was closely associated with the size of the tumour (14.3%, 54.1% and 51.8% for pT1a-b, pT1c and pT2 tumours respectively) and with the size of the SN metastasis: 15.9% IHC detected micrometastasis, 33.3% and 78.8% micro- and macrometastasis detected with H&E staining respectively. NSNP was found in 24.0% and 42.8% of patients with pT1c breast cancer and with micrometastasis detected by IHC and H&E staining. The node positivity rate reached 81.1% for pT1c lesions with macrometastasis in the SN. For the patients with pT2 breast cancer, these rates were 12.5% (IHC), 28.5% (H&E) 91.1% (macrometastasis).CONCLUSIONS: We are unable to isolate precisely a subset of patients for whom total axillary lymph node dissection would be unnecessary. A subset of 14 small tumours (<1cm diameter) demonstrated micrometastases in the SN without NSNP.     

Sentinel-node biopsy in axillary lymph-node staging under local anaesthesia in breast cancer: technical aspect

OBJECTIVE: To perform sentinel node with local anaesthesia in the breast carcinoma without frozen section. So we used definitive histological and immunohistochemical results of sentinel node the day of conserving surgery with complete axillary lymph node dissection under general anaesthesia in case of involved nodes. METHODS: Patients with a stage TNM > T1 or N1, a multicentric breast cancer, a neoadjuvant chemotherapy, an allergy, an obesity or no detection of hot sentinel node were excluded. Patients in ambulatory surgery had scintigraphy 3 hours after injection of radiotracer. If we had a hot sentinel node, we applied Emla 5% cream on the areolar and axillary site and gave midazolam. We performed an intradermal injection of 2 ml of xylocaine with adrenaline above cancer and in the subareolar site in case of non-palpable cancer. With the same needle, we injected 2 ml of blue dye. We injected so 2 ml of xylocaine with adrenaline in the axillary hot spot. We completed local anaesthesia with 16 ml of xylocaine with adrenaline step by step on the route that intraoperative gamma probe showed us. RESULTS: We performed 17 patients (52.6 years [38-62]; body mass index = 23.7 [20-34.1], size of tumour = 10.8 mm [1-25]). We detected 100% of sentinel node. We had a secondary haematoma which was evacuated. CONCLUSION: Perform sentinel node under local anaesthesia is possible for patients with no obesity but radio tracer is absolutely necessary.     

Definitive radiotherapy or chemoradiotherapy in the treatment of merkel cell carcinoma

AimsMerkel cell carcinoma (MCC) is a radiosensitive tumour. Radiotherapy has an important role in its treatment, including definitive management. This study aimed to determine the in-field control achieved with definitive radiotherapy or chemoradiotherapy (CRT) and to examine patterns of relapse.Materials and methodsPatients treated with definitive radiotherapy or CRT for biopsy-confirmed MCC were identified from records of the Royal Prince Alfred Hospital and Melanoma Institute Australia. Definitive treatment was defined as treatment delivered to macroscopic or residual microscopic disease at the primary site or in regional nodes. Patients with distant metastatic disease at presentation and those treated electively or adjuvantly (i.e. after microscopically clear excision) were excluded.ResultsOf 26 patients treated with definitive radiotherapy (n = 18) or CRT (n = 8), 20 were disease free at last follow-up (median follow-up 23.5 months). Five of the six patients who recurred did so at distant sites, with two experiencing simultaneous in-field failure at treated nodal sites where there had been macroscopic disease at presentation. Eighty-nine per cent of all patients and 85% of those with macroscopic disease were free of in-field recurrence at 2 years.ConclusionDefinitive radiotherapy or CRT produces excellent in-field disease control in the treatment of primary and regionally metastatic MCC.     

PRIMARY NEUROENDOCRINE CARCINOMA OF THE SKIN (NERKEL CELL TUMOR)

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Interferon-alpha inhibits proliferation and induces apoptosis of merkel cell carcinoma in vitro

Merkel cell carcinoma is a tumor with aggressive biological behavior and limited response to chemotherapy. The present study investigated the effect of interferon (IFN)-alpha on growth and apoptosis of Merkel carcinoma cells in vitro. Proliferation of MCC-1 cell line was reduced dose-dependently by IFN-alpha and diminished when higher IFN-alpha concentrations were used. Additionally, IFN-alpha potently decreased DNA-synthesis and Ki67/MIB-1 proliferation index of MCC-1 cultures. Furthermore, IFN-alpha induced dose-dependently apoptosis of MCC-1 cells as shown by caspase-3 activation, and detection of apoptotic DNA strand breaks and fragmented nuclei. These findings suggest that IFN-alpha may have antitumor activity against Merkel cell carcinoma.     

Role of radiotherapy in the management of merkel cell carcinoma of the skin

The role of radiotherapy in treating local and regional disease in patients with clinically localized Merkel cell carcinoma remains controversial. Given the lack of randomized evidence and patient and treatment heterogeneity in published retrospective series, sound clinical judgment is required to assess individual patient risk factors. Although many single-institution series have shown that adjuvant radiation to the primary tumor site decreases the risk for local and regional failure, evidence is emerging that there is a cohort of patients at relatively low risk for local recurrence after wide local excision alone. Node dissection, radiotherapy, and combined modality treatment may all play a role in managing occult or clinically evident nodal disease, depending on the anatomic location of draining lymphatics and the extent of microscopic or macroscopic disease. For select patients, primary radiotherapy is a reasonable option with a low risk for local or regional recurrence.     

Laparoscopic retroperitoneal lymph-node dissection in metastatic nonseminomatous germ-cell tumors

ObjectivesTo support laparoscopic post-chemotherapy retroperitoneal lymph-node dissection (L-PC-RPLND) as a potential new standard, we report on a large dataset of patients systematically undergoing L-PC-RPLND.Patients and methodsPatients with unilateral residual mass (≥1 cm), normalized markers, limited encasement (<30%) of gross retroperitoneal vessels underwent unilateral L-PC-RPLND with no adjuvant chemotherapy. Surgical performances, histology, hospital stay, complications within 30 days and follow-up visits were recorded. Multivariable linear and logistic regression models were used.ResultsBetween February 2011 and January 2021, 151 consecutive patients underwent L-PC-RPLND. Median size of the residual mass was 25 mm (interquartile range [IQR] 20–35 mm). Overall median operative time was 208 min (IQR 177–241) and was 51 min longer (p-value <0.001) for right L-PC-RPLNDs. Eleven procedures were converted to open surgery. Median number of removed and positive nodes was 11 (IQR 8–16) and 1 (IQR 1–2), respectively. Mean hospital stay was 2 days (IQR 2–3). Nine complications (6%) occurred: two were Clavien-Dindo grade III. Definitive pathology revealed post-pubertal teratoma in 65.6%, fibro-necrotic tissue in 23.8%, teratoma with malignant somatic component in 6.6% and viable tumour in 4.0% patients. In multivariable linear regression models, fibro-necrotic tissue (32 min, CI 8.5–55.5; p < 0.01) and residual volume (1.05 min, CI 0.24–1.85; p < 0.01) achieved independent predictor status for longer operative time. All patients, but one, are alive and disease-free after a median follow-up of 22 months (IQR 10, 48).ConclusionL-PC-RPLND, when adequately planned, is safe and effective for most patients with low to medium volume residual masses.     

Survivin downregulation is not required for T antigen knockdown mediated cell growth inhibition in MCV infected merkel cell carcinoma cells

The relationship between the biomarker of vitamin D status, 25(OH)D, and the risk for colorectal neoplasia is suggestive but equivocal. Questions remain regarding whether there are differential associations between 25(OH)D and colorectal adenoma by gender, colorectal subsite or features of baseline and recurrent adenomas. We sought to investigate the relationship between 25(OH)D and both baseline and recurrent adenoma characteristics. Our study was conducted among 2,074 participants in a pooled population of two clinical intervention trials of colorectal adenoma recurrence. A cross‐sectional analysis of 25(OH)D and baseline adenoma characteristics and a prospective study of recurrent adenomas and their characteristics were conducted. There was a statistically significant inverse association between the concentrations of 25(OH)D and the presence of three or more adenomas at baseline. Compared to participants with 25(OH)D levels of <20 ng/mL, the adjusted odds ratios (ORs) (95% condifdence intervals [CIs]) were 0.99 (0.70–1.41) for those with concentrations of ≥20 and <30 ng/mL, and 0.73 (0.50–1.06) among participants with levels of ≥30 ng/mL (p‐trend = 0.05). Baseline villous histology was also significantly inversely related to 25(OH)D levels (p‐trend = 0.04). Conversely, 25(OH)D concentrations were not associated with overall colorectal adenoma recurrence, with ORs (95% CIs) of 0.91 (0.71–1.17) and 0.95 (0.73–1.24; p‐trend = 0.85). These findings support the concept that the relationship between vitamin D and colorectal neoplasia may vary by stage of adenoma development.     

Level IIb neck dissection guided by fine-needle aspiration for N1b papillary thyroid carcinoma

BackgroundThe extent of neck dissection for patients with papillary thyroid carcinoma (PTC) metastasis in lateral cervical lymph nodes is still debated. Studies aiming to omit level IIb were generally based on postoperative histopathologic information. The purpose of this study was to evaluate the predictive value of fine-needle aspiration (FNA) for level II lymph nodes in identifying candidates for neck dissection sparing level IIb before surgery.MethodsWe prospectively enrolled 156 consecutive previously untreated PTC patients with lateral neck metastases who were subjected to 178 therapeutic lateral neck dissections (including level IIa, IIb, III, IV, and Vb) between June 2018 and August 2021. Ultrasound-guided FNA of suspicious lymph nodes at level II was preoperatively performed. The cytology of FNA and thyroglobulin (Tg) washout concentration with other clinical predictors was analyzed for lymph node metastases at level IIb.ResultsPreoperative ultrasonography revealed suspicious lymph nodes at level II in 118 cases, and fifty were positive on FNA results. Metastasis at level IIb was seen in 17 (9.6%) of the postoperative specimens. By univariate analysis, the rate of level IIb metastasis was significantly higher in patients with FNA-positive lymph nodes at level II (P<0.001, odds ratio = 16.899). The tumor sizes of the two FNA-negative level IIb metastatic lymph nodes were 0.4 mm and 3 mm.ConclusionsLevel IIb lymph node dissection may be omitted in the treatment of N1b PTC patients if FNA to level II lymph nodes is negative.     

Clinical emergence of neurometastatic merkel cell carcinoma: a surgical case series and literature review

Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine neoplasm of possible viral origin and is known for its aggressive behavior. The incidence of MCC has increased in the last 15 years. Merkel cell carcinoma has the potential to metastasize, but rarely involves the central nervous system. Herein, we report three consecutive surgical cases of MCC presenting at a single institution within 1 year. We used intracavitary BCNU wafers (Gliadel^®) in two cases. Pathological features, including CK20 positivity, consistent with MCC, were present in all cases. We found 33 published cases of MCC with CNS involvement. We suggest that the incidence of neurometastatic MCC may be increasing, parallel to the increasing incidence of primary MCC. We propose a role for intracavitary BCNU wafers in the treatment of intra-axial neurometastatic MCC.