Case Study B: Radiation Monotherapy for Extensive Local and In-Transit Merkel Cell Carcinoma
Presentation: A 93-year-old male presented to the dermatologist with multiple firm, deeply erythematous nodules covering the majority of the parietal scalp (Fig. 13.1). He stated that the nodules appeared rapidly, never bled, and were not painful. Punch b
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Sherrif F. Ibrahim, Sue S. Yom, and Siegrid S. Yu
Presentation: A 93-year-old male presented to the dermatologist with multiple firm, deeply erythematous nodules covering the majority of the parietal scalp (Fig. 13.1). He stated that the nodules appeared rapidly, never bled, and were not painful. Punch biopsies were performed at two locations and both were shown to be consistent with Merkel cell carcinoma (MCC). His past medical history was notable for hypertension, hyperlipidemia, and coronary artery disease. Initial workup included a full body PET/CT scan to determine the extent of local disease and the presence of regional lymph node involvement or distant metastases. The PET/CT revealed the known multiple scalp nodules, consistent with in-transit disease, and an incidental renal cell carcinoma; no evidence of lymph node involvement or metastatic spread was noted, categorizing him
S.F. Ibrahim (*) Department of Dermatology, University of Rochester Medical Center, 400 Red Creek Drive, Suite 200, Rochester, NY 14623, USA e-mail: [email protected] S.S. Yom Department of Radiation Oncology, University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA 94115, USA e-mail: [email protected] S.S. Yu Department of Clinical Dermatology, UCSF Dermatologic Surgery & Laser Center, 1701 Divisadero Street, Third Floor, San Francisco, CA 94115-0316, USA e-mail: [email protected]
as having Stage IIIB disease. The patient’s case was then presented at the multidisciplinary tumor board. Representatives from dermatology, head and neck surgery, medical oncology, radiation oncology, and plastic surgery collectively felt that surgical management of the patient’s disease was not in his best interest. His advanced age, medical comorbidities, and the degree of cutaneous involvement were factors raised to support this decision. Furthermore, it was felt that there would be a high risk of recurrence with surgery alone and an unacceptable delay of adjuvant therapy with such an extensive surgical procedure. Sentinel lymph node biopsy (SLNB) was likewise not recommended given the extent of disease at presentation, complicating the ability of the surgical team to correctly identify all associated draining lymph node basins. Given the known radiosensitivity of MCC to radiation therapy (RT), initial RT with the intent of local control was the favored treatment approach. Once RT was decided upon, additional discussion was held to determine the extent of the primary treatment field and whether or not to incorporate elective treatment to the draining lymph node basins of the neck. The latter was declined by the patient and his family given the increased dose of radiation, entailing associated risks for greater acute xerostomia and mucositis. Furthermore, with the degree of cutaneous disease, radiation fields to comprehensively include the next echelon of draining nodes would be bilateral, further increasing morbidity of treatment
M. Alam et al. (eds.), Merkel Cell Carcinoma, DOI 10.1007/978-1-4614-6608
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