Local Excision (Primary, Recurrent Disease)
While surgery is widely accepted as the mainstay of treatment for primary and recurrent Merkel cell carcinoma, there is great variability in the excision margins employed. In part, this derives from the sparsity of outcomes data regarding surgical extirpa
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Local Excision (Primary, Recurrent Disease) Melanie Warycha and Murad Alam
Introduction and History Merkel cell carcinoma was first described by Toker in 1972 as “trabecular carcinoma” and later characterized as an aggressive tumor of neuroendocrine origin, arising as an asymptomatic erythematous to violaceous papule or nodule on sun-exposed skin [1]. Since this initial report, at least 2,000 cases of Merkel cell carcinoma have been reported in the literature, with an estimated 1,400 new cases diagnosed each year in the United States [2, 3]. While advances in the molecular biology and pathogenesis of Merkel cell carcinoma have been recently elucidated, the rarity of this tumor has prevented establishment of validated prognostic indicators and treatment guidelines [4]. In fact, management decisions up to this point remain controversial and have been based primarily on retrospective case reports and case series, with no prospective randomized trials to date. While wide surgical excision with margins of at least 2–3 cm was initially recommended for primary treatment of this tumor, many M. Warycha Mount Kisco Medical Group, Department of Dermatology, 110 South Bedford Road, Mount Kisco, NY 10549, USA e-mail: [email protected] M. Alam (*) Department of Dermatology, Northwestern University, 676 North St. Clair Street, Suite 1600, Chicago, IL 60611, USA e-mail: [email protected]
reports have since shown histopathologic clearance with even narrower margins. Mohs surgery has also emerged as an effective treatment modality for primary Merkel cell carcinoma. In this chapter, we comprehensively review the surgical management of Merkel cell carcinoma and offer an evidence-based treatment algorithm by which to manage this aggressive tumor.
Patient Selection Prior to proceeding with surgery, it is important to have the histopathology reviewed by a dermatopathologist with adequate experience in identifying Merkel cell carcinoma. As certain histopathologic criteria, like lymphovascular invasion and mitotic rate, have been associated with survival, it is important to have this information documented [5, 6]. Once the diagnosis has been confirmed, patients with primary Merkel cell carcinoma should be promptly referred for surgical evaluation, including either standard wide excision or Mohs surgery, the data for which will be presented later in this chapter. In devising a treatment strategy, the size of the tumor should be assessed as this will help guide whether a surgical approach is feasible or not, keeping in mind that most lesions will need at least a 1 cm margin to achieve histopathologic clearance. A detailed medical and surgical history should also be obtained. Given that these tumors often occur in the elderly, comorbidities need to be considered, with patients referred for presurgical clearance
M. Alam et al. (eds.), Merkel Cell Carcinoma, DOI 10.1007/978-1-4614-6608-6_6, © Springer Science+Business Media New York 2013
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when warranted. A comprehensive skin examination is useful, with focused attenti
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