INVESTIGATIVE REPORT
699 Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV
Outcome of Combined Treatment of Surgery and Adjuvant Radiotherapy in Merkel Cell Carcinoma
Eckhard FIEDLER 1 and Dirk VORDERMARK 2
1
Department of Dermatology , and 2 Department of Radiation Oncology , Martin Luther University Halle-Wittenberg , Halle ( Saale ), Germany
In recent analyses of Merkel cell carcinoma , prognosis is poor even in stages I and II . We performed a monocentric retrospective study of 37 consecutive cases with Merkel cell carcinoma stage I to III treated with a combination of surgery and adjuvant radiation to evaluate progression-free and overall survival . The median primary tumour diameter was 17.9 mm . Cases consisted of 31 primary tumours , of which 13 had negative sentinel lymph node biopsy ( IA n = 10 and IIA n = 3 ) and 18 no sentinel lymph node biopsy ( IB n = 15 and IIB n = 3 ), 2 tumours with positive sentinel lymph node biopsy ( IIIA ) and 4 with local macrometastasis ( IIIB ). The median age was 71 years and the median follow-up was 60.4 months . The 5-year progressionfree survival was 83.8 % and 5-year disease-specific survival was 95.7 % ( overall survival 93.0 %). So far , our results show a high survival rate with combined treatment of surgery and adjuvant radiotherapy in early tumour stages of Merkel cell carcinoma .
Key words : Merkel cell carcinoma ; MCC ; combined treatment ; adjuvant radiotherapy .
Accepted Jan 29 , 2018 , Epub ahead of print Jan 30 , 2018 Acta Derm Venereol 2018 ; 98 : 699 – 703 .
Corr : Eckhard Fiedler , MD , Department of Dermatology , Martin Luther University Halle-Wittenberg , Ernst-Grube-Straße 40 , DE-06120 Halle ( Saale ), Germany . E-mail : eckhard . fiedler @ halle-hautarzt . de
In the literature , Merkel cell carcinoma ( MCC ) is described as an aggressive metastasizing neuroendocrine skin tumour . In current papers , high mortality rates are reported even in low tumour stages ( 1 , 2 ). A 5-year overall survival ( OS ) rate of 64 % is reported for localized tumours ( stage I and II ), and 39 % for loco-regional lymph node metastases ( stage III ) ( 2 ). Beside excision with wide margins , adjuvant radio therapy ( RT ) of the primary tumour site and regional lymph node bed in early tumour stages has been widely recommended for more than 20 years ( 3 ), though it still remains controversial ( 4 ). The question of suitable tumour stages for systemic approaches arises in light of new therapeutic strategies , including PD1 inhibitors ( 2 , 5 ).
This research is a retrospective monocentric study of consecutive patients with MCC who were treated with excision and adjuvant RT and followed up at the Department of Dermatology of the Martin Luther University Halle-Wittenberg from 2000 to 2017 .
SIGNIFICANCE
In literature Merkel cell carcinoma is depicted as a rare but aggressive and metastasizing skin tumour . Our results of 37 consecutive patients treated by combined surgery and adjuvant radiotherapy show a low regional recurrence rate as well as a high 5-year disease-specific survival rate ( 95.7 %). The combination of surgery and adjuvant radiotherapy may improve the management of localized MCC with or without limited involvement of loco regional lymph nodes . Because of the discrepancy between the effects of combined therapy versus surgery alone systemic therapies could also be considered if due to contraindication to RT a combined therapy is impossible .
MATERIAL AND METHODS
Between 2000 and 2017 , 41 consecutive patients with histologically and immunohistologically-confirmed diagnosis of MCC came for therapy and follow-up care to the Department of Dermatology .
If there was neither contraindication nor refusal of treatment , an R0-resection – if possible with wide excision margins – and adjuvant RT of the primary tumour site and regional lymph node bed were performed . Doses of 48 to 60 Gy were used . Due to side effects of radiotherapy 2 patients received 28 Gy and 34 Gy only . After therapy , the patients were transferred to regular follow-up .
Sentinel lymph node biopsy ( SLNB ) was performed in 13 patients ( 35.1 %). The median excision margin was dependent on the location of the primary tumour site : limbs 18 mm ( n = 24 ; range 0.1 – 30 ), head and neck 10 mm ( n = 11 ; range 1.0 – 20 ), and trunk 20 mm ( n = 2 ; range 20.0 / 20.0 ). The median excision margin was 10 mm in all 37 cases . Cases with primary distant metastases ( stage IV ) or inoperable bulky disease were excluded , as were cases in which the patient refused combined treatment ( excision and RT ). Ten-year follow-up included clinical ( months 0 to 48 : every 3 months , months 48 to 120 : every 6 months ) and ultra sound examination of primary tumour site and regional lymph nodes ( months 0 to 24 : every 3 months , months 24 to 60 : twice a year , months 60 to 120 : once a year ), chest X-rays and abdominal ultra sound : months 0 to 120 : once a year . TNM staging was made according to UICC TNM 7 th edition ( 6 ). Statistics including Kaplan Meier survival analysis were performed using IBM SPSS statistical software .
RESULTS
Of 41 MCC patients , 3 were in need of systemic therapy ( 2 stage IV and 1 with bulky metastatic disease ( stage III )). Another patient refused radiotherapy . The remaining 37 cases are shown in Table I . The group under
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2895 Acta Derm Venereol 2018 ; 98 : 699 – 703