What is the treatment of choice for a Merkel cell carcinoma (MCC) tumor?

Updated: Jan 18, 2019
  • Author: Arjun S Joshi, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

The treatment of choice for the primary lesion in MCC is surgical excision. Because of the high propensity for local recurrence, wide local excision including 2-3 cm of normal-appearing skin is the standard recommendation for reducing the incidence of recurrence. However, this margin is not always possible in the head and neck region.

In addition, in a study of patients with MCC, 35.4% of whom had primary head and neck lesions, Perez et al found that, in comparing resection margins of 1 cm, 1.1-1.9 cm, and 2 cm or more, the 1 cm margins were not associated with a greater rate of local recurrence or significantly different rates of disease-specific and overall survival. [28]

In practice, a disease-free margin appears to be most important factor in the evaluation of patient outcomes.

For the reasons just discussed, Mohs micrographic surgery followed by radiation therapy has proven to be an equally effective option for small primary facial MCCs. This surgical approach has the advantage of sparing as much normal adjacent tissue as possible, an important consideration when the primary lesion occurs on cosmetically important areas of the head and neck. Studies have demonstrated equivalent rates of local disease control with Mohs surgery and radiation therapy, as compared with standard surgical excision.

Treatment of first- and second-echelon nodal basins for the clinically negative neck (stage I) is controversial. Some suggest that prophylactic lymphadenectomy should not be performed routinely. On the other hand, based on a retrospective case series and literature review, Papadiochos et al recommended that in patients with head and neck MCC, elective regional lymph node management rather than observation be employed even when there is no identifiable lymph node disease. [29]

However, although prophylactic lymphadenectomy substantially decreases the local recurrence rate, it does not appear to affect disease survival. Some surgeons recommend prophylactic neck dissection for aggressive tumors, that is, those >2 cm, those with >10 mitotic figures per high-power field, and/or those with histologic evidence of lymphatic involvement.

Most surgeons are now performing intraoperative lymphoscintigraphy in most cases, reserving neck dissection for cases involving nodal positivity. Lymphoscintigraphy may spare patients from unnecessary lymphadenectomy, and it theoretically improves accuracy in staging clinically localized MCC. This treatment has been described in only a few centers, and its role in the routine management of MCC remains undefined.


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