|
 
 



  




  
|



















 
!


!

" !
#

" !
# 
 "


!!

! 
 $ 
" 
 
%!

Ä | 
Ä Introduction.. Merkel cell carcinoma is a rare, aggressive
Introduction
neuroendocrine cell carcinoma arising in the sun-
sun-exposed skin of
elderly patients. Most of these tumors are located in the dermis. An
unusual clinical presentation of such a tumor in the subcutis, if not
biopsied, may be easily mistaken as a benign lesion. Case
Presentation.. An 83-
Presentation 83-year-
year-old white woman presented with a
7ºmm subcutaneous mass that
several--month history of a painless 7º
several
was initially thought to be a lipoma. A conservative follow-
follow-up was
planned. At the insistence of the patient, an excisional biopsy of the
mass was performed revealing a subcutaneous Merkel cell
carcinoma. The tumor cells stained positively for CK 20,
chromogranin, and synaptophysin. No other primary or metastatic
tumors found after a thorough work-
work-up. The patient was treated
with local irradiation. She remains disease free at her six-
six-month
follow--up visit. Conclusion
follow Conclusion.. When a new growth is encountered in
the sun-
sun-exposed skin of elderly patients, a biopsy is warranted
even if the lesion clinically appears benign.
Ä [


  
Ä An 83-
83-year-
year-old white American woman of European descent
presented to the Dermatology clinic complaining of a small painless
lump on her left cheek that had been present for several months.
She did not have a past history of any significant medical illness
including any neoplastic disease.
Ä Physical examination revealed a 7-7-mm soft papule with overlying
intact skin on the left cheek. There was no evidence of any sun-
sun-
induced skin lesion. There were no palpable lymph nodes in the
neck. Clinical impression was that of a benign subcutaneous nodule
such as a lipoma. The patient was advised of conservative follow-
follow-
up, but the patient insisted on having the lesion removed.
Ä An excisional biopsy was performed. The excised specimen was
an ovoid fragment of adipose tissue measuring 1- 1-cm in size
attached to an ellipse of normal skin measuring 1.9 X 0.5 cm.
Ä Microscopic examination revealed an intact atrophic epidermis,
solar elastosis of the dermis, and several dark tumor nodules in
the subcutaneous adipose tissue (Figures 1 and 2). The neoplasm
was composed of dark, small undifferentiated cells with ill-
ill-
defined cell borders showing large hyperchromatic nuclei with
numerous mitotic figures (Figure 3). The tumor cells stained
dot-like pattern (Figure 4) and
positively for CK 20 showing a dot-
were also positive for chromogranin (Figure 5) and synaptophysin
(Figure 6). They were negative for CK 5/6, S-S-100, and LCA
immunostains. The diagnosis of subcutaneous Merkel cell
carcinoma (MCC) was made.
ë
[
Dermal solar
degeneration and dark
tumor nodule in the
subcutaneous tissue.
ë
&

?
ffere ae


ark ephel

eplas
 flaes wh
he a
pse
ssue.
ë
'
The
eplas ells shw
vague ell b
es,
lage plemph
le, a
mes
m fges.
ë
(
The
m ells ae
psve f CK20
a
shw a Ơ
-
lkeơ pae f
sa  g.
ë
)
The
m ells ae
psve f
hmga  .
ë
*
The
m ells ae
psve f
sy apphys .
Ä A hgh l al a
a
lgal wkp was 
eake 
exl
e he pssble pmay ee
 e a mas,
espeally ha f l g. The pae  was f
 be fee f
he pmay  measa ms.
Ä The pae  efse
sgal  eve  a
was eae
wh
lal a
a a he bpsy se. A he sx-
sx-m h fllw-
fllw-p
vs, he pae  ema s asympma a
fee f m.
Ä &
 
Ä Mekel ell a ma (MCC) s a ae, aggessve a es
a ma as g fm ee
 e ells f he
ems.
l
Cl ally, M
MCC s f
 s -expse
aeas sh as he fae 
ek a
pese s as a small (less ha 2 m), e
 vle ase


le wh  a vely g sk . The les s sally pa less a

ap
ly gw g. The ppla s ms mm ly affee
ae
aasa s ve he age f 70 a
he mm sppesse
[1 [1-4].
Ä Mspally, he m 
le f M s mpse
f small
ells wh sa  yplasm, lage le, f ely ga la hma ,
a
mes m fges. M s bes
ffee ae
fm he
a es ms by mm hshemal sa s. M ells sa
psvely f ykea 20  a haaes
-

-lke pae a

sa egavely f S- S-100 (psve  mela ma), TTFTTF--1 a
K7,
(psve  small ell l g a ma), a
LA (psve 
lymphma) [4 [4]. A

 ally, M ells sa psvely f
ee
 e makes hmga  a
sy apphys . Ele
mspy shws haaes  ayplasm eseey
ga les [1[1].
Ä Mekel ell a ma alms always ases  he
ems, b
hee has bee  e epe
ase  he leae f M as g
 sba es fa [2[2]. O ase epese s he se
epe

ase,   k wle
ge, f M as g  sba es a
pse
sse.
Ä Teame  f M  l
es w
e exs , se  el lymph 
e
bpsy, a
lal a
a . Nea
va  hemheapy s 
emme
e
. Pg ss s vaable a
ms
epe
e   sage
f
sease a pese a . Oveall, lal ee e afe exs
s  ab 40 pee  f ases, whle eg al lymph 
e
measass s  ab 30 pee  f pae s [[44].
Ä 0
e fe
sk fas assae
wh M ae: age geae ha
50 yeas, Epea a esy, lavle (?
) a
a ,
mm mpmse
sae,   fe wh Mekel ell
lymavs
Plymavs (My
). Feqe y f M  eases
amaally
 pae s afe he age f 50 yeas sgges g a amla
f  ge  eve s. Rega
 g ?
a
a , M ms ae
pese   s -expse
aeas sh as he hea
a
ek. ae s
wh have 
eg e p psale a
?
A eame  ae a
hghe  
e e. Thse f Epea
ee  ae ge eally me
ssepble  hs a
a a
heefe have a  ease

pevale e f M. A assa s als e
 pae s wh
ae mm mpmse
 a 11- 11-fl
 ease   
e e f M
has bee see  pae s wh A0DS a
a 5- 5-fl
 ease 
pae s wh have 
eg e ga a spla a . F ally, a
ela bewee My
a
M has bee esablshe
[[5 5, 6].
Ä Ree  eseah has se ghe e
he ela bewee My

a
M. My
DNA s f
 he ma y f M ms b
s als mm ly f
 mal sse  l
 g salva a

sses f he ppe
gesve a. A ee  s
y sggess ha
he My
 egaes   he Lage T a ge p  l al
expa s , a
hs  ep f he Lage T a ge s  see
  m ells [[55]. A he s
y 
aes ha lwe maly
f M s assae
wh My
val  ega vess hse
Ms wh My
[[6 6]. Ths
aa sggess he pssbly f

ffee  meha sms f 
 g  ge ess. My
DNA s
bqs  ae a
M s elavely ae sgges g ha hs
may be  e f ma y fas  vlve
 he  ge 
a sfma  M.
Ä  
Ä M. Heah, N. James, B. Lems, e al., l al haaess f
Mekel ell a ma a
ag ss  195 pae s: he AE0O?
feaes,, J al f he Amea Aa
emy f Demalgy,
feaes Demalgy, vl.
58, . 3, pp. 375-
375-381, 2008.
Ä G.- W.-. ha g, H.-
G.-S. Ha g, W.- H.-S. Lee, J. A. M. Tayl, T.-
T.-Y.
he g, a
.-
.-Y. he , Mekel ell a ma as g fm he
sba es fa f he am wh  a sk , Demalg
Sge ,, vl. 31, . 6, pp. 717
Sge 717--719, 2005.
Ä M. H. Swa a
J. Y , Mekel ell a ma, ma, Sem as 
O lg ,
lg , vl. 34, . 1, pp. 51
51--56, 2007.
Ä . Nghem a
N. James, Mekel ell a ma,  Fpak's
Demalg  Ge eal Me
 e e,, K. Wlf, L. A. Gl
smh, e al.,
E
s., hape 120, MGaw
MGaw--Hll, New Yk, NY, ?SA, 7h e
 ,
2008.
Ä J. J. Ge
e a
The Rkvlle Mekel ell a ma Gp,
Mekel ell a ma: ee  pgess a
e  pes 
elg , pahge ess, a
l al ma ageme ,, J al f
l al O lg
lg ,, vl. 27, . 24, pp. 4021
4021--4026, 2009.
Ä R. K. Ga
h, A. S. Rse beg, a
S. . Smah, Mekel ell
pl mavs: a p
ae
p
ae,, J al f a es ahlg
ahlg ,, vl.
36, . 12, pp. 1327-
1327-1329, 2009.
Ä 

, Heagley DE, halpa J, x M, Sheha JM


,
(2010)., A  sal l al pese a f Mekel ell
a ma: a ase ep. ase Reps  Me
 e
905414.. M0D: 20300432 [[bme

2010Ale 0D 905414 bme
-- 
exe

f MEDL0NE
MEDL0NE].].