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Merkel cell carcinoma: a rare cause of hypervascular nasal tumor.

Cutaneous neuroendocrine carcinoma, first described in 1972, is an aggressive disease usually occurring in sun-exposed skin. Other sites have been described, however; such tumors occasionally occur within the nasal fossa. A high rate of metastasis (>30%) explains the poor prognosis. Descriptions of the imaging features of these tumors, mainly located in cutaneous region, are rare. We therefore present the imaging features of two cases of Merkel cell carcinoma involving the sinonasal region, suggestive of a hypervascular tumor.

Aged↗

The intermediate filament cytoskeleton of cutaneous neuroendocrine carcinoma (Merkel cell tumour). Immunohistochemical and biochemical analyses.

The presence and distribution of cytokeratins, neurofilament proteins, vimentin and glial fibrillary acidic protein were studied in 10 cutaneous neuroendocrine carcinomas (CNEC) by immunohistochemical techniques, using specific antibodies. In all cases tumour cells were specifically stained with antibodies to mouse liver cytokeratin component D in paraffin-embedded formalin-fixed and frozen sections. Moreover, one- and two-dimensional SDS-polyacrylamide gel electrophoresis of high salt/detergent resistant cytoskeletal residues from tumour material, isolated by microdissection from frozen sections, revealed the presence of cytokeratin components 8 and 18 which are characteristic constituents of cytokeratin filaments of simple epithelia. Neurofilament proteins were detected by immunocytochemistry in tumour cells from 2 patients, from whom frozen material was available, and their presence was also positively identified in cytoskeletal residues by immunoblotting using specific antibodies. Glial fibrillary acidic protein and vimentin could not be demonstrated in tumour cells. Our studies did not confirm the suggested origin of CNEC from epidermal Merkel cells.

Adenocarcinoma↗

Merkel cell carcinoma--a problem with microscopically controlled surgery.

Trabecular cell carcinoma, originally described by Toker, is a malignant skin tumor, probably of Merkel cell origin. These tumors are locally aggressive and may metastasize. Prompt surgical removal is mandatory. The clinical features are often not diagnostic, and diagnosis is primarily by histologic examination. Special studies, especially electron microscopy, may be required to differentiate this tumor from others. During surgery, particularly with Mohs microscopically controlled excision, provision must be made for proper handling of the specimen so that these special studies can be carried out.

Adenocarcinoma↗

Neuroendocrine carcinoma (Merkel cell tumor?) presenting as a subcutaneous tumor. An ultrastructural and immunohistochemical study of three cases.

The clinical and pathological features of three unusual soft tissue tumors are presented. They occurred in the groin of elderly patients in the subcutaneous tissue. In Case 1, the inguino-crural tumor coexisted with a second mass in the pelvis. The tumors had a tendency to recur locally and to invade the regional lymph nodes. Metastatic dissemination of the disease resulted in the death of the patient in Case 3. Histologically, the tumors appeared composed of small round cells with scanty cytoplasms, arranged in diffuse, poorly cohesive or solid sheets. In places, a trabecular pattern was noted. Mitotic figures were numerous. Some cells exhibited argyrophil granules. The ultrastructural study revealed compact whorls of intermediate filaments and neurosecretory granules. All three cases displayed a paranuclear dot-like positive reaction with antibodies to cytokeratins and neurofilaments. A diffuse cytoplasmic immunostaining for neuron-specific enolase was present in Cases 1 and 2. Protein S-100, vimentin and leucocyte common antigen could not be demonstrated. All these characteristics, except for the subcutaneous location, are shared with neuroendocrine (Merkel cell) tumors of the skin.

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Mutation analysis of P73 and TP53 in Merkel cell carcinoma.

The p73 gene has been mapped to 1p36.33, a region which is frequently deleted in a wide variety of neoplasms including tumours of neuroectodermal origin. The p73 protein shows structural and functional homology to p53. For these reasons, p73 was considered as a positional and functional candidate tumour suppressor gene. Thus far, mutation analysis has provided no evidence for involvement of p73 in oligodendrogliomas, lung carcinoma, oesophageal carcinoma, prostatic carcinoma and hepatocellular carcinoma. In neuroblastoma, two mutations have been observed in a series of 140 tumours. In view of the occurrence of 1p deletions in Merkel cell carcinoma (MCC) and the location of p73 we decided to search for mutations in the p73 gene in five MCC cell lines and ten MCC tumours to test potential tumour suppressor function for this gene in MCC. In view of the possible complementary functions of p73 and TP53 we also examined the status of the TP53 gene. Sequence analysis of the entire coding region of the p73 gene revealed previously reported polymorphisms in four MCCs. In one MCC tumour, a mis-sense mutation located in the NH2-terminal transactivation region of the p73 gene was found. These results show that p73, analogous to neuroblastoma, is infrequently mutated in MCC. This is also the first report in which the role of TP53 in MCC has been investigated by sequencing the entire coding region of TP53. TP53 mis-sense mutations and one non-sense mutation were detected in three of 15 examined MCCs, suggesting that TP53 mutations may play a role in the pathogenesis or progression of a subset of MCCs. Moreover, typical UVB induced C to T mutations were found in one MCC cell line thus providing further evidence for sun-exposure in the aetiology of this rare skin cancer.

Base Sequence↗

[Merkel cell tumor (neuroendocrine carcinoma of the skin) in an unusual location. Immunohistochemical and lectin histochemical findings].

Neuroendocrine carcinoma of the skin usually occurs in elderly individuals. Head and neck are the most common primary sites followed by the extremities and trunk. As this tumor represents a remarkable rarity in younger people, we report the case of a 33-year-old woman with a neuroendocrine carcinoma in an unusual localization. Diagnosis was based on the results of the examination of a metastasis in the inguinal lymph nodes. The lesion at the Labium minus pudendi which is to be considered the primary tumor was detected several months later. Diagnosis of Merkel cell tumor until recently had depended on ultrastructural demonstration of dense-core membrane-bound granules. Today, diagnosis can be secured also by optical light microscopy, on the basis of a certain constellation of immunohistochemical and lectin histochemical findings.

Adult↗

Incidence of nonlocalization of sentinel lymph nodes using preoperative lymphoscintigraphy in 74 consecutive head and neck melanoma and Merkel cell carcinoma patients.

INTRODUCTION: Lymphatic drainage pathways in the head and neck region are more variable than in any other location of the body. Occasionally, head and neck lymphoscintograms fail to identify a definitive lymphatic drainage pattern, making preoperative and intraoperative identification of sentinel nodes very difficult. The purpose of this study was to determine the incidence of nonlocalization on lymphoscintigraphy of sentinel nodes in patients with head and neck cutaneous malignancies. METHODS: A retrospective chart review was conducted of a single surgeon's (WKS) 135 consecutive head and neck melanoma and Merkel cell cancer patients from August 1997 to August 2002. In all cases. technetium-99m sulfur colloid was the radioactive tracer used by the nuclear medicine department to perform the lymphoscintograms. RESULTS: Of the 135 patients, 74 underwent preoperative lymphoscintigraphy in preparation for performing a sentinel lymph node biopsy. Of these 74 patients, 5 (6.8%) were found to have nonlocalization of a sentinel node(s). Of the 5 patients who failed to localize, 3 had primary lesions near the midline scalp, while 2 had primary lesions located on the cheek. Two of the 5 patients underwent reinjection of the radioisotope by the treating surgeon (WKS) but failed to further localize the radiotracer. All 5 patients went on to have wide local excision of the primary cancer on the day of the lymphoscintogram, as well as undergoing intraoperative examination of all head and neck nodal basins with a handheld gamma detector. No focal areas of radiation were identified and no lymph nodes were biopsied. To date, 1 patient has developed distant metastases and has succumbed to her disease. The remaining 4 patients are free of disease. CONCLUSION: In a series of 135 consecutive patients with head and neck cutaneous malignancies, 74 of whom were treated with preoperative lymphoscintograms, a nonlocalization rate of 6.8% was found. This is a significant rate of nonlocalization and reflects either the inherent difficulty in imaging the head and neck region and/or the possible rapid rate of dye washout via multiple lymphatic drainage pathways that exist in this location.

Aged↗

Normal Merkel cells express a synaptophysin-like immunoreactivity.

Synaptophysin (SY), a specific component of the membrane of presynaptic vesicles, has been reported as a novel marker for neurons, certain neuroendocrine cells and their neoplasms including neuroendocrine carcinomas of the skin. The origin of the Merkel cells (MC) being far from clear, this study was performed to establish if normal MC express SY. It is demonstrated by immunofluorescence and immunoelectron microscopy using a monoclonal antibody SY38 to this glycoprotein that normal MC in man, rabbit and pigs express an SY-like reactivity. Although immunoblotting identification of the immunoreactive material gave negative results, it is likely that normal MC contain SY. By immunoelectron microscopy, the staining was located at the surface of cytoplasmic vesicles. In view of the possible involvement of SY in the Ca2+-dependent neurotransmitter release, the observation of an SY-like immunoreactivity in MC supports the view that they are epithelial neuroendocrine cells and that they may possess a neurosecretory function.

Animals↗

Criteria for the diagnosis of primary endocrine carcinoma of the skin (Merkel cell carcinoma). A histological, immunohistochemical and ultrastructural study of 13 cases.

Thirteen cases of primary endocrine carcinoma of the skin (Merkel cell carcinoma) were reviewed with the aim of defining the morphological, immunohistochemical and ultrastructural criteria for diagnosis. The tumour cells were characterized by their scanty cytoplasm, generally small uniform nuclei with finely dispersed chromatin and multiple small nucleoli. Nuclear shapes varied from round to spindle, with larger and pleomorphic forms predominating in 2 tumours. A striking feature seen in 12 tumours was the occurrence of a "ball-in-mitt" pattern represented by 1 or 2 crescentic tumour cells closely wrapped around an oval cell. Staining for neuron-specific enolase was the most consistent marker of the tumour and the characteristic juxtanuclear globular staining for keratin and cytokeratin and the occasional coexpression of neurofilament set this tumour apart from other cutaneous neoplasms, in particular, metastatic carcinoid tumours and oat cell carcinoma from the lung. The fine structural features of note were striking paranuclear or juxtanuclear whorls of intermediate filaments, seen in 7 cases, the presence of variable numbers of membrane-bound dense core granules of 80-150 nm diameter in all cases and cytoplasmic spinous or microvillous projections containing microfilaments in 4 cases. Less consistent characteristics of primary endocrine carcinomas of the skin included cell moulding, argyrophilia and immunohistochemical staining for ACTH, VIP and calcitonin. The high frequency of vessel invasion in this series is in keeping with the high rate of local recurrence, lymph node metastases and visceral dissemination reported. The distinction from other similar appearing tumours in the skin is discussed.

Adult↗

Merkel cell tumour: report of a case.

We report the case of a 75-year-old lady with recurrent primary cutaneous Merkel cell tumours. The condition can be misdiagnosed as lymphoma or anaplastic carcinoma, and the definitive diagnosis can be made only by electron microscopy of fresh tissue. This is the first reported case in the British literature.

Aged↗

Selective sentinel lymphadenectomy for malignant melanoma, Merkel cell carcinoma, and squamous cell carcinoma.

To date, selective sentinel lymphadenectomy (SSL) should be considered a standard approach for staging patients with primary invasive melanoma greater than or equal to 1 mm. It is imperative that the multidisciplinary team master the techniques of preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and postoperative pathologic evaluation of the sentinel lymph nodes (SLNs). An SLN is defined as a blue, "hot" and any subsequent lymph node greater than 10% of the ex vivo count of the hottest lymph node. Any enlarged or indurated lymph node in the nodal basin should be excised. Frozen sections are not recommended. For extremity melanoma, delayed SSL may be performed. Preoperative lymphoscintigraphy for extremity melanoma may be done the night before so that the surgery can be scheduled as the first case of the following day. Every surgeon who uses blue dye should be aware of the potential adverse reaction to isosulfan blue and treatment for such a potential fatal reaction. A complete lymph node dissection is done if the SLN is found to be positive. Elective lymph node dissection (ELND) should not be done if an SSL can be performed as a staging procedure. SSL has further been applied to stage the nodal basin for Merkel cell carcinoma and high-risk squamous cell carcinoma. It is important for investigators involved with the SSL to follow the clinical outcome of these patients, so that the role of SSL can be further defined.

Carcinoma, Merkel Cell↗

Loss of distal axons and sensory Merkel cells and features indicative of muscle denervation in hindlimbs of P0-deficient mice.

Mice lacking the major Schwann cell myelin component P0 show a severe dysmyelination with pathological features reminiscent of the Déjérine-Sottas syndrome in humans. Previous morphological and electrophysiological studies on these mice did not only demonstrate a compromised myelination and myelin maintenance, but were suggestive of an impairment of axons as well. Here, we studied the axonal pathology in P0-deficient mice by quantitative electron microscopy. In addition, we investigated epidermal receptor end organs by immunocytochemistry and muscle pathology by histochemistry. In proximal sections of facial and femoral nerves, axon calibers were significantly reduced, whereas the number of myelin-competent axons was not diminished in 5- and 17-month-old P0-deficient mice. However, in distal branches of the femoral and sciatic nerve (digital nerves innervating the skin of the first toe) the numbers of myelin-competent axons were reduced by 70% in 6-month-old P0-deficient mice. Immunolabeling of foot pads revealed a corresponding loss of Merkel cells by 75%, suggesting that survival of these cells is dependent on the presence or maintenance of their innervating myelinated axons. In addition, quadriceps and gastrocnemius muscles showed pathological features indicative of denervation and axonal sprouting. These findings demonstrate that loss of an important myelin component can initiate degenerative mechanisms not only in the Schwann cell but also in the distal portions of myelinated axons, leading to the degeneration of specialized receptor end organs and impairment of muscle innervation.

Animals↗

Multiple neuroendocrine carcinomas (so-called Merkel cell tumours) of the skin. Report on two cases with unique clinical course.

Two neuroendocrine carcinomas of the skin (so-called Merkel cell tumours) are presented. In both cases multiple tumour nodules developed within the course of the disease. The light and electron microscopic observations correspond with the findings reported in other neuroendocrine carcinomas. As a variable morphological and clinical pattern for these tumours seems to exist we consider our two cases with their unique clinical picture to be an obviously infrequent variant of this tumour disease, we propose for it the term "multiple neuroendocrine carcinoma syndrome".

Adenocarcinoma↗

Origin of spinal cord meninges, sheaths of peripheral nerves, and cutaneous receptors including Merkel cells. An experimental and ultrastructural study with avian chimeras.

The origin of cells covering the nervous system and the cutaneous receptors was studied using the quail-chick marking technique and light and electron microscopy. In the first experimental series the brachial neural tube of the quail was grafted in place of a corresponding neural tube segment of the chick embryo at HH-stages 10 to 14. In the second series the leg bud of quail embryos at HH-stages 18-20 was grafted in place of the leg bud of the chick embryos of the same stages and vice versa. It was found that all meningeal layers of the spinal cord, the perineurium and the endoneurium of peripheral nerves, as well as the capsular and inner space cells of Herbst sensory corpuscles, develop from the local mesenchymal cells. Schwann cells and cells of the inner core of sensory corpuscles are of neural crest origin. The precursors of Merkel cells migrate similarly to the Schwann cells into the limb bud where they later differentiate. This means that in addition to the Schwann cells and the melanocytes a further neural crest-derived subpopulation of cells enters the limb.

Animals↗

[Neuroendocrine (Merkel cell) skin cancer. Electron microscopic study].

The study is concerned with the results of light and electron microscopic examination of 2 cases of neuroendocrine (Merkel cell) carcinoma of the skin. Both patients developed multiple widely-distributed intra- and subcutaneous nodules. Histologically, tumors were mostly trabecular. Electron microscopic examination revealed neuroendocrine secretory granules, small bundles of intermediate fibers, a well-defined Golgi complex and a relatively high level of vesicular structures. There were some basal membrane fragments. It is suggested that they originate from polypotential epithelial stem cells.

Aged↗

Neuroendocrine (Merkel cell) tumor of the skin: fine-needle aspiration cytology, histology, electron microscopy and immunohistochemistry of 12 cases.

A series of 12 cases of neuroendocrine (Merkel cell) tumor of the skin, observed in the last 4 years, is reported. The mean age of the patients, 10 females and 2 males, was 62.4 years. The head, buttocks and extremities were the primary locations. The recurrence rate was 33.3% and 2 patients died of their disease. The histology is characterized by small round cells growing in solid sheets, nests or trabeculae. Ultrastructural study showed cytoplasmic membrane-bound granules of neurosecretory type and collections of perinuclear intermediate filaments as constant findings. The presence of cytoskeletal proteins was studied with monoclonal antibodies against cytokeratin and neurofilaments, as well as neuron-specific enolase reactivity, by the immunoperoxidase technique in 7 cases. Cytokeratin was demonstrated in 5 tumors and neurofilaments in 3, whereas the neuron-specific enolase was positive in all tested cases. In 4 patients a fine-needle aspiration biopsy of the primary, skin recurrences or lymph node metastasis was performed, showing the reliability of this technique in the diagnosis and staging of the disease.

Adenocarcinoma↗

[Merkel cell carcinoma of the upper eyelid].

Case report of a rare eyelid tumor in an 83-year-old woman. The excised lesion was classified as a neuroendocrine Merkel cell carcinoma on the basis of histologic, ultrastructural, and immunohistochemical examination. Detection of neurosecretory granules by electron microscopy and the characteristic cytokeratin and neurofilament pattern supported the diagnosis. The patient developed a local recurrence, which was successfully removed. There is no evidence of regional or distant metastases.

Aged↗