Pathologic nodal evaluation improves prognostic accuracy in Merkel cell carcinoma: Analysis of 5823 cases as the basis of the first consensus staging system - 24/04/13

Doi : 10.1016/j.jaad.2010.02.056

Bianca D. Lemos, MD ^a,^{^{These authors contributed equally to this study.}}, Barry E. Storer, PhD ^d,^{^{These authors contributed equally to this study.}}, Jayasri G. Iyer, MD ^a,^{^{These authors contributed equally to this study.}}, Jerri Linn Phillips, MA, CTR ^e, Christopher K. Bichakjian, MD ^f, L. Christine Fang, MD ^b, Timothy M. Johnson, MD ^f, Nanette J. Liegeois-Kwon, MD, PhD ^h, Clark C. Otley, MD ⁱ, Kelly G. Paulson, PhD ^a, Merrick I. Ross, MD ^g, Siegrid S. Yu, MD ^k, Nathalie C. Zeitouni, MD ^l, David R. Byrd, MD ^c,ⁿ, Vernon K. Sondak, MD ^j, Jeffrey E. Gershenwald, MD ^g, Arthur J. Sober, MD ^m, Paul Nghiem, MD, PhD ^a,^d,^n,^⁎
^a Department of Medicine/Dermatology, University of Washington, Seattle, Washington
^b Department of Radiation Oncology, University of Washington, Seattle, Washington
^c Department of Surgery, University of Washington, Seattle, Washington
^d Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
^e Commission on Cancer of the American College of Surgeons, Chicago, Illinois
^f Department of Dermatology, University of Michigan, Ann Arbor, Michigan
^g University of Texas M. D. Anderson Cancer Center, Houston, Texas
^h Johns Hopkins Medicine, Baltimore, Maryland
ⁱ Department of Dermatology, Mayo Clinic, Rochester, Minnesota
^j H. Lee Moffitt Cancer Center and Research Institute and the University of South Florida, Tampa, Florida
^k Department of Dermatology, University of California at San Francisco, San Francisco, California
^l University of Buffalo, Roswell Park Cancer Institute, Buffalo, New York
^m Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
ⁿ Seattle Cancer Care Alliance, Seattle, Washington

Reprint requests: Paul Nghiem, MD, PhD, 815 Mercer St, Brotman 242, Seattle, WA 98109.

Abstract

Background

The management of Merkel cell carcinoma (MCC) has been complicated by a lack of detailed prognostic data and by the presence of conflicting staging systems.

Objective

We sought to determine the prognostic significance of tumor size, clinical versus pathologic nodal evaluation, and extent of disease at presentation and thereby derive the first consensus staging/prognostic system for MCC.

Methods

A total of 5823 prospectively enrolled MCC cases from the National Cancer Data Base had follow-up data (median 64 months) and were used for prognostic analyses.

Results

At 5 years, overall survival was 40% and relative survival (compared with age- and sex-matched population data) was 54%. Among all MCC cases, 66% presented with local, 27% with nodal, and 7% with distant metastatic disease. For cases presenting with local disease only, smaller tumor size was associated with better survival (stage I, ≤2 cm, 66% relative survival at 5 years; stage II, >2 cm, 51%; P < .0001). Patients with clinically local-only disease and pathologically proven negative nodes had better outcome (76% at 5 years) than those who only underwent clinical nodal evaluation (59%, P < .0001).

Limitations

The National Cancer Data Base does not capture disease-specific survival. Overall survival for patients with MCC was therefore used to calculate relative survival based on matched population data.

Conclusion

Although the majority (68%) of patients with MCC in this nationwide cohort did not undergo pathologic nodal evaluation, this procedure may be indicated in many cases as it improves prognostic accuracy and has important treatment implications for those found to have microscopic nodal involvement.

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Key words : clinical staging, Merkel cell carcinoma, neuroendocrine carcinoma of the skin, pathologic staging, prognosis, sentinel lymph node biopsy, staging

Abbreviations used : AJCC, F/U, MCC, NCDB, TNM

Plan

Methods

Results

Extent of disease at presentation and survival

Clinical versus pathologic lymph node staging

Components of the new staging system

Discussion

	Dr Lemos is currently affiliated with the Department of Dermatology, Emory University, Atlanta, GA.
	Supported by National Institutes of Health (NIH) K02-AR50993; American Cancer Society (ACS) RSG-08-115-01-CCE; ACS Jerry Wachter Merkel Cell Carcinoma (MCC) Fund; NIH K24-CA139052; an unrestricted educational grant from Schering Pharmaceutical, Kenilworth, NJ; the David & Rosalind Bloom Endowment for MCC Research; and the University of Washington MCC Patient Gift Fund.
	Conflicts of interest: None declared.