Review Note
Last Update: 02/18/2024 05:30 AM
Current Deck: Part 2::6. High Yield Questions::Skin
PublishedCurrently Published Content
Front
A 58
year old man presents after local excision of a 3cm Merkel cell carcinoma from
the upper lateral right arm (over the deltoid). There is a positive radial
margin of 0.2mm and there is prominent lymphovascular space invasion.
What management options are
available for this patient? What would you recommend? Justify your answer. (4)
Back
There are 2 issues to address in this case 1.
Management of the primary 2. Management of the draining lymph nodes (right
axillary LN in this case)
For the primary excised with a positive radial margin
(0.2mm) and prominent LVSI. The risk of primary recurrence is high hence
options are either for a wider excision or treatment with adjuvant
radiotherapy.
· I will recommend proceeding
with radiation treatment as this patient will likely require further radiation
treatment even after a wider excision. MCC is radiosensitive and radiation
treatment to the primary is likely to be as effective as a wider excision in
terms of achieving local control (No head to head studies).
· This reduces the need for
additional procedures and associated side effects of using 2 modalities instead
of one.
Management of draining lymphatics
· Ideally, a sentinel lymph node
biopsy was performed at the time of excision of the primary.
· About 10% of MCC return with
clinically undetected positive SLN
· If SLNbx is done after excision
of the primary, there is a higher false positive rate due to disruption of
lymphatic drainage post op.
· In the absence of SLNB, I will
recommend radiotherapy to the axillary lymphatic group, ideally in continuity
with the primary and intransite skin.
SLNB negative
· Assuming SLNB is negative as
the stem states that there is no further disease
· It is reasonable to omit
treatment to the axillary nodes and continue surveillance with clinical exam
+/- imaging such as CT or ultrasound of the axilla.
· I will still recommend adjuvant
radiation to the primary site as discussed above.
Further information, not for memorising (no card)
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