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Unusual Case Presentation of an Ulcerative Variant of Merkel Cell Carcinoma

By: Vanessa A. Carter, BS
Posted: Tuesday, May 18, 2021

Nagendra Singh Beniwal, DNB, of Military Hospital, Ramgarh, Jharkhand, India, and colleagues presented a case of Merkel cell carcinoma with rare clinical features in the Indian Dermatology Online Journal. The investigators described these ulcerated growths as imitations of squamous cell carcinoma and noted that they seemed to manifest without immunosuppression.

An 85-year-old male presented with an asymptomatic growth that gradually developed over 4 years but rapidly progressed within the past 4 months. Histopathologic examination revealed a fungating growth with ulceration and discrete, subcentimetric, hyperpigmented to erythematous satellite plaques. Results from biochemical and hematologic tests were normal, and the patient was HIV-negative.

Skin biopsy revealed round blue cell tumors with a nests and trabeculae pattern, high nucleocytoplasmic ratio, dispersed powdery chromatin, scant cytoplasm, brisk mitotic activity, and inconspicuous nucleoli, the authors observed. In both the underlying squamous epithelium and tumor cells, a high MIB-1 labeling index was identified. At tumor margins, the lymphovascular invasion was present.

A diagnosis of Merkel cell carcinoma with carcinoma in situ changes in the lining squamous epithelium was made based on the presence of high-grade dysplasia, high MIB-1 index, and no evidence of invasion by dysplastic squamous cells. A fluorodeoxyglucose-avid exophytic lesion in the abdomen and subcutaneous nodular lesions in the inguinal region was discovered through a PET-CT scan, which the authors thought likely indicative of metastasis. Therefore, the patient underwent wide local excision of the tumor, with a 1-cm margin.

Further analysis of the removed mass unveiled an encapsulated nodular ulcerative tumor. The residual surface was observed to be a soft, gray-pink with noticeable punctate hemorrhage and necrosis. The man underwent radiotherapy but declined chemotherapy; he died within 2 months of diagnosis.

Disclosure: The study authors reported no conflicts of interest.



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