Management of Sentinel Lymph Node Metastasis in Merkel Cell Carcinoma: Completion Lymphadenectomy, Radiation, or Both?

• Published in: Annals of surgical oncology 2019-02, Vol.26 (2), p.379-385
• Main Authors: Perez, Matthew C., Oliver, Daniel E., Weitman, Evan S., Boulware, David, Messina, Jane L., Torres-Roca, Javier, Cruse, C. Wayne, Gonzalez, Ricardo J., Sarnaik, Amod A., Sondak, Vernon K., Wuthrick, Evan J., Harrison, Louis B., Zager, Jonathan S.
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; BIOPSY; Carcinoma, Merkel Cell - pathology; Carcinoma, Merkel Cell - therapy; CARCINOMAS; Combined Modality Therapy; Demography; DISEASE INCIDENCE; Disease Management; Female; Follow-Up Studies; Humans; Lymph Node Excision - mortality; LYMPH NODES; Lymphatic Metastasis; Lymphatic system; Lymphedema; Male; Medicine; Medicine & Public Health; Melanoma; METASTASES; Middle Aged; Morbidity; Neoplasm Micrometastasis; Neoplasm Recurrence, Local - pathology; Neoplasm Recurrence, Local - therapy; Oncology; PATIENTS; Prognosis; RADIOLOGY AND NUCLEAR MEDICINE; Radiotherapy - mortality; Retrospective Studies; Sentinel Lymph Node - pathology; Sentinel Lymph Node Biopsy; Skin cancer; Skin Neoplasms - secondary; Skin Neoplasms - therapy; SURGERY; Surgical Oncology; Surgical site infections; Survival Rate; TOXICITY
• ISSN: 1068-9265; 1534-4681; 1534-4681
• DOI: 10.1245/s10434-018-6810-1

Background Approximately 30% of patients with clinically localized Merkel cell carcinoma (MCC) show nodal involvement on sentinel lymph node biopsy (SLNB). Optimal management of SLNB-positive disease has not been defined. This study compared outcomes after completion lymphadenectomy (CLND), radiation, and combined CLND plus radiation after a positive SLNB. Methods All patients treated at a single institution for SLNB-positive MCC (1998–2015) were retrospectively evaluated, with examination of patient demographics, clinicopathologic characteristics, outcomes, and regional toxicity. Results The study identified 71 evaluable patients with SLNB-positive disease. The median age of these patients was 76 years, and 76.1% were men. Of the 71 patients, 11 (15.5%) underwent CLND, 40 (56.3%) received radiation, and 20 (28.2%) underwent CLND plus postoperative radiation. Lymphovascular invasion was significantly more common in the radiation-alone cohort ( p  = 0.04). For the three cohorts, the median percentages of nodal involvement were respectively 2, 10, and 30% ( p  = 0.06). After a median follow-up period of 22.3 months, four patients had recurrence in their regional nodal basin (3 radiation-alone patients and 1 CLND + radiation patient). The three cohorts did not differ significantly in the development of distant metastases ( p  = 0.68) or overall survival ( p  = 0.72). Six patients experienced surgical-site infections (2 CLND and 4 CLND + radiation patients), and three patients experienced symptomatic lymphedema (1 CLND patient and 2 CLND + radiation patients). Conclusions Regional failure was infrequent (≤ 10%) regardless of treatment, and morbidity appeared to be low with all approaches. Given that multiple treatment approaches can be successful in treating micrometastatic MCC, future efforts should be directed at refining criteria for allocating patients to a specific method, or possibly no further nodal basin treatment, in an effort to maximize regional control at the lowest cost and morbidity.