Special Topic

Merkel Cell Carcinoma: Diagnosis,

Management, and Outcomes
Alex Senchenkov, M.D.
Steven L. Moran, M.D.
Rochester, Minn.
Summary: Merkel cell carcinoma is a rare, aggressive cutaneous malignancy
with high rates of recurrence, metastases, and mortality. Its nonspecific clin-
ical presentation often delays the diagnosis, and its treatment is still contro-
versial because of the infrequent nature of the tumor. The authors provide
an overview of the current literature on epidemiology, cause, pathogenesis,
staging, management, and outcomes of this disease. Effective diagnostic
and treatment modalities such as wide local excision of the primary tumor,
importance of sentinel node biopsy for staging, evidence for the use of ad-
juvant radiation therapy, and emphasis on a multidisciplinary treatment
approach of Merkel cell carcinoma as it pertains to surgical practice are
reviewed. (Plast. Reconstr. Surg. 131: 771e, 2013.)

M EPIDEMIOLOGY
erkel cells were first described in pigs
and moles by Friedrich Merkel in 1875
as tactile cells, which are now believed
to be slowly adapting type I mechanoreceptors
in the basal layer of the epidermis that provide
information about touch and hair movement.1,2
The Merkel cell’s embryonic origin is believed to
be from the neural crest.3,4 In 1972, Cyril Toker
described “trabecular carcinoma of the skin.”5
Later, this tumor was linked to the Merkel cell
as the precursor cell after a subsequent ultra-
structural study revealed dense core granules6
and was named Merkel cell carcinoma.7 The
most accepted theory of the origin of Merkel
cell carcinoma from Merkel cells has never been
established beyond doubt. Different locations of
Merkel cells that are in the epidermis and have
acral distribution, and Merkel cell carcinoma,
which is located in the dermis and does not have
acral predilection,2 and differences in neurose-
cretory proteins in Merkel cell carcinoma com-
pared with Merkel cells, have raised some doubts
about this theory. Some authors still believe that
pluripotent (totipotent) stem cells acquire neu-
roendocrine characteristics during the process
of malignant transformation and therefore8 still
prefer the term “neuroendocrine carcinoma of
the skin.”9
From the Division of Plastic and Reconstructive Surgery and
the Department of Orthopedics, Mayo Clinic.
Received for publication August 12, 2012; accepted Novem-
ber 2, 2012.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3182865cf3
Before 1972, this tumor was referred to as
undifferentiated skin carcinoma, and the diag-
nosis of Merkel cell carcinoma was uncommon
before the 1980s. In 1986, a histologic code was
assigned to Merkel cell carcinoma, which permit-
ted accurate recordings of new cases. The inci-
dence of Merkel cell carcinoma tripled between
1986 and 200110 and quadrupled by 2006, reach-
ing an annual incidence rate of 0.6 per 100,000
according to the U.S. Surveillance, Epidemiology
and End Results program.11 Accuracy of the diag-
nosis markedly improved with the introduction of
specific immunostains such as the cytokeratin-20
in 1992.12
Merkel cell carcinoma is much more common
in white (94 percent) than in black patients
(1 percent).11,13 Most cases occur in the elderly,
with the average age at presentation being 72
years,13 and only 5 percent of patients are younger
than 50 years. It affects 1.6 to 2.3 times more men
than women,11,13,14 and the men are also younger
at the time of diagnosis (71 versus 76 years).1,13,14
CAUSE AND PATHOGENESIS
The geographic incidence of Merkel cell car-
cinoma in whites has been linked to increased sun
exposure as measured by the ultraviolet B index
(highest in Hawaii).13 Similarly, anatomical dis-
tribution of this tumor favors sun-exposed areas,
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 771e

with 36 percent originating on the face and a total
of 46 to 48 percent in the head and neck region,
followed by the extremities (35 to 38 percent) and
the trunk (11 to 17 percent).13,14 A typical ultra-
violet B–induced p53 mutation was reported in a
Merkel cell carcinoma cell line.15 There was a 100-
fold increase in the incidence of Merkel cell car-
cinoma observed in psoriasis patients treated with
methoxsalen and ultraviolet A.16 Arsenic expo-
sure17 and infrared skin damage8 also have been
implicated as possible factors in the development
of this tumor.
The risk of Merkel cell carcinoma is markedly
elevated in immunocompromised individuals,
particularly those with suppression of T-cell immu-
nity. Increased risk of Merkel cell carcinoma was
reported in chronic lymphocytic leukemia (30-
fold),18 advanced human immunodeficiency virus
and acquired immunodeficiency syndrome infec-
tion (13-fold),19 and organ transplant recipients
(10-fold).20 Organ transplant patients develop
Merkel cell carcinoma at an earlier age. Mean age
at the time of diagnosis is 53 years, and 49 per-
cent of patients are younger than 50 years. The
disease that presented, on average, 7 years after
transplantation, was multicentric in 20 percent
and advanced (stage II and III) in 70 percent.
Merkel cell carcinoma was associated with the
second malignancy in 57 percent of kidney trans-
plant patients.20,21 Interestingly, partial regression
of metastatic Merkel cell carcinoma was observed
following discontinuation of immunosuppressive
therapy.22
Previously unknown polyomavirus virus,
named Merkel cell polyomavirus, was found in
eight of 10 (80 percent) Merkel cell carcinoma
tumors. It was monoclonally integrated in the
host genome, suggesting that viral infection
preceded clonal expansion of the tumor.23 This
type of viral genome integration has previously
been described in virus-mediated oncogenesis of
other tumors (e.g., cervical cancer with human
papillomavirus) and is a hallmark of oncogenic
viruses. The proteins derived from Merkel cell
polyomavirus are present in many Merkel cell
carcinoma tumors and are likely to play a role
in oncogenesis.24 This molecular mechanism, by
viral infection alone, is unlikely to explain the
pathogenesis of Merkel cell carcinoma. First,
20 percent of Merkel cell carcinoma tumors do
not express Merkel cell polyomavirus. Second,
a large number of the general population is
exposed to the virus in childhood, but Merkel
cell carcinoma remains an uncommon tumor of
older adults. Nevertheless, this work may prove
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Plastic and Reconstructive Surgery • May 2013
to be the first model of polyomavirus-mediated
human neoplasm.
CLINICAL PRESENTATION
Merkel cell carcinoma is an aggressive
malignant tumor because of a relatively high local,
regional, and distant recurrence and metastatic
potential. The clinical presentation of Merkel cell
carcinoma is nonspecific. Although any region
of the body can be affected, this tumor most
commonly involves sun-exposed and sun-damaged
areas, with nearly half of the tumors located in the
head and neck and almost 40 percent located on
the extremities.1 Merkel cell carcinoma usually
presents as a nontender, rapidly growing, painless,
single, red to violaceous, firm intradermal
papule (Fig. 1) or nodule (Fig. 2) that can reach
considerable size (Fig. 3). The tumor can be of skin
color (Fig. 4). Epidermis overlying the tumor is
usually preserved, but ulceration or crusting is not
uncommon (Fig. 3). Clinical features of Merkel
cell carcinoma, such as asymptomatic, expanding,
immunosuppressed, older than 50 years, and
ultraviolet-exposed fair skin are summarized in
the acronym AEIOU. According to the review
of the National Cancer Database, at the time of
presentation, 66 percent of patients have local
disease, 27 percent have regional lymph node
metastases, and 7 percent have distant metastatic
disease.25 Similarly, the Surveillance, Epidemiology
and End Results Program reported 0.08 percent in
situ, 49.3 percent local, 31.3 percent regional, 7
percent distant, and 11.2 percent unknown extent
of disease at presentation.11 Fourteen percent
of patients with Merkel cell carcinoma present
with visceral or lymph node metastases but have
unknown primary tumor.18
Fig. 1. Merkel cell carcinoma presented as a firm intradermal
upper arm papule.
Volume 131, Number 5 • Merkel Cell Carcinoma
Fig. 2. Merkel cell carcinoma of the cheek presenting as red or
violaceous nodules.
Fig. 3. Ulcerated and crusted locally advanced Merkel cell carci-
noma of the upper arm. (Courtesy of Nho Tran, M.D.)
DIAGNOSTIC EVALUATION
The diagnosis of Merkel cell carcinoma is
established by biopsy. The appearance of early
Merkel cell carcinoma is misleadingly benign, and
the tumor is often thought to be a benign epider-
mal cyst until a biopsy specimen is obtained. His-
tologic confirmation by close-margin excisional,
incisional, or punch biopsy is necessary to dif-
ferentiate the lesion from basal or squamous cell
Fig. 4. Merkel cell carcinoma presenting as a papule of skin color.
carcinoma, amelanotic melanoma, keratoacan-
thoma, adnexal tumors, or cutaneous metastatic
disease.26 Elliptical biopsy incisions should be ori-
ented parallel to dermal lymphatics to minimize
interference with future sentinel node biopsy and
wide local excision. Routine hematoxylin and
eosin staining reveals small, round, blue cells with
large prominent nuclei, which is typical for other
neuroendocrine tumors. Immunohistochemis-
try is required to further classify this small round
blue cell tumor. Cytokeratin-20 is characteristic
for Merkel cell carcinoma (89 to 100 percent) but
present only in one-third of small-cell lung can-
cers. In contrast, thyroid transcription factor-1 is
usually absent in Merkel cell carcinoma but com-
mon in small-cell lung cancers.27 Neuron-specific
enolase, chromogranin A, and neural cell adhe-
sion molecules are additional though less specific
markers.28
Merkel cell carcinoma is a tumor that follows
the Halstedian model of metastatic spread, with
an orderly, stepwise progression of metastases
to regional nodes before hematogenous
dissemination.29–33 Evaluation of the tumor spread
at the time of presentation (staging) will determine
treatment approach and prognosis. Involvement
of regional lymph nodes is relatively common
and early. It often occurs in the absence of deep
invasion by primary tumor or large tumor size;
however, intralymphatic (“in-transit”) metastases
are uncommon. Regional lymph nodes are
examined as part of the initial physical assessment.
The presence of regional adenopathy deserves
cytologic evaluation, preferably with ultrasound-
guided fine-needle aspiration to distinguish
between metastatic and inflammatory adenopathy.
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 Plastic and Reconstructive Surgery • May 2013

Both ultrasound and computed tomography cytologic assessment (fine-needle aspiration or

are used, depending on the clinical setting, the
anatomical location, and the surgeon’s preference.
Combination of physical examination, imaging,
and image-guided fine-needle aspiration are useful
in determining gross metastatic involvement of
the lymph nodes (macrometastases), which would
allow the surgeon to proceed with therapeutic
lymph node dissection. In clinically negative
regional lymph nodes, however, microscopic
metastatic disease is present in 29 to 32 percent of
Merkel cell carcinoma patients.34,35
Merkel cell carcinoma patients with large
or ulcerated primary tumors and/or palatable
regional metastases are at risk for distant meta-
static disease. Although no consensus exists in the
literature, advanced imaging modalities such as
computed tomography/positron emission tomog-
raphy fusion have superior ability for detecting
distant metastatic spread in rapidly proliferating
tumors,36,37 and may be helpful in localizing Merkel
cell carcinoma with unknown primary tumor.38
STAGING
Clinical staging is determined by the extent of
the tumor spread at the time of the initial evalu-
ation and before the first oncologic treatment.
Size of the primary tumor; involvement of the sur-
rounding structures; enlargement of the regional
lymph nodes; and presence of distant metastases
based on physical examination, imaging, and
core biopsies) are components of this clinical
assessment (Table 1). Pathologic staging is based
on postoperative histologic evaluation of the
extent of tumor spread.
Regional nodal metastatic disease is defined as
tumor spread confined to one or two contiguous
nodal basins. In contrast to malignant melanoma,
current American Joint Committee on Cancer
staging for Merkel cell carcinoma does not have
a subcategory for in-transit metastatic disease.39
Histologic assessment of the regional lymph nodes
is the key to pathologic staging and is unusu-
ally important for this particular tumor. It is best
accomplished by sentinel node biopsy followed
by comprehensive pathologic evaluation of the
sentinel node. The patients whose sentinel node
biopsy results were negative had a significantly
better 5-year relative survival (76 percent) than
those who were clinically observed (59 percent; p <
0.0001).25 Because approximately one-third (29 to
32 percent) of Merkel cell carcinoma patients with
clinically negative lymph nodes will harbor micro-
scopic lymph node metastases,34,35,40 the distinction
between clinical and pathologic staging (par-
ticularly histologic evaluation of lymph nodes) is
highly significant for predicting outcomes.25 This
formed the basis for separating subgroups A and
B in stages I and II in the current American Joint
Committee on Cancer staging system.39
Merkel cell carcinoma has a high affinity to
lymph nodes. Distant nonregional lymph nodes

Table 1. New American Joint Committee on Cancer Staging Classification of Merkel Cell Carcinoma and
Survival*
Relative Survival (yr)
Stage Group Definition 1 3 5
Stage 0 0 Tumor in situ No data No data No data
Stage I: primary tumor IA Microscopically negative lymph nodes (pN0) 100 86 79
­diameter ≤2 cm (T1) IB Clinically negative, but not microscopically exam- 90 70 60
ined lymph nodes (cN0)
Stage II: primary tumor ­diameter >2 cm
2 to ≤ 5 cm (T2), IIA Primary tumor confined to skin (T2/3) with 90 64 58
­microscopically negative lymph nodes (pN0)
>5 cm limited to skin (T3) IIB Primary tumor confined to skin (T2/3) with 81 58 49
­clinically negative, but not microscopically
examined lymph nodes (cN0)
Outside skin (T4) IIC Primary tumor involving underlying structures 72 55 47
(T4) without regional metastases (N0)
Stage III: regional nodal IIIA Any primary tumor with nodal micrometastases 76 50 42
metastases (pN1a)
IIIB Any primary tumor with nodal macrometastases 70 34 26
(pN1b) or in-transit metastases (N2)
Stage IV: distant metastases IV Any primary or nodal disease with distant 44 20 18
­metastatic disease
*Data from Lemos BD, Storer BE, Iyer JG, et al. Pathologic nodal evaluation improves prognostic accuracy in Merkel cell carcinoma: Analysis
of 5823 cases as the basis of the first consensus staging system. J Am Acad Dermatol. 2010;63:751–761; and Edge SB, Byrd DR, Compton CC, et al.
AJCC Cancer Staging Manual. Vol. 1, 7th ed. New York: Springer; 2010.

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Volume 131, Number 5 • Merkel Cell Carcinoma
are the most common sites of metastatic spread,
followed by liver, lung, bone, brain, and any other
organs.
TREATMENT
Treatment is dependent on clinical stage and
may include any combination of excision, radia-
tion therapy, and chemotherapy. The infrequent
nature of Merkel cell carcinoma precludes large-
scale randomized clinical trials to address contro-
versies of the width of the surgical margin and
the use of adjuvant radiation therapy. Although
Merkel cell carcinoma is radiosensitive, the tra-
ditional treatment is surgical and has largely
been extrapolated from melanoma treatment
experience.
Surgical Treatment
Wide local excision of the primary tumor
with negative margins to the investing fascia or
pericranium is the mainstay of surgical treatment.
The width of margins, however, is controversial,41
but a 1- to 2-cm margin has been advocated
based on retrospective data31 and the National
Comprehensive Cancer Network.42 Similarly, the
extension of margins beyond 1.1 cm did not have
an impact on local recurrence rates in another
large study.32 Two-centimeter margins should
probably be reserved for Merkel cell carcinoma
primary tumors greater than 2 cm in diameter.28
An alternative to wide local excision is modified
Mohs micrographic surgery that uses the Mohs
excision technique followed by reexcision of
the entire margin with a width of 0.5 to 1 cm.
This margin is then subjected to pathologic
examination. Mohs excision is comparable to
wide local excision local control,43,44 histologic
inspection of the entire surgical margin, and
tissue preservation advantage of the Mohs
technique. The latter is exceedingly valuable
for head and neck Merkel cell carcinoma and
in proximity to cosmetically sensitive structures.
Boyer et al. reported a 5-year survival of 79
percent with a 4 percent rate of local recurrence,
a 16 percent rate of regional recurrence, and
an 8 percent incidence of distant metastatic
spread for patients treated with Mohs excision
alone. These values were not statistically differ­
ent for the group treated with adjuvant radiation
therapy.44
Management of the regional disease is the
critical point in the treatment of Merkel cell car-
cinoma. The initial approach was based on the
observation of clinically negative regional lymph
nodes. Regional recurrences were treated with
salvage lymphadenectomies. These recurrences,
however, frequently represented the delayed
manifestation of micrometastases that were
present in the lymph nodes at the time of initial
presentation and treatment. In this setting, local
and particularly regional adjuvant irradiation
following removal of the primary tumor was ben-
eficial in reducing local and regional relapse45
because it treated regional micrometastases.
Sentinel lymph node biopsy relies on selec­
tive sampling of the first lymph node(s)
draining the primary tumor. Its localization is
aided by preoperative lymphoscintigraphy and
intraoperative blue dye lymph node mapping. The
sentinel node is identified and studied extensively,
and its histology has been demonstrated to
represent the status of the rest of the lymph
node basin for melanoma46 and a number of
other tumors. The tumors with a high affinity
to and frequency of lymphatic spread, such as
Merkel cell carcinoma, are amenable to accurate
staging by sentinel node biopsy because tumor
involvement of the sentinel node precedes spread
of the tumor to other regional lymph nodes and
hematogenous metastases. Sentinel node biopsy
has been shown to have both therapeutic and
prognostic significance in Merkel cell carcinoma
patients. Positive sentinel node biopsy results
predict the risk of local, regional, and distant
recurrence.34,40 For patients with metastatic
disease in the sentinel node, therapeutic node
dissection is generally recommended based on the
multidisciplinary consensus.28 Adjuvant radiation
therapy may be considered to reduce the rate
of regional failures,40 particularly in high-risk
patients. Alternatively, definitive nodal irradiation
can be delivered without completion of regional
lymph node dissection. Negative sentinel node
biopsy results denote a substantially lower rate of
regional recurrences of 3 to 8 percent.35,40 This is
related to the false-negative rate of sentinel node
biopsy, which is estimated to be approximately
15 percent.35 This rate is higher for Merkel cell
carcinoma than it is for melanoma. Several possible
explanations exist: (1) more common multinodal
involvement; (2) more common head and neck
locations; and (3) more common subcutaneous
spread of Merkel cell carcinoma that often has a
different lymphatic drainage pattern than that for
intradermal injection. Use of adjuvant radiation
therapy to treat Merkel cell carcinoma patients
with negative sentinel node biopsy results remains
controversial.
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Table 2. Recommended Radiation Therapy Doses
Dose (Gy)
Primary tumor site
Resection with negative margins
Microscopic positive margins
Grossly positive margin
Regional lymph node basin
Pathologically negative lymph nodes
Clinically negative without surgical staging
Failed sentinel node biopsy
Micrometastases
   Extremities or trunk
   Head and neck
Macrometastases
   Axilla or groin
   Head and neck
NR, not recommended.
Patients with clinically positive regional
lymph nodes confirmed cytologically require
evaluations for distant metastatic spread. In the
absence of distant metastases, therapeutic lymph-
adenectomy is indicated. Despite this effort,
however, most of these patients with stage IIIB
Merkel cell carcinoma will die as a result of their
disease, with only 26 percent of patients alive at
5 years.25,39
Radiation Therapy
Merkel cell carcinoma is a radiosensitive
tumor. Radiation therapy is used for the treat-
ment of local and regional disease as a single
definitive modality or as a postoperative (adju-
vant) therapy following completion of surgical
treatment. Definitive radiation therapy usually
delivers 45 to 70 Gy and is typically used in
patients who are either not acceptable surgical
candidates because of medical comorbidities,
or whose tumors are unresectable because of
advanced disease. Local and regional control
within the irradiated field of 75 percent has been
reported.47 Adjuvant radiation therapy usually
includes primary tumor site and regional lymph
nodes (Table 2). A number of studies reported
improved local and regional control for com-
bined surgical and radiation treatment, with the
highest level of evidence being a comprehensive
review of 132 published studies48 and retrospec-
tive review of the Surveillance, Epidemiology
and End Results Program database.49 Routine
administration of adjuvant radiotherapy is con-
troversial. Postoperative irradiation is strongly
indicated in high-risk patients that have bulky
regional disease, extracapsular extension, and
multiple metastatic lymph nodes with more than
four axillary or more than 10 inguinal lymph
nodes42 (Table 3).
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Plastic and Reconstructive Surgery • May 2013
Table 3. Indications for Postoperative Radiation
Therapy
Primary tumor >1 cm in diameter
50–56 Absence of surgical assessment of lymph node basin
56–60 Positive sentinel node without completion of node dissection
60–66 Bulky nodal disease with multiple (4+ axillary and 10+
­inguinal) lymph node metastases
NR Extracapsular spread
46–50 Salvage operation for recurrent disease
46–50 Positive margins that cannot be surgically reexcised
50
50–56
Chemotherapy
50–54 The aggressive biology of Merkel cell carci-
50–56
noma, with high rates of regional and systemic
metastases, makes the use of systemic chemother-
apy appealing. Indeed, chemotherapy has high
initial response rates in metastatic settings, but
it is also associated with frequent and substantial
toxicity that affects quality of life and mortality.
This makes it difficult to administer adjuvant che-
motherapy in the absence of detectable disease
to patients, many of whom are old and medically
compromised.
Concurrent chemoradiation therapy is based
on the premise of chemosensitization of the
tumor to radiation therapy. Randomized trial
TROG 96:07 has examined the efficacy of
radiation therapy with and without concurrent
chemotherapy (carboplatin and etoposide) in
Merkel cell carcinoma and failed to show a survival
benefit.50 Similarly, adjuvant chemotherapy did
not demonstrate improvement in survival in
several underpowered studies.32,33 Neoadjuvant
chemotherapy relies on the induction of remission
followed by consolidation with local and regional
radiation therapy.51 The initial response rate is
high, but data supporting the survival benefit are
lacking in the literature.
Multiagent chemotherapy with regimens that
are used in the treatment of small-cell lung carci-
noma is typically used for management of distant
disease. An overall response rate of 57 percent
has been reported.52 Responses to combinations
of cyclophosphamide/doxorubicin/vincristine
(61.5 to 70 percent), platinum/etoposide (47 to
60 percent), and doxorubicin/cisplatin (100 per-
cent) were observed.52,53 The median duration of
response was 8 months overall, with 3 months for
partial and 20 months for complete responses.52
Data to support the use of chemotherapy are lack-
ing because of the infrequent nature of Merkel
cell carcinoma. Adjuvant chemotherapy is not
routinely recommended unless the clinical situa-
tion dictates a high risk of distant metastatic dis-
ease.42 The main considerations for chemotherapy
Volume 131, Number 5 • Merkel Cell Carcinoma
administration are patients at high risk for devel-
opment or with presence of distant metastatic dis-
ease, and patients with recurrent disease in whom
effective surgical and radiation treatments are not
feasible.
FOLLOW-UP
Merkel cell carcinoma has a high recur-
rence rate, and close follow-up is necessary. Mean
relapse time is 8 months, and 90 percent of recur-
rences occur within the first 2 years after initial
treatment.28,32,54 National Comprehensive Cancer
Network guidelines recommend follow-up visits
every 1 to 3 months during the first year, every
3 to 6 months during the second year, and every
6 to 12 months thereafter. These follow-up visits
include a review of systems focused on the symp-
toms suggestive of recurrent metastatic disease or
second malignancy and examination of the surgi-
cal site, regional and nonregional lymph nodes,
and total skin examination.42 Imaging is used as
clinically indicated.
OUTCOMES
Merkel cell carcinoma is a very aggressive
disease, with a mortality rate that exceeds that of
melanoma.55 The disease has a 2-year mortality
rate of 28 percent.32 Merkel cell carcinoma recurs
locally in 25 to 30 percent, regionally in 52 to 59
percent, and distantly in 34 to 36 percent.31,41,56
Remarkably, even for a small tumor with a micro-
scopically negative sentinel node, 5-year mortality
is 21 percent.39
The new American Joint Committee on
Cancer staging system is based on the survival
analysis of the records of 4700 Merkel cell carci-
noma patients from the National Cancer Data-
base (Table 1).25,39 Particular emphasis is placed
on histologic staging of the lymph nodes as a
significant predictor of the outcome of this
aggressive disease. Additional factors such as
primary tumor thickness, lymphocyte infiltra-
tion, histologic growth pattern, lymphovascular
invasion, size of the tumor nests in the lymph
nodes, and extracapsular extension are under
investigation in relevance to the prognosis of
this tumor.39
Future directions will focus on the accuracy of
surgical staging and development of more effec-
tive adjuvant therapies such as immunotherapy,
targeted immunostimulation, and gene therapy in
light of recent breakthroughs in Merkel cell poly-
omavirus oncogenesis.
Alex Senchenkov, M.D.
Mayo Clinic
200 First Street SW
Rochester, Minn. 55905
senchenkov@yahoo.com
Acknowledgments
The authors thank Heather M. Vaith and John P.
Hedlund for assistance in preparation of this article.
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