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Stages of Merkel Cell Carcinoma

Posted on November 4, 2015 in Skin Cancer

Written by Dr. McCall

Learn more about the author

What are the Stages of Merkel Cell Carcinoma?

KEY POINTS

  • What is Merkel Cell Carcinoma?
  • The following stages are used for Merkel cell carcinoma:
    • Stage 0 (carcinoma in situ)
    • Stage IA
    • Stage IB
    • Stage IIA
    • Stage IIB
    • Stage IIC
    • Stage IIIA
    • Stage IIIB
    • Stage IV
  • Risks that cause Merkel Cell Carcinoma
  • Merkel Cell Carcinoma detection and diagnosis
  • After Merkel cell carcinoma has been diagnosed, tests are done to find out if cancer cells have spread to other parts of the body.
  • There are three ways that cancer spreads in the body.
  • Cancer may spread from where it began to other parts of the body.
  • Treatment Options for Merkel Cell Carcinoma
    • Surgery for Merkel Cell Carcinoma
    • Radiation Therapy for Merkel Cell Carcinoma
    • Chemotherapy for Merkel Cell Carcinoma
  • Why do I need a Cancer Treatment Plan?

What is Merkel Cell Carcinoma?

Merkel cell carcinoma is a very rare disease in which malignant (cancer) cells form in the skin. Merkel cells are found in the top layer of the skin. These cells are very close to the nerve endings that receive the sensation of touch.

Merkel cell carcinoma, also called neuroendocrine carcinoma of the skin or trabecular cancer, is a very rare type of skin cancer that forms when Merkel cells grow out of control. Merkel cell carcinoma starts most often in areas of skin exposed to the sun, especially the head and neck, as well as the arms, legs, and trunk.

Merkel cell carcinoma tends to grow quickly and to metastasize (spread) at an early stage. It usually spreads first to nearby lymph nodes and then may spread to lymph nodes or skin in distant parts of the body, lungs, brain, bones, or other organs.

The following stages are used for Merkel cell carcinoma:

Stage 0 (carcinoma in situ)

In stage 0, the tumor is a group of abnormal cells that remain in the place where they first formed and have not spread. These abnormal cells may become cancer and spread tolymph nodes or distant parts of the body.

Stage IA

In stage IA, the tumor is 2 centimeters or smaller at its widest point and no cancer is found when the lymph nodes are checked under a microscope.

Stage IB

In stage IB, the tumor is 2 centimeters or smaller at its widest point and no swollen lymph nodes are found by a physical exam or imaging tests.

Stage IIA

In stage IIA, the tumor is larger than 2 centimeters and no cancer is found when the lymph nodes are checked under a microscope.

Stage IIB

In stage IIB, the tumor is larger than 2 centimeters and no swollen lymph nodes are found by a physical exam or imaging tests.

Stage IIC

In stage IIC, the tumor may be any size and has spread to nearby bone, muscle, connective tissue, or cartilage. It has not spread to lymph nodes or distant parts of the body.

Stage IIIA

In stage IIIA, the tumor may be any size and may have spread to nearby bone, muscle, connective tissue, or cartilage. Cancer is found in the lymph nodes when they are checked under a microscope.

Stage IIIB

In stage IIIB, the tumor may be any size and may have spread to nearby bone, muscle,connective tissue, or cartilage. Cancer has spread to the lymph nodes near the tumor and is found by a physical exam or imaging test. The lymph nodes are removed and cancer is found in the lymph nodes when they are checked under a microscope. There may also be a second tumor, which is either:

  • Between the primary tumor and nearby lymph nodes; or
  • Farther away from the center of the body than the primary tumor is.

Stage IV

In stage IV, the tumor may be any size and has spread to distant parts of the body, such as the liver, lung, bone, or brain.

Risks That Cause Merkel Cell Carcinoma

Sun exposure and having a weak immune system can affect the risk of Merkel cell carcinoma. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for Merkel cell carcinoma include the following:

  • Being exposed to a lot of natural sunlight.
  • Being exposed to artificial sunlight, such as from tanning beds or psoralen and ultraviolet A (PUVA) therapy for psoriasis.
  • Having an immune system weakened by disease, such as chronic lymphocytic leukemia or HIV infection.
  • Taking drugs that make the immune system less active, such as after an organ transplant.
  • Having a history of other types of cancer.
  • Being older than 50 years, male, or white.

Detection and Diagnosis of Merkel Cell Carcinoma

Merkel cell carcinoma usually appears as a single painless lump on sun-exposed skin. This and other changes in the skin may be caused by Merkel cell carcinoma or by other conditions. Check with your doctor if you see changes in your skin.

Merkel cell carcinoma usually appears on sun-exposed skin as a single lump that is:

  • Fast-growing.
  • Painless.
  • Firm and dome-shaped or raised.
  • Red or violet in color.

Tests and procedures that examine the skin are used to detect and diagnose Merkel cell carcinoma.

The following tests and procedures may be used:

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Full-body skin exam: A doctor or nurse checks the skin for bumps or spots that lookabnormal in color, size, shape, or texture. The size, shape, and texture of the lymph nodes will also be checked.
  • Skin biopsy : The removal of skin cells or tissues so they can be viewed under amicroscope by a pathologist to check for signs of cancer.

After Merkel cell carcinoma has been diagnosed, tests are done to find out if cancer cells have spread to other parts of the body.

The process used to find out if cancer has spread to other parts of the body is calledstaging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

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CT scan (CAT scan)

A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. A CT scan of the chest and abdomen may be used to check for primary small cell lung cancer, or to find Merkel cell carcinoma that has spread. A CT scan of the head and neck may also be used to find Merkel cell carcinoma that has spread to the lymph nodes. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

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MRI (magnetic resonance imaging)

A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

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PET scan (positron emission tomography scan)

A procedure to find malignanttumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

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Lymph node biopsy

There are two main types of lymph node biopsy used to stage Merkel cell carcinoma.

  • Sentinel lymph node biopsy : The removal of the sentinel lymph node duringsurgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologistviews the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.
  • Lymph node dissection : A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer. For a regional lymph node dissection, some of the lymph nodes in the tumor area are removed. For a radical lymph node dissection, most or all of the lymph nodes in the tumor area are removed. This procedure is also called lymphadenectomy.

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Immunohistochemistry

 A test that uses antibodies to check for certain antigens in a sample of tissue. The antibody is usually linked to a radioactive substance or a dye that causes the tissue to light up under a microscope. This type of test may be used to tell the difference between different types of cancer.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if Merkel cell carcinoma spreads to the liver, the cancer cells in the liver are actually cancerous Merkel cells. The disease is metastatic Merkel cell carcinoma, not liver cancer.

Treatment Options for Merkel Cell Carcinoma

  • New types of treatment are being tested in clinical trials.
  • Patients may want to think about taking part in a clinical trial.
  • Patients can enter clinical trials before, during, or after starting their cancer treatment.
  • Follow-up tests may be needed.
  • There are different types of treatment for patients with Merkel cell carcinoma.

Different types of treatments are available for patients with Merkel cell carcinoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Surgery for Merkel Cell Carcinoma

One or more of the following surgical procedures may be used to treat Merkel cell carcinoma:

Wide local excision: The cancer is cut from the skin along with some of the tissue around it. A sentinel lymph node biopsy may be done during the wide local excision procedure. If there is cancer in the lymph nodes, a lymph node dissection also may be done.

Lymph node dissection: A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer. For a regional lymph node dissection, some of the lymph nodes in the tumor area are removed; for a radical lymph node dissection, most or all of the lymph nodes in the tumor area are removed. This procedure is also called lymphadenectomy.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation Therapy for Merkel Cell Carcinoma

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy for Merkel Cell Carcinoma

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Why Do I Need a Cancer Treatment Plan?

A cancer treatment plan is a valuable tool for cancer patients, as well as their doctors and caregivers. There are many benefits of a cancer treatment plan:

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Informed Cancer Care Team

There will likely be many specialists involved in the treatment of your cancer, including an oncologist, radiation oncologist, surgeon, pathologist, and all of their teams. Others involved in your care may include a case manager, rehabilitation specialist, palliative care specialist, pharmacist, social worker, and dietitian.

Understanding your cancer and treatment intentions is integral for each of these members of your care team. A detailed, updated cancer treatment plan ensures all of these professionals can effectively contribute to your cancer treatment.

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Informed Doctors Outside of Your Cancer Care

Your cancer is almost certainly your priority right now, but it may not be your only one. It’s important to maintain your health outside of your cancer, especially if you have preexisting conditions.

You should share your cancer treatment plan with your general practitioner, as well as any specialists you see for other medical problems. This will help them to adjust their own treatments effectively.

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Planning and Scheduling Care

As mentioned above, your cancer treatment plan will include your schedule for treatments. By having this in writing, you can plan with members of your family, friends, and even your employer.

You can use your treatment plan to ensure you’ll have the support you need. For example, you can use your cancer treatment plan to schedule rides to and from treatment, take time off work, or ask for help with symptoms from caregivers.

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Identifying Community Resources

Sometimes your cancer treatment plan can help you identify holes in your scheduling and planning. For example, your treatment schedule may not align with your spouse’s time off. Luckily, there are community resources that can help patients in times of need.

If transportation, lodging, or care pose a problem, a detailed cancer treatment plan will help you identify and solve those issues.

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Understanding Symptoms and Care Options

A cancer treatment plan will outline both short and long term symptoms and side effects you may experience with your treatments. This is valuable for a number of reasons:

  • It helps you prepare for those symptoms
  • It helps you identify any unusual symptoms you should discuss with your doctor
  • It may include details for how to manage these symptoms.

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Understanding Your Insurance & Expenses

Finally, a cancer treatment plan can help with insurance and expenses. It’s possible that your insurance will cover all or most of your cancer treatment. However, it’s important to confirm whether this is true and, if not, how you will pay for additional expenses.

Outlining all of your treatments and communicating this to your insurance provider is the first step in developing an understanding around the potential costs of your treatment.

SERO and Your Cancer Treatment Plan

Cancer can be overwhelming, but a cancer treatment plan can help simplify the experience for both patients and their doctors.

In addition to expert specialization, the radiation oncologists at SERO are dedicated to supporting our clients. One of our greatest assets in doing so is a cancer treatment plan. Your cancer care team will likely provide a written cancer treatment plan.

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