Merkel Cell Carcinoma

Left: Merkel cell carcinoma recurrence a few months after excision. Right: Progressive increase in size of recurrence over a few months. (Dr. Noorali Bharwani)
Left: Merkel cell carcinoma recurrence a few months after excision. Right: Progressive increase in size of recurrence over a few months. (Dr. Noorali Bharwani)

82 year-old male nursing home resident presented with a subcutaneous lump on the left knee for three to six months. Medical history includes head injury with intra-cranial bleed due to a fall, resulting in permanent physical disability and cognitive deficit.

The lump was about four cm in diameter. The patient and family requested excision biopsy as the patient kept drawing their attention to the lump that progressively turned red, as if it was getting inflamed. My first impression was that this was not a lipoma but probably an inflamed sebaceous cyst. It was excised under local anesthetic without any complications.


Merkel cell carcinoma of the skin, 4 cm in size. Peripheral and deep margins were extensively involved with lymphovascular invasion.

Merkel Cell Carcinoma (MCC)

Merkel cell carcinoma, a rare type of skin cancer, usually appears as a flesh to bluish-red colored nodule on sun-exposed areas, like the face, head and neck.

Merkel cell carcinoma is usually found in older people. Around 80% are caused by Merkel cell polyomavirus. Exposure to sunlight and a weak immune system increase the chance of developing MCC.

The tumor is locally invasive and also spreads rapidly through the body. Early diagnosis and treatment lowers the chance of metastasis.

Since the lesion has no distinguishable features from other skin cancers, the first treatment is surgical excision. Once the pathology report comes back the lesion can be identified as Merkel cell carcinoma. Further therapies like lymph node biopsy, radiation or chemotherapy can be considered if needed, to prevent metastasis and recurrence.

In this case, no further investigation or treatment were planned, as the patient’s quality of life would be extremely poor should he survive recurrence. The family decided it was time to let nature take its course.

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Making a Mountain out of a Molehill to Prevent Skin Cancer

A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)
A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)

The other day a gentleman asked me, “Doctor B, I have a mole. Do you think I have melanoma?” I didn’t think he had a mole. I thought it was a skin tag. He said, “OK doc, tell me what does a mole look like and when should I worry about it.”

Defining a mole is not easy. People use the word very loosely to describe any blemish on the skin as a mole.

The majority of moles appear during the first two decades of a person’s life, with about one in every 100 babies being born with moles. Acquired moles are a form of benign new growths, while congenital moles, or congenital nevi, are considered a minor malformation and may be at a higher risk for melanoma. Moles are also known as nevi. Most of them have no malignant potential. But real moles and sunburns have a potential to become cancerous.

Real moles are skin growths that are usually brown or black. During sun exposure, teenage years and pregnancy, these cells multiply and become darker. They can be anywhere on the skin, alone or in clusters. Most moles appear in early childhood and by the age of 20, one can have anywhere between 10 to 50 or more moles. Some moles may appear later in life.

Most moles are benign. The only moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20. If you notice changes in a mole’s colour, height, size or shape, you should have these moles checked. If the moles bleed, ooze, itch, appear scaly or become tender or painful then it is time to have them removed and checked for cancer.

The following ABCDEs are important signs of moles that could be cancerous:

  • Asymmetry – one half of the mole does not match the other half.
  • Border – the border or edges of the mole are ragged, blurred or irregular.
  • Colour – the colour of the mole is not the same throughout or has shades of tan, brown, black, blue, white or red.
  • Diameter – the diameter of a mole is six millimetres or larger.
  • Evolution – are the moles changing over time?

Melanoma is one of the three common skin cancers. The other two are basal cell carcinoma and squamous cell carcinoma. Melanoma is the most serious form of skin cancer. If diagnosed and removed early then the cure rate can be excellent. Once the cancer advances and spreads to other parts of the body, it is hard to treat.

Does melanoma occur in children? Yes, approximately two per cent of melanomas occur in patients under the age of 20 years and about 0.4 per cent of melanomas occur in pre-pubertal children.

We can reduce the risk of skin cancer by protecting against sun exposure and sunburn. Natural protection (shade) is considered the best protection. And sunscreen (SPF 15 or higher) should be adjunct to natural protection. Wear sun protective clothing. Wear wide brim hats. And use eyeglasses that block both UVA and UVB light.

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Indoor Tanning Beds are Not Safer than Natural Sunlight

A woman lying in a tanning bed. (Stockbyte/Thinkstock)
A woman lying in a tanning bed. (Stockbyte/Thinkstock)

Many snowbirds are getting ready to move down south for winter. Some are also booking holidays to get away for a couple weeks to warmer places. The idea is to get away from cooler temperatures, spend time on a beach and soak in the natural sunlight. Before they go away, some travellers visit indoor tanning salons to get a mild tan thinking that this would protect them from sunburn and skin cancer.

There are people who like to look tanned year round and visit indoor tanning salons on a regular basis ignoring the fact that indoor tanning is as bad as basking in the natural sunlight. Some parents encourage their children to visit indoor tanning salons. Studies have shown indoor tanning bed use and childhood sunburns increase skin cancer in young adults.

There is no doubt, exposure to ultraviolet (UV) radiation damages your skin, whether the exposure comes from tanning beds or natural sunlight. The damage eventually leads to premature aging of the skin and skin cancer.

A recent Mayo Clinic study, published in the April 2012 issue of Mayo Clinic Proceedings, found dramatic rise in skin cancer in young adults, especially among people under 40. Researchers speculate indoor tanning bed use and childhood sunburns are key culprits. The study found the incidence of melanoma has escalated, and young women are the hardest hit.

“We anticipated we’d find rising rates, as other studies are suggesting, but we found an even higher incidence than the National Cancer Institute had reported using the Surveillance, Epidemiology and End Result database, and in particular, a dramatic rise in women in their 20s and 30s,” says lead investigator Jerry Brewer, M.D., a Mayo Clinic dermatologist, who was quoted in one of the reports.

The study found the incidence of melanoma increased eightfold among young women and fourfold among young men. The lifetime risk of melanoma is higher in males than females, but the opposite is true in young adults and adolescents. The good news is mortality rates from the disease have improved over the years, likely due to early detection of skin cancer and prompt medical care.

If you are a frequent user of indoor tanning beds then you are 74 per cent more likely to develop melanoma. Young women frequent indoor tanning salons more often than young men even though many of them know indoor tanning has carcinogenic effects that increase the risk of melanoma.

A study from New Brunswick showed that by Grade 12, one-third of girls were using tanning salons, and one-third of them were going with their mothers, says a report in the Medical Post. It is unacceptable that mothers should encourage their daughters to expose themselves to well recognized carcinogens. There are seven other studies involving nearly 7,400 cases showing that first exposure to sunbeds before age 35 increase melanoma risk by 75 per cent.

The message is clear, exposure to ultraviolet rays ultimately lead to premature aging of the skin and skin cancer. So, understand the risk and take care of yourself. There are many ways to enjoy winter months. Be safe and have fun.

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Bob Marley and Importance of Melanoma in Darker-Pigmented Population

A reggae hat. (iStockphoto/Thinkstock)
A reggae hat. (iStockphoto/Thinkstock)

A case of recurrent melanoma in a Caucasian male – temple area.

I enjoy Bob Marley music. I listen to his songs quite often. As most of you know, Bob Marley was a Jamaican singer-songwriter and musician. In May 1981, he died at a very young age of 36 from melanoma. This was tragic. If he would have listened to his doctors then, who knows, he would still be around entertaining us with live performances.

In 1977, Marley was found to have malignant melanoma under the nail of one of his toes. Marley turned down doctors’ advice to have his toe amputated, citing his religious beliefs. He followed the Rastafari tradition. The spread of melanoma to his lungs and brain caused his death. Before his death, he is reported to have said, “Money can’t buy life”.

Bob Marley’s case is interesting from a medical point of view. First, melanoma is not that common in black population and secondly, melanoma under the nail (subungual) is not common either. It is an accepted fact that malignant melanoma in black population and other minority ethnic populations represents an aggressive disease highly associated with invasive lesions. They present with more advanced stage of disease at diagnosis, and consequently with a decreased survival compared with Caucasians.

Melanoma is the sixth most common cancer in North America and the single most common one among young adults 25-29 years old. Lifetime risk of developing melanoma in whites is currently estimated at 1 in 50, compared to 1 in 1000 in African-Americans.

Darker-pigmented populations are consistently reported to have lower risk for melanoma, possibly related to protection from ultraviolet radiation (UVR) provided by melanin.

Melanin is the primary determinant of skin color. It is also found in hair, the pigmented tissue underlying the iris of the eye, and other pigmented areas of the body and brain. The melanin in the skin is produced by cells called melanocytes. Some individuals have very little or no melanin in their bodies, a condition known as albinism.

Production of melanin is stimulated by DNA damage induced by UVB-radiation, and it leads to a delayed development of a tan. It is an excellent photoprotectant. This is because it efficiently absorbs harmful UV-radiation (ultraviolet) and transforms the energy into harmless heat. This prevents the indirect DNA damage that is responsible for the formation of malignant melanoma and other skin cancers.

Caucasians have a predilection to develop lesions on sun-exposed surfaces, including face and neck. Blacks have lesions predominantly located on sun-protected mucosal and acral sites.

Acral sites are the palms, soles, under the nails and in the mouth. It occurs on non hair-bearing surfaces of the body which may or may not be exposed to sunlight. Unlike other forms of melanoma, acral lentiginous melanoma (ALM) does not appear to be linked to sun exposure.

Lentiginous means small, flat, pigmented spot on the skin or under the nail. The reason these lesions have poor prognosis is because they are quite often clinically misdiagnosed.

In fact, an estimated one-third to one-half of all cases of ALM are incorrectly diagnosed at initial presentation as the more commonly appearing benign skin lesions including warts, infections, ulcers, callus, traumatic wounds, and blood clots. Some melanomas have no pigment and these are hard to diagnose early unless you notice some change.

The moral of today’s story is: be vigilant, protect against UV rays, and report to your doctor if there is any change in a mole. If you have a pigmented lesion under a nail, palm of your hands, or sole of your feet which does not go away (a blood clot will slowly disappear) then get a biopsy done. And listen to your doctor. Melanoma can be cured if picked up early.

Long live Bob Marley and his music.

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