Complete remission of Merkel cell carcinoma of the scalp with local and regional metastases after topical treatment with dinitrochlorbenzol.

Merkel cell carcinoma (MCC) is a highly aggressive tumor with a high percentage of recurrence, metastatic spread, and mortality. Treatment of metastasized MCC is not standardized and prognosis of metastasized MCC is often poor. Current protocols recommend surgery, adjuvant radiation therapy, and often lymph node dissection to prevent recurrences. A few sporadic reports of spontaneous regression of MCC suggest a so far not yet characterized role and potential of the immune system in controlling this tumor. We describe a 69-year-old man with extended inoperable MCC of the scalp including multiple local and regional metastases who responded with complete remission to 4 weekly treatments of topically applied immune-modulating dinitrochlorbenzol. Together with subsequent irradiation, remission has now lasted for more than 1 year.

Sarcoidal-type allergic contact granuloma: a rare complication of ear piercing.

As body piercing is increasingly en vogue, complications are on the rise as well. Biopsies of such lesions can impose special problems to the reviewing dermatopathologist. We present two patients who developed papulonodular lesions at the sites of ear piercings. Unexpectedly, the findings included prominent sarcoidal granuloma formation with confluent areas of fibrinoid necrosis. An infectious etiology was excluded. However, patch testing revealed contact allergy to palladium, platinum, and nickel. Interestingly, histopathologic examination of the patch test sites also demonstrated granuloma formation. These findings suggest that the lesions represent allergic contact granulomas. When confronted with this special type of tissue reaction in skin biopsies of piercing sites, the reviewing dermatopathologist should consider the possibility of an allergic reaction. Careful history and thorough diagnostic procedures, including biopsy of the patch test site can establish the diagnosis of contact allergic granuloma.

Identification of activated matrix metalloproteinase-2 (MMP-2) as the main gelatinolytic enzyme in malignant melanoma by in situ zymography.

The involvement of extracellular matrix-degrading enzymes, such as matrix metalloproteinases and serine proteases, during tumour progression and metastasis is well established. In particular, the activation of pro-matrix metalloproteinase (MMP)-2 on the surface of malignant cells by membrane-bound MT1-MMP has been shown to contribute to the invasive abilities of various tumours. This study presents evidence that in tissue of malignant melanomas, increased effective gelatinolytic activity is mainly located at sites where melanoma cells interact with the surrounding extracellular matrix. Forty-one primary melanomas (30 superficial spreading and 11 nodular type) and six lymph node metastases were investigated by a modified technique of gelatin in situ zymography. This technique localizes areas of effective proteolytic activity within tissue sections. In 28/41 (68%) primary melanomas and in 6/6 (100%) metastases, considerable proteolysis was detected at the invading part of the tumour and especially at sites of tumour-stroma interactions, whereas no or only weak proteolytic activity was localized within the centres of solid nests of tumour cells. Zymographic analysis of extracts obtained from different areas of microdissected melanoma specimens identified activated MMP-2 as the enzyme responsible for this activity. Immunohistochemical analysis detected strong staining for MMP-2 and MT1-MMP, even in areas in which no proteolytic activity was found by in situ zymography, emphasizing the importance of more functional techniques for the investigation of balanced proteolytic systems. This technology makes it possible to draw conclusions regarding the balance between activated proteases and inhibitors, which are frequently found to be present together in close proximity in vivo.

Role of postoperative radiotherapy in the management of Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumor of the skin with a high potential of locoregional relapse after surgery alone. This report is an update of our experience in the treatment of MCC. From January 1990 to May 2000, 31 patients with MCC, 13 men and 18 women aged between 34 and 92 years, were treated at the University of Cologne, Germany. Primary tumor sites were in the head and neck region in 13 patients, limbs in 13, and trunk in 5. The tumors were stage I in 26 of 31 patients, stage II in 4 of 31 and stage III in 1 of 31. Treatment included surgery alone in 14 of 31 patients, adjuvant postoperative radiotherapy in 16 of 31 patients, 1 of them had incomplete surgery, and definitive radiotherapy in 1 of 31 patients (stage III). Median overall survival (OS) after first diagnosis was 32 months (95% confidence interval: 0-75 months) with a 3-year OS rate of 47% (95% CI: 25-69%). Six of 31 patients relapsed locally after a median of 4 months, 10 of 31 patients developed regional node metastases, and 7 of 31 patients distant metastases. Nine patients died as a direct result of MCC. Locoregional control and disease-free survival were significantly improved in the group with postoperative radiotherapy (p = 0.023). Uni- and multivariate analysis revealed that head and neck location of the tumor and the lack of postoperative radiotherapy are unfavorable prognostic factors. Postoperative radiotherapy to the primary tumor region and the regional lymphatics is effective in the prevention of locoregional recurrence. Prospective clinical trials should be performed to confirm these observations.