case_images: PMC7545440_01
case_images: Patient clinical course. A timeline was provided beginning at day 0, set to the initial histological Merkel cell carcinoma diagnosis of the left cheek nodule. Abbreviations: MCC, Merkel cell carcinoma; PET/CT: positron emission tomography/computed tomography; FDG: fluorodeoxyglucose; OSH: outside hospital; XRT: radiation therapy; US: ultrasound; LFTs: liver function tests.
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case_images: fig1
case_images: Shave biopsy of a 14 mm firm nodule 2 months prior to presentation to our clinic had shown MCC extending to peripheral and deep tissue edges with perinuclear dot-like positivity for CK20, positivity for synaptophysin, weak focal reactivity for AE1/AE2, and negative staining for TTF-1 (Figures 1 and 2).
case_images: Shave biopsy pathology from the left cheek primary lesion. (a) Small purple cells consistent with neuroendocrine carcinoma. (b) Positivity for synaptophysin. (c) Perinuclear dot-like positivity for cytokeratin 20. (d) Primary lesion two weeks after initial confirmatory biopsy.
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case_images: fig2
case_images: Shave biopsy of a 14 mm firm nodule 2 months prior to presentation to our clinic had shown MCC extending to peripheral and deep tissue edges with perinuclear dot-like positivity for CK20, positivity for synaptophysin, weak focal reactivity for AE1/AE2, and negative staining for TTF-1 (Figures 1 and 2).
case_images: Staging PET/CT scan. (a) Primary site of disease to the left cheek. (b) Regional metastasis to the left parotid.
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case_images: fig3
case_images: FDG avidity in the primary left cheek mass, as well as focal activity in multiple intraparotid lymph nodes, with no evidence of distant disease (Figure 3). Past medical history was notable for hypertension, hyperlipidemia, depression, and degenerative joint disease; there was no prior history of skin cancer or immunosuppression. Family history was negative for melanoma or nonmelanoma skin cancers.
case_images: Primary site of disease to the left cheek (27 x 22 mm) at the time of presentation to our multidisciplinary clinic (7.5 weeks after confirmatory biopsy).
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case_images: fig4
case_images: Our examination revealed an exophytic, friable tumor measuring 27 mm x 22 mm on the left cheek and palpable mass in the left parotid and submandibular areas (Figure 4).
case_images: (a) Truncal eruption of pink macules and thin papules with minimal overlying scale coalescing centrally at the upper back and chest, with extension to the rest of torso and upper extremities, hospital day 4. (b) Biopsy revealed an interface dermatitis with dyskeratosis and superficial perivascular lymphocytic infiltrate. (c) Primary lesion to the left cheek showing significant recession on clinical examination after bimodality therapy, hospital day 4.
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case_images: fig5
case_images: A punch biopsy revealed an interface dermatitis with dyskeratosis and superficial perivascular lymphocytic infiltrate (Figure 5).
case_images: (a) Right upper quadrant ultrasound, hospital day 4, was notable for diffusely heterogeneous hepatic parenchyma with scattered hypoechoic lesions, suspicious for malignancy. No intrahepatic biliary ductal dilatation was observed. (b) Core liver biopsy revealed metastatic disease occupying roughly 60% of the total parenchyma. Background hepatic parenchyma was without signs of marked inflammation. (c) Gross inspection of the liver revealed replacement of the parenchyma by firm tan/yellow confluent nodules and punctate hemorrhagic areas. (d) Cross section of hepatic tissue recapitulated overwhelming tumor burden.
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case_images: fig6
case_images: An ultrasound-guided nonfocal liver biopsy was obtained, which confirmed extensive metastatic disease (Figures 6(a) and 6(b)). At autopsy, 80% of the hepatic parenchyma was found to be replaced by tumor, with the remaining background tissue revealing steatosis, cholestasis, and necrosis with minimal inflammation (Figures 6(c) and 6(d)).