Stages

If Merkel Cell is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has spread. Also, the doctor will perform more tests to identify if the cancer has spread to other areas of the body. Such tests may include imaging tests -- CT scan, magnetic resonance imaging (MRI), bone scan, or x-ray.

The first section on this page explains how cancer spreads. The second section provides an overview of the additional tests that will likely be performed once Merkel Cell is diagnosed. The third section explains the staging of Merkel Cell itself, while the fourth section indicates treatment methods generally used according to the stage of Merkel Cell Carcinoma.

The Spreading of Cancer

There are three ways that cancer spreads in the body:

Through tissue. Cancer invades the surrounding normal tissue.

Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.

Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary tumor and travel through the lymph or blood to other places in the body, another, or secondary tumor, may form. This process is called metastasis. The secondary, or metastatic, tumor is the same type of cancer as the primary tumor. For example, if Merkel Cell spreads to the bones, the cancer cells in the bones are actually Merkel Cell cancer cells. The disease is Metastatic Merkel Cell Carcinoma, not bone cancer.

Additional Tests

Once Merkel Cell Carcinoma has been diagnosed, another series of tests will be run to establish if and where the cancer has spread. Following are the most common tests:

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.

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).

PET Scan (Positron Emission Tomography Scan): A procedure to find malignant tumor 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.

Octreotide Scan: A type of radionuclide scan used to find carcinomas and other types of tumors. A small amount of radioactive octreotide (a hormone that attaches to carcinoid tumors) is injected into a vein and travels through the bloodstream. The radioactive octreotide attaches to the tumor and a special camera that detects radioactivity is used to show where the tumor cells are in the body.

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 during surgery. 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 pathologist views 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.

Stages of 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 to lymph nodes or distant parts of the body.

Stage I is divided into Stage IA and Stage IB:

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

Stage II is divided into Stage IIA, Stage IIB and Stage IIC:

Stage IIA - In stage IIA, the tumor is larger than two 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 two 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 III is divided into Stage IIIA and Stage IIIB:

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

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.

Merkel Cell Carcinoma Treatment By Stage

In all cases, treatment should be individualized for you. Although cancers are classified into particular stages, each person is unique.

Stage I - Treatment may include surgery to remove the tumor, such as wide local excision with or without lymph node dissection or radiation therapy after surgery or a clinical trial of a new treatment.

Stage II - Treatment may include surgery to remove the tumor, such as wide local excision with or without lymph node dissection or radiation therapy after surgery or a clinical trial of a new treatment.

Stage III - Treatment may include a wide local excision with or without lymph node dissection or radiation therapy or a clinical trial of chemotherapy.

Stage IV - Treatment may include the following as palliative treatment to relieve symptoms and improve quality of life: chemotherapy, surgery, radiation therapy or a clinical trial of a new treatment.

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