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NEOADJUVANT REGIONAL CHEMOTHERAPY TO TREAT UNRESECTABLE RECURRENT MERKEL CELL CARCINOMA
S Liebscher, J Mammen
University of Kansas School of Medicine

Background
Merkel cell carcinoma (MCC) is a rare, aggressive, cutaneous disease with a high propensity for local-regional recurrence.1 NCCN guidelines for treating the disease are primarily surgical with wide local excision (WLE) of the primary tumor and sentinel lymph node biopsy (SLNB) to assess for lymph node metastasis. In cases of local-regional recurrence, treatment with systemic therapy, radiation therapy, surgery, or a combination thereof is recommended.24 One option that has shown promise over the past decade is the use of hyperthermic isolated limb perfusion (HILP) for the management of recurrent local-regional disease.510 We present one case of neoadjuvant HILP to successfully treat unresectable, locally recurrent, MCC of the right upper extremity (RUE).

Results
The case is a 79-year-old male who initially presented with MCC isolated to the RUE. He underwent WLE with SLNB (pT2N0M0) followed by 5,000 cGy of radiation therapy to the RUE. He remained disease-free for two years until he developed a recurrence in the right axilla. He underwent a right axillary lymph node dissection followed by chemoradiation and treatment with avelumab. MRI two months following completion of systemic treatment demonstrated progression of disease now involving the medial margins of the bicep, brachialis, and triceps musculature as well as the brachial artery and vein, basilic vein, and ulnar and medial cutaneous nerves. He underwent HILP to the RUE via right axillary artery and vein cannulation with 22mg of melphalan (12mg/L) for 60 min at a rate of 300 mL/minute and a temperature of 42C. His postoperative course was uneventful, and he was discharged on postoperative day three. An MRI obtained 5 weeks postoperatively demonstrated a significant decrease in mass size from 4.3 x 3.9 x 5.8 cm to 2.2 x 1.0 x 1.5 cm with no involvement of the neurovascular structures. He proceeded with WLE with negative margins and had sustained local-regional control for 12 months. Later, he developed metastatic disease to the pancreas and is currently undergoing systemic treatment.

Conclusion
This case demonstrates the neoadjuvant use of HILP to successfully treat an advanced, unresectable, local-regional recurrence of MCC and allow for surgical resection and durable local-regional control.


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