In this interview, Dr. Jacob talks with Douglas and Jared about recognizing and managing Merkel cell carcinoma, an aggressive tumor that rarely announces itself at the time of biopsy.
In this video
Dr. Jacob emphasizes that Merkel cell carcinoma is "rarely on the clinician's radar at the time of biopsy" — there's "no obvious blinking red light." The classic picture is an elderly male with a rapidly growing, changing pink nodule on the head and neck, and the risk climbs in patients who are immunosuppressed from medications or transplant. Because the lesion grows fast, a high level of suspicion and making the diagnosis early is what gives patients their best chance.
On biopsy technique, he reassures clinicians that depth of invasion matters for prognosis but won't change management, so unlike a pigmented lesion where a thin shave is a problem, whatever you're comfortable doing to make the diagnosis is fine. For treatment, patients undergo wide excision, more aggressive scanning, and often radiation of the primary site given the risk of local recurrence. And he offers real hope: a bullet point he'd written calling for "more effective therapy" was struck out that day because immunotherapy is proving very effective.
- Keep a high index of suspicion for Merkel cell in elderly, immunosuppressed patients with a rapidly growing pink nodule on the head and neck.
- There's no obvious tell at biopsy — the lesion is rarely on the clinician's radar, so early diagnosis depends on suspicion.
- Depth of invasion affects prognosis but not management, so a thin shave that would be a problem for suspected melanoma is acceptable here — the priority is making the diagnosis.
- Management is aggressive: wide excision, a lower threshold for scans, and often radiation of the primary site because of local recurrence risk.
- Immunotherapy is now proving very effective — enough that Dr. Jacob struck 'we need more effective therapy' from his talk.
