The role of surgeons in the treatment of Merkel cell carcinoma (MCC) of the skin is reviewed, with respect to diagnosis and treatment. Most of the data in the literature are case reports. Surgery is the mainstay of treatment. A wide local excision, with sentinel node (SLN) biopsy, is the recommended treatment of choice. If SLN is involved, nodal dissection should be performed; unless patient is unfit, then regional radiotherapy can be given. Surgeons should always refer patients for assessment of the need for adjuvant treatments. Adjuvant radiotherapy is well tolerated and effective to minimize recurrence. Adjuvant chemotherapy may be considered for selected node-positive patients, as per National Comprehensive Cancer Network guideline. Data are insufficient to assess whether adjuvant chemotherapy improves survival. Recurrent disease should be treated by complete surgical resection if possible, followed by radiotherapy and possibly chemotherapy. Generally results of multimodality treatment for recurrent disease are better than lesser treatments. Future research should focus on newer chemotherapy and molecular targeted agents in the adjuvant setting and for gross disease. 1. Introduction Merkel cell carcinoma (MCC) of the skin is also called trabecular carcinoma, cutaneous neuroendocrine carcinoma, or Merkeloma. It is an uncommon, highly malignant primary cutaneous carcinoma. It is thought to arise from Merkel's cells located in the basal layer of the epidermis and hair follicles, associated with sensory neurites in the dermal papillae, which are the mechanoreceptors in the skin. MCC occurs mostly in white elderly with an equal incidence in men and women. About 78% of patients are older than 59 years. It may be slightly more common in females [1, 2]. There is no sexual predilection in the age group below 60 years. After 60 years, MCC are more often seen in female patients. The tumor is most often located in the head and neck region (50.8%) or the extremities (33.7%). The exact etiology is not known, but is postulated to relate to sunlight, immunosuppression, and infection by a Polyoma virus. The discovery of Merkel cell polyomavirus is a major breakthrough [3]. MCC occurs more frequently in immunosuppressed patients, for example, transplant recipients or AIDS patients. The association of a polyoma virus with this tumor may explain the increased incidence in immunosuppression. The immunological aspect of the cancer is very interesting, with some case reports of complete or partial spontaneous remission [4]. The incidence rate is increasing which could be
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