CASE REPORT
A 32-year-old female with an unremarkable medical history presented to
the clinic with a small, non-tender, and erythematous nodule on the
dorsolateral aspect of her left arm, which initially appeared three
months before. Since then, the nodule had slowly darkened and grown to 1
cm ×1 cm in size. Her history and physical exam were insignificant
except for multiple warts on the dorsal aspect of the right hand.
(Figure 1). Initially, the patient was suspected of having an infectious
cyst and was treated with 10-days of antibiotics. However, she was
unresponsive to antibiotics and was evaluated by a surgeon, who
diagnosed the lesion as an abscess and surgically removed it.
After two weeks, a rapidly growing mass measuring 4 cm ×4 cm originated
from the incised area. The mass was surgically excised again but
reappeared within one week, measuring 5 cm ×5 cm, after which the
patient was referred to our hospital for further evaluation. The
magnetic resonance imaging (MRI11We first met the patient after
her last surgery. Unfortunately, the patient did not take any pictures
from the arm mass at the disease onset and intervals between
surgeries.) of the left arm with and without contrast showed multiple
enhancing lesions at the subdermal region of the posterolateral aspect
of the left arm with multiple enlarged axillary lymph nodes, the largest
of which measured approximately 17 mm, suggestive of metastasis. The
tumor was radically excised with negative surgical margins. Microscopic
examination of the lesion demonstrated a neoplastic round cell tumor
with prominent foci of necrosis (Figure 2). IHC staining revealed
neoplastic cells with positive expression for CD99, Ck20, and NSE
(Figure 2), but no LCA, Vimentin, CD3, CD20, and HMB45 expression
consistent with MCC (Figure 3). Also, The MCPyV PCR real-time of the
lesion was positive.
High-resolution computed tomography (HRCT) Scan of the chest and
abdominopelvic area with and without contrast showed lymphadenopathy 39
mm×25 mm in the left axillary fossa along with a calcified lymph node
(6mm) in the abdominal cavity beyond the left abdominal muscle. She was
diagnosed with stage III MCC and subsequently treated with adjuvant
radiation to her left arm and axilla with 45.0 Grays (Gy) of radiation
in 35 fractions, followed by six cycles of chemotherapy with etoposide
and cisplatin. The patient’s post-treatment PET/CT scan showed no
evidence of neoplastic disease and supported remission. However,
high-dose chemotherapy caused frequent myalgias and weakened immune
system. Unfortunately, she developed febrile neutropenia and expired due
to septic shock one month after the last chemotherapy course.