Extrafacial granuloma faciale presenting as an annular plaque of the scalp

Abstract

adjuvant radiation therapy (RT) for localized disease as recommended by NCCN guidelines. 2 While patients in Terushkin et al.'s investigation did not have clinically palpable lymphadenopathy, there are no data on sentinel node status for pathologic staging, which is central to management of MCC given the high prevalence (approximately 33% across numerous studies) of occult nodal metastasis in patients with clinical N0 disease. 3 Given the lack of baseline pathologic nodal evaluation, it is unclear how the authors accurately determined nodal recurrence.The authors do not address whether there was a selection process or algorithm for choosing MMS over WLE in their clinic during this 18-year time period, introducing a possible source of bias.Evaluating the efficacy of MMS versus WLE + RT is difficult without prospective data, and retrospective studies have to control for potential confounders and selection bias, which may have influenced the outcomes of the present study, especially in the absence of head-to-head comparisons. In one study in the National Cancer Database, an analysis of 6227 patients demonstrated that WLE with RT had improved overall survival over MMS alone after accounting for age, sex, comorbidities, primary site of lesion, and tumor size on propensity score matched analysis. 4 While the authors suggest that MMS may obviate the need for adjuvant radiation, a locoregional recurrence rate of 35.7% (20/56 primaries) was observed in their study, which could plausibly have been lower if occult nodal disease was detected and radiation was given. Although MMS has demonstrated low recurrence rates in other cutaneous neoplasms, in some investigations, this approach has resulted in local recurrence rates exceeding 20% when applied for MCC. 5 Furthermore, a growing body of evidence suggests that surgical margins of at least 1 cm plus adjuvant RT compared to surgery alone are associated with improved overall survival and reduced risk of locoregional recurrence for patients with Stage I and II disease. 6,7 The study by Terushkin et al. offers a unique perspective on MMS for early stage MCC; however, given the aggressive nature of MCC with high rates of recurrence and clinically occult nodal spread, these results are unlikely to influence current guidelines which recommend SLNB and surgical excision with wide margins (>1 cm) with the addition of adjuvant radiation when larger margins are not clinically feasible.

A Case of Granuloma Faciale Successfully Treated with Minocycline

“… 2 Clinical manifestations of GF include single or multiple reddish brown or purplish red nodules and plaques on the face, occasionally occurring in areas outside the face. 3 The progression of skin lesions is slow and persistent, rarely self subsiding, causing a risk of disfigurement. Therefore, once diagnosed, active treatment is of paramount importance.…”