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Merkel cell carcinoma (MCC) is an uncommon malignancy originating in epidermis. The anti-tumour necrosis factor (TNF)-α is used to treat psoriasis, rheumatoid arthritis and other inflammatory diseases. We report here a case of MCC in a relatively young patient that showed exceptionally rapid progression, which is uncommon for this type of tumour. The tumour appeared after 18 months of etanercept treatment. Cessation of its rapid growth was associated with interruption of anti-TNF-α treatment. CASE REPORT A 50-year-old white woman was referred to our clinic with an erythematous nodular lesion on her neck. Approximately 3 months previously she had first noticed a small (diameter approximately 1.5 cm) nodule that had rapidly increased in size and consistency and was soon associated with bleeding episodes following mild mechanical trauma. Physical examination revealed a shiny, firm, non-tender red polypoid nodule, approximately 2 × 2 cm in size with a wide erythematous base and no clinical lymphadenopathy (Fig. 1a). The lesion was scheduled for a diagnostic incisional biopsy. At the general physical examination the patient was in good health with no specific pathological signs or symptoms, apart from psoriatic arthritis without skin manifestations. This condition had been treated during the preceding 18 months with injections of etanercept (50 mg/week), with a good clinical response. The patient stated that she had never used any other immunosuppressive drugs or had phototherapy. Two weeks after visiting our clinic, at the time scheduled for the incisional biopsy, the lesion appeared markedly enlarged (4 × 3 cm) and the patient reported pain at the site of the tumour and in adjacent neck tissue (Fig. 1b). At that time, etanercept therapy was discontinued and the patient was given 8 mg/day corticosteroid and 7.5 mg methotrexate every 10 days. Fifteen days after the biopsy, when the stitches were removed, no further growth of the tumour was observed. The patient reported that the lesion had stopped growing 2 days after the withdrawal of etanercept therapy. The histopathological diagnosis was MCC. The patient was referred to the plastic surgery department for removal of the lesion. On physical examination, no local or regional lymph nodes were detected and blood test results were normal. A computed tomography (CT) scan of the thorax and of abdomen detected no lesions. However, despite excision with wide margins, the patient developed laterocervical locoregional lymph nodal metastases 6 months later. She died 16 months after the diagnosis from systemic metastases due to MCC.

Rapid Growth of Merkel Cell Carcinoma During Etanercept Treatment of Psoriatic Arthritis: Cause or Coincidence?