BMC Cancer 2005, 5:106 http://www.biomedcentral.com/1471-2407/5/106 Decarboxylation (APUD) cells, which are of neuroecto- dermal origin [6,7]. The tumor is composed of small blue cells with hyper- chromatic nuclei and minimal cytoplasm. Mitoses, nuclear fragments and lymphovascular invasion are almost invariable features [8]. Immunoistochemistry for cytokeratin species more typical of simple epitelial cells than keratinocytes, permits a differential identification of Merkel cells in tissue sections [9]. The immunoistochem- ical profile is characterized of positivity for Neuron-Spe- cific Enolase (NSE), Neurofilament Protein (NFP) and CD57- CD99 [10]. A single punctate zone of cytoplasmic immunoreactivity for cytokeratins especially CK20 is more characteristic [11]. The reaction for CK20 has been used as a finding against metastatic small cell carcinoma of the lung (Cytokeratin 7+ and Thyroid Transcription Factor 1+), small cell melanoma (S100+) and lymphoma (Leucocyte Common Antigen +) [12]. MCC appears to metastasize principally via the lymphat- ics in a predictable stepwise fashion, with an initial involvement of the regional lymph nodes and subsequent systemic spread [13]. If the lymph nodes are not palpable, the pathological examination of the primary tumor (larger than 2 cm, high mitotic rate and lymphatic inva- sion) serves as a parameter for the need of lymph node biopsies [5]. Surgical excision with tumor free margins is the primary therapy for stage I-localized disease, with a 64% of survival in 5 years. However recent studies have shown that there is no clear evidence of a difference in sur- vival [2,14], when the margins of resection are less than the 2–3 cm as generally recommended [2,13] In fact, Mohs micrographic surgery may be more effica- cious than wide excision as it inspects all major borders, including the deep margin (MCC often shows extensive vertical growth) and also allows maximal sparing of nor- mal additional tissue, especially in such cosmetically sen- sitive anatomic areas as the face [15]. A useful adjunct in the treatment of MCC is the sentinel node mapping, which identifies the status of the first draining lymph node and allows to avoid unnecessary lymphadenecto- mies and the resulting postoperative morbidity [16]. MCC cells are radiosensitive, and several studies have argued for the benefits of radiation therapy not only after resection for local recurrence and palliation but as well as adjuvant treatment after initial surgery with curative intent [12]. Chemotherapy is the least studied theraupetic component and propably is mandatory in unresectable or unmanagable by radiotherapy tumors, as well as in meta- static disease [8,17]. CLL occurs primarily in middle-aged and elderly individ- uals, with increasing frequency in successive decades of life. It involves slow proliferation and accumulation of incompetent B-lymphocytes and concurrent abnormali- ties in both humoral and cellular immunity. The majority of patients live 5–10 years, with an initial course that is relatively benign but followed by a terminal, progressive and resistant fase lasting 1–2 years. During the later phase, morbidity is considerable both from the disease and the associated incidence of malignant neoplasms (especially skin cancers as squamous cell carcinoma, Kaposi sarcoma and melanoma) [19]. CLL shares a clinical and morpho- logical overlap with Small Lymphocytic Lymphoma (SLL). In fact if a patient has an absolute lymphocytosis of > 5000/mm3 in the peripheral blood, CLL is diagnosed, regardless of the findings in the lymph node [19]. Treatment of CCL ranges from periodic observation with treatment of infectious, hemorrhagic or immunologic complications to a variety of therapeutic options, includ- ing steroids, alkylating agents, purine analogues, combi- nation chemotherapy, monoclonal antibodies and transplant options [20]. As it occurs in an elderly popula- tion, progresses slowly and generally is not curable, it is usually treated in a conservative fashion [21]. Involved- field radiation therapy with relatively low doses of radia- tion can effect an excellent response for both CLL and Small Lymphocytic Lymphoma, especially when the lym- phoma cells are contained in one or two areas of lymph nodes in the same part of the body. Case presentation An 84-year old white male, presented at the Department of Dermatology (6th IKA Oncological Hospital of Athens) with a pale, ulcerated lesion (1.3 cm in diameter), on the middle of his lower lip. There was no associated lymphad- enopathy and an excisional biopsy was performed. His- topathological and immunoistochemical features revealed a Merkel cell carcinoma (MCC) but as the exci- sion was incomplete the patient was sheduled for a wider excision in the following 2 months. In the meantime, the lesion recurred and the patient returned with a protruding white lesion of 1.1 cm in diameter. There was no associ- ated lynphadenopathy and a wider excision, with an 8 mm margin, was performed. Histopathology confirmed the nature of MCC and the second excision was within healthy margins. Two months later, the patient was referred to the Depat- ment of Plastic Surgery, for another protruding ulcerated lesion, 3 cm in diameter, on his lower lip (Fig 1). On examination, multiple palpable lymph nodes in the sub- mandibular and cervical area (superficial and deep cervi- cal lymphadenopathy) were present. Page 2 of 6 (page number not for citation purposes)