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Case Reports
. 2019 Apr 5:9:223.
doi: 10.3389/fonc.2019.00223. eCollection 2019.

Rescue of Immunotherapy-Refractory Metastatic Merkel Cell Carcinoma With Conventionally Fractionated Radiotherapy and Concurrent Pembrolizumab

Affiliations
Case Reports

Rescue of Immunotherapy-Refractory Metastatic Merkel Cell Carcinoma With Conventionally Fractionated Radiotherapy and Concurrent Pembrolizumab

Brooke C Bloom et al. Front Oncol. .

Abstract

Merkel cell carcinoma has historically had dismal prognosis with limited cytotoxic chemotherapy options that provide durable control of metastatic disease. The advent of anti-programmed death protein (anti-PD1)/anti-programmed death-ligand 1 (anti-PD-L1) directed immunotherapy has shown initial promise in Merkel cell carcinoma and radiation might augment immune responses. We present a case report of a 70-year-old male who underwent resection of Merkel cell carcinoma of the right thigh with a close margin and positive right inguinal involvement. Due to high-risk features, the patient was treated with adjuvant radiation to the right groin and with systemic carboplatin/etoposide, but developed local failure requiring salvage surgical resection. The patient then developed metastatic disease with biopsy proven retroperitoneal involvement refractory to doxorubicin/cyclophosphamide chemotherapy. The patient was then transitioned to single-agent pembrolizumab with a partial response for 10 months until developing progressive disease involving the left inguinal and left external iliac nodal regions. The progressive left inguinal/pelvic disease was treated with conventionally fractionated intensity modulated radiation therapy to a dose of 45 Gy delivered in 25 fractions. Following radiation therapy, the patient had complete response of all sites of disease throughout the body on imaging by RECIST criteria including retroperitoneal and mediastinal disease outside the radiation field. At 20 months post-radiation, the patient remains on pembrolizumab without evidence of disease on imaging. Herein, we present a case of durable response of metastatic Merkel cell carcinoma treated with concurrent radiation and pembrolizumab, providing evidence that radiation might improve systemic responses to anti-PD1/PD-L1 directed immune therapy. Ongoing prospective trials evaluating the utility of radiation in conjunction with immunotherapy for Merkel cell carcinoma are anticipated to provide clarity on the frequency and durability of abscopal responses when radiation is combined with immune checkpoint inhibitors.

Keywords: Merkel cell carcinoma; PD-1; PD-L1; abscopal; checkpoint; immunotherapy; radiation.

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Figures

Figure 1
Figure 1
Representative histologic image of patient's Merkel cell carcinoma with hematoxylin and eosin staining.
Figure 2
Figure 2
Adjuvant radiation therapy plan of right thigh and groin showing axial and coronal representation.
Figure 3
Figure 3
PET-imaging demonstrating metastatic dissemination of Merkel cell carcinoma. (A) whole body positronic imaging showing bilateral pelvic and retroperitoneal SUV avidity consistent with metastatic disease. (B) representative fused PET CT-scan axial imaging showing SUV avid retroperitoneal adenopathy.
Figure 4
Figure 4
Isolated left pelvic nodal progression on pembrolizumab. PET-scan showing SUV avid progression involving the left inguinal and left external iliac regions.
Figure 5
Figure 5
Intensity modulated radiation therapy (IMRT) plan for left pelvic nodal progression to a prescription dose of 45 Gy delivered in 25 fractions with concurrent pembrolizumab.

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