MERKEL CELL CARCINOMA
Merkel cell carcinoma (MCC) is an aggressive skin cancer with a high risk of local recurrence and distant metastasis. Risk of recurrence is 25% to 75% based on initial stage at diagnosis. Optimal treatment of this potentially life-threatening cancer is rapidly evolving across multiple specialties and requires multidisciplinary consultation.
Treatment pearls: For most patients, after initial biopsy diagnosis, prompt referral to an academic center, whole body PET/CT imaging, and a baseline Merkel polyomavirus oncoprotein antibody titera are helpful first steps in management.a To order: https://testguide.labmed.uw.edu/public/view/AMERK See Tables 105-1 and 105-2.
Table Graphic Jump Location Table 105-2Merkel Cell Carcinoma Treatment Table for Systemic Medications ||Download (.pdf) Table 105-2 Merkel Cell Carcinoma Treatment Table for Systemic Medications
|MEDICATION NAME ||INDICATION ||MECHANISM OF ACTION ||DOSING SCHEDULE ||ADVERSE EFFECTS ||SUGGESTED MONITORING ||LEVEL OF EVIDENCE |
|Avelumaba ||Metastatic MCC ||Anti PD-L1 immune checkpoint inhibitor ||IV infusion every 2 wkb || |
Immediate: infusion-related reactions.
Immune-related adverse events (IRAE): fatigue, endocrinopathies, skin rash including possible SJS or TEN, hepatitis, nephritis, pneumonitis, colitis, myocarditis, myasthenia gravis, other neurological toxicities, ocular disorders anemia, lymphocytopenia, thrombocytopenia
Prior to initiating: screening for HBV
Prior to each dose: CMP, CBC, TSH, free T4, cortisol, ACTH, LDH, pregnancy test if indicated
Annually: eye exam
|Pembrolizumaba ||Metastatic and locally advanced MCC ||Anti PD-1 immune checkpoint inhibitor ||IV infusion every 3 or 6 weeksb ||Same as for avelumab ||Same as for avelumab ||IIA5 |
|Nivolumab ||Metastatic MCC ||Anti PD-1 ||IV infusion every 2 or 4 weeksb ||Same as for avelumab ||Same as for avelumab ||IIA6 |
|Ipilimumab ||Metastatic MCC ||Anti CTLA-4 ||IV infusion every 3 weeksb ||Same as for avelumab ||Same as for avelumab ||III7 |
|Carboplatin/etoposide ||Metastatic MCC ||Carboplatin: platinum alkylating chemotherapeutic ||Carboplatin every 3 wk for 4 cycles with etoposide given last 2 cyclesb ||Bone marrow suppression, vomiting, hypersensitivity reactions, pain, electrolyte imbalances, weakness || |
Prior to initiating: screening for TB and HBV
Prior to each cycle: CMP, CBC
|Pazopanib ||Metastatic MCC ||Tyrosine kinase inhibitor ||Oral, daily ||Hepatotoxicity, diarrhea, nausea, anorexia, vomiting, electrolyte abnormalities, QT prolongation, weakness, hemorrhage, neutropenia, thrombocytopenia, hypertension, hyperglycemia || |
Prior to initiating and at wk 3, 5, 7, and 9; at mo 3 and 4; then as clinically indicated: LFTs, CBC
At baseline: BMP, pregnancy test
At baseline at every 6-8 wk: TSH, free T4
|Octreotide ||Metastatic MCC ||Somatostatin analog ||IM, 20 mg monthly ||Gastrointestinal distress, peripheral edema, arthralgia hyperglycemia ||At baseline and every 3 mo: thyroid function tests, glucose ||IV10 |
|T-VEC ||Metastatic MCC ||Oncolytic virus ||Intra-lesional ||Fatigue, chills, nausea, pain at injection site, myalgias, fever ||Injection site complications ||IV11 |