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Chapter 105: Merkel Cell Carcinoma

Lindsay Gunnell; Song Park; Paul Nghiem

MERKEL CELL CARCINOMA

Therapeutic Approach

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 105-1Merkel Cell Carcinoma Treatment Flowcharts
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Table 105-1 Merkel Cell Carcinoma Treatment Flowcharts

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Table 105-2Merkel Cell Carcinoma Treatment Table for Systemic Medications
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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

 IIA4
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

 IIA8
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

 IV9
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

aFDA-approved therapy.

bDosing varies per protocol.

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