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Multisite Progression of Merkel Cell Carcinoma and Simultaneous Immune-Related Adverse Events

By: Joshua D. Madera, MS
Posted: Tuesday, November 17, 2020

For patients with Merkel cell carcinoma, immunosuppression may be avoided through an earlier diagnosis of disease progression, according to a case report published in Case Reports in Dermatological Medicine. Earlier diagnosis might facilitate and expedite palliative and curative treatment for these patients, explained David Michael Miller, MD, PhD, of Massachusetts General Hospital, Boston, and colleagues.

A 77-year-old woman presented with recent rapid growth of a left cheek nodule. Shave biopsy revealed Merkel cell carcinoma positive for keratin 20 and synaptophysin, with weak reactivity for cytokeratin AE1 and AE2. Furthermore, there was focal intense fluoro-2-deoxy-D-glucose avidity in the left cheek mass and intraparotid lymph nodes. Moreover, the patient’s family history was significant for hyperlipidemia, hypertension, depression, and degenerative joint disease.

Upon physical examination, a 27 mm x 22 mm exophytic, friable tumor was identified on the left cheek, with palpable nodules in the left parotid and submandibular areas. However, the anti–Merkel cell polyomavirus oncoprotein antibody was negative. Further analysis revealed stage IIIb disease with variations in TP53, PDGFRA, FLT3, and RB1 genes. The extent of the patient’s disease led to the decision to pursue bimodal therapy with 200 mg of intravenous pembrolizumab and radiation therapy.

After receiving treatment for 2 months, the patient presented with complaints of oropharyngeal discomfort. Then, she returned with additional symptoms, including nausea, vomiting, somnolence, slurred speech, and shortness of breath. Laboratory analysis showed transaminitis, conjugated hyperbilirubinemia, elevated alkaline phosphate levels, and elevated prothrombin time international normalized ratio, for which she was treated with empiric broad-spectrum antibiotics. As her hepatic function worsened, ultrasonography revealed diffuse, heterogenous hepatic parenchyma with metastatic disease. The postmortem autopsy revealed a hepatic tumor with surrounding steatosis, cholestasis, and necrosis.

“Multisite progression of disease may mimic simultaneous presentation of multiple immune-related adverse events,” commented the authors.

Disclosure: For full disclosures of the study authors, visit

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