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Lessans S, O'Connell KA, Choe J. Systemic Therapy for Non-Melanoma Skin Cancers: Latest Advances. Curr Oncol Rep 2024:10.1007/s11912-024-01570-1. [PMID: 38954315 DOI: 10.1007/s11912-024-01570-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW This review provides an update on approved and emerging systemic therapies in the treatment of locally advanced or metastatic non-melanoma skin cancers (squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma). RECENT FINDINGS Many studies demonstrate the effectiveness of immunotherapy for all types of non-melanoma skin cancer. For basal cell carcinoma (BCC), hedgehog inhibitors (HHI) remain first-line but with poor tolerability. Numerous clinical trials studying both neoadjuvant and adjuvant use of anti-PD-1 and anti-PD-L1 therapies in advanced NMSC are under investigation. There is a growing number of systemic therapies available to treat non-melanoma skin cancers. The advent of immunotherapy has revolutionized the field and greatly improved survival compared to historical survival rates with cytotoxic chemotherapy.
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Affiliation(s)
- Spencer Lessans
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katie A O'Connell
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Choe
- Department of Hematology/Oncology, Vanderbilt University Medical Center, Preston Research Building 790, 2220 Pierce Ave, Nashville, TN, 37232, USA.
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Singh N, McClure EM, Akaike T, Park SY, Huynh ET, Goff PH, Nghiem P. The Evolving Treatment Landscape of Merkel Cell Carcinoma. Curr Treat Options Oncol 2023; 24:1231-1258. [PMID: 37403007 DOI: 10.1007/s11864-023-01118-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/06/2023]
Abstract
OPINION STATEMENT Merkel cell carcinoma (MCC) has a high risk of recurrence and requires unique treatment relative to other skin cancers. The patient population is generally older, with comorbidities. Multidisciplinary and personalized care is therefore paramount, based on patient preferences regarding risks and benefits. Positron emission tomography and computed tomography (PET-CT) is the most sensitive staging modality and reveals clinically occult disease in ~ 16% of patients. Discovery of occult disease spread markedly alters management. Newly diagnosed, localized disease is often managed with sentinel lymph node biopsy (SLNB), local excision, primary wound closure, and post-operative radiation therapy (PORT). In contrast, metastatic disease is usually treated systemically with an immune checkpoint inhibitor (ICI). However, one or more of these approaches may not be indicated. Criteria for such exceptions and alternative approaches will be discussed. Because MCC recurs in 40% of patients and early detection/treatment of advanced disease is advantageous, close surveillance is recommended. Given that over 90% of initial recurrences arise within 3 years, surveillance frequency can be rapidly decreased after this high-risk period. Patient-specific assessment of risk is important because recurrence risk varies widely (15 to > 80%: Merkelcell.org/recur) depending on baseline patient characteristics and time since treatment. Blood-based surveillance tests are now available (Merkel cell polyomavirus (MCPyV) antibodies and circulating tumor DNA (ctDNA)) with excellent sensitivity that can spare patients from contrast dye, radioactivity, and travel to a cancer imaging facility. If recurrent disease is locoregional, management with surgery and/or RT is typically indicated. ICIs are now the first line for systemic/advanced MCC, with objective response rates (ORRs) exceeding 50%. Cytotoxic chemotherapy is sometimes used for debulking disease or in patients who cannot tolerate ICI. ICI-refractory disease is the major problem faced by this field. Fortunately, numerous promising therapies are on the horizon to address this clinical need.
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Affiliation(s)
- Neha Singh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Erin M McClure
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Tomoko Akaike
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Song Y Park
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Emily T Huynh
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
| | - Peter H Goff
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Paul Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, 850 Republican Street, Box 358050, Seattle, WA, USA.
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Becker JC, Beer AJ, DeTemple VK, Eigentler T, Flaig MJ, Gambichler T, Grabbe S, Höller U, Klumpp B, Lang S, Pföhler C, Posch C, Prasad V, Schlattmann P, Schneider-Burrus S, Ter-Nedden J, Terheyden P, Thoms K, Vordermark D, Ugurel S. S2k-Leitlinie - Merkelzellkarzinom - Update 2022. J Dtsch Dermatol Ges 2023; 21:305-317. [PMID: 36929546 DOI: 10.1111/ddg.14930_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/09/2022] [Indexed: 03/18/2023]
Affiliation(s)
- Jürgen C Becker
- Translational Skin Cancer Research (TSCR), Deutsches Konsortium für translationale Krebsforschung (DKTK), Partnerstandort Essen, Klinik für Dermatologie, Universitätsmedizin Essen, Deutsches Krebsforschungszentrum, Heidelberg
| | | | - Viola K DeTemple
- Universitätsklinik für Dermatologie, Venerologie, Allergologie und Phlebologie, Johannes Wesling Klinikum Minden
| | - Thomas Eigentler
- Klinik für Dermatologie, Venerologie und Allergologie, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Michael J Flaig
- Klinik und Poliklinik für Dermatologie und Allergologie, Klinikum der Universität München, LMU München
| | - Thilo Gambichler
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum
| | | | | | | | - Stephan Lang
- Hals-Nasen-Ohren-Klinik am Universitätsklinikum Essen
| | - Claudia Pföhler
- Klinik für Dermatologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Posch
- Hautklinik Campus Biederstein, Technische Universität München
| | - Vikas Prasad
- Klinik für Nuklearmedizin, Universitätsklinikum Ulm
| | | | | | | | - Patrick Terheyden
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | - Kai Thoms
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Göttingen
| | - Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Halle
| | - Selma Ugurel
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen
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Becker JC, Beer AJ, DeTemple VK, Eigentler T, Flaig M, Gambichler T, Grabbe S, Höller U, Klumpp B, Lang S, Pföhler C, Posch C, Prasad V, Schlattmann P, Schneider-Burrus S, Ter-Nedden J, Terheyden P, Thoms K, Vordermark D, Ugurel S. S2k Guideline - Merkel cell carcinoma (MCC, neuroendocrine carcinoma of the skin) - Update 2022. J Dtsch Dermatol Ges 2023; 21:305-320. [PMID: 36929552 DOI: 10.1111/ddg.14930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/09/2022] [Indexed: 03/18/2023]
Abstract
Merkel cell carcinoma (MCC, ICD-O M8247/3) is a rare, malignant, primary skin tumor with epithelial and neuroendocrine differentiation. The tumor cells share many morphologic, immunohistochemical, and ultrastructural features with cutaneous Merkel cells. Nevertheless, the cell of origin of MCC is unclear. MCC appears clinically as a reddish to purple spherical tumor with a smooth, shiny surface and a soft to turgid, elastic consistency, usually showing rapid growth. Spontaneous and often complete regressions of the tumor are observed. These likely immunologically-mediated regressions explain the cases in which only lymph node or distant metastases are found at the time of initial diagnosis and why the tumor responds very well to immunomodulatory therapies even at advanced stages. Due to its aggressiveness, the usually given indication for sentinel lymph node biopsy, the indication of adjuvant therapies to be evaluated, as well as the complexity of the necessary diagnostics, clinical management should already be determined by an interdisciplinary tumor board at the time of initial diagnosis.
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Affiliation(s)
- Jürgen C Becker
- Translational Skin Cancer Research (TSCR), Deutsches Konsortium für translationale Krebsforschung (DKTK), Partnerstandort Essen, Department of Dermatology, University Hospital Essen, German Cancer Research Center (DKFZ), Heidelberg
| | - Ambros J Beer
- Department of Nuclear Medicine, University Hospital Ulm
| | - Viola K DeTemple
- Department of Dermatology, Venereology, Allergology and Phlebology, Johannes Wesling Klinikum, Minden
| | - Thomas Eigentler
- Department of Dermatology, Venereology and Allergology, University Hospital Berlin
| | - Michael Flaig
- Department and Clinic for Dermatology and Allergology, LMU Klinikum Munich
| | - Thilo Gambichler
- Department of Dermatology, Venereology and Allergology, Ruhr University Bochum
| | | | | | | | - Stephan Lang
- Department of Ear, Nose and Throat Medicine, University Hospital Essen
| | - Claudia Pföhler
- Department of Dermatology, University Hospital Saarland, Homburg/Saar
| | - Christian Posch
- Department of Dermatology Campus Biederstein, Technical University Munich
| | - Vikas Prasad
- Department of Nuclear Medicine, University Hospital Ulm
| | | | | | - Jan Ter-Nedden
- Professional Association of German Dermatologists, Hamburg
| | - Patrick Terheyden
- Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Lübeck
| | - Kai Thoms
- Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, Göttingen
| | | | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen
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Advances in Management and Therapeutics of Cutaneous Basal Cell Carcinoma. Cancers (Basel) 2022; 14:cancers14153720. [PMID: 35954384 PMCID: PMC9367462 DOI: 10.3390/cancers14153720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Basal cell carcinoma (BCC) is the most common malignancy in humans with a range of treatment options available. Tumor and patient characteristics aid in risk-stratification, which influences treatment considerations. Here, we review the advancements in surgical, topical, field, immunotherapeutic, molecular-targeted, and experimental treatment modalities that can be employed in the correct clinical setting for the treatment of BCC. Abstract Basal cell carcinoma (BCC), the most common cancer in humans, is a malignant neoplasm of cells derived from the basal layer of the epidermis. Tumor characteristics such as histologic subtype, primary versus recurrent tumor, anatomic location, size, and patient attributes determine the risk level and acceptable treatment options. Surgical options offer histologic confirmation of tumor clearance. Standard excision provides post-treatment histologic assessment, while Mohs micrographic surgery (MMS) provides complete margin assessment intraoperatively. Additional treatment options may be employed in the correct clinical context. Small and low-risk BCCs, broad field cancerization, locally-advanced disease, metastatic disease, cosmetic concerns, or morbidity with surgical approaches raise consideration of other treatment modalities. We review herein a range of treatment approaches and advances in treatments for BCC, including standard excision, MMS, electrodesiccation and curettage, ablative laser treatment, radiation therapy, targeted molecular therapies, topical therapies, field therapies, immunotherapy, and experimental therapies.
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Ramelyte E, Restivo G, Mannino M, Levesque MP, Dummer R. Advances in the drug management of basal cell carcinoma. Expert Opin Pharmacother 2022; 23:573-582. [PMID: 35081851 DOI: 10.1080/14656566.2022.2032646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Basal cell carcinoma (BCC) is the most common skin cancer in humans. Recently, BCCs were suggested to be classified into 'easy to treat' and 'difficult to treat,' and different therapeutic options are suggested for their management. AREAS COVERED In this review, the authors discuss treatment options that are approved, recommended for, or are still in development for treatment of BCC. The review covers approved local therapies, such as imiquimod and 5-fluorouracil, and systemic therapies, such as hedgehog inhibitors. New medical agents, investigated in clinical trials, are reviewed. These include: targeted therapies, such as GLI antagonists or anti-VEGFR agents, immunotherapies, such as checkpoint inhibitors, recombinant cytokines or silencing RNA, as well as intralesional virotherapies with modified adeno- or herpes viruses. EXPERT OPINION The progress made in recent years has improved the management of patients with advanced BCC; however, neither tumor targeting nor immune system engaging agents provide a cure. New treatment approaches directed not only to known targets but also the tumor microenvironment are in development and are anticipated to improve the management of difficult to treat BCC.
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Affiliation(s)
- Egle Ramelyte
- Department of Dermatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Gaetana Restivo
- Department of Dermatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Maria Mannino
- Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy
| | - Mitchell P Levesque
- Department of Dermatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Salloum A, Koblinski J, Bazzi N, Zeitouni NC. Talimogene Laherparepvec in Non-Melanoma Cancers. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2021; 14:18-25. [PMID: 34980955 PMCID: PMC8675341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Talimogene laherparepvec (T-VEC) is the first oncolytic virus therapy approved by the United States Food and Drug Administration (in 2015) for the treatment of advanced-stage melanoma. Despite a paucity of Phase III trials for T-VEC as a therapy for non-melanoma cancers, successful off-label use of T-VEC for this purpose has been reported in the literature. OBJECTIVE We sought to review the literature describing T-VEC as a treatment for non-melanoma cancer. METHODS Systematic searches of the PubMed literature database and ClinicalTrials.gov website were performed in July 2020, focusing on T-VEC in combination with non-melanoma cancer, including squamous cell carcinoma, Merkel cell carcinoma, sarcoma, cutaneous B-cell lymphoma, and cutaneous T-cell lymphoma. Articles were screened based on their title and abstract. RESULTS Nine articles with 87 patients were included. Relevant articles included case reports, case series, and Phase I and Phase II trials. The majority of patients in the studies had refractory cancers or had been heavily pretreated. Overall, T-VEC demonstrated efficacy for non-melanoma cancer, both independently and in combination with biologics. CONCLUSION T-VEC has demonstrated efficacy for non-melanoma cancers. Phase III trials of T-VEC for this indication are warranted to expand its clinical utility.
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Affiliation(s)
- Antoine Salloum
- Dr. Salloum is with the Department of Dermatology at Saint George Hospital University Medical Center in Beirut, Lebanon, and Dermatologic Surgicenter in Philadelphia, Pennsylvania
- Drs. Koblinski and Zeitouni are with the University of Arizona College of Medicine in Phoenix, Arizona
- Dr. Bazzi is with the Faculty of Medicine at Lebanese University in Beirut, Lebanon
| | - Jenna Koblinski
- Dr. Salloum is with the Department of Dermatology at Saint George Hospital University Medical Center in Beirut, Lebanon, and Dermatologic Surgicenter in Philadelphia, Pennsylvania
- Drs. Koblinski and Zeitouni are with the University of Arizona College of Medicine in Phoenix, Arizona
- Dr. Bazzi is with the Faculty of Medicine at Lebanese University in Beirut, Lebanon
| | - Nagham Bazzi
- Dr. Salloum is with the Department of Dermatology at Saint George Hospital University Medical Center in Beirut, Lebanon, and Dermatologic Surgicenter in Philadelphia, Pennsylvania
- Drs. Koblinski and Zeitouni are with the University of Arizona College of Medicine in Phoenix, Arizona
- Dr. Bazzi is with the Faculty of Medicine at Lebanese University in Beirut, Lebanon
| | - Nathalie C Zeitouni
- Dr. Salloum is with the Department of Dermatology at Saint George Hospital University Medical Center in Beirut, Lebanon, and Dermatologic Surgicenter in Philadelphia, Pennsylvania
- Drs. Koblinski and Zeitouni are with the University of Arizona College of Medicine in Phoenix, Arizona
- Dr. Bazzi is with the Faculty of Medicine at Lebanese University in Beirut, Lebanon
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8
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Park SY, Doolittle-Amieva C, Moshiri Y, Akaike T, Parvathaneni U, Bhatia S, Zaba LC, Nghiem P. How we treat Merkel cell carcinoma: within and beyond current guidelines. Future Oncol 2021; 17:1363-1377. [PMID: 33511866 PMCID: PMC7983043 DOI: 10.2217/fon-2020-1036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Merkel cell carcinoma (MCC) is an aggressive skin cancer associated with a high risk of local recurrence and distant metastasis. Optimal care of this potentially life-threatening cancer is critical but challenging because: physicians are often unfamiliar with its management due to rarity, and MCC management remains controversial, in part because it is rapidly evolving across multiple specialties. While guidelines offer a broad overview of management, they are often not sufficient when making decisions for individual patients. Herein, we present a literature review as well as practical approaches adopted at our institutions for staging, surveillance and therapy of MCC. Each of these areas are discussed in light of how they can be appropriately customized for prevalent but challenging situations. We also provide representative examples of MCC patient scenarios and how they were managed by a multidisciplinary team to identify suitable evidence-based, individualized treatment plans. Merkel cell carcinoma (MCC) is a skin cancer with a high risk of recurrence and distant spread. Optimal care of this cancer is important. However, management is challenging because it is rare and its treatment is continuously evolving across multiple specialties. While treatment guidelines offer a broad overview of management, they are often not detailed enough to provide appropriate patient-specific assistance. Herein, we present a review of recent studies and our suggestions relevant to MCC staging, surveillance and treatment options. Each of these areas are discussed in light of how they can be appropriately customized for challenging situations often encountered by practitioners. We also provide representative examples of MCC patient scenarios and how they were managed by a multidisciplinary team to identify evidence-based, individualized treatment plans.
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Affiliation(s)
- Song Y Park
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Coley Doolittle-Amieva
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Yasman Moshiri
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Tomoko Akaike
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA
| | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, WA 98109, USA
| | - Shailender Bhatia
- Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - Lisa C Zaba
- Department of Dermatology, Stanford University, Palo Alto, CA 94304, USA
| | - Paul Nghiem
- Division of Dermatology, University of Washington at South Lake Union, Seattle, WA 98109, USA.,Department of Radiation Oncology, University of Washington, Seattle, WA 98109, USA
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10
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Babadzhanov M, Doudican N, Wilken R, Stevenson M, Pavlick A, Carucci J. Current concepts and approaches to merkel cell carcinoma. Arch Dermatol Res 2020; 313:129-138. [PMID: 32666149 DOI: 10.1007/s00403-020-02107-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Abstract
Merkel cell carcinoma (MCC) is an aggressive and rare cutaneous cancer of the mechanoreceptor unit of the skin with a neuroendocrine origin. MCC incidence has been on the rise over the past two decades. Risk factors include old age, chronic UV exposure, and immunosuppression. Although MCC is a cutaneous malignancy that is often misdiagnosed as a benign nodule at the time of diagnosis, it has an aggressive disease course due to its high recurrence and metastatic potential. The PD-1/PD-L1 checkpoint blockade has recently shown promising results in the management of advanced MCC. Avelumab and pembrolizumab are considered the new standard of care for metastatic MCC. Despite advances in the field, studies are needed to elucidate the role of immunotherapy for patients who are resistant to treatment. Most ongoing clinical trials aim to assess the efficacy of checkpoint inhibitor combination therapies. This article reviews the most current literature on the surgical and medical management of MCC.
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Affiliation(s)
| | | | - Reason Wilken
- Dermatology, NYU Langone Med Center, New York, NY, USA
| | | | - Anna Pavlick
- Dermatology, NYU Langone Med Center, New York, NY, USA
| | - John Carucci
- Dermatology, NYU Langone Med Center, New York, NY, USA.
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11
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Wollina U, Koch A, Cardoso JC. Advanced Merkel cell carcinoma—A focus on medical drug therapy. Dermatol Ther 2020; 33:e13675. [DOI: 10.1111/dth.13675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden Academic Teaching Hospital Dresden Germany
| | - André Koch
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden Academic Teaching Hospital Dresden Germany
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Steven N, Lawton P, Poulsen M. Merkel Cell Carcinoma - Current Controversies and Future Directions. Clin Oncol (R Coll Radiol) 2020; 31:789-796. [PMID: 31594644 DOI: 10.1016/j.clon.2019.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 12/12/2022]
Abstract
Merkel cell carcinoma is a rare, aggressive neuroendocrine skin malignancy. Evidence for management comes from case series and single-arm trials. Optimal outcomes require assessment of the patient in a multidisciplinary team setting. Rapid diagnosis and staging are essential for locoregional control and may reduce metastasis. Sentinel lymph node biopsy (SLNB) adds prognostic information. FDG-positron emission tomography has high sensitivity and specificity and affects management in a quarter of cases. Surgical excision and radiotherapy provide good locoregional control even with positive margins. Wide surgical margins are needed if adjuvant radiotherapy is not used. It is uncertain whether adjuvant radiotherapy or elective surgery for uninvolved nodes or for patients selected by positive SLNB improves survival. Total doses of 50 Gy provide high levels of control for microscopic disease but at least 60 Gy should be given for macroscopic disease. Chemotherapy can be given safely with radiotherapy, but the benefit of adjuvant chemotherapy remains uncertain. Trials of adjuvant immune therapy are underway. Unresectable primaries might be controlled with radiotherapy alone or combination systemic therapy, radiotherapy and surgery. Metastatic disease often responds to chemotherapy, but the response duration can be short. Immunity is central to disease control. Immune checkpoint inhibitor treatment resulted in high response rates in chemotherapy-naive patients and lower rates in chemotherapy-refractory patients. Durable responses are observed.
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Affiliation(s)
- N Steven
- University of Birmingham, Birmingham, UK.
| | - P Lawton
- University of Nottingham, Nottingham, UK
| | - M Poulsen
- The University of Queensland, Brisbane, Queensland, Australia
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Abstract
Merkel cell carcinoma is a rare and aggressive cutaneous malignancy of neuroendocrine origin-an often-missed diagnosis due to the wide histopathologic differential diagnosis of malignant small blue cell tumors. The advent of electron microscopy and immunohistochemistry staining for cytokeratin 20, a shared neuroendocrine marker, greatly improved diagnostic accuracy. Over the past decade, staging, treatment, and surveillance of the cancer have progressed at a remarkably rapid pace. Herein, the authors provide an update on the current guidelines around diagnosis and management and review the exciting advancements on the horizon.
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Affiliation(s)
- Yun Xue
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02215, USA
| | - Manisha Thakuria
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02215, USA; Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, 450 Brookline Avenue, Boston, MA 02115, USA.
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14
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Fröhlich A, Hoffmann F, Niebel D, Egger E, Kukuk GM, Toma M, Sirokay J, Bieber T, Landsberg J. Talimogene Laherparepvec in Advanced Mucosal Melanoma of the Urethra Upon Primary Resistance on Immune Checkpoint Inhibition: A Case Report. Front Oncol 2020; 10:611. [PMID: 32457834 PMCID: PMC7225290 DOI: 10.3389/fonc.2020.00611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/03/2020] [Indexed: 01/10/2023] Open
Abstract
Background: Mucosal melanomas including melanomas of the urogenital tract represent a rare type of melanoma characterized by low mutational burden and poor prognosis. Immune checkpoint inhibition has so far only been assessed in a limited number of mucosal melanoma patients and, in contrast to response in cutaneous melanoma, was associated with disappointing response rates. The oncolytic viral immunotherapy Talimogene laherparepvec (T-VEC) has recently been approved for treatment of locally advanced or unresectable melanoma. T-VEC combines direct oncolytic effects with local and systemic immune-mediated anti-tumor response. Our rationale to use T-VEC in this case was an expected augmentation of immunogenicity by tumor lysis to overcome primary resistance of a mucosal melanoma to immune checkpoint blockade. Objective: To report the first case of an advanced mucosal melanoma of the urethra treated with intralesional application of Talimogene laherparepvec. Case Report: A 78-years old female patient was diagnosed with an advanced mucosal melanoma of the urethra with inguinal lymph node metastases and intravaginal mucosal metastases. Shortly after surgical resection of the tumor mass, intravaginal mucosal metastases, and new nodal metastases in proximity of the left iliac vessels were diagnosed. The patient was treated with the anti-PD1 antibody pembrolizumab and obtained a stable disease lasting for 30 weeks. However, upon checkpoint inhibition the patient developed a loco-regional progressive disease featuring bleeding intravaginal metastases, while nodal metastases remained stable. We stopped treatment with pembrolizumab and administered T-VEC directly into the intravaginal mucosal metastases. After five injections T-VEC yielded a partial response with clinical regression of the injected mucosal metastases. Disease remained stable for 16 weeks under biweekly T-VEC treatment. Thereafter the patient showed disease progression in nodal metastases. T-VEC was discontinued. Immunotherapy with pembrolizumab was restarted but failed to achieve a response. Finally, targeted therapy with imatinib was induced in presence of a druggable c-KIT mutation, leading to a considerable response of all tumor sites that is still ongoing. Conclusion: T-VEC represents an effective and well-tolerated treatment option for patients with loco-regionally advanced mucosal melanoma. In combination with immunotherapy, T-VEC bears the potential of synergistic effects to overcome the specific primary resistance of mucosal melanoma to immune checkpoint blockade.
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Affiliation(s)
- Anne Fröhlich
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Friederike Hoffmann
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Dennis Niebel
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Eva Egger
- Department of Gynaecology, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Guido M Kukuk
- Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
| | - Marieta Toma
- Department of Pathology University Hospital Bonn, Rheinische-Friedrich-Wilhelms -Universität Bonn, Bonn, Germany
| | - Judith Sirokay
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Thomas Bieber
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology and Allergy, Rheinische-Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
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15
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Fröhlich A, Niebel D, Fietz S, Egger E, Buchner A, Sirokay J, Landsberg J. Talimogene laherparepvec treatment to overcome loco-regional acquired resistance to immune checkpoint blockade in tumor stage IIIB-IV M1c melanoma patients. Cancer Immunol Immunother 2020; 69:759-769. [PMID: 32052079 PMCID: PMC7183503 DOI: 10.1007/s00262-020-02487-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Resistance to immune checkpoint blockade and targeted therapy in melanoma patients is currently one of the major clinical challenges. With the approval of talimogene laherparepvec (T-VEC), oncolytic viruses are now in clinical practice for locally advanced or non-resectable melanoma. Here, we describe the usage of T-VEC in stage IVM1b-M1c melanoma patients, who achieved complete remission or stable disease upon systemic treatment but suffered from a loco-regional recurrence. To our knowledge, there are no case reports so far describing T-VEC as a means to overcome acquired resistance to immune checkpoint blockade or targeted therapy. METHODS All melanoma patients in our department treated with T-VEC in the period of 2016-2018 were evaluated retrospectively. Data on clinicopathological characteristics, treatment response, and toxicity were analyzed. RESULTS Fourteen melanoma patients were treated with T-VEC in our center. Six patients (43%) received T-VEC first-line. In eight patients (57%), T-VEC followed a prior systemic therapy. Three patients with M1b stage and one patient with M1c stage melanoma were treated with T-VEC. These patients suffered from loco-regional progress, whilst distant metastases had regressed during prior systemic treatment. 64% of patients showed a benefit from therapy with T-VEC. The durable response rate was 36%. CONCLUSION T-VEC represents an effective and tolerable treatment option. This is true not only for loco-regionally advanced melanoma patients, but also for patients with stable or regressive systemic metastases who develop loco-regionally acquired resistance upon treatment with immune checkpoint blockade or targeted therapy. A sensible selection of suitable patients seems to be crucial.
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Affiliation(s)
- Anne Fröhlich
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dennis Niebel
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Simon Fietz
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Eva Egger
- Department of Gynecology, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Andrea Buchner
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Judith Sirokay
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology and Allergy, University of Bonn, Sigmund-Freud-Str. 25, Venusberg-Campus 1, 53127, Bonn, Germany.
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16
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Jing L, Ott M, Church CD, Kulikauskas RM, Ibrani D, Iyer JG, Afanasiev OK, Colunga A, Cook MM, Xie H, Greninger AL, Paulson KG, Chapuis AG, Bhatia S, Nghiem P, Koelle DM. Prevalent and Diverse Intratumoral Oncoprotein-Specific CD8 + T Cells within Polyomavirus-Driven Merkel Cell Carcinomas. Cancer Immunol Res 2020; 8:648-659. [PMID: 32179557 DOI: 10.1158/2326-6066.cir-19-0647] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 12/16/2019] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
Merkel cell carcinoma (MCC) is often caused by persistent expression of Merkel cell polyomavirus (MCPyV) T-antigen (T-Ag). These non-self proteins comprise about 400 amino acids (AA). Clinical responses to immune checkpoint inhibitors, seen in about half of patients, may relate to T-Ag-specific T cells. Strategies to increase CD8+ T-cell number, breadth, or function could augment checkpoint inhibition, but vaccines to augment immunity must avoid delivery of oncogenic T-antigen domains. We probed MCC tumor-infiltrating lymphocytes (TIL) with an artificial antigen-presenting cell (aAPC) system and confirmed T-Ag recognition with synthetic peptides, HLA-peptide tetramers, and dendritic cells (DC). TILs from 9 of 12 (75%) subjects contained CD8+ T cells recognizing 1-8 MCPyV epitopes per person. Analysis of 16 MCPyV CD8+ TIL epitopes and prior TIL data indicated that 97% of patients with MCPyV+ MCC had HLA alleles with the genetic potential that restrict CD8+ T-cell responses to MCPyV T-Ag. The LT AA 70-110 region was epitope rich, whereas the oncogenic domains of T-Ag were not commonly recognized. Specific recognition of T-Ag-expressing DCs was documented. Recovery of MCPyV oncoprotein-specific CD8+ TILs from most tumors indicated that antigen indifference was unlikely to be a major cause of checkpoint inhibition failure. The myriad of epitopes restricted by diverse HLA alleles indicates that vaccination can be a rational component of immunotherapy if tumor immune suppression can be overcome, and the oncogenic regions of T-Ag can be modified without impacting immunogenicity.
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Affiliation(s)
- Lichen Jing
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Mariliis Ott
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Candice D Church
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Rima M Kulikauskas
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Dafina Ibrani
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Jayasri G Iyer
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Olga K Afanasiev
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Aric Colunga
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Maclean M Cook
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington
| | - Hong Xie
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | | | - Kelly G Paulson
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Aude G Chapuis
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Shailender Bhatia
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul Nghiem
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David M Koelle
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington. .,Department of Laboratory Medicine, University of Washington, Seattle, Washington.,Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington.,Benaroya Research Institute, Seattle, Washington
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17
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Abstract
PURPOSE OF REVIEW Merkel cell carcinoma (MCC), a rapidly progressing skin cancer, has poor prognosis. We reviewed the epidemiology, pathogenesis, diagnosis and treatment of MCC, with a focus on recent therapeutic advancements. RECENT FINDINGS Risk factors for MCC, such as old age, immunosuppression, polyomavirus infection and exposure to UV radiation have already been identified, but the underlying mechanisms leading to carcinogenesis still need clarification. On the basis of recent advances, immunotherapy - in particular, inhibition targeting the programmed cell death protein 1/programmed death-ligand 1 (PD1)/PDL1) immune checkpoint blockade - is currently being investigated in the treatment of metastatic MCC. Avelumab, an anti-PDL1 antibody, was the first drug to be approved internationally as second-line monotherapy for patients with advanced MCC, based on results from the JAVELIN Merkel 200 clinical trial. Avelumab has also recently been approved as first-line treatment for advanced MCC in Europe. Pembrolizumab (anti-PD1) in first-line and nivolumab (anti-PD1) in first-line and second-line treatments are two other checkpoint inhibitors that are under investigation, and showing promising results. New innovative therapies are also in development. SUMMARY New insights concerning advances in MCC diagnosis and treatment have been highlighted. Immunotherapy for metastatic MCC constitutes a recent breakthrough in an unmet medical need, but alternative therapies should continue to be investigated.
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Affiliation(s)
- Véronique Del Marmol
- Department of Dermatology and Venereology, Hopital Erasme-Université Libre de Bruxelles, Brussels, Belgium
| | - Celeste Lebbé
- APHP, Department of Dermatology, Saint-Louis Hospital, Sorbonne Paris Cité Université, Paris Diderot, INSERM U976, Paris, France
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18
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Haitz K, Khosravi H, Lin JY, Menge T, Nambudiri VE. Review of talimogene laherparepvec: A first-in-class oncolytic viral treatment of advanced melanoma. J Am Acad Dermatol 2020; 83:189-196. [PMID: 32004650 DOI: 10.1016/j.jaad.2020.01.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 01/21/2020] [Accepted: 01/02/2020] [Indexed: 11/15/2022]
Abstract
Talimogene laherparepvec (T-VEC) is an oncolytic virus based on herpes simplex virus type 1 approved for intralesional treatment of advanced melanoma. In this article, we review the clinical literature on T-VEC for advanced melanoma and provide a practical approach to using T-VEC in the dermatologic surgery and oncology clinic. PubMed was used to conduct a systematic literature review of articles describing the structure, basic science, and clinical and therapeutic properties of T-VEC. The national clinical trials database was also searched for T-VEC clinical trials. Phase I to III clinical trials and early real-world experience have shown the efficacy of T-VEC in advanced melanoma as single or combination therapy with tolerable adverse effects. We conclude that with a standardized clinical approach and training, dermatologists can pave the way in using T-VEC and future oncolytic virus therapies in appropriate clinical scenarios.
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Affiliation(s)
- Karyn Haitz
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Dermatology, University of Miami Miller School of Medicine, Miami, Florida
| | - Hasan Khosravi
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jennifer Y Lin
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tyler Menge
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Combined Dermatology Program, Boston, Massachusetts
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts.
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19
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Nguyen MH, Leong SP, Abendroth R, Kashani-Sabet M, Kim KB. Complete clinical response to intralesional talimogene laherparepvec injection in a patient with recurrent, regionally advanced Merkel cell carcinoma. JAAD Case Rep 2019; 5:849-851. [PMID: 31649970 PMCID: PMC6804468 DOI: 10.1016/j.jdcr.2019.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | | | | | | | - Kevin B. Kim
- Correspondence to: Kevin B. Kim, MD, California Pacific Medical Center Research Institute, 2333 Buchanan St, San Francisco, CA 04115.
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20
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Westbrook BC, Norwood TG, Terry NLJ, McKee SB, Conry RM. Talimogene laherparepvec induces durable response of regionally advanced Merkel cell carcinoma in 4 consecutive patients. JAAD Case Rep 2019; 5:782-786. [PMID: 31516997 PMCID: PMC6728723 DOI: 10.1016/j.jdcr.2019.06.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Key Words
- CR, complete response
- CT, computed tomography
- FDA, US Food and Drug Administration
- ICB, immune checkpoint blockade
- MCC, Merkel cell carcinoma
- MCPyV, Merkel cell polyomavirus
- Merkel cell carcinoma
- ORR, objective response rate
- PD-L1, programmed death ligand 1
- PET, positron emission tomography
- PFS, progression-free survival
- SUV, standardized uptake values
- TVEC, talimogene laherparepvec
- advanced Merkel cell carcinoma
- durable response
- immunotherapy
- oncolytic virus
- regionally advanced Merkel cell carcinoma
- talimogene laherparepvec
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Affiliation(s)
- Brian C Westbrook
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - T Graham Norwood
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Nina L J Terry
- Department of Radiology, General Radiology and Cardiopulmonary Section, University of Alabama at Birmingham Medicine, Birmingham, Alabama
| | - Svetlana B McKee
- Division of Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Conry
- Division of Hematology Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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21
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Immune Checkpoint Inhibitors and Beyond: An Overview of Immune-Based Therapies in Merkel Cell Carcinoma. Am J Clin Dermatol 2019; 20:391-407. [PMID: 30784027 DOI: 10.1007/s40257-019-00427-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Merkel cell carcinoma (MCC) is an aggressive skin cancer. Until 2017, patients with advanced disease were typically treated with conventional chemotherapies, with a median response duration of 3 months. Increased evidence of the role of the immune system in controlling this cancer has paved the way for immune-based therapies, with programmed cell death protein 1 (PD-1)/programmed cell death protein ligand 1 (PD-L1) inhibitors at the frontline. Avelumab, an anti-PD-L1 antibody, was the first-ever drug approved in advanced MCC after showing meaningful efficacy in a second-line setting. Objective responses were observed in one-third of patients and, most importantly, were durable with half of patients and one-third of patients still alive at 1 and 2 years, respectively. When used in a first-line setting, PD-1/PD-L1 inhibitors (avelumab, pembrolizumab, nivolumab) are even more promising as objective responses are observed in approximately 50-70% of patients within the first 4-8 weeks of treatment. Safety profiles are acceptable with 10-20% of patients experiencing adverse events grade ≥ 3. PD-1/PD-L1 inhibitors are considered the standard of care in advanced MCC and are currently being investigated in the adjuvant and neoadjuvant settings. However, innovative treatments are still needed in the metastatic setting, as approximately 50% of these patients will not persistently respond to currently available immunotherapies, and no predictors of response are available yet. Therefore, other immunotherapeutic strategies are now being investigated-ideally in combinations-to enhance the various aspects of the immune response against tumoral cells.
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22
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Abstract
Merkel cell carcinoma is an aggressive neuroendocrine carcinoma with increasing incidence over the past few decades. The TNM Staging System used for Merkel cell carcinoma was updated by the American Joint Committee on Cancer in 2017. Clinical practice guidelines were updated by the National Comprehensive Cancer Network on August 31, 2018. This article reviews the most recent evidence-based updates on staging and management.
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Affiliation(s)
- Christine Cornejo
- Department of Dermatology, University of Pennsylvania, 2 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, USA
| | - Christopher J Miller
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, 1st Floor South Pavilion, 3400 Civic Center Boulevard, Suite 1-330S, Philadelphia, PA 19104, USA.
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23
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Garcia-Carbonero R, Marquez-Rodas I, de la Cruz-Merino L, Martinez-Trufero J, Cabrera MA, Piulats JM, Capdevila J, Grande E, Martin-Algarra S, Berrocal A. Recent Therapeutic Advances and Change in Treatment Paradigm of Patients with Merkel Cell Carcinoma. Oncologist 2019; 24:1375-1383. [PMID: 30962295 DOI: 10.1634/theoncologist.2018-0718] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/15/2019] [Indexed: 01/14/2023] Open
Abstract
Merkel cell carcinoma (MCC) is a rare, aggressive, primary cutaneous neuroendocrine tumor that typically presents as an indurated nodule on sun-exposed areas of the head and neck in the white population. Major risk factors include immunosuppression, UV light exposure, and advanced age. Up to 80% of MCC are associated with Merkel cell polyomavirus. About 50% of patients present with localized disease, and surgical resection with or without adjuvant radiotherapy is generally indicated in this context. However, recurrence rates are high and overall prognosis rather poor, with mortality rates of 33%-46%. MCC is a chemosensitive disease, but responses in the advanced setting are seldom durable and not clearly associated with improved survival. Several recent trials with checkpoint inhibitors (pembrolizumab, avelumab, nivolumab) have shown very promising results with a favorable safety profile, in both chemonaïve and pretreated patients. In 2017, avelumab was approved by several regulatory agencies for the treatment of metastatic MCC, the first drug to be approved for this orphan disease. More recently, pembrolizumab has also been approved by the U.S. Food and Drug Administration in this setting. Immunotherapy has therefore become the new standard of care in advanced MCC. This article reviews current evidence and recommendations for the diagnosis and treatment of MCC and discusses recent therapeutic advances and their implications for care in patients with advanced disease. This consensus statement is the result of a collaboration between the Spanish Cooperative Group for Neuroendocrine Tumors, the Spanish Group of Treatment on Head and Neck Tumors, and the Spanish Melanoma Group. IMPLICATIONS FOR PRACTICE: Merkel cell carcinoma (MCC) is an uncommon aggressive skin cancer associated with advanced age, UV light exposure, and immunosuppression. Up to 80% are associated with Merkel cell polyomavirus. MCC is a chemosensitive disease, but tumor responses in the advanced setting are short-lived with no long-term survivors. Recent clinical trials with immune checkpoint inhibitors (i.e., pembrolizumab, avelumab, nivolumab) have shown promising results, with avelumab becoming the first drug to receive regulatory approval for this orphan indication. Further follow-up is needed, however, to define more adequately the long-term benefits of these drugs, and continued research is warranted to optimize immunotherapeutic strategies in this setting.
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Affiliation(s)
- Rocio Garcia-Carbonero
- Medical Oncology Department, Instituto de Investigacion Sanitaria Hospital 12 de Octubre (imas12), UCM, CNIO, CIBERONC, Madrid, Spain
| | - Ivan Marquez-Rodas
- Medical Oncology Department, Gregorio Marañon University Hospital, CIBERONC, Madrid, Spain
| | | | | | - Miguel Angel Cabrera
- Medical Oncology Department, Nuestra Señora de la Candearia University Hospital, Santa Cruz de Tenerife, Spain
| | - Jose Maria Piulats
- Medical Oncology Department, Institut Catala d'Oncologia, IDIBELL, CIBERONC, Hospitalet de Llobregat, Barcelona, Spain
| | - Jaume Capdevila
- Medical Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Enrique Grande
- Medical Oncology Department, MD Anderson Cancer Center Madrid, Madrid, Spain
| | | | - Alfonso Berrocal
- Medical Oncology Department, University General Hospital of Valencia, Valencia, Spain
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24
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Tétu P, Baroudjian B, Madelaine I, Delyon J, Lebbé C. [Update in treatment for Merkel Cell Carcinoma and clinical practice guide]. Bull Cancer 2018; 106:64-72. [PMID: 30579571 DOI: 10.1016/j.bulcan.2018.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/31/2018] [Accepted: 11/06/2018] [Indexed: 12/30/2022]
Abstract
Merkel Cell Carcinoma (MCC) is a rare neuroendocrine skin cancer that is associated with frequent recurrences and a high mortality rate. In the recent past years, incidence rates of MCC have increased in the USA, Australia and Europe. About one third of patients present metastatic disease at the time of diagnosis or will develop metastases in the course of their disease. Although advanced MCC is chemosensitive, responses to cytotoxic chemotherapy are mostly of short duration and toxicity is potentially high. Recently, considerable progress has been made in the MCC field with the arrival of immunotherapy, particularly anti-PD-1 and anti-PD-L1 antibodies which have demonstrated impressive frequency and durability of response and were well-tolerated. However, about 50 % of advanced patients do not respond to immunotherapy and urgent need exists to identify biomarkers and predictive factors. Moreover, many randomized prospective studies are evaluating the efficacy and safety of novel therapeutics and patients with advanced stages are encouraged to participate in clinical trials. This article synthetizes the actual clinical practice guidelines, the safety and efficacy data from the recent clinical trials and the on-going clinical trials to help clinicians in the treatment of MCC patients.
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Affiliation(s)
- Pauline Tétu
- AP-HP Dermatology, hôpital Saint-Louis, Paris 7 Diderot University, Department of Dermatology, Inserm U976, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Barouyr Baroudjian
- AP-HP Dermatology, hôpital Saint-Louis, Paris 7 Diderot University, Department of Dermatology, Inserm U976, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Isabelle Madelaine
- AP-HP Pharmacology, hôpital Saint-Louis, Paris 7 Diderot University, Department of Pharmacology, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Julie Delyon
- AP-HP Dermatology, hôpital Saint-Louis, Paris 7 Diderot University, Department of Dermatology, Inserm U976, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Céleste Lebbé
- AP-HP Dermatology, hôpital Saint-Louis, Paris 7 Diderot University, Department of Dermatology, Inserm U976, 1, avenue Claude-Vellefaux, 75010 Paris, France
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25
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Lara KM, In GK, Matcuk GR, Mehta A, Hu JS. Talimogene laherparepvec in combination with pembrolizumab leads to a complete response in a patient with refractory Merkel cell carcinoma. JAAD Case Rep 2018; 4:1004-1006. [PMID: 30450405 PMCID: PMC6226586 DOI: 10.1016/j.jdcr.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Kristi M Lara
- University of Southern California, Los Angeles, California
| | - Gino K In
- University of Southern California, Los Angeles, California
| | | | - Arjun Mehta
- University of Southern California, Los Angeles, California
| | - James S Hu
- University of Southern California, Los Angeles, California
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27
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Conry RM, Westbrook B, McKee S, Norwood TG. Talimogene laherparepvec: First in class oncolytic virotherapy. Hum Vaccin Immunother 2018; 14:839-846. [PMID: 29420123 PMCID: PMC5893211 DOI: 10.1080/21645515.2017.1412896] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Oncolytic viruses represent a novel drug class in which native or modified viruses mediate tumor regression through selective replication within and lysis of tumor cells as well as induction of systemic antitumor immunity capable of eradicating tumor at distant, uninjected sites. Talimogene laherparepvec (TVEC) is a type I herpes simplex virus genetically modified to preferentially replicate in tumor cells, enhance antigen loading of MHC class I molecules and express granulocyte-macrophage colony-stimulating factor to increase tumor-antigen presentation by dendritic cells. It is presently the only oncolytic virus approved by the FDA with an indication for advanced melanoma based upon improved durable response rate in a randomized, phase III trial. Clinical trials are underway in melanoma investigating TVEC as neoadjuvant monotherapy and in combination with checkpoint inhibitors for unresectable disease as well as in an array of other malignancies. It is appropriate to review TVEC's biology mechanism of action, clinical indication and future directions as a prototype of the burgeoning class of oncolytic viruses.
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Affiliation(s)
- Robert M Conry
- a Medicine/Division of Hematology and Oncology, University of Alabama at Birmingham , Birmingham , AL , USA
| | - Brian Westbrook
- b Medicine, University of Alabama at Birmingham , Birmingham , AL , USA
| | - Svetlana McKee
- a Medicine/Division of Hematology and Oncology, University of Alabama at Birmingham , Birmingham , AL , USA
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