Sex Differences in Overall Survival and the Effect of Radiotherapy in Merkel Cell Carcinoma-A Retrospective Analysis of a Swedish Cohort

Sex-related differences in the efficacy and toxicity of cancer treatments

Differences between the biological sexes have long been observed in cancer incidence and prevalence, and in treatment outcomes including efficacy and toxicity. Ideally, there should be sufficient information to improve the individualization of cancer treatment by incorporating sex into treatment decisions. Necessary information should include: the nature and source of these differences; whether inherent to the specific cancer (such as molecular profiles, metabolic behaviors, and immune responses); the pathophysiological mechanisms of the specific cancer; or the pharmacokinetic and pharmacodynamic profiles of different cancer drugs. The influence of gender, which is defined as the sociocultural construct that determines societal norms for males and females, should also be included in personalized decision-making. This review aimed to describe the current evidence on the impact of sex and gender on treatment effects, outcomes, and toxicity profiles in cancer patients. Data for the influence of gender were negligible, whereas clinical studies and meta-analyses in different cancer types have identified differences between males and females in the effectiveness on survival outcomes of immunotherapy, chemotherapy, targeted therapy, and radiotherapy. Similarly, toxicity profiles of different cancer treatments varied between sexes. Based on these observed differences, it seems clear that sex should be included as an important variable when individualizing treatment; however, more research into sex- and gender-related differences in cancer treatment efficacy and toxicity, and the causes for these differences, is required before this can be fully incorporated into individualized treatment programs in real-world clinical practice.

A systematic review of sex and gender differences in treatment outcome of inflammatory skin diseases: Is it time for new guidelines?

BACKGROUND

Gender- and sex-specific differences in medicine were long-time disregarded. Despite numerous indications of gender- and sex-specific influences on the treatment of dermatological conditions, these have not yet been systematically investigated.

OBJECTIVES

To meet this unmet need, we conducted the present systematic review on the topic of gender and sex differences in the treatement outcome of skin diseases.

METHODS

Embase (via Ovid), PubMed Medline and Web of Science were searched, in between January 2001 and December 2022. English and german randomized controlled trials, prospective and retrospective cohorts and case-control studies that examined differences between men and women in treatment outcomes of skin diseases were included.

RESULTS

Two authors independently screened the reports for eligibility, one extracted all data (the second double-checked) and critically appraised the quality and risk of bias of the studies. Eighty-three reports were included. The largest share of the identified publications focused on gender differences in psoriasis and psoriatic arthritis (n = 49), followed by melanoma (n = 8) and sporadic studies (n < 5) of inflammatory, infectious and autoimmune skin diseases. The main topics in which gender differences could be identified were choice of treatment, time to initiation of treatment, therapy response, adverse events, adherence and treatment satisfaction. For psoriasis, gender differences could be found in all aspects, while for the other skin diseases specific publications on gender differences are still missing.

CONCLUSIONS

This systematic review shows numerous gender differences but also reveals major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize a patient-centred, individualized, gender-equal healthcare. PROSPERO Registration: CRD42022306626.

Effectiveness and Safety of Treatments for Early-Stage Merkel Cell Carcinoma: A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Studies

OBJECTIVE

The lack of consensus on the benefits and harms of standard therapies, including surgery (SRx), radiotherapy (RTx), chemotherapy (CTx), and their combinations among early-stage MCC, prompted this study.

METHODS

A systematic review and meta-analysis of randomized and non-randomized studies published between January 01, 1972, and January 31, 2023, and having overall survival (OS), local recurrence (LR), regional recurrence (RR), disease-specific survival (DSS), and/or disease-free survival (DFS) as outcomes was conducted using the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed (NCBI), Scopus (ELSEVIER), and Web of Science (CLAVIRATE) databases. Hazard ratios (HRs) and their variances were pooled using the inverse variance heterogeneity model.

RESULTS

Forty-nine studies representing 46,215 participants were included in the meta-analysis. A statistically significant improvement in OS was observed for groups administered adjuvant RTx (SRx + RTx) compared to SRx only (HR = 0.78, 95% CI, 0.62-0.99), albeit with statistically significant heterogeneity (Q = 532.30, p < 0.001) and a large amount of inconsistency (I2 = 94%, 95% CI, 93.0-95.5). Both LR (HR = 1.52, 95% CI, 0.37-6.19) and RR (HR = 0.41, 95% CI, 0.09-1.78) were not statistically significant. In addition, DSS (HR = 0.58, 95% CI, 0.24-1.40) was not statistically significant but DFS was (HR = 0.35, 95% CI, 0.13-0.93). Subgroup analyses revealed that adjuvant radiotherapy was more effective in local than regional MCC. The E-value suggested that the RTx dose was a confounder of the observed effectiveness of adjuvant RTx; and also, the use of CTx following adjuvant RTx, did not impact the strength of evidence for OS.

CONCLUSIONS

Although adjuvant RTx improves survival and recurrence outcomes among early-stage MCC, the safety and effectiveness of standard therapies in MCC remains poorly studied and, thus, affects the synthesis of evidence across important patient and clinical characteristics. Future research on the comparative effectiveness of different therapies is needed.

Incidence, mortality and survival of Merkel cell carcinoma: a systematic review of population-based studies

BACKGROUND

Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer that most commonly occurs in ultraviolet-exposed body sites. The epidemiology of MCC in different geographies and populations is not well characterized.

OBJECTIVES

The objective of this systematic review is to summarize evidence on the incidence, mortality and survival rates of MCC from population-based studies.

METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from database inception to 6 June 2023. No geographic, age or date exclusions were applied. We included population-based studies of MCC that reported the incidence, survival or mortality rate, and also considered systematic reviews. A data-charting form was created and validated to identify variables to extract. Two reviewers then independently charted the data for each included study with patient characteristics, and estimates of incidence rate, mortality rate, and survival rate and assessed the quality of included studies using the Joanna Briggs Institute Checklist for Prevalence studies, Newcastle-Ottawa Scale and Assessment of Multiple Systematic Reviews. We abstracted age-, sex-, stage- and race-stratified outcomes, and synthesized comparisons between strata narratively and using vote counting. We assessed the certainty of evidence for those comparisons using the Grading of Recommendations, Assessments, Developments and Evaluations framework.

RESULTS

We identified 11 472 citations, of which 52 studies from 24 countries met our inclusion criteria. Stage I and the head and neck were the most frequently reported stage and location at diagnosis. The incidence of MCC is increasing over time (high certainty), with the highest reported incidences reported in southern hemisphere countries [Australia (2.5 per 100 000); New Zealand (0.96 per 100 000) (high certainty)]. Male patients generally had higher incidence rates compared with female patients (high certainty), although there were some variations over time periods. Survival rates varied, with lower survival and/or higher mortality associated with male sex (moderate certainty), higher stage at diagnosis (moderate-to-high certainty), older age (moderate certainty), and immunosuppression (low-to-moderate certainty).

CONCLUSIONS

MCC is increasing in incidence and may increase further given the ageing population of many countries. The prognosis of MCC is poor, particularly for male patients, those who are immunosuppressed, and patients diagnosed at higher stages or at an older age.

Merkel Cell Carcinoma Mimicking a Pyogenic Granuloma on the Thumb

Merkel cell carcinoma (MCC) is a rare and aggressive skin cancer that can present with various clinical manifestations. An 80-year-old male, known to have chronic lymphocytic leukaemia presented with a lesion on his left thumb, initially thought to be a pyogenic granuloma. The lesion was cauterized with silver nitrate but remained persistent. A curettage biopsy was performed, and a histopathological examination revealed MCC. The patient was subsequently referred to dermatology and plastic surgery for further management. The lesion was excised; a full-thickness skin graft was used to close the defect. This case highlights the importance of considering MCC in the differential diagnosis of skin lesions, even if they present with a benign appearance.

Clinicopathological features, MCPyV status and outcomes of Merkel cell carcinoma in solid-organ transplant recipients: a retrospective, multicentre cohort study

BACKGROUND

The proportion of Merkel cell carcinomas (MCCs) in solid-organ transplant recipients (SOTR) harbouring Merkel cell polyomavirus (MCPyV) is unknown, as are factors affecting their outcomes.

OBJECTIVE

To describe clinicopathological features of MCC in SOTR, investigate the tumoral MCPyV-status and identify factors associated with tumour outcomes.

METHODS

Retrospective, international, cohort-study. MCPyV-status was investigated by immunohistochemistry and polymerase chain reaction.

RESULTS

A total of 30 SOTR and 44 consecutive immunocompetent patients with MCC were enrolled. SOTR were younger at diagnosis (69 vs. 78 years, P < 0.001). Thirty-three percent of SOTR MCCs were MCPyV-positive vs. 91% of immunocompetent MCCs (P = 0.001). Solid-organ transplantation was associated with an increased cumulative incidence of progression (SHR: 3.35 [1.57-7.14], P = 0.002), MCC-specific mortality (SHR: 2.55 [1.07-6.06], P = 0.034) and overall mortality (HR: 3.26 [1.54-6.9], P = 0.002). MCPyV-positivity and switching to an mTOR inhibitor (mTORi) after MCC diagnosis were associated with an increased incidence of progression (SHR: 4.3 [1.5-13], P = 0.008 and SHR: 3.6 [1.1-12], P = 0.032 respectively) in SOTR.

LIMITATIONS

Retrospective design and heterogeneity of SOTR cohort.

CONCLUSIONS

MCPyV appears to play a less prominent role in the aetiopathogenesis of MCC in SOTR. SOTR have a worse prognosis than their immunocompetent counterparts and switching to an mTORi after the diagnosis of MCC does not improve progression.

The impact of merkel cell polyomavirus positivity on prognosis of merkel cell carcinoma: A systematic review and meta-analysis

Introduction

There are numerous findings over the past decade have indicated that Merkel cell carcinoma (MCC) may have two pathways of pathogenesis: one related to ultraviolet irradiation and the other to the Merkel cell polyomavirus (MCPyV). However, the predictive and clinicopathological value of MCPyV positivity in MCC patients is still debatable. This article aims to examine the most recent data regarding this issue.

Methods

The thorough literature searches were conducted in the Medline Ovid, PubMed, Web of Science, the Cochrane CENTRAL Databases, and Embase Databases until December 31, 2021. The associations between overall survival (OS), Merkel cell carcinoma-specific survival (MSS), recurrence-free survival (RFS), progression-free survival (PFS), clinicopathologic features, and MCPyV positivity were examined in our meta-analysis.

Results

This meta-analysis included a total of 14 studies involving 1595 patients. Our findings demonstrated a significant correlation between MCPyV positivity and improved OS (HR=0.61, 95%CI:0.39-0.94, P=0.026) and improved PFS (HR=0.61, 95% CI: 0.45-0.83, P=0.002). MCPyV positivity did not, however, appear to be associated with either MSS (HR=0.61, 95%CI: 0.28-1.32, P=0.209) or RFS (HR= 0.93, 95%CI: 0.37-2.34, P=0.873). Pooled results revealed a correlation between MCPyV positivity with gender (male vs. female, OR=0.606, 95%CI: 0.449-0.817, P=0.001), histopathological stage (AJCC I-II vs. III-IV, OR=1.636, 95%CI: 1.126-2.378, P=0.010) and primary site (head and neck vs. other sites, OR=0.409, 95%CI: 0.221-0.757, P=0.004).

Conclusion

These results imply that MCPyV positivity may present a promising predictive biomarker for human MCC and call for further study.

Diagnosis and treatment of Merkel cell carcinoma: European consensus-based interdisciplinary guideline - Update 2022

Merkel cell carcinoma (MCC) is a rare skin cancer, accounting for less than 1% of all cutaneous malignancies. It is found predominantly in white populations and risk factors include advanced age, ultraviolet exposure, male sex, immunosuppression, such as AIDS/HIV infection, haematological malignancies or solid organ transplantation, and Merkel cell polyomavirus infection. MCC is an aggressive tumour with 26% of cases presenting lymph node involvement at diagnosis and 8% with distant metastases. Five-year overall survival rates range between 48% and 63%. Two subsets of MCC have been characterised with distinct molecular pathogenetic pathways: ultraviolet-induced MCC versus virus-positive MCC, which carries a better prognosis. In both subtypes, there are alterations in the retinoblastoma protein and p53 gene structure and function. MCC typically manifests as a red nodule or plaque with fast growth, most commonly on sun exposed areas. Histopathology (small-cell neuroendocrine appearance) and immunohistochemistry (CK20 positivity and TTF-1 negativity) confirm the diagnosis. The current staging systems are the American Joint Committee on Cancer/Union for international Cancer control 8th edition. Baseline whole body imaging is encouraged to rule out regional and distant metastasis. For localised MCC, first-line treatment is surgical excision with postoperative margin assessment followed by adjuvant radiation therapy (RT). Sentinel lymph node biopsy is recommended in all patients with MCC without clinically detectable lymph nodes or distant metastasis. Adjuvant RT alone, eventually combined with complete lymph nodes dissection is proposed in case of micrometastatic nodal involvement. In case of macroscopic nodal involvement, the standard of care is complete lymph nodes dissection potentially followed by post-operative RT. Immunotherapy with anti-PD-(L)1 antibodies should be offered as first-line systemic treatment in advanced MCC. Chemotherapy can be used when patients fail to respond or are intolerant for anti-PD-(L)1 immunotherapy or clinical trials.

Multimodal Strategy in Localized Merkel Cell Carcinoma: Where Are We and Where Are We Heading?

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine tumor of the skin whose incidence is rising. Multimodal treatment is crucial in the non-metastatic, potentially curable setting. However, the optimal management of patients with non-metastatic MCC is still unclear. In addition, novel insights into tumor biology and newly developed treatments (e.g., immune checkpoint inhibitors) that dramatically improved outcomes in the advanced setting are being investigated in earlier stages with promising results. Nevertheless, the combination of new strategies with consolidated ones needs to be clarified. We reviewed available evidence supporting the current treatment recommendations of localized MCC with a focus on potentially ground-breaking future strategies. Advantages and disadvantages of the different treatment modalities, including surgery, radiotherapy, chemotherapy, and immunotherapy in the non-metastatic setting, are analyzed, as well as those of different treatment modalities (adjuvant as opposed to neoadjuvant). Lastly, we provide an outlook of remarkable ongoing studies and of promising agents and strategies in the treatment of patients with non-metastatic MCC.

Merkel Cell Carcinoma With Isolated Pancreatic Metastasis

Merkel cell carcinoma (MCC) is a highly aggressive cutaneous neuroendocrine carcinoma, frequently associated with distant metastasis. However, recurrence of MCC manifesting with only pancreatic involvement is exceedingly rare. A 53-year-old man presented to our institution with abdominal discomfort 3 months after initial resection of chest wall MCC. Imaging revealed lesions in the pancreas and peripancreatic lymph nodes. Pathology obtained through endoscopic ultrasound confirmed recurrence of MCC. He underwent chemotherapy with cisplatin and etoposide, resulting in a complete resolution of the pancreatic lesions. Unfortunately, he passed away from sudden cardiac arrest while being in remission from MCC. Immunohistochemistry is crucial in differentiating MCC from primary pancreatic glandular and neuroendocrine tumors. While there are no definitive guidelines in the management of pancreatic lesions associated with MCC, checkpoint inhibitor immunotherapy is increasingly being used.