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Aims The activity that the immune checkpoint inhibitor (ICI) cemiplimab has recently demonstrated has led to a paradigm shift in the management of patients with advanced cutaneous squamous cell carcinoma (cSCC). To identify predictive biomarkers of response to ICIs in advanced cSCC, we studied 33 patients who received ICI therapy at the Dana-Farber/Harvard Cancer Center (DF/HCC) and analysed sequencing data for a subset of these patients. Methods We collected clinical data using electronic health records and genomic data using the institutional OncoPanel platform of the DF/HCC. We compared tumour genomics with data from previously sequenced cSCC cohorts. Results We observed high tumour mutational burden regardless of smoking status and response to ICI and longer median overall survival among those patients who achieved an ICI response. We compared the genetic data from our cohort with data from other cohorts that included fewer patients with distant metastatic disease. Although our cohort had a similar genetic landscape to those of comparator cohorts, mutations in PIK3C2B were more common in our study. In our cohort, copy number alterations (CNAs) in the 3q chromosomal arm appeared to predict response to ICI therapy. Conclusion CNAs in the 21–27 bands of chromosome arm 3q, a region that includes PIK3CA, ETV5 and BCL6, may represent predictors of response to ICI and may be candidates for drug targeting in combination or sequence with ICI agents.

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.

Purpose/objective(s) Serum antibodies to the Merkel oncoprotein (AMERK) are expressed in approximately 50% of patients (pts) with MCC and can be used to monitor for recurrence. This study aimed to describe changes in AMERK levels after RT for MCC and identify patterns that predict disease recurrence. Materials/methods Pts with MCC were identified retrospectively if they had curative-intent postoperative or definitive RT at a single institution from 2010-2020. Pts treated with RT at other institutions were excluded due to inability to assess RT quality, previously shown to impact MCC outcomes. All patients had a pre-RT AMERK and at least one post-RT AMERK (median no. Tests 5, range 1-10). Changes in AMERK were described and compared using Wilcoxon rank sum test for two-sample non-parametric comparisons and the Chi-square test for recurrence association. Results Of 202 MCC pts treated at our institution, 61 curatively treated pts had a pre-RT AMERK test performed. AMERK was detectable in 27 of the 61 patients (44%) with a median value of 2950 (range 127 to 115,000 [upper limit of assay]). Detectable pre-RT AMERK was associated with decreased MCC recurrence compared to pts with undetectable pre-RT AMERK (OR 0.35, 95% CI 0.12,1.04). The 27 pts with positive pre-RT AMERK had Stages I (n = 5), II (n = 1), and III (n = 21) from sites of the extremity (n = 14), head/neck (n = 7), unknown primary (n = 4), and trunk (n = 2). Pts with gross disease at RT (n = 11) had higher median pre-RT AMERK than those without gross disease at RT (n = 16) (median 8550 vs. 1840, P = 0.06). With a median follow-up of 20 months (range 2.3-61.3), there were 7 recurrences, all were distant. All AMERK-positive pts were alive at last follow-up except for the single immunosuppressed pt who recurred and died of MCC. A ≥50% AMERK reduction by 6-months after RT had a sensitivity of 95% (95% CI 74-100) for detecting disease-free status and a negative predictive value of 83% (95% CI 41-97%), reflecting the probability of recurrence if 115,00 value, had initiated high-dose corticosteroids for a comorbid condition. Out of 8 recurrence-free patients with AMERK levels available more than 2-years post-RT, 50% (4 of 8) had detectable AMERK (range 239-1960, > 2 years post-RT). Conclusion Reduction in AMERK post-RT can be used to predict MCC recurrence, which rarely occurs with a sustained ≥50% reduction by 6-months post-RT. AMERK may be persistently detectable in recurrence-free pts beyond 2 years. Further research is needed to determine the impact of corticosteroid initiation on AMERK levels.

Background Merkel cell carcinoma is a rare cancer for which the standard-of-care is immune checkpoint blockade in the recurrent/metastatic setting. However, immunotherapy is not effective in all patients. A greater understanding of molecular mechanisms and potential predictive biomarkers are unmet needs for clinicians and researchers. Methods We undertook a retrospective analysis of 45 patients treated at our institution from 2013 to 2020 to understand the clinical and genomic correlates of clinical benefit from immunotherapy. We gathered data from the electronic health record, including provider notes and results from our institutional next-generation sequencing panel of actionable genomic alterations. Results Our cohort predominantly included individuals with stage III disease at diagnosis and stage IV disease at the time of diagnosis of recurrent/metastatic disease. Most patients received immunotherapy in the first line. 43% of patients experienced an objective response to immunotherapy (median duration of response 24.2 months, 95% confidence interval 8.8-not reached) and median overall survival was 15.5 months (95% confidence interval 9.0–28.7) (median follow-up 25.2 months). Lower stage at diagnosis of primary disease and shorter disease-free interval between completion of initial treatment and recurrence were each associated with greater odds of response (odds ratio of 0.06, p=0.04 for stage; odds ratio 0.75, p=0.05 for disease-free interval). The most common single-nucleotide variants among the sequenced cohort were those in TP53 (59%) and RB1 (51%). Single-nucleotide variants in the ARID2 and NTRK1 genes were associated with response without Bonferroni correction (p=0.05), while none of Merkel cell polyomavirus status, total mutational burden, ultraviolet mutational signatures, and copy-number alterations predicted outcomes (figure 1). Conclusions Patients with shorter disease-free interval after definitive treatment may be particularly suitable candidates for immunotherapy. Our molecular findings point to ARID2 and NTRK1 as potential predictive markers and/or therapeutic targets (e.g., with Trk inhibitors), although this association needs to be confirmed in a larger sample. Acknowledgements AJK receives research funding from the American Society of Hematology and from the Pritzker School of Medicine. Ethics Approval The study was approved by the Dana-Farber institutional review board, protocol numbers 11–104 and 17–000. Consent Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Merkel cell carcinoma is a rare cancer for which immune checkpoint blockade is standard-of-care for recurrent/metastatic disease. However, not all patients benefit from immunotherapy. A greater understanding of molecular mechanisms and predictive biomarkers are unmet needs. We retrospectively analyzed electronic health records and next-generation sequencing data of 45 patients treated at our institution from 2013 to 2020 to understand clinical and genomic correlates of benefit from immunotherapy. Our cohort predominantly included individuals with stage III disease at primary disease diagnosis and individuals with stage IV disease at recurrent/metastatic disease diagnosis. Most received immunotherapy as first-line treatment. 43% experienced objective response (median duration of response 24.2 months, 95% confidence interval 8.8-not reached). Median overall survival was 15.5 months (95% confidence interval 9.0-28.7) (median follow-up 25.2 months). Less advanced stage at primary disease diagnosis and shorter disease-free interval between completion of initial treatment and recurrence were each associated with greater odds of response (odds ratio of 0.06, p = 0.04 for stage; odds ratio 0.75, p = 0.05 for disease-free interval). Single-nucleotide variants in ARID2 and NTRK1 were associated with response (p = 0.05, without Bonferroni correction), while none of Merkel cell polyomavirus status, total mutational burden, ultraviolet mutational signatures, and copy-number alterations predicted outcomes. Patients with shorter disease-free interval may be particularly suitable immunotherapy candidates. Our molecular findings point to ARID2 and NTRK1 as potential predictive markers and/or therapeutic targets (e.g., with Trk inhibitors), although this association needs to be confirmed in a larger sample.

Background: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin cancer. Prior to the advent of immunotherapy, treatment options were limited. In our study, we evaluate the impact of tumor cell PD-L1 expression and tumor immune microenvironment on survival in MCC patients who were not treated with immune checkpoint inhibitors. Methods: Clinical data and tissue samples were collected from 78 patients with confirmed MCC treated at Dana-Farber Cancer Institute. Specimens were analyzed for the distribution of PD-L1 by immunohistochemistry staining (IHC) and standardized analysis. Results were correlated with survival data. Results: In this study, membrane and cytoplasmic MCC tumor cell staining for PD-L1 was detected in 22.4% (15 of 67) of cases and PD-L1 staining of intratumoral microvessels and PD-L1 positive immune cells at the infiltrative margins of the tumor in 92.5% (62 of 67) of cases. In patients untreated with immune checkpoint inhibitors, median overall survival was not different for patients based on PD-L1 expression (PD-L1+ 64 months vs. PD-L1- not reached; HR = 1.26, 95% CI: 0.46–3.45; p = 0.60). Conclusion: PD-L1 expression is frequently detected in MCC tumor cells and tumor microenvironment. PD-L1 expression did not affect prognosis in this cohort that had not received PD-1/L1 blockade.

Background Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine carcinoma of the skin caused by either the integration of Merkel cell polyomavirus (MCPyV) and expression of viral T antigens or by ultraviolet-induced damage to the tumor genome from excessive sunlight exposure. An increasing number of deep sequencing studies of MCC have identified significant differences between the number and types of point mutations, copy number alterations, and structural variants between virus-positive and virus-negative tumors. However, it has been challenging to reliably distinguish between virus positive and UV damaged MCC. Methods In this study, we assembled a cohort of 71 MCC patients and performed deep sequencing with OncoPanel, a clinically implemented, next-generation sequencing assay targeting over 400 cancer-associated genes. To improve the accuracy and sensitivity for virus detection compared to traditional PCR and IHC methods, we developed a hybrid capture baitset against the entire MCPyV genome and software to detect integration sites and structure. Results Sequencing from this approach revealed distinct integration junctions in the tumor genome and generated assemblies that strongly support a model of microhomology-initiated hybrid, virus-host, circular DNA intermediate that promotes focal amplification of host and viral DNA. Using the clear delineation between virus-positive and virus-negative tumors from this method, we identified recurrent somatic alterations common across MCC and alterations specific to each class of tumor, associated with differences in overall survival. Finally, comparing the molecular and clinical data from these patients revealed a surprising association of immunosuppression with virus-negative MCC and significantly shortened overall survival. Conclusions These results demonstrate the value of high-confidence virus detection for identifying molecular mechanisms of UV and viral oncogenesis in MCC. Furthermore, integrating these data with clinical data revealed features that could impact patient outcome and improve our understanding of MCC risk factors.

BackgroundThis study sought to determine the efficacy and safety profile of cabozantinib in patients with advanced Merkel cell carcinoma (MCC).Experimental DesignThis prospective, phase II, single-institution trial enrolled patients with platinum-failure, recurrent/metastatic MCC to receive cabozantinib 60 mg orally daily until disease progression, withdrawal from study, or severe toxicity. The primary endpoint was disease control rate. Secondary endpoints included overall survival (OS), progression-free survival (PFS), and toxicity. Immunohistochemistry for VEGFR-2, MET, and HGF expression and next-generation sequencing of tumor tissue were performed and correlated with outcome.ResultsEight patients were accrued from January 24, 2014, to June 8, 2016. The study was closed prematurely because of toxicity and lack of responses. The most frequent adverse events were grades 1 and 2 and included anorexia, fatigue, nausea, hypothyroidism, and dysgeusia. Two patients developed nonhealing, painful ulcers and tumor-skin fistula. One patient had stable disease for 8 months. One patient withdrew from the study after 2 weeks of therapy because of adverse events. Three patients required dose reduction because of toxicity. Median PFS and OS were 2.1 and 11.2 months, respectively. No expression of MET, HGF, or VEGFR-2 was identified in tumor cells by immunohistochemistry of patients’ tissue samples.ConclusionCabozantinib was poorly tolerated and did not demonstrate activity in patients with recurrent/metastatic, platinum-failure MCC. It is unclear whether preselection of patients with the specific upregulation or genetic alteration in the targets for cabozantinib would have changed the results of this study. (Clinical trial identification number: NCT02036476)Implications for PracticeThis phase II study demonstrated poor tolerability and lack of activity of cabozantinib in an unselected group of patients with advanced Merkel cell carcinoma. Although it is unclear whether preselection of patients with the specific upregulation and genetic alterations in targets for cabozantinib would have changed the results of this study, this would have likely led to an extremely rare patient population that would take many years to accrue.

Purpose Merkel cell carcinoma (MCC) is an aggressive cutaneous malignancy. However, factors associated with disease presentation and outcomes remain uncertain, especially in light of recent changes in workup, such as sentinel lymph node biopsy. Therefore, this study used the SEER database to examine factors that could affect stage at presentation and treatment. Methods We identified 4,543 patients and evaluated associations between sex, race, age, primary disease site, disease presentation, and treatment. We also used univariate and multivariate analyses to examine the effect of these factors on disease-specific survival (DSS) and overall survival (OS). We specifically conducted subgroup analyses on a more modern cohort of patients with MCC treated between 2006 and 2012. Results Male sex, older age, larger tumor size, and primary tumors of the scalp, neck, or trunk were associated with a higher burden of nodal disease. Multivariate predictors of worse DSS/OS in both the recent and overall cohort included age older than 75 years, number of lymph nodes involved, tumors greater than 5 cm, metastatic disease, or lack of radiation therapy. The number of involved nodes was the best predictor of DSS/OS. Associations with radiation therapy were most pronounced in patients with nodal disease and those not undergoing surgery. Conclusions Sex, age, tumor size, and primary site of disease correlated with burden of nodal disease in MCC. Associations between disease presentation and treatment strategies such as radiation and DSS and OS have remained relatively constant in the modern era from 2006 to 2012 compared with findings from prior studies.

BACKGROUND Cutaneous lymphadenoma (CL) is rare neoplasm that clinically and histologically resembles basal cell carcinoma (BCC). CL, composed of dermal basaloid epithelial islands with prominent admixed lymphocytes, characteristically contains cytokeratin 20 (CK20)-positive Merkel cells (MCs). However, CK20 may be of limited use because of low MC density in small samples. CK17 is expressed diffusely throughout BCC. We investigated the discriminatory utility of CK17 and CK20 in CL and BCC. METHODS A retrospective clinicopathological review of 11 cases of CL and 14 BCC was performed. CK20-positive MCs within basaloid tumor lobules and CK17 immunohistochemical staining and pattern of expression were recorded. RESULTS Intratumoral CK20-positive MCs were identified in 4/11 CL cases (36.4%) and 0/14 BCC cases (p = 0.012, sensitivity = 0.36). CK17 showed diffuse positive staining in all 14 BCC cases. CK17 showed a distinct patchy and peripheral rim staining in basaloid islands of 10/11 CL cases (p

BACKGROUND: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy of neuroendocrine origin, with about 30 cases of brain metastasis (BM) reported in the literature. Historically, the treatment of neuro-metastatic MCC has largely included chemotherapy (CT) and radiotherapy (RT). The aim was to investigate predictors of overall survival (OS) in neuro-metastatic MCC. METHODS: In this retrospective study, we surveyed institutional databases and additionally conducted a systematic review of the literature to identify cases reporting on management of distant MCC BM. A pooled analysis was performed on the institutional and literature cases to assess predictors of OS. Survival analysis was done on R (ver 3.4.0) using a Log Rank statistic and cox proportional hazard ratio. RESULTS: Forty cases were included for analysis, describing operative (14) and non-operative (26) management. Median time from initial MCC diagnosis to CNS involvement was 17.0-mos (IQR 10.5- 26.5), and most patients had a single BM (62.5%). Management of intracranial disease included RT (84.2%), systemic therapy (59.5%) and surgical resection (35%). Operative management was associated with a lower intracranial burden of disease (BoD, single BM: op 92.9% vs. non-op 46.2%, p=0.004), but similar systemic BoD. Median OS was longer in patients treated with neurosurgery (73-mos, 95%CI:31–115 vs. 25-mos, 95%CI:17–44, p ‹ 0.001). Both neurosurgery (HR 0.18, 95%CI:0.06–0.54, p=0.002) and having a single BM (multiple BM or leptomeningeal disease: HR 2.51, 95%CI:1.12–5.6, p=0.03) conferred an OS benefit on risk-unadjusted analysis. On multivariable analysis, only neurosurgical resection was an independent predictor of OS (HR 0.16, 95%CI:0.04–0.59, p=0.006), controlling for age, BoD and RT. Systemic therapy and RT were not associated with OS. CONCLUSIONS: Resection of MCC BM may confer a survival benefit relative to non-operative management given appropriate patient selection. Prospective investigation of multimodal management of neurometastatic MCC is warranted, especially given the promise of new immunotherapy agents in treating MCC.

Background Merkel cell carcinoma (MCC) is a rare cutaneous malignancy of neuroendocrine origin, with about 30 cases of brain metastasis (BM) reported in the literature. Historically, the treatment of neurometastatic MCC has largely included chemotherapy and radiotherapy. The aim was to investigate predictors of overall survival (OS) in neurometastatic MCC. Methods In this retrospective study, we surveyed institutional databases and conducted a systematic review of the literature to identify cases reporting on management of distant MCC BM. A pooled survival analysis was performed on the institutional and literature cases to assess predictors of OS. Results Forty cases were included for analysis, describing operative [14] and non-operative [26] management. Median time to central nervous system involvement was 17.0-mos (interquartile range 10.5–26.5), and most patients had a single BM (62.5%). Management of intracranial disease included radiotherapy (82.5%), systemic therapy (59.5%) and surgical resection (35%). Operative management was associated with a lower intracranial burden of disease (BoD), but similar systemic BoD. Both neurosurgery (hazard ratio [HR] 0.18, 95% confidence interval [CI]: 0.06–0.54, p = 0.002), having RT (HR 0.37, 95% CI: 0.14:0.93, p = 0.04) and having a single BM (extensive intracranial BoD: HR 2.51, 95% CI: 1.12–5.6, p = 0.03) conferred an OS benefit on risk-unadjusted analysis. Only, neurosurgical resection was an independent predictor of OS (HR 0.12, 95% CI: 0.03–0.49, p = 0.003), controlling for age, BoD and radiotherapy. Conclusions Resection of MCC BM may confer a survival benefit given appropriate patient selection. Prospective investigation of multimodal management of neurometastatic MCC is warranted, especially given the promise of new immunotherapy agents in treating MCC.

Merkel cell polyomavirus is the primary etiological agent of the aggressive skin cancer Merkel cell carcinoma (MCC). Recent studies have revealed that UV radiation is the primary mechanism for somatic mutagenesis in nonviral forms of MCC. Here, we analyze the whole transcriptomes and genomes of primary MCC tumors. Our study reveals that virus-associated tumors have minimally altered genomes compared to non-virus-associated tumors, which are dominated by UV-mediated mutations. Although virus-associated tumors contain relatively small mutation burdens, they exhibit a distinct mutation signature with observable transcriptionally biased kataegic events. In addition, viral integration sites overlap focal genome amplifications in virus-associated tumors, suggesting a potential mechanism for these events. Collectively, our studies indicate that Merkel cell polyomavirus is capable of hijacking cellular processes and driving tumorigenesis to the same severity as tens of thousands of somatic genome alterations., IMPORTANCE A variety of mutagenic processes that shape the evolution of tumors are critical determinants of disease outcome. Here, we sequenced the entire genome of virus-positive and virus-negative primary Merkel cell carcinomas (MCCs), revealing distinct mutation spectra and corresponding expression profiles. Our studies highlight the strong effect that Merkel cell polyomavirus has on the divergent development of viral MCC compared to the somatic alterations that typically drive nonviral tumorigenesis. A more comprehensive understanding of the distinct mutagenic processes operative in viral and nonviral MCCs has implications for the effective treatment of these tumors.

Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine cutaneous malignancy, with a predilection for sun-exposed sites in elderly patients. Despite an incidence 30 times less than that of melanoma, its disease-specific mortality is three times higher. Management of MCC remains challenging because of a limited understanding of its molecular biology, lack of prospective clinical trials, and limitations associated with retrospective reviews of therapeutic options. With the recent discovery of an associated human polyomavirus, significant progress has been made in the understanding of the pathogenesis of this malignancy. With this progress, there has been increasing optimism regarding new tools in the therapeutic armamentarium to fight this deadly disease. Here we present an overview on MCC with an emphasis on the most recent biologic discoveries and the rationale for novel targeted and immunotherapies.

9577Background: Despite its rising incidence and aggressive behavior, MCC remains an orphan disease with no active agents. Immunosuppression, UV exposure and MCPyV are known risk factors. A better ...

1004 Background: Neratinib (HKI-272) is an orally administered irreversible pan-ErbB receptor tyrosine kinase inhibitor. In an ongoing phase II study, the preliminary objective response rate was 26% in patients with ErbB2+ advanced breast cancer with prior trastuzumab therapy. This study assessed the safety and preliminary efficacy of the combination of neratinib plus trastuzumab. Methods: Patients with advanced ErbB2+ breast cancer that progressed following trastuzumab therapy were enrolled. The primary endpoint was 16-week progression free survival rate (PFS). In part 1 (dose escalation), patients received neratinib 160 mg or 240 mg daily plus trastuzumab 4 mg/kg IV loading dose then 2 mg/kg weekly. In part 2, patients received weekly trastuzumab with neratinib 240 mg daily. Timed blood samples were collected for PK analyses. PK analysis is ongoing. Results: 45 patients (part 1 n = 8; part 2 n = 37) were enrolled (mean age 52 yr); 9 are active. In part 1, cohorts 1 and 2 were fully enrolled with 4 patients each. No dose limiting toxicities were observed. Most common AEs, any grade, were diarrhea (91%), nausea (51%), anorexia (40%), vomiting (38%), and asthenia (27%). Grade 3/4 AEs were diarrhea (13%), nausea (4%), vomiting (4%). Two patients receiving neratinib 240 mg reported AEs leading to withdrawal. No AEs of congestive heart failure and no significant drops of left ventricular ejection fraction were reported. Among 33 patients evaluable for efficacy, objective response rate was 27% (95% CI, 13% - 46%); 16-week PFS rate (for part 2) 47% (95% CI, 29% - 63%); median PFS was 19 weeks (95% CI 15 - 32 weeks). Conclusions: Neratinib plus trastuzumab was well tolerated with no significant or unexpected toxicities, and demonstrated clinical activity. [Table: see text]

Merkel cell carcinoma (MCC) is a highly aggressive neuroendocrine skin cancer with profound but poorly understood resistance to chemotherapy, which poses a significant barrier to clinical MCC treatment. Here we show that ATP-binding cassette member B5 (ABCB5) confers resistance to standard-of-care MCC chemotherapeutic agents and provide proof-of-principle that ABCB5 blockade can inhibit human MCC tumor growth through sensitization to drug-induced cell cytotoxicity. ABCB5 expression was detected in both established MCC lines and clinical MCC specimens at levels significantly higher than those in normal skin. Carboplatin- and etoposide-resistant MCC cell lines exhibited increased expression of ABCB5, along with enhanced ABCB1 and ABCC3 transcript expression. ABCB5-expressing MCC cells in heterogeneous cancers preferentially survived treatment with carboplatin and etoposide in vitro and in human MCC xenograft-bearing mice in vivo. Moreover, patients with MCC also exhibited enhanced ABCB5 positivity after carboplatin- and etoposide-based chemotherapy, pointing to clinical significance of this chemoresistance mechanism. Importantly, ABCB5 blockade reversed MCC drug resistance and impaired tumor growth in xenotransplantation models in vivo. Our results establish ABCB5 as a chemoresistance mechanism in MCC and suggest utility of this molecular target for improved MCC therapy.