Clinical and molecular characteristics associated with response to therapeutic PD-1/PD-L1 inhibition in advanced Merkel cell carcinoma

January 28, 2022


Journal for Immunotherapy of Cancer

Publication Date

January 28, 2022


Spassova I, Ugurel S, Kubat L, Zimmer L, Terheyden P, Mohr A, Andtback HB, Villabona L, Leiter U, Eigentler T, Loquai C, Hassel JC, Gambichler T, Haferkamp S, Mohr P, Pfoehler C, Heinzerling L, Gutzmer R, Utikal JS, Horny K, Schildhaus HU, Habermann D, Hoffmann D, Schadendorf D, Becker JC

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The immune system plays an important role in preventing the development and progression of Merkel cell carcinoma (MCC). As such, immune checkpoint inhibitor (ICI) therapy (like Pembrolizumab or Avelumab) has become an excellent option for patients with advanced MCC. This study aimed to identify clinical and molecular characteristics that are predictive of treatment response. It was found that absence of immunosuppression, a limited number of tumor-affected organs, and an elevated number of ‘killer’ (CD8 T) cells within the tumor were associated with a higher chance of responding to immune therapy.


Background Based on its viral-associated or UV-associated carcinogenesis, Merkel cell carcinoma (MCC) is a highly immunogenic skin cancer. Thus, clinically evident MCC occurs either in immuno-compromised patients or based on tumor-intrinsic immune escape mechanisms. This notion may explain that although advanced MCC can be effectively restrained by treatment with PD-1/PD-L1 immune checkpoint inhibitors (ICIs), a considerable percentage of patients does not benefit from ICI therapy. Biomarkers predicting ICI treatment response are currently not available.

Methods The present multicenter retrospective study investigated clinical and molecular characteristics in 114 patients with unresectable MCC at baseline before treatment with ICI for their association with therapy response (best overall response, BOR). In a subset of 21 patients, pretreatment tumor tissue was analyzed for activation, differentiation and spatial distribution of tumor infiltrating lymphocytes (TIL).

Results Of the 114 patients, n=74 (65%) achieved disease control (BOR=complete response/partial response/stable disease) on ICI. A Bayesian cumulative ordinal regression model revealed absence of immunosuppression and a limited number of tumor-involved organ systems was highly associated with a favorable therapy response. Unimpaired overall performance status, high age, normal serum lactate dehydrogenase and normal serum C reactive protein were moderately associated with disease control. While neither tumor Merkel cell polyomavirus nor tumor PD-L1 status showed a correlation with therapy response, treatment with anti-PD-1 antibodies was associated with a higher probability of disease control than treatment with anti-PD-L1 antibodies. Multiplexed immunohistochemistry demonstrated the predominance of CD8+ effector and central memory T cells (TCM) in close proximity to tumor cells in patients with a favorable therapy response.

Conclusions Our findings indicate the absence of immunosuppression, a limited number of tumor-affected organs, and a predominance of CD8+ TCM among TIL, as baseline parameters associated with a favorable response to PD-1/PD-L1 ICI therapy of advanced MCC. These factors should be considered when making treatment decisions in MCC patients.

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