IMUNOTHERAPY APPLIED IN METASTATIC MERCKEL NEOPLASIA USING IMMUNOSUPPRESSANTS

Case presentation: A.L., male, 59 years old, with history of renal transplantation by amyloidosis in October/2015 and in use of cyclosporine, predinisone, carvedilol and spironolactone. In February 2018 it envolved with a progressive growth nodule on the right hand dorsum and nodule in the right malar region, and was submitted to resection with a pathology compatible with Merckel cell carcinoma immunohistochemistry positive to Chromogranin and Sinaptofisin in the malar region and squamous cell carcinoma in the dorsal region of the right hand. In July 2018, a new nodule appears in the malar region with new resection and selective cervical dissection with anatomopathological compatible with metastasis of Merkel cell carcinoma in four of four lymph nodes found. Again, a new lesion appears in the pre -auricular region with palpable lymph nodes in the right cervical region in September/2018. A new procedure is performed showing Carcinoma of Merckel cells relapsed with infiltration into parotid and submandibular glands, compromised surgical margins, metastases in forty eight of fifty-four lymph nodes evaluated, including with extranodal extension. In same month was evaluated by a oncology team, which was requested PET-CT whose result evidenced a 2.2 cm nodule resense in the left infraorbital dermis (SUV 9.3) and initiated adjuvant radiotherapy in the malar region. In November of 2018, there was a new significant local tumor progression during radiotherapy. Started avelumabe concomitant of ciclosporin suspension and dose reduction of prednisone worsening of renal function however without indication of hemodialysis. It evolves with satisfactory response, including complete response in the evaluation of March/2019 with good tolerance to immunotherapy. Discussion: Merckel cell carcinoma is a neuroendocrine cancer of the skin, with high potential for aggressiveness, most frequently affecting the face, head and neck, and correlated to prolonged exposure to the sun, advanced age and use of immunosuppressants. Chemotherapy regimens do not show good survival rates, so immunotherapy acts on PD-1 and PD-L1- aggregates good clinical, radiological and quality of life results. Final Comments: Immunotherapy adds positive responses in metastatic merckel cell carcinoma with good tolerance, representing a safe and effective treatment option.