PMC6459944_01
Representative histologic image of patient's Merkel cell carcinoma with hematoxylin and eosin staining.
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F1
A 70-year-old male was diagnosed with Merkel Cell carcinoma of the right thigh (Figure 1).
Adjuvant radiation therapy plan of right thigh and groin showing axial and coronal representation.
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F2
Due to close surgical margins and inguinal nodal involvement, the patient received adjuvant intensity modulated radiation therapy (IMRT) to the right thigh and right pelvic and inguinal nodal region to a dose of 50 Gy delivered in 25 fractions (Figure 2), as well as consolidative carboplatin and etoposide post-operatively.
PET-imaging demonstrating metastatic dissemination of Merkel cell carcinoma. (A) whole body positronic imaging showing bilateral pelvic and retroperitoneal SUV avidity consistent with metastatic disease. (B) representative fused PET CT-scan axial imaging showing SUV avid retroperitoneal adenopathy.
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F3
Shortly after locoregional recurrence in the right pelvic nodal region, the patient developed metastatic disease involving bilateral pelvic nodes and the retroperitoneum on PET-scan (Figure 3).
Isolated left pelvic nodal progression on pembrolizumab. PET-scan showing SUV avid progression involving the left inguinal and left external iliac regions.
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F4
After 10 months of pembrolizumab (15 cycles), the patient had an isolated left inguinal and external iliac nodal progression (Figure 4).
Intensity modulated radiation therapy (IMRT) plan for left pelvic nodal progression to a prescription dose of 45 Gy delivered in 25 fractions with concurrent pembrolizumab.
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F5
For this reason, the patient was treated to the involved left inguinal and left external iliac nodes with IMRT to a dose of 45 Gy delivered in 25 fractions with concurrent pembrolizumab (Figure 5), without any acute radiation side effects.