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An autoimmune-based, paraneoplastic neurologic syndrome following checkpoint inhibition and concurrent radiotherapy for merkel cell carcinoma: case report

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Abstract

Purpose

Merkel cell carcinoma is highly sensitive to both radiation and immunotherapy. Moreover, concurrent radioimmunotherapy may capitalize on anti-tumor immune activity and improve Merkel cell treatment response, although an enhanced immune system may cross-react with native tissues and lead to significant sequelae.

Methods

Here we present a case study of a patient with metastatic Merkel cell carcinoma treated with radiotherapy concurrent with pembrolizumab.

Results

After radioimmunotherapy, the patient developed sensory neuropathy, visual hallucinations, and mixed motor neuron findings. Neurologic dysfunction progressed to profound gastrointestinal dysmotility necessitating parenteral nutrition and intubation with eventual expiration.

Conclusion

This case represents a unique autoimmune paraneoplastic neurologic syndrome, likely specific to neuroendocrine tumors and motivated by concurrent radioimmunotherapy. Recognition of the potential role of radioimmunotherapy may provide an advantage in anticipating these severe sequelae.

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Fig. 1

Notes

  1. Timmerman R (2014) Personal communication

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Acknowledgements

Austin Kirschner is supported by the National Institutes of Health grant, no. 5K12CA090625-18 from the Vanderbilt Clinical Oncology Research Development Program.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Vanderbilt University Medical School, Nashville, TN, USA

    Alexander D. Sherry & Michael Bezzerides

  2. Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN, USA

    Mohamed H. Khattab, Guozhen Luo & Austin N. Kirschner MD, PhD

  3. Department of Medicine, Division of Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN, USA

    Kristin K. Ancell

Authors
  1. Alexander D. Sherry
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  2. Michael Bezzerides
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  6. Austin N. Kirschner MD, PhD
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Corresponding author

Correspondence to Austin N. Kirschner MD, PhD.

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Conflict of interest

M.H. Khattab reports research funding from Varian Medical Systems and Brainlab. A.D. Sherry, M. Bezzerides, G. Luo, K.K. Ancell, and A.N. Kirschner declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was exempt from IRB review per VUMC IRB Policy I.B.1. All identifiable patient information has been omitted, and the information contained in the manuscript is anonymized. The patient reported in this study provided written informed consent authorizing use and disclosure of his protected health information.

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Author contributions

All authors contributed to the study conception and design, data collection, and interpretation. The first draft of the manuscript was written by Alexander Sherry and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Sherry, A.D., Bezzerides, M., Khattab, M.H. et al. An autoimmune-based, paraneoplastic neurologic syndrome following checkpoint inhibition and concurrent radiotherapy for merkel cell carcinoma: case report. Strahlenther Onkol 196, 664–670 (2020). https://doi.org/10.1007/s00066-020-01582-3

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