Single administration of avelumab induced a complete response in thyroid transcription factor 1-positive combined Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an aggressive neoplasm and patients with metastasis have poor survival outcomes. Recently, avelumab, an anti-programmed death ligand 1 (PD-L1) immune checkpoint inhibitor, was approved for first-line treatment in patients with metastatic MCC. While the administration interval of avelumab is every 2 weeks, the durable effect of a single administration of avelumab is unknown. Additionally, the effect of avelumab in pure MCC or combined MCC concurrent with non-MCC histology has not been fully elucidated. Herein, we report a case of combined MCC concurrent with squamous cell carcinoma; the patient had a complete response after a single administration of avelumab. Although the levels of avelumab were outside the detection limit within 12 weeks, a remarkable efficacy remained for more than 28 weeks after administration. Immunohistochemical analyses revealed that the expression of PD-L1 and Merkel cell polyomavirus large T antigen was almost negative or only partial in the primary tumor lesion of this patient. Conversely, thyroid transcription factor 1 (TTF-1) expression was positive in the primary MCC lesion, which is consistent with a previous report that combined MCC is positive for TTF-1 expression. In conclusion, this case study presents a rare case of TTF-1-positive combined MCC showing complete response after a single administration of avelumab.