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PubMed This is a summary of 22 peer-reviewed journal articles Updated
Oncology · Merkel Cell Carcinoma

Navigating Your Treatment: From Surgery to Immunotherapy

At a Glance

Merkel cell carcinoma (MCC) treatment depends on the cancer's stage. Localized MCC is typically treated with surgery and radiation to remove the tumor and prevent recurrence. For advanced MCC, immunotherapies like avelumab and pembrolizumab are now the preferred standard of care.

The treatment for Merkel cell carcinoma (MCC) has evolved rapidly. Today, your care is highly personalized based on the stage of your cancer—meaning how large the tumor is and whether it has spread to other parts of your body. Because MCC is aggressive, the standard of care often involves a combination of surgery, radiation, and, in many cases, modern immunotherapy [1][2].

Treating Localized Disease (Stage I and II)

When the cancer is found only in the skin, the goal is to remove the primary tumor and check for any hidden spread.

  1. Surgery: You will likely undergo either Wide Local Excision (WLE)—where the surgeon removes the tumor plus a margin of healthy tissue—or Mohs Micrographic Surgery, which removes the tumor layer-by-layer to spare healthy skin [3][4]. Research shows that both are effective for achieving clear margins [5][6].
  2. Staging the Nodes: A Sentinel Lymph Node Biopsy (SLNB) is a standard part of surgery. It is the most accurate way to find microscopic cancer cells in nearby lymph nodes [4][7].
  3. Radiation: After surgery, adjuvant radiation therapy is often recommended to the site of the original tumor and sometimes the nearby lymph nodes [1][8]. This “clean up” radiation helps reduce the risk of the cancer returning [9][10].

Treating Advanced Disease (Stage III and IV)

If the cancer has spread to the lymph nodes or distant organs, the focus shifts to systemic (body-wide) treatments.

Immunotherapy is now the preferred first-line treatment for advanced MCC, replacing older chemotherapy because it often results in longer-lasting responses with fewer side effects [11][12]. These drugs are called PD-1/PD-L1 inhibitors, and they work by essentially “taking the brakes off” your immune system so it can recognize and destroy the cancer cells [13][14].

FDA-approved immunotherapies for advanced MCC include:

  • Avelumab (Bavencio): The first drug approved specifically for metastatic MCC [15][16].
  • Pembrolizumab (Keytruda): Widely used for many cancers and established as a standard for advanced MCC [17][18].
  • Retifanlimab (Zynyz): A newer PD-1 inhibitor shown to be effective in patients who haven’t yet received chemotherapy [19].

Treatment Strategy Logic

Your care team generally follows this decision-making process:

If your cancer is… Then the standard strategy is…
Localized (Skin Only) Surgery (WLE or Mohs) + SLNB + Adjuvant Radiation [4][8].
Regional (Nodes Only) Surgery + Nodal Radiation or Surgery + Immunotherapy [9][2].
Advanced/Metastatic First-line Immunotherapy (Avelumab, Pembrolizumab, or Retifanlimab) [11][13].

A Note on “Adjuvant” Immunotherapy

You may wonder if you should receive immunotherapy after surgery even if your cancer hasn’t spread to distant organs (this is called “adjuvant” therapy). As of mid-2026, adjuvant immunotherapy is not yet the standard of care for all patients, as major trials like ADMEC-O are still evaluating its long-term benefits [20][21]. However, for patients at very high risk of recurrence, your doctor might discuss this as an option or suggest a clinical trial [21][22].

Common questions in this guide

Do I need a sentinel lymph node biopsy for MCC?
Yes, a sentinel lymph node biopsy (SLNB) is a standard part of surgery for localized MCC. It is the most accurate way to check if microscopic cancer cells have already spread to nearby lymph nodes.
Should I have Mohs surgery or a Wide Local Excision?
Both Mohs surgery and Wide Local Excision (WLE) are highly effective at removing the primary tumor with clear margins. Your surgical oncologist or dermatologist will recommend the best option based on the tumor's size and location on your body.
Why do I need radiation after MCC surgery?
Radiation therapy is often used after surgery to target the original tumor site and sometimes the surrounding lymph nodes. This 'clean up' approach is designed to destroy any remaining microscopic cancer cells and reduce the risk of the tumor returning.
What is the best treatment for advanced Merkel cell carcinoma?
Immunotherapy is now the standard first-line treatment for advanced MCC that has spread to distant organs. Drugs like avelumab, pembrolizumab, and retifanlimab work by unblocking your immune system so it can recognize and destroy cancer cells.
Will I get immunotherapy after my surgery?
Receiving immunotherapy after surgery to prevent recurrence (adjuvant therapy) is not currently the standard of care for all patients. However, if you are at a very high risk of recurrence, your doctor might discuss this option or recommend participating in a clinical trial like ADMEC-O.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is my cancer candidate for Mohs surgery, or is a Wide Local Excision (WLE) more appropriate for its location?
  2. 2.Given my stage, what is the specific benefit of adding adjuvant radiation to my treatment plan?
  3. 3.Is a sentinel lymph node biopsy (SLNB) necessary for me, and when should it be performed?
  4. 4.If I have advanced disease, which immunotherapy—avelumab, pembrolizumab, or retifanlimab—do you recommend as a first-line treatment?
  5. 5.Are there any open clinical trials, such as those studying adjuvant immunotherapy (like the ADMEC-O trial), that I should consider?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (22)
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    Updates for Management of Merkel Cell Carcinoma of the Head and Neck: A Systematic Review.

    Kimball KM, Pember BJ, Soliman NM, Nemer KM

    Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2026; (52(6)):513-520 doi:10.1097/DSS.0000000000004967.

    PMID: 41411499
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    Updates on Merkel Cell Carcinoma.

    Emge DA, Cardones AR

    Dermatologic clinics 2019; (37(4)):489-503 doi:10.1016/j.det.2019.06.002.

    PMID: 31466589
  3. 3

    Importance of Surgical Margins in Patients with Early-Stage Merkel Cell Carcinoma.

    Cowman AW, Lourdault K, Hanes D, et al.

    Dermatology and therapy 2025; (15(3)):733-746 doi:10.1007/s13555-025-01345-x.

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    Response to "Mohs surgery for early-stage Merkel cell carcinoma (MCC) achieves local control better than wide local excision +/- radiation therapy with no increase in MCC-specific death".

    Nguyen KA, Maloney NJ, Fonseca A, et al.

    International journal of dermatology 2022; (61(4)):e143-e144 doi:10.1111/ijd.15723.

    PMID: 34143433
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    No difference in survival for primary cutaneous Merkel cell carcinoma after Mohs micrographic surgery and wide local excision.

    Moore KJ, Thakuria M, Ruiz ES

    Journal of the American Academy of Dermatology 2023; (89(2)):254-260 doi:10.1016/j.jaad.2023.04.042.

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    Demographics and outcomes of stage I and II Merkel cell carcinoma treated with Mohs micrographic surgery compared with wide local excision in the National Cancer Database.

    Singh B, Qureshi MM, Truong MT, Sahni D

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    Prognostic factors in Merkel cell carcinoma patients undergoing sentinel node biopsy.

    Mattavelli I, Patuzzo R, Torri V, et al.

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    Treatment of primary Merkel cell carcinoma: Radiotherapy can be an effective, less morbid alternative to surgery.

    Hong AM, Stretch JR, Thompson JF

    European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 2021; (47(2)):483-485 doi:10.1016/j.ejso.2020.05.013.

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    Impact of total radiotherapy dose on survival for head and neck Merkel cell carcinoma after resection.

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    Optimal adjuvant radiotherapy dose for stage I, II or III Merkel cell carcinoma: an analysis of the National Cancer Database.

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This page provides educational information about Merkel cell carcinoma treatments and guidelines. It does not replace professional medical advice, and you should always consult your oncology team to determine the safest treatment plan for your specific stage.

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