Highlight
This comprehensive multicenter cohort study compared circulating tumor DNA (ctDNA) and Merkel cell polyomavirus (MCPyV) antibody testing for surveillance of Merkel cell carcinoma (MCC) recurrence. The findings indicate that ctDNA exhibits significantly higher positive and negative predictive values for disease recurrence compared to antibody testing. Importantly, combining both biomarkers confers minimal additional benefit beyond ctDNA alone, positioning ctDNA as a superior and more reliable marker for clinical monitoring and risk stratification in MCC patients.
Study Background
Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine skin cancer characterized by high rates of recurrence, with up to 40% of patients experiencing relapse after initial treatment. Approximately 80% of MCC cases are associated with Merkel cell polyomavirus (MCPyV) infection, which influences tumor biology and clinical course. Surveillance for disease recurrence is critical to improving patient outcomes by enabling early therapeutic interventions. Currently, two blood-based biomarkers are used clinically for monitoring MCC recurrence: MCPyV oncoprotein antibodies and circulating tumor DNA (ctDNA). MCPyV antibodies reflect the host immune response to viral oncoproteins, while ctDNA provides direct molecular evidence of tumor-derived genetic material in plasma. Despite their clinical use, it is unclear which biomarker offers superior accuracy for detecting recurrence, an unmet need addressed by this study.
Study Design
This multicenter prospective cohort study was conducted between April 2020 and March 2024 across three US academic centers: Stanford University, Dana-Farber Brigham, and University of Washington. It enrolled 169 patients with stage I-IV MCC who were clinically disease-free at baseline and had detectable MCPyV antibodies at diagnosis. Serial paired blood tests measuring ctDNA and MCPyV antibodies were performed for disease surveillance. CtDNA positivity was defined as any detectable mean tumor molecules per milliliter of plasma above zero, while a rising antibody titer was defined as a 30% or greater increase compared to prior levels. Paired tests had to be performed within 45 days of each other, with a median testing interval of 96 days. The primary endpoint was confirmed clinical recurrence of MCC during a median follow-up of 483 days. Predictive performance metrics including positive predictive value (PPV), negative predictive value (NPV), and hazard ratios (HR) were calculated and compared between the two assays.
Key Findings
Among the 169 patients, 703 paired tests were analyzed, and 36 clinical recurrences occurred in 32 patients. The study demonstrated that ctDNA had superior performance in detecting recurrence compared to MCPyV antibody testing. At 365 days, ctDNA showed a PPV of 73% (95% CI, 58%-85%) versus 52% (95% CI, 32%-71%) for antibodies (P = .02). The NPV at 90 days was also significantly higher with ctDNA (99%, 95% CI, 98.8%-100%) compared to antibodies (97%, 95% CI, 95%-98%; P = .001). Furthermore, ctDNA positivity was associated with a markedly greater hazard ratio for recurrence (HR 47.9; 95% CI, 16.5-139) compared to antibody titer rises (HR 7.3; 95% CI, 3.8-13.9), resulting in a hazard ratio ratio of 6.6 (P < .001). Importantly, the combined use of both ctDNA and antibody tests identified only one additional recurrence beyond ctDNA testing alone, highlighting the minimal additive value of antibody testing when ctDNA results are available.
Expert Commentary
This study provides compelling evidence favoring ctDNA as the preferred biomarker for MCC surveillance. The direct detection of tumor-derived genetic fragments in plasma enables earlier and more reliable identification of disease recurrence compared to serologic measures of immune response. The high negative predictive value of ctDNA is particularly clinically valuable, offering reassurance in ruling out recurrence and potentially reducing unnecessary imaging or invasive procedures. Although MCPyV antibodies remain useful in specific clinical contexts, such as in patients with virus-associated MCC, their lower predictive accuracy and minimal additive benefit limit their utility as standalone surveillance tools.
Limitations include the requirement for detectable MCPyV antibodies at baseline for inclusion, which restricts applicability to virus-negative MCC cases. The study’s median follow-up, while sufficient to capture many recurrences, may underestimate late relapses. Additionally, heterogeneous treatment backgrounds and imaging protocols across centers may influence recurrence detection timing. Nonetheless, the findings align with growing literature supporting ctDNA as a transformative biomarker across multiple malignancies.
Mechanistically, ctDNA reflects active tumor burden through the release of DNA fragments into circulation from apoptotic or necrotic tumor cells. This contrasts with MCPyV antibody titers, which primarily reflect host immune memory responses and may lag behind tumor dynamics. Implementation of ctDNA testing into routine clinical practice requires optimization for assay sensitivity, cost, and integration with existing clinical workflows.
Conclusion
In conclusion, this landmark multicenter study establishes circulating tumor DNA as a more accurate and reliable biomarker than MCPyV antibody testing for monitoring recurrence in patients with Merkel cell carcinoma. CtDNA testing offers superior predictive values and stronger risk stratification capability, enabling improved clinical decision-making and personalized surveillance strategies. Future research should focus on extending these findings to virus-negative MCC, refining ctDNA assay sensitivity, and integrating biomarker data into comprehensive management algorithms to optimize patient outcomes.
Funding and ClinicalTrials.gov
The study was supported by institutional grants from participating academic centers. No specific clinical trial registration was reported in the cited publication.
References
1. Thakuria M, Akaike T, Silk AW, et al. ctDNA or Merkel Virus Antibodies for Surveillance of Merkel Cell Carcinoma Recurrence. JAMA Dermatol. 2026; published online July 8. doi:10.1001/jamadermatol.2026.42418167
2. Becker JC, Stang A, DeCaprio JA, et al. Merkel cell carcinoma. Nat Rev Dis Primers. 2017;3:17077. doi:10.1038/nrdp.2017.77
3. Nghiem PT, Bhatia S. Merkel cell carcinoma: update and review. Hematol Oncol Clin North Am. 2018;32(2):187-203. doi:10.1016/j.hoc.2017.11.011
4. Alonzo TA, Parmigiani G. Statistical methods for early detection of cancer recurrence. Melanoma Res. 2003;13(1):79-86. doi:10.1097/00008390-200302000-00013
