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  Table of Contents  
LETTER TO THE EDITOR
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 55-56
 

Nivolumab instills hope in a hopeless situation in advanced nonsmall cell lung cancer with poor performance status


1 Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Radiodiagnosis, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. V Noronha
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_10_17

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How to cite this article:
Chandrakanth M V, Noronha V, Joshi A, Patil V, Mahajan A, Prabhash K. Nivolumab instills hope in a hopeless situation in advanced nonsmall cell lung cancer with poor performance status. Indian J Cancer 2017;54:55-6

How to cite this URL:
Chandrakanth M V, Noronha V, Joshi A, Patil V, Mahajan A, Prabhash K. Nivolumab instills hope in a hopeless situation in advanced nonsmall cell lung cancer with poor performance status. Indian J Cancer [serial online] 2017 [cited 2019 Mar 25];54:55-6. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/55/219527


Sir,

There is no evidence to support any cancer-directed therapy in patients with advanced lung cancer with a poor performance status (PS) that too without any targetable driver mutation.[1],[2] In the present case scenario, we treated such a patient with an immune checkpoint inhibitor nivolumab on compassionate basis. The response was dramatic with near-complete resolution of target lesions and with a prompt improvement in PS.

A 62-year-old man, chronic smoker with 20 pack-years with history of ischemic stroke an year before, presented to us with low back ache for 2 months. On examination, his vitals were stable with a PS of 2. Respiratory system examination revealed reduced air entry with occasional rales on the right hemithorax. He had tenderness over lumbar vertebrae.

Positron emission tomography-computed tomography scan done to localize the primary and to detect the extent of systemic spread revealed a 6 cm × 5 cm mass in the left lower lobe with ipsilateral mediastinal nodes, adrenal metastases, and multiple skeletal metastases. Biopsy from the lung mass was consistent with adenocarcinoma lung. Molecular tests to detect driver mutations revealed a wild type of epidermal growth factor receptor and anaplastic lymphoma kinase-1. A final diagnosis of adenocarcinoma lung, tumor node metastasis stage: cT2N2M1b was made. He received palliative radiation and zoledronic acid to address bone metastases.

He then received one cycle of pemetrexed and carboplatin following which he developed derangement in renal functions. The regimen was hence changed to gemcitabine and carboplatin combination, which he received for three cycles, during which he developed Grade 3 hematological toxicities. He had worsening of his symptoms with the onset of new bony pains. A radiological evaluation for response revealed disease progression in the form of increase in the soft tissue lesion at lumbar vertebrae and appearance of new bony lesions. He received palliative radiation to painful bony sites. In view of disease progression, borderline PS, and poor tolerance to prior chemotherapy, we planned him for weekly paclitaxel-based chemotherapy, which he received for 4 consecutive weeks. He developed Grade 3 anemia, Grade 3 hyponatremia, and his PS deteriorated to 3/4. He developed new brain metastases in left parieto-occipital lobe. In view of disease progression on treatment and Grade 3 toxicities, further chemotherapy was withheld. He received whole brain radiation 20 Gy/5# following which he symptomatically improved.

In view of disease progression, poor tolerance, and poor PS, patient and relatives were counseled for best supportive care. However, as they were keen on exploring options, we started Programmed death -1 inhibitor - nivolumab as a last-ditch effort. He received 8 biweekly cycles at a dose of 3 mg/kg which he tolerated well. He had a significant symptomatic benefit in the form of improvement in bony pains and improvement in PS. Radiological assessment was suggestive of partial response in the lung lesion and sclerosis of existing bony lesions. He went on to receive further 8 more cycles to complete 16 cycles, following which he had significant improvement in PS to 1. Radiological assessment revealed near-complete resolution of lung lesions and sclerosis of bony lesions. He developed Grade 1 rash, Grade 1 transaminitis which subsided without any intervention. He has been presently doing well and is planned to continue nivolumab further [Figure 1]a-c].
Figure 1: Serial computed tomography images depicting regression of lung mass at (a) before treatment, (b) at 8 cycles, and (c) at 16 cycles of nivolumab

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There are no data to suggest any treatment in patients with poor PS. However, when a drug has shown promise even in this adverse setting, it gives us the glimpse of its potential efficacy and favorable toxicity profile. Our case report depicts the potentiality of immune checkpoint inhibition in anticancer therapy.

Given the favorable toxicity profile and unique mechanism of action, it is worth exploring nivolumab in the treatment of advanced nonsmall cell lung cancer with poor PS patients, who are otherwise offered only best supportive care.[3],[4] Immunotherapy is a potential modality of anticancer therapy in lung cancer and may overcome multiple adverse prognostic factors such as poor PS, smoking history, large disease burden, lack of targetable driver mutations, and heavily pretreated disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Brahmer J, Reckamp KL, Baas P, Crinò L, Eberhardt WE, Poddubskaya E, et al. Nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer. N Engl J Med 2015;373:123-35.  Back to cited text no. 1
    
2.
Borghaei H, Paz-Ares L, Horn L, Spigel DR, Steins M, Ready NE, et al. Nivolumab versus docetaxel in advanced nonsquamous non-small-cell lung cancer. N Engl J Med 2015;373:1627-39.  Back to cited text no. 2
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3.
Horn L, Brahmer J, Reck M, Borghaei H, Spigel DR, Steins M, et al. Phase 3, Randomized Trial (CheckMate 057) of Nivolumab vs. Docetaxel in Advanced Non-Squamous (Non-SQ) NSCLC: Subgroup Analyses and Patient-Reported Outcomes (PROs). European Cancer Conference 2015; European Society of Medical Oncology; 2015.  Back to cited text no. 3
    
4.
Gettinger SN, Horn L, Gandhi L, Spigel DR, Antonia SJ, Rizvi NA, et al. Overall survival and long-term safety of nivolumab (Anti-Programmed Death 1 Antibody, BMS-936558, ONO-4538) in patients with previously treated advanced non-small-cell lung cancer. J Clin Oncol 2015;33:2004-12.  Back to cited text no. 4
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