Clinician-to-Clinician Update Clinician-to-Clinician Update

Repeat Nivolumab Achieves Near-Complete Lung Cancer Symptom Resolution

April 2018

Contributed by Manish Patel, DO

Lung cancer is often diagnosed at later stages, making for less-successful therapy and shorter survival. Smoking cessation can lessen risk, and earlier screening and diagnosis improve treatment options. New treatments such as immunotherapies can lengthen survival.

Patient

A 62-year-old woman was seen for hemoptysis. She had a 30-year history of smoking a pack a day but had quit smoking in the early 1980s, making her ineligible for screening, according to National Lung Screening Trial criteria. Imaging scans showed a right hilar mass with associated mediastinal adenopathy. Biopsy results revealed adenocarcinoma of the lung and mediastinal lymph nodes positive for metastatic disease. A PET scan showed no evidence of metastasis to the brain or other distant sites. Her disease was classified as at stage IIIA.

Management

Her case was discussed at the multidisciplinary tumor conference, and she was deemed not a likely surgical candidate at that time due to requirement of a pneumonectomy. She was treated with concurrent chemoradiation and weekly carboplatin-taxol and irradiation therapy followed by 2 cycles of consolidation chemotherapy.

About 1 year later, she saw her physician again for assessment of hemoptysis and new deep venous thrombosis. A CT scan did not show any obvious disease recurrence, but she underwent bronchoscopy that revealed a new endobronchial lesion in the right main stem bronchus. The lesion was biopsied and found to be consistent with recurrent lung adenocarcinoma. A PET scan showed metastases to her ribs and malignant pleural effusion.

She received carboplatin and pemetrexed therapy, with the course of the disease remaining stable. After 2 cycles of maintenance pemetrexed, disease progressed in her lung. She developed an obstruction of her right lower-lobe bronchus, worsening pleural effusion, and new metastasis in her left adrenal gland. At that time, her physicians decided to place her on nivolumab therapy in an off-trial regimen. After initiation of nivolumab, she had an endobronchial stent placed and a tumor surgically removed from her airway to palliate symptoms of shortness of breath. This treatment was initially successful; however, by 3 weeks postsurgery, shortness of breath returned.

Repeat bronchoscopy showed mucus and growth of the tumor into the stent, causing recurrent bronchial obstruction. Repeat thoracic surgery removed the tumor from the airway. At this point, the patient was considering palliative care and hospice, but instead decided to try repeat nivolumab therapy. One month later, after completing 4 treatments of nivolumab, her symptoms became less severe, shortness of breath almost completely resolved, and she was gaining weight. A scan performed at that time showed slight decrease in right hilar lymphadenopathy.

Over time, she had a partial response with near complete resolution of the left adrenal mass and a decrease in hilar adenopathy. She did well for over 1 year with only mild arthralgia as a side effect of therapy. An esophageal cancer developed about 15 months after she had started nivolumab therapy, and she ultimately succumbed to this cancer.

Discussion

Early cancer detection improves therapeutic outcomes, but patients with lung cancer can benefit from newer immunotherapies. Response to immunotherapy, however, can be delayed, and careful interpretation of findings at early points in the treatment cycle is required. Within this context, it is reasonable to provide palliative measures in order to allow patients to continue treatment and have more time to develop a full response.

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