|LETTER TO THE EDITOR
|Year : 2022 | Volume
| Issue : 3 | Page : 868-869
Durable complete response after stereotactic body radiation therapy in immunotherapy-resistant non-small cell lung cancer
Miguel J Sotelo1, Santiago Cabezas-Camarero2, Alejandro Riquelme3, Coralia Bueno3
1 Department of Medical Oncology, Hospital María Auxiliadora; Aliada Oncological Center; Oncological Research Unit, Clínica San Gabriel, Lima, Peru
2 Department of Medical Oncology, Hospital Universitario Clínico San Carlos, Madrid, Spain
3 Department of Medical Oncology, Hospital Universitario Infanta Cristina, Madrid, Spain
|Date of Submission||11-Jul-2020|
|Date of Decision||29-Aug-2020|
|Date of Acceptance||07-Oct-2020|
|Date of Web Publication||22-Jun-2022|
Miguel J Sotelo
Department of Medical Oncology, Hospital María Auxiliadora, Aliada Oncological Center, Oncological Research Unit, Clínica San Gabriel, Avda. Miguel Iglesias 968, San Juan de Miraflores, 15801 Lima
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sotelo MJ, Cabezas-Camarero S, Riquelme A, Bueno C. Durable complete response after stereotactic body radiation therapy in immunotherapy-resistant non-small cell lung cancer. J Can Res Ther 2022;18:868-9
|How to cite this URL:|
Sotelo MJ, Cabezas-Camarero S, Riquelme A, Bueno C. Durable complete response after stereotactic body radiation therapy in immunotherapy-resistant non-small cell lung cancer. J Can Res Ther [serial online] 2022 [cited 2022 Aug 10];18:868-9. Available from: https://www.cancerjournal.net/text.asp?2022/18/3/868/347794
We report the case of a patient with advanced PD-L1 negative non-small cell lung cancer (NSCLC), who was started on second-line treatment with nivolumab in August 2015, achieving a complete response. One year later, monotopic oligoprogression occurred in a right adrenal metastasis, that was treated with stereotactic body radiation therapy (SBRT) and subsequent maintenance nivolumab, achieving a sustained complete response. In February 2019, after 43 months of continued treatment with nivolumab, with 18F-fludeoxyglucose-positron emission tomography scan showing no evidence of active disease [Figure 1], treatment was discontinued after a discussion with the patient. Ever since, periodic imaging (every 3 months) has shown no evidence of disease, confirming a durable complete response that lasts for >4 years so far.
|Figure 1: 18F-Fludeoxyglucose-positron emission tomography scan in February 2019, showing no evidence of macroscopic disease|
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While the optimal duration of immunotherapy (IO) in NSCLC is not established, a protracted treatment course could be associated with a greater benefit without an increase in toxicity, although with a higher economic burden. In an exploratory analysis on 163 patients randomized to the CheckMate 153 study, treatment with nivolumab for >1 year prolonged progression-free survival and showed a positive trend for overall survival, compared to 1 year of treatment. On the other hand, there are data suggesting that the reintroduction of IO in patients who discontinued it in the absence of PD, could continue to be effective. Indeed, while most pembrolizumab studies on NSCLC established a maximum treatment duration of 2 years, in Keynote-010, 14 out of 79 patients received a second course of pembrolizumab due to PD after withdrawing it due to a sustained response after a 2-year initial treatment course, achieving six partial responses (43%) and five stabilizations (36%). Therefore, after a durable complete response, the pros and cons of discontinuing IO should be discussed with patients.
This case suggests that the synergistic effects of sequential treatment with radiotherapy (RT) and IO may have had a prominent role in the patient's outcome. RT has the ability to enhance the antitumor activity of immune checkpoint inhibitors and in some cases even reverse primary or secondary resistance.
When our patient received SBRT, the only site of macroscopic disease was the right adrenal metastasis. However, as a principle in oncology, metastatic macroscopic disease theoretically also means the presence of microscopic disease. In this regard, the sequence nivolumab → SBRT → nivolumab not only eliminated the irradiated adrenal metastasis but also have elicited a still ongoing immune response against micrometastases because no new lesions have appeared to date, >4 years after SBRT. Indeed, there is evidence that supports the hypothesis that the combination of IO and RT can favor a powerful immune response that, in addition to acting on macroscopic disease, will also permanently act on microscopic disease, functioning as a vaccine.
As our case illustrates, and considering the few therapeutic options in patients with advanced NSCLC progressing to IO, in those patients who oligoprogress after an initial response to IO, SBRT followed by maintenance IO may be an effective and well-tolerated approach.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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