Complete Remission With Fourth-Line Immunotherapy After Chemotherapy Failure in a Lung Cancer Patient With Severe Autoimmune Disease: An Unexpected Turn in Oncologic Management

Abstract

The indication for nivolumab in patients with advanced non-small cell lung cancer (NSCLC) who have progressed to first-line platinum-based systemic therapy was one of the first indications for immunotherapy approved by regulatory agencies. However, it is generally the case that patients with autoimmune diseases (AIDs) are excluded from studies due to the risk of immune exacerbations and a higher rate of immune-related adverse effects. This deprives these patients of the potential benefits they could obtain from immunotherapy, especially in those cases with favorable biomarkers of a good response. In this study, we present a clinical case of a patient with rapidly progressive multiple sclerosis (MS) of years of evolution, who obtained an impressive response to immunotherapy as a last therapeutic option, remaining cancer-free to date.

Keywords: autoimmune disease; complete response; immune related adverse events; immunotherapy; lung cancer.

Figure 1. CT scan on September 27, 2022, showing mass of 5 x 4 cm in lower left lobe (red arrow)

This image corresponds to the primary tumor before being operated on.

Figure 2. Histological section showing adenocarcinoma of solid and papillary pattern

A) Microscopic (histological) examination: Histologically, the lesion was a neoplasm of epithelial origin, composed of atypical cuboidal or columnar cells with oval nuclei, irregular nuclear membranes, prominent nucleoli, and eosinophilic or clear cytoplasm. These cells were predominantly arranged in solid nests (solid pattern: 80%) or around fibrovascular cores (papillary/micropapillary pattern: 20%). The tumor showed involvement of the visceral pleura (PL2), with no clear evidence of lymphovascular invasion, perineural invasion, or STAS. No lymph nodes were submitted with the specimen. Immunohistochemical study: On immunohistochemical analysis, the tumor cells were positive for TTF-1 and napsin-A, and negative for p63, consistent with a diagnosis of primary lung adenocarcinoma. B) An additional immunohistochemical study for PD-L1 (PD-L1 22C3, DAKO) showed positivity in the majority of tumor cells (TPS: 90%). Final pathological diagnosis: High-grade (G3) pulmonary adenocarcinoma STAS: Spread through air spaces; TPS: Tumor proportion score

Figure 3. December 2023 CT scan showing disease progression with new hepatic lesions

This image corresponds to the appearance of new metastatic liver lesions after receiving three cycles of pemetrexed. The red arrow corresponds to a new 13-mm metastatic lesion in segment III.

Figure 4. June 2024 CT scan showing complete response of hepatic lesions

This image corresponds to the same plane as in Figure 3, with the disappearance of metastatic liver lesions after receiving 12 cycles of nivolumab.