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Case report: complete response and long-term survival on third-line immunotherapy in patient with pleural
Željka Jurić Čuljak1, Snježana Tomić2, Kristina Šitum3
1Department of Pulmonary Diseases, University Hospital of Split, Split, Croatia.
Introduction:
Pleural mesothelioma (PM) is a rare neoplasm with median survival time range from 8 to 14 months from diagnosis, and the 5-year survival rate less than 10%, indicating a poor prognosis. The standard treatment for unresectable PM for a long time has been polychemotherapy with pemetrexed and cisplatin for fit patients. Currently, the combination of the anti PD-1 inhibitor nivolumab and the anti-CTLA4 inhibitor ipilimumab has been recognized as the best possible frontline therapy (especially in the sarcomatoid or biphasic type) due to improved outcomes compared to the standard chemotherapy combination. There are still no established predictive biomarkers for any type of systemic therapy in this disease.
Case Presentation:
Patient who presented with cough and dyspnea has been diagnosed with advanced epithelioid type PM in May 2016. He was treated with three lines of therapy, including an antiangiogenic agent and immunotherapy with pembrolizumab in the third line. Immunotherapy with the PD-1 inhibitor pembrolizumab achieved a complete and prolonged response that transferred to long- term survival. Seven years from diagnosis, the patient is still alive. Histological findings showed an unusually immune-inflamed tumor microenvironment possibly leading to excellent response on immunotherapy.
Conclusions:
The course of the disease in our patient points out that we need better predictive biomarkers to direct the treatment algorithm, as some of the patients, although chemorefractory to the best chemotherapy option, can sustain great benefit of second-line chemotherapy in combination with antiangiogenic agent, and especially immunotherapy, even in late lines of therapy.
Insights
Advanced pleural mesothelioma (PM) treatment can be improved with immunotherapy, even in later lines. This case highlights a patient achieving long-term survival with PD-1 inhibitor pembrolizumab, emphasizing the need for predictive biomarkers.
Area of Science:
- Oncology
- Immunotherapy
- Malignant Pleural Mesothelioma
Background:
- Pleural mesothelioma (PM) has a poor prognosis with limited survival rates.
- Standard treatment for unresectable PM has been pemetrexed and cisplatin chemotherapy.
- Combination immunotherapy (nivolumab and ipilimumab) is now a recognized frontline therapy.
Observation:
- A patient with advanced epithelioid PM received three lines of therapy, including pembrolizumab.
- This patient achieved a complete and prolonged response to PD-1 inhibitor immunotherapy.
- Seven years post-diagnosis, the patient remains alive with a highly immune-inflamed tumor microenvironment.
Findings:
- Immunotherapy with pembrolizumab resulted in long-term survival for this patient.
- The patient's tumor microenvironment was unusually immune-inflamed, correlating with the response.
- This case suggests potential benefits from immunotherapy even in later treatment lines.
Implications:
- There is a critical need for predictive biomarkers to guide systemic therapy selection in PM.
- Patients refractory to standard chemotherapy may still benefit significantly from immunotherapy.
- Optimizing treatment algorithms requires better understanding of individual patient responses to therapy.
