Concurrent Radiation With Nivolumab and Chemotherapy for Nodal-Only Distant Metastatic Stage IV Esophageal Carcinoma

The clinical response rates for patients with stage IV human epidermal growth factor receptor 2 (HER2) negative esophageal carcinoma treated with immunotherapy and chemotherapy remain low, around 10%. HER2 is a protein that is found on the surface of a cell, including cancer cells. This receptor can sometimes be targeted to help eradicate the cancer cell. Immunotherapy is a type of treatment that stimulates the immune system to eradicate other cancer cells in the body. Cancer cells often have a protein on their surface called programmed cell death ligand 1 (PD-L1). This protein binds to the programmed cell death 1 (PD-1) protein that is on white blood cells. The binding of these two proteins prevents the white blood cell from eradicating the cancer cell. Immunotherapy prevents the binding of these proteins and thus increases the chances of the white blood cell eliminating the cancer cell. The addition of concurrent radiation could improve this response rate by direct cell kill, increase the immunotherapy response via the abscopal effect, and eliminate micro-metastatic cancer. Obtaining a complete clinical response could be a prognostic marker for improved outcomes. A complete clinical response is where the imaging scans and/or direct visual examination of certain parts of the body show no evidence of cancer. We now present a unique case of concurrent radiation with nivolumab and chemotherapy for a distant nodal-only metastatic stage IV esophageal patient who obtained a complete clinical response within three months of his last radiation treatment.