The advent of immune checkpoint targeted immunotherapy has seen a spectrum of immune-related phenomena in both tumor responses and toxicities. We describe a case of pseudoprogression that pushes the limits of immune-related response criteria and challenges the boundaries and definitions set by trial protocols. A middle-aged man with conventional clear cell renal cell carcinoma (RCC) had received multiple prior systemic treatments including vascular endothelial growth factor receptor tyrosine kinase inhibitors, as well as multiple surgeries and radiotherapy treatments. He was eventually started on nivolumab-the anti-programmed death receptor-1 monoclonal antibody approved for the treatment of advanced RCC. Clinical deterioration was observed soon after a 100 mg dose of nivolumab, with onset of acute renal failure and declining performance status. Radiologic progression was documented in multiple sites including worsening tumor infiltration of his residual kidney. The patient was on palliative treatment and visited by the home hospice team in an end-of-life situation. The patient unexpectedly improved and went on to achieve a durable tumor response. The case is illustrative of an extreme manifestation of pseudoprogression, and impels us to probe the assumptions and controversies surrounding this phenomenon.
Cancer immunology, immunotherapy : CII. 2018 May 04 [Epub ahead of print]
Alvin S Wong, Yee-Liang Thian, Jeevesh Kapur, Cheng-Nang Leong, Patrick Kee, Chun-Tsu Lee, Martin B Lee
Department of Hematology-Oncology, National University Cancer Institute, National University Health System, NUHS Tower Block level 7, 1E Kent Ridge Road, Singapore, 119228, Singapore. ., Department of Diagnostic Imaging, National University Health System, Singapore, Singapore., Department of Radiation Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore., Hospice Care Association, Singapore, Singapore., Department of Hematology-Oncology, National University Cancer Institute, National University Health System, NUHS Tower Block level 7, 1E Kent Ridge Road, Singapore, 119228, Singapore., Department of Medicine, National University Health System, Singapore, Singapore.