CLINICAL CASE STUDY published: 26 October 2012 doi: 10.3389/fonc.2012.00152
Maintenance treatment with chemotherapy and immunotherapy in non-small cell lung cancer: a case report Anabella Llanos 1*, Mariana Savignano 2 and Gabriela Cinat 1 1 2
Department of Sarcoma and Melanoma, Instituto Angel H. Roffo, Buenos Aires, Argentina Department of Clinical Oncology, Instituto Angel H. Roffo, Buenos Aires, Argentina
Edited by: Daniel Gomez, Universidad Nacional de Quilmes, Argentina Reviewed by: Maria L. Ardigo, Laboratorio Elea SACIFyA, Argentina Guillermo Chantada, Hospital JP Garrahan, Argentina *Correspondence: Anabella Llanos, Department of Sarcoma and Melanoma, Instituto Angel H. Roffo, 5481 San Martin Avenue, Buenos Aires, PC 1417, Argentina. e-mail: anabllanos@hotmail.com
A 53-years-old woman was diagnosed with lung adenocarcinoma state IV (synchronous pleural involvement) in April 2009. First-line systemic treatment included six cycles of Carboplatin, Paclitaxel, and Bevacizumab. Partial response was achieved. Maintenance therapy with Bevacizumab and Pemetrexed was given from September 2009 to February 2010. No response changes were observed. Immunotherapy was initiated, and then Pemetrexed was given with the same disease status. Both treatments were well tolerated. Immunotherapy toxicity included reaction at the site of injection grade 2. At present, the patient is still on this treatment. Given the poor prognosis of patients with advanced lung cancer, the combination of both treatments during the stable phase of the disease may improve progression-free survival. Keywords: vaccines, lung cancer, immunotherapy, chemotherapy, concurrent review
CASE PRESENTATION A 53-years-old woman otherwise previously healthy and a nonsmoker, was diagnosed with lung adenocarcinoma, stage IV T 3 Nx M1a (TNM classification 7th edition) on April 2009. On March 2009, she presented with functional class III dyspnea. A Chest X-ray showed veiling in the left side of the thorax. CAT scans were performed, and a solid lung mass in the left lower lobe, associated with pleural effusion and moderate lung collapse was seen contralateral pleural effusion was also evidenced. Bronchoscopy showed extrinsic compression of the left lower lobe bronchus. Pleural biopsy by thoracoscopy, and pleurodesis with sclerosing agents were performed (talc). Histological examination of the pleura revealed a proliferation of epithelial-like atypical cells arranged in glands, nests, and cords with moderate anisocytosis, anisokaryosis, macronucleoli, and scattered mitoses. Pleural fluid was positive for neoplastic cells. Immunostaining techniques were performed against the following antigens: cytokeratin 7, cytokeratin 20, calrretinina, chromogranin, and TTF, which were positive for cytokeratin 7 and TTF. These morphological findings are related to moderately differentiated adenocarcinoma of pulmonary etiology. Cobas EGFR test was non-mutated. First line chemotherapy with carboplatin AUC 6 + paclitaxel 200 mg/m2 + bevacizumab 15 mg/kg every 21 days was started on May 2009. The patient received six cycles, and this regimen finished in September 2009. Tumor assessment showed partial response (RECIST). Maintenance therapy with bevacizumab 15 mg/kg + pemetrexed 500 mg/m2 every 21 days was administered no significant toxicity was associated with these regimens. Bevacizumab was discontinued in February 2010 and the patient was included in a compassionate program
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including Racotumomab. Pemetrexed was administered together with immunotherapy, and the patient is still on treatment. Partial response was maintained (Figure 1). As for toxicity associated with the investigational regimen the patient exhibited a reaction at the site of injection of the vaccine grade 2. Adverse events related to pemetrexed were not different from expected, asthenia grade 2.
BACKGROUND Non-small cell lung cancer (NSCLC) is about 85% of all newly diagnosed cases of lung cancer, and the leading cause of cancer related mortality worldwide. Despite some advances in therapy, the overall prognosis is not encouraging yet; as for all stages of this devastating disease, less than 20% of patients are alive 5 years after diagnosis, in the setting of metastatic disease, the median overall survival (OS) is below 1 year and 4–6 months without treatment (Fong et al., 2005; Jemal et al., 2010; Winter et al., 2011). Conventional therapies for NSCLC such as surgery and radiotherapy are quite effective in the treatment of localized tumors; in the setting of progressive disease, chemotherapy is still the treatment of choice but, because of toxicity involving normal tissue, its use is often limited. The introduction of first-generation chemotherapy (platinum based regimens including paclitaxel, docetaxel, gemcitabine or vinorelbine) has proven to have only limited activity. The response rate was 10–15%, with slight improvement in OS with median survival rates below 11 months, and 31–36% at 1 year (Winter et al., 2011). Nowadays, many patients with advanced NSCLC will benefit from the individualized regimens based on the identifiable molecular characteristics of their tumors. The tumor molecular profile should help select the appropriate agents for a given patient (Kim et al., 2012).
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